Is targeted fortification of human breast milk an optimal nutrition strategy for preterm infants? An interventional study

Abstract

BackgroundFortifying human milk contributes to the prevention of postnatal growth failure in preterm infants. Because of the natural variability of human milk, targeted fortification of human milk has been advocated. However, data regarding the efficacy and safety of prolonged targeted fortification are scarce. We aimed to assess the safety of targeted fortification of human milk in preterm infants compared with standard fortification, as well as the effects on infant growth.MethodsWe conducted an interventional study during hospital stay in healthy very low birth weight preterm infants who were exclusively fed human milk. Pools of human milk collected for 24 h were analysed using mid-infrared transmission spectroscopy. Targeted fortification of human milk was performed by adding macronutrients to native human milk to obtain optimal ratios of fat (4.4 g), carbohydrates (8.8 g), and protein (3 g) per 100 ml. The intervention period lasted 4–7 weeks. Weekly weight and daily growth rates were compared with those of a standardized fortification group of very low birth weight preterm infants who received standard fortified human milk (n = 10). The osmolality as well as the metabolic and gastrointestinal tolerance were monitored. Intergroup differences were evaluated using the Mann–Whitney U-test.ResultsA total of 10 preterm infants (birth weight 1223 ± 195 g; gestational age 29.1 ± 1.03 weeks) were enrolled and 118 samples of pooled milk were analysed. On average, 1.4 ± 0.1 g of protein, 2.3 ± 0.5 g of carbohydrate, and 0.3 ± 0.1 g of fat per 100 ml were added to the milk. Osmolality values after target fortification were within recommended limits (376 ± 66 mOsml/kg). Weekly weight gain (205.5 g; 95 % CI 177–233 vs 155 g; 95 % CI 132–178; p = 0.025) and daily growth rates (15.7 g/kg/day; 95 % CI 14.5–16.9 vs 12.3 g/kg/day; 95 % CI 10.7–13.9; p = 0.005) were higher in infants receiving target fortification than in infants receiving standardized fortification. The infants receiving targeted fortified milk consumed similar volumes as infants in the standardized fortification group (148 ± 4.5 vs 146 ± 4 ml/kg/day). No signs of either gastrointestinal or metabolic intolerance were observed.ConclusionsTarget fortification appears to promote growth in very low birth weight preterm infants without any detrimental effects.Trial registration NCT02716337

The Effect of Additives for Reflux or Dysphagia Management on Osmolality in Ready‐to‐Feed Preterm Formula: Practice Implications

“…It is known that there is high variability in feed-thickening practices, and consequences of thickeners are numerous and may include NEC, hypernatremia, malabsorption of nutrients, constipation, dehydration, delayed GI transit, fatigue from nipple extraction, difficulty extracting liquid, decreased oral intake, or prolonged transition of oral feeding in the presence of oropharyngeal dysphagia. 1,6,19,[22][23][24][25][26][27][28][29][30][31][34][35][36][37][38] In addition, each 1 tsp/oz rice cereal or oatmeal adds 5 kcal/oz, and this increased energy density alters metabolism, which can lead to excessive body fat deposits. 19,39 Thickeners are frequently used to treat dysphagia with the assumption that thickening decreases the flow rate, thus increasing oropharyngeal transit time to improve airway protection and oromotor control.…”

Nutritional management of surgical newborns and infants in the acute phase and during follow up

“…19 When feeding human milk to preterm infants, fortification is necessary in order to meet the high nutritional requirements of these infants. 20,21 Even after necrotizing enterocolitis development, fortification is required in order to promote adequate growth N o n -c o m m e r c i a l u s e o n l y even though the optimal timing of its introduction has not been elucidated yet. The use of human milk-based fortifiers has been advocated so that infants can be fed an exclusive diet of human milk, which has been associated with more beneficial effects than feeding human milk fortified with cow's milk derived fortifiers.…”

30th Congress of the Italian Society of Neonatology - Lombardy section | Bergamo, 3-4 February 2017

“…Alcuni di questi ultimi diventano essenziali nel nato prematuro, nel quale è stata dimostrata l'immaturità degli specifici enzimi coinvolti nella loro produzione. Nel nato pretermine l'apporto di proteine attraverso la NPT si pone come obiettivo quello di far proseguire, nella vita postnatale, la velocità di crescita fetale (15)(16)(17)(18)(19)(20) g/kg/die a 24-28 w, 10 g/kg/die a termine di gestazione) per cercare di ridurre il rischio di deficit di crescita al quale vanno incontro i neonati nelle prime settimane di vita, a causa del maggior dispendio di energia. 8 Il fabbisogno proteico fetale giornaliero è stato stimato tra 3,6 e 4,8 g/kg, risultando inversamente proporzionale all'età gestazionale, tuttavia le proteine durante tale periodo della vita non vengono utilizzate solo per l'accrescimento ma anche come fonte di energia.…”

“…Non sono stati riportati valori di osmolarità superiori a quelli raccomandati. Contrariamente ai risultati riportati da Rochow et al, 17 Morlacchi et al 18 hanno dimostrato una migliore crescita in un gruppo di 10 nati pretermine che ricevevano latte materno fortificato in modo individualizzato, per una durata media di 5,6±0,9 settimane, quando confrontata con quella di un gruppo storico di controllo che assumeva latte materno fortificato con modalità standard (Tabella 2).…”

“…Clinicamente definita dalla presenza di almeno 2 delle seguenti condizioni: letargia, stupor o coma, anomalie del tono o della postura, anomalie dei riflessi neonatali (suzione, grasp, Moro), ridotta o assente attività spontanea, disfunzione autonomiche (bradicardia, apnea, anomalie pupillari), convulsioni e dalla presenza di anomalie moderate-severe al tracciato di fondo dell'aEEG o di convulsioni. Una recente cochrane del 2013, comprendente 11 studi con 1505 neonati a termine o late preterm con encefalopatia moderata o severa ed evidenza di asfissia intrapartum, ha dimostrato: la riduzione di mortalità/disabilità neurologiche maggiori a 18 mesi con ; la riduzione della mortalità con un NNT di 11 (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25); la riduzione della disabilità neurologiche nei sopravvissuti con un . Gli eventi avversi significativi sono limitati alla bradicardia sinusale e alla piastrinopenia.…”