Should Human Milk Be Fortified For a Premature Baby?

Attempts to fortify human milk for preemies are very common…  …It all sounds great, but there are many problems associated with fortification.

Newest related post:  Fortify Human Milk for Premature Infants?

See Also:  What You Need to Know Now About Feeding A Premature Baby

and Preemie Feeding: Human Milk Fortifier? Donor Milk?
for more information on feeding preemies.

Below is excerpted from “BABY MATTERS.” Even more up-to-date information on the question of fortifying premature infants’ mother’s milk is available in “BABY POOP.”

Attempts to fortify human milk for preemies are very common. Calcium and phosphorous are often added in attept to improve early bone mineralization. Protein is added in an attempt to increase growth rate. Other vitamins and minerals are often added as well. It all sounds great, but there are many problems associated with fortification.

One study analyzed the feeding of a high-protein formula that contained
3 times the protein of human milk, comparing this feed to mother’s milk in low-weight babies. The growth rates were similar, but the high-protein infants had high levels of toxins from protein breakdown in their blood (urea and creatinine). Additionally, two amino acids (components of protein), phenylalanine and tyrosine, were found to be too high in the formula-fed infants’ blood. In excessive amounts, these hinder nervous system development.

Another study reviewed protein utilization in a formula with extra cow’s milk protein added, compared with human milk with extra human milk protein added. The human protein fortified infants gained more weight and had better protein balance. A more recent examination of nonhuman protein enrichment of mother’s milk found more severe illnesses and a reduced duration of “full” breastfeeding while a greater duration of full breastfeeding was associated with better growth scores.

Most breastmilk fortification contains cow’s milk proteins. These are not desirable with breastmilk or in preemie formulas (although they are in nearly all formulas). A few of the problems with these dairy proteins are the high incidence of bovine protein intolerance associated with intestinal inflammation, bleeding, and diarrhea; the slow breakdown of these large proteins in the tiny system, preventing additional formula feedings as early as they are needed for proper caloric intake; and the increased risk of developing childhood diabetes — the risk being greater the earlier cow’s milk proteins are introduced (all of these topics are addressed elsewhere in the book).

It has been shown that breastmilk fortified with any cow’s milk products, which includes nearly any preemie or infant formula or milk fortification powder, reduces the immune protective properties of mother’s milk. A higher rate of infection is seen in infants fed fortified breastmilk versus those fed only human milk. The immune protection from mother can be reduced by fortification in part because E. coli bacterial growth in the intestine increases, which mother’s milk alone hinders. This bacterial flora sets the stage for many diarrheal illnesses. Non-iron-containing soy derived products do not promote E. coli and lead to a lesser increase in infection
overall; however, soy can also cause allergic intolerance.

Various researchers are interested in supplementing elements such as sodium, phosphorous, calcium, and vitamins to the breastfed preemie. These can all be provided without dairy products or iron. Iron supplements will feed E. coli and other challenging bacteria, blocking much of breastmilk’s infection protection, and is not needed in most cases. Vitamins shouldn’t be harmful in low quantities according to the research to date, and vitamin D may enhance bone building when neither mother nor infant is obtaining much sun exposure.

In a German study, half of the preterm infants receiving medium or high levels of calcium supplementation were found to have dangerous calcification in their kidneys, and many suffered abdominal distension as well. We have already seen that breastfed preemies eventually show very good bone mineralization with no supplementation. Another study suggests that bone mineralization in breastfed preemies is as high as in formula-fed preemies by just a few months after birth, but the concern continues about the light bone mineral content early on for breastfed low-birthweight infants.

While it seems a little backwards to use formula-fed infants as the gold standard, comparisons to intrauterine growth are used as well. Breastfed preemies’ bones may lag behind formulafed preemies in this arena. While a very low level of calcium and phosphorous supplementation to the breastfed preemie does not appear harmful, the latest review of studies is unable to confirm an advantage. Added vitamin D may help these to be absorbed.

If protein fortification is desired, it should come from a human or possibly
soy source. Much more research is needed in this area. Vitamin fortifications
appear to have little downside, as opposed to minerals, proteins, or
other components.

