Comparison of the Effect of Two Human Milk Fortifiers on Clinical Outcomes in Premature Infants

Abstract

The use of human milk fortifiers (HMF) helps to meet the high nutritional requirements of the human milk-fed premature infant. Previously available powdered products have not met the protein requirements of the preterm infant population and many neonatologists add powder protein modulars to help meet protein needs. The use of powdered products is discouraged in neonatal intensive care units (NICU) due to concern for invasive infection. The use of a commercially available acidified liquid product with higher protein content was implemented to address these two concerns. During the course of this implementation, poor growth and clinically significant acidosis of infants on Acidified Liquid HMF (ALHMF) was observed. The purpose of this study was to quantify those observations by comparing infant outcomes between groups receiving the ALHMF vs. infants receiving powdered HMF (PHMF). A retrospective chart review compared outcomes of human milk-fed premature infants <2000 g receiving the ALHMF (n = 23) and the PHMF (n = 46). Infant growth, enteral feeding tolerance and provision, and incidence of necrotizing enterocolitis (NEC), metabolic acidosis, and diaper dermatitis were compared between the two groups. No infants were excluded from this study based on acuity. Use of ALHMF resulted in a higher incidence of metabolic acidosis (p = 0.002). Growth while on HMF as measured in both g/kg/day (10.59 vs. 15.37, p < 0.0001) and in g/day (23.66 vs. 31.27, p = 0.0001) was slower in the ALHMF group, on increased mean cal/kg/day (128.7 vs. 117.3, p = 0.13) with nearly twice as many infants on the ALHMF requiring increased fortification of enteral feedings beyond 24 cal/ounce to promote adequate growth (48% vs. 26%, p = 0.10). Although we were not powered to study NEC as a primary outcome, NEC was significantly increased in the ALHMF group. (13% vs. 0%, p = 0.03). Use of a LHMF in an unrestricted NICU population resulted in an increase in clinical complications within a high-acuity NICU, including metabolic acidosis and poor growth. Although further research is needed to assess outcomes among infants with a variety of clinical acuities, gestational ages, and weights to confirm these findings, based on this experience, caution is urged to avoid potential risks.

Association of metabolic acidosis with bovine milk-based human milk fortifiers

“…The results of this study support the work recently published by Thoene et al, 23 who showed a significantly higher incidence of metabolic acidosis in infants receiving acidified liquid HMF as compared with powdered HMF. They also found that infants had better daily weight gain on powdered HMF despite higher enteral calories and protein in the liquid HMF group.…”

Human Milk Banking: a bridge between the preterm mother and infant; the experience from a Greek Public Perinatal Center

“…Though, many contradictory statements are found in the literature concerning the nutritional value of the human milk and the impact of prematurity and other maternal associated factors on its macronutrients and energy levels [20][21][22][23][24][25] . However, in most studies, found in the literature, concerning the nutritional value of donor milk, it is stated that banked milk, after pasteurization process, does not contain sufficient protein, fat and energy levels to sustain adequately a LBW infant, as the pasteurization process decreases mostly fat and protein analogies [26][27] . Significant variation in human milk's macronutrients (protein, fat, carbohydrates) and energy, either being raw or pasteurized, is a barrier that needs to be exceeded, to fulfill the preterm infants' nutritional needs.…”

“…Raw mother's milk macronutrients and energy are analyzed periodically (two to three times a week). For donor banked milk, macronutrients' and energy's analysis is conducted as soon as the milk is pasteurized [14,16,27] . Our experience is that this feeding and fortification policy, when infants are fed with an exclusive targeted fortified human milk diet, results in improved neonatal outcomes at hospital discharge.…”

“…To analyze macronutrients and energy proportions, commercial infrared human milk analyzers have been proposed as efficient and practical tools. Human milk analyzers are easy to handle and provide in a single run, using only a small amount of milk (2-5 mls), the necessary information on milk's macronutrients and energy [27][28][29][30] . Given that kind of information, neonatologists are able to easily prescribe the quantity and quality of either the bovine or human-milk based fortifiers that are necessary for each infant's nutritional needs.…”

Necrotizing Enterocolitis: A Narrative Review of Updated Therapeutic and Preventive Interventions

“…There is no primary literature that proves any particular mode of fortification has a direct effect for promoting NEC. Some small studies suggest that acidified liquid human milk fortifier (HMF) versus powdered HMF may lead to increased cases of NEC (27). More research needs to be done to provide more defined guidelines for enteral feeding practices and preventing the development of NEC.…”