Human Milk for the Premature Infant

Abstract

Synopsis Premature infants are a heterogeneous group with widely differing needs for nutrition and immune protection with risk of growth failure, developmental delays, necrotizing enterocolitis, and late-onset sepsis increasing with decreasing gestational age and birth weight. Human milk from women delivering prematurely has more protein and higher levels of many bioactive molecules compared to milk from women delivering at term. Human milk must be fortified for small premature infants to achieve adequate growth. Mother’s own milk improves growth and neurodevelopment and decreases the risk of necrotizing enterocolitis and late-onset sepsis and should therefore be the primary enteral diet of premature infants. Donor milk is a valuable resource for premature infants whose mothers are unable to provide an adequate supply of milk, but presents significant challenges including the need for pasteurization, nutritional and biochemical deficiencies and a limited supply.

Human milk fortification strategies for improved in-hospital growth of preterm infants

“…The benefits which are dependent on both the dose and the duration of breastfeeding, include the reduction in the incidence of necrotising enterocolitis (NEC), late-onset sepsis and retinopathy, better feeding tolerance and improved neurodevelopmental outcomes. 7,8 The benefits can be attributed to nutritional and non-nutritional factors in human milk, such as bioactive, growth and immunological factors. The composition of human milk is dynamic and does not only vary from mother to mother, but also from feed to feed and within a feed.…”

“…Levels of protein, fat and sodium decline over time until they are similar to those seen in mature milk. 7,11,12 Challenges in the use of human milk for the premature infant include the availability of mother's own milk, sustainability of expressing milk when infants are not feeding on the breast, the effect of pasteurisation on the nutritional and immunological content of donor milk, and transmission of viruses, including human immunodeficiency virus. The most important challenge is probably that unfortified human milk does not meet the nutritional requirements of most preterm infants.…”

“…The most important challenge is probably that unfortified human milk does not meet the nutritional requirements of most preterm infants. 7,13 This is particularly problematic in those born before 34 weeks gestational age; infants with a birth weight of less than 1800 g; those who are small for their gestational age (SGA); infants with fluid restrictions; and, those with co-morbidities that increase nutrient requirements. 7,9 To illustrate the above, the protein and energy requirements of a 1 kg infant are compared to the nutritional content of mature human milk at volumes typically prescribed for preterm infants.…”

“…7,13 This is particularly problematic in those born before 34 weeks gestational age; infants with a birth weight of less than 1800 g; those who are small for their gestational age (SGA); infants with fluid restrictions; and, those with co-morbidities that increase nutrient requirements. 7,9 To illustrate the above, the protein and energy requirements of a 1 kg infant are compared to the nutritional content of mature human milk at volumes typically prescribed for preterm infants. As can be seen from Table 1, human milk at the lower fluid intake of 150 ml/kg body weight/ day does not meet protein or energy requirements as recommended by the American Academy of Paediatrics (AAP) and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN).…”

“…5 Human milk is the feed of choice for all infants, 6 yet it should be fortified to meet the nutritional requirements of preterm infants, especially the very small, very immature infant. 7,8 Standard fortification of human milk, that is the addition of fortifier in amounts per volume as specified by the manufacturer, rarely meets the recommended intake of protein, and any shortfall in protein supply is not only growth limiting, but may carry the risk of neurocognitive impairment. [8][9][10] This article proposes to offer an integrative review and critical analysis of fortification strategies of human milk for improved in-hospital growth of preterm infants.…”