© Linda Folden Palmer

For Linda Palmer’s most recent and complete information on feeding premature infants and the questions about fortifications, see her most recent book:  

———————————————————-Resources

R.N. Musoke et al., “Breastfeeding promotion: feeding the low birth weight infant,” Int J Gynaecol Obstet (Kenya) 31, suppl. 1 (1990): 57–9.
G.P. Mathur et al., “Breastfeeding in babies delivered by cesarean section,” Indian Pediatr 30, no. 11 (Nov 1993): 1285–90.
J. Contreras-Lemus J et al., “[Morbidity reduction in preterm newborns fed with milk of their own mothers],” Bol Med Hosp Infant Mex 49, no. 10 (Oct 1992): 671–7.
M.A. Hylander et al., “Human milk feedings and infection among very low birth weight infants,” Pediatrics 102, no. 3 (Sep 1998): E38.
S.P. Srivastava et al., “Mortality patterns in breast versus artificially fed term babies in early infancy: a longitudinal study,” Indian Pediatr 31, no. 11 (Nov 1994): 1393–6.
S. Awasthi et al., “Mortality patterns in breast versus artificially fed term babies in early infancy: a longitudinal study,” Indian Pediatr 28, no. 3 (Mar 1991): 243–8.
M. Armand et al., “Effect of human milk or formula on gastric function and fat digestion in the premature infant,” Pediatr Res 40, no. 3 (Sep 1996): 429–37.
R.J. Schanler et al., “Bone mineralization outcomes in human milk-fed preterm infants,” Pediatr Res 31, no. 6 (Jun 1992): 583–6.
J. Ramasethu et al., “Weight gain in exclusively breastfed preterm infants,” J Trop Pediatr (India) 39, no. 3 (Jun 1993): 152–9.
N.J. Bishop et al., “Early diet of preterm infants and bone mineralization at age five years,” Acta Paediatr (England) 85, no. 2 (Feb 1996): 230–6.
G. Putet et al., “Nutrient balance, energy utilization, and composition of weight gain in very-low-birth-weight infants fed pooled human milk or a preterm formula,” J Pediatr 105, no. 1 (Jul 1984): 79–85.
A. Lucas et al., “A randomised multicentre study of human milk versus formula and later development in preterm infants,” Arch Dis Child Fetal Neonatal Ed (England) 70, no. 2 (Mar 1994): F141–6.
B. Lozoff, “Birth and ‘bonding’ in non-industrial societies,” Dev Med Child Neurol 25, no. 5 (Oct 1983): 595–600.
K. Christensson, “Fathers can effectively achieve heat conservation in healthy newborn infants,” Acta Paediatr (Sweden) 85, no. 11 (Nov 1996): 1354–60.
J Bauer et al., “Metabolic rate and energy balance in very low birth weight infants during kangaroo holding by their mothers and fathers,” J Pediatr (Germany) 129 no. 4 (Oct 1996): 608–11.
K. Christensson et al., “Separation distress call in the human neonate in the absence of maternal body contact,” Acta Paediatr (Sweden) 84, no 5 (May 1995): 468–73.
C.C. Lambesis et al., “Effects of surrogate mothering on physiologic stabilization in transitional newborns,” Birth Defects Orig Artic Ser 15, no. 7 (1979): 201–23.
L. Vaivre-Douret et al., “[Kangaroo method and care],” Arch Pediatr (France) 3, no. 12 (Dec 1996): 1262–9.
R.A. Kambarami et al., “Kangaroo care versus incubator care in the management of well preterm infants — a pilot study,” Ann Trop Paediatr 18, no. 2 (Jun 1998): 81–6.
P.R. Messmer et al., “Effect of kangaroo care on sleep time for neonates,” Pediatr Nurs 23, no. 4 (Jul–Aug 1997): 408–14.
S.M. Ludington-Hoe et al., “Birth-related fatigue in 34–36-week preterm neonates: rapid recovery with very early kangaroo (skin-to-skin) care,” J Obstet Gynecol Neonatal Nurs 28, no. 1 (Jan–Feb 1999): 94–103.
C.J. Tornhage et al., “Plasma somatostatin and cholecystokinin levels in preterm infants during kangaroo care with and without nasogastric tube-feeding,” J Pediatr Endocrinol Metab 11, no. 5 (Sep–Oct 1998): 645–51.
K. Gloppestad, Vard Nord Utveckl Forsk (Norway) 16, no. 1 (spring 1996): 22–7.
N.M. Hurst et al., “Skin-to-skin holding in the neonatal intensive care unit influences maternal milk volume,” J Perinatol 17, no. 3 (May–Jun 1997): 213–7.
