Breast Milk Additives and Infant Formula

Abstract

Breast milk is recommended for very preterm infants but fortification is required to increase its nutrient density in order to promote growth and development. Even with fortification, those born extremely preterm and those who are fluid restricted may not achieve intrauterine growth targets. Thus, fortification beyond routine amounts may be necessary for some infants. Further study is necessary to determine optimal methods, types and amounts of fortification, as well as upper limits of osmolality, so as to ensure avoidance of feeding intolerance and necrotizing enterocolitis whilst achieving appropriate rate of weight gain and accretion of nutrients. The efficacy of new formulations of fortifiers and infant formulae needs further study. Key points• Breast milk requires fortification to meet the nutrient needs of preterm infants; monitoring protein intake via blood urea nitrogen to guide fortification looks promising.• Breast milk fortifiers have variable effects on osmolality of fortified expressed breast milk.• Randomised controlled trials are required to assess the efficacy of recently revised formulations of breast milk fortifier and preterm formulae in the context of their ability to meet nutritional requirements for growth and effect on osmolality and feeding intolerance.• Use of gum-based thickening agents for treatment of regurgitation is associated with increased risk of necrotising enterocolitis in preterm and term infants.

Preterm human milk composition: a systematic literature review

“…Notably, protein, energy and PER targets for infants weighing <1000 g are achieved when 0·5 g of protein powder is added to feeds in addition to BMF and fed at volumes between 140 and 160, and similarly these targets are achieved at lower volumes (130-140 ml/kg per d) when 1·0 g of protein powder is added in addition to routine amounts of BMF. This level of fortification is currently being practised in some neonatal units around the globe, with the understanding that additional, intact protein powder does not adversely affect osmolality of the feeds (55) , and with acceptance that protein intakes may be greater than needed for some preterm infants if the native content of the milk is actually higher than anticipated (56) . The efficacy and safety of these fortification practices have not been well studied, and further research is needed to determine the best formulation and the amount of fortifier that can be safely added to preterm milk to optimise preterm growth, developmental and metabolic outcomes.…”

Bovine milk fortifiers and fortified pasteurized donor human milk for premature infant nutrition. Peptidomic overview

“…Commercial fortifiers could be partially or extensively hydrolyzed, to reduce the antigenicity and allergenicity of milk proteins, as well as to improve their digestibility. They could also be made of intact milk proteins (Sherriff & McLeod, 2013). The degree of hydrolysis and the composition of peptides formed also depend from the proprietary manufacturing conditions such as type of protease(s), temperature, hydrolysis time, enzyme/protein ratio (Bu, Luo, Chen, Liu, & Zhu, 2013).…”