Fortification of Human Milk for Preterm Infants: Update and Recommendations of the European Milk Bank Association (EMBA) Working Group on Human Milk Fortification

Abstract

Evidence indicates that human milk (HM) is the best form of nutrition uniquely suited not only to term but also to preterm infants conferring health benefits in both the short and long-term. However, HM does not provide sufficient nutrition for the very low birth weight (VLBW) infant when fed at the usual feeding volumes leading to slow growth with the risk of neurocognitive impairment and other poor health outcomes such as retinopathy and bronchopulmonary dysplasia. HM should be supplemented (fortified) with the nutrients in short supply, particularly with protein, calcium, and phosphate to meet the high requirements of this group of babies. In this paper the European Milk Bank Association (EMBA) Working Group on HM Fortification discusses the existing evidence in this field, gives an overview of different fortification approaches and definitions, outlines the gaps in knowledge and gives recommendations for practice and suggestions for future research. EMBA recognizes that “Standard Fortification,” which is currently the most utilized regimen in neonatal intensive care units, still falls short in supplying sufficient protein for some VLBW infants. EMBA encourages the use of “Individualized Fortification” to optimize nutrient intake. “Adjustable Fortification” and “Targeted Fortification” are 2 methods of individualized fortification. The quality and source of human milk fortifiers constitute another important topic. There is work looking at human milk derived fortifiers, but it is still too early to draw precise conclusions about their use. The pros and cons are discussed in this Commentary in addition to the evidence around use of fortifiers post discharge.

Evaluation of Total Antioxidant Capacity and Total Oxidant Status of Preterm and Term Breast Milk during the Course of Lactation and within a Nursing Session

“…Therefore, fortification of BM with nutrients is recommended especially for infants with very low birth weight. 36 Fortification can be an option to increase antioxidant capacity of preterm BM which is low even in early stages of lactation compared with healthy term BM. Most of the multinutrient fortifiers contain antioxidant vitamins which may offer some improvement in antioxidant capacity of BM.…”

Urinary Metabolomic Profile of Preterm Infants Receiving Human Milk with Either Bovine or Donkey Milk-Based Fortifiers

“…The achievement of optimal growth is one of the main targets for the successful management of preterm infant care [1]. Inadequate nutrition and/or poor postnatal growth have been reported as negatively associated with neurocognitive outcomes in preterm infants [2].…”

“…Although human milk (HM) is undoubtedly the gold standard of nutrition for every newborn, in the case of premature birth, it is inadequate for the nutritional needs of infants since it provides insufficient amounts of some nutrients. HM should therefore be supplemented (fortified) with specific nutrients, and particularly with protein, calcium and phosphate [1,4]. Although HM fortification is widely used in neonatal intensive care units all over the world, preterm infants receiving fortification often still experience suboptimal growth and feeding intolerance.…”

Concentrated Preterm Formula as a Liquid Human Milk Fortifier at Initiation Stage in Extremely Low Birth Weight Preterm Infants: Short Term and 2-year Follow-up Outcomes

“…The nutritional content of unfortified HM, however, can not completely support the growth of preterm infants [11,12]. The literature recommends fortified human milk in infants born before 32 weeks gestation and for certain infants born at 32-36 weeks of gestation [13]. Human milk fortifier (HMF) (24 kcal/oz) is indicated for all breast milk-fed infants weighing less than 2000 g and should be initiated when the infant is tolerating breast milk feeds of 25 cm 3 /day.…”