P. De Chateau and B. Wiberg, “Long-term effect on mother–infant behavior of extra contact during the first hour post partum. I. First observations at 36 hours,” Acta Paediatr Scand 66, no. 2 (Mar 1977): 137–43.
G. Gale et al., “Skin-to-skin (kangaroo) holding of the intubated premature infant,” Neonatal Netw 12, no. 6 (Sep 1993): 49–57.
M.E. Wegman, “Infant mortality: some international comparisons,” Pediatrics 98, no. 6, part 1 (Dec 1996): 1020–7.
M.J. Martin Puerto et al., “[Early discharge of low-birth-weight neonates. 5-year experience],” An Esp Pediatr (Spain) 38, no. 1 (Jan 1993): 20–4
L.S. Adair et al., “The duration of breast-feeding: How is it affected by biological, sociodemographic, health sector, and food industry factor?” Demography 30, no. 1 (Feb 1993): 63–80.
K. Aisaka et al., “[Effects of mother-infant interaction on maternal milk secretion and dynamics of maternal serum prolactin levels in puerperium],” Nippon Sanka Fujinka Gakkain Zasshi (Japan) 37, no. 5 (May 1985): 713–20.
V. Nedkova and S. Tanchev, “[Serum levels of prolactin, progesterone and estradiol in nursing mothers,]” Akush Ginedol (Solfiia) (Bulgaria) 34, no. 3 (1995): 22–3.
S.J. Gross, “Growth and biochemical response of preterm infants fed human milk or modified infant formula,” N Engl J Med 308, no. 5 (Feb 3 1983): 237–41.
G. Boehm et al., “[Consequences of the composition of breast milk for the nutrition of underweight newborn infants. II. Lipids and lactose],” Kinderarztl Prax (Germany) 57, no. 9 (Sep 1989): 443–50.
Narayanan, “Human milk for low birthweight infants: immunology, nutrition and newer practical technologies,” Acta Paediatr Jpn (Japan) 31, no. 4 (Aug 1989): 455–61.
K. Pridham et al., “The effects of prescribed versus ad libitum feedings and formula caloric density on premature infant dietary intake and weight gain,” Nurs Res 48, no. 2 (Mar–Apr 1999): 86–93.
R.J. Schanler and S.A. Abrams, “Postnatal attainment of intrauterine macromineral accretion rates in low birth weight infants fed fortified human milk,” J Pediatr 126, no. 3 (Mar 1995): 441–7.
S. Awasthi et al., “Is high protein milk beneficial for SGA-terms?” Indian Pediatr 26, no. 1 (Jan 1989): 45–51.
G. Boehm et al., “[Protein utilization by premature infants with a birth weight less than 1,500 g during nutrition with MANSAN or breast milk protein],” Kinderarztl Prax (German) 59, no. 1–2 (Jan–Feb 1991): 26–30.
R. Quan et al., “The effect of nutritional additives on anti-infective factors in human milk,” Clin Pediatr (Phila) 33, no. 6 (Jun 1994): 325–8.
A. Lucas et al., “Randomized outcome trial of human milk fortification and developmental outcome in preterm infants,” Am J Clin Nutr (England) 64, no. 2 (Aug 1996): 142–51.
J. Kreuder et al., “[Efficacy and side effects of differential calcium and phosphate administration in prevention of osteopenia in premature infants],” Monatsschr Kinderheilkd (Germany) 138, no. 11 (Nov 1990): 775–9.
S.J. Gross, “Bone mineralization in preterm infants fed human milk with and without mineral supplementation,” J Pediatr 111, no. 3 (Sep 1987): 450–8.
J. Neuzil et al., “Oxidation of parenteral lipid emulsion by ambient and phototherapy lights: potential toxicity of routine parenteral feeding,” J Pediatr 126, no. 5, part 1 (May 1995): 785–90.
D.A. Kelly, “Liver complications of pediatric parenteral nutrition — epidemiology,” Nutrition 14, no. 1 (Jan 1998): 153–7.
R.L. Fisher, “Hepatobiliary abnormalities associated with total parenteral nutrition,” Gastroenterol Clin North Am 18, no. 3 (Sep 1989): 645–66.
K. Simmer et al., “The use of breast milk in a neonatal unit and its relationship to protein and energy intake and growth,” J Paediatr Child Health 33, no. 1 (Feb 1997): 55–60.
A. Lucas and T.J. Cole, “Breast milk and neonatal necrotising enterocolitis,” Lancet (England) 336, no. 8730 (Dec 1990): 1519–23.
V. Araujo et al., “Impact of oxygen therapy on antioxidant status in newborns,” Biofactors 8, nos. 1–2 (1998): 143–7.
L. Daniels et al., “Selenium status of preterm infants: the effect of postnatal age and method of feeding,” Acta Paediatr 86, no. 3 (Mar 1997) 281–8.