Target Fortification of Breast Milk: Predicting the Final Osmolality of the Feeds

Abstract

For preterm infants, it is common practice to add human milk fortifiers to native breast milk to enhance protein and calorie supply because the growth rates and nutritional requirements of preterm infants are considerably higher than those of term infants. However, macronutrient intake may still be inadequate because the composition of native breast milk has individual inter- and intra-sample variation. Target fortification (TFO) of breast milk is a new nutritional regime aiming to reduce such variations by individually measuring and adding deficient macronutrients. Added TFO components contribute to the final osmolality of milk feeds. It is important to predict the final osmolality of TFO breast milk to ensure current osmolality recommendations are followed to minimize feeding intolerance and necrotizing enterocolitis. This study aims to develop and validate equations to predict the osmolality of TFO milk batches. To establish prediction models, the osmolalities of either native or supplemented breast milk with known amounts of fat, protein, and carbohydrates were analyzed. To validate prediction models, the osmolalities of each macronutrient and combinations of macronutrients were measured in an independent sample set. Additionally, osmolality was measured in TFO milk samples obtained from a previous clinical study and compared with predicted osmolality using the prediction equations. Following the addition of 1 g of carbohydrates (glucose polymer), 1 g of hydrolyzed protein, or 1 g of whey protein per 100 mL breast milk, the average increase in osmolality was 20, 38, and 4 mOsm/kg respectively. Adding fat decreased osmolality only marginally due to dilution effect. Measured and predicted osmolality of combinations of macronutrients as well as single macronutrient (R2 = 0.93) were highly correlated. Using clinical data (n = 696), the average difference between the measured and predicted osmolality was 3 ± 11 mOsm/kg and was not statistically significant. In conclusion, the prediction model can be utilized to estimate osmolality values after fortification.

ASPEN Safe Practices for Enteral Nutrition Therapy

“…It is suggested that this time be as short as feasible to limit the breakdown of nutrients in HBM. Articles using prior renditions of the current human milk fortifiers reported an increase in osmolarity over time 18 , 19 …”

Human Milk Fortification with Bovine Colostrum Is Superior to Formula‐Based Fortifiers to Prevent Gut Dysfunction, Necrotizing Enterocolitis, and Systemic Infection in Preterm Pigs

“…The fortified DHMs were adjusted to approach the protein and energy levels in sow's milk (see Table ; 55 g of protein and 1040 kcal/L in sow's milk). It was decided to use diluted DHM and slightly overall lower protein and energy concentrations than in sow's milk to avoid high osmolality in the DHM+NAN diet, containing maltodextrin and extensively hydrolyzed protein . ENF and NAN fortifiers differ with regard to the nature of protein (intact vs hydrolyzed milk protein) and the source of nonprotein energy (vegetable oil vs maltodextrin; Table ).…”

Infant food applications of complex carbohydrates: Structure, synthesis, and function

“…[158] Handling methods and source of glucose polymer additives alter the biological effect of these polymers. [158–160]…”

“…[158, 160] As fortifiers, glucose polymers provide carbohydrate and energy sources to meet some of the nutritional requirements of fast-growing or diet-restricted infants. [159, 160] Lactose ( 11 ) and various monosaccharides are often substituted with glucose polymers to lower the osmotic concentration of infant formula. [158, 161] A decrease in osmotic concentration is thought to be advantageous because hyperosmolarity is associated with diarrhea and necrotizing enterocolitis.…”

“…[158, 161, 162] Conversely, fortifying human milk with glucose polymers has been shown to increase the osmotic load due to the action of endogenous breast milk amylase that breaks down polysaccharides into smaller oligosaccharides and monosaccharides. [18, 159, 160]…”