Human Milk Fortification for Preterm Infants

Abstract

Oft-villainized infant formula has been invited back into the neonatal intensive care unit (NICU) by Chinnappan et al, 1 who demonstrate the role of preterm formula (PTF) to supplement, rather than supplant, human milk (HM).HM is the best nutrition for infants of all gestational ages. 2-4 However, HM does not provide adequate nutrients for low-birthweight (LBW) and very low-birth-weight (VLBW) infants when delivered at the usual feeding volumes. The developing infant's organs are susceptible to the insult of undernutrition. Suboptimal growth, retinopathy of prematurity, bronchopulmonary dysplasia, and neurocognitive impairments are frequently reported in preterm infants receiving exclusive HM. 2,3,5,6 The challenges can be magnified in low-and middleincome countries (LMICs), where malnutrition is more prevalent.There are multiple approaches to improve a preterm infant's nutrient intake in LMICs. The World Health Organization has proposed a stepwise progression to optimize feeding for LBW and VLBW infants in LMICs with a strong recommendation to use mother's own milk (MOM) or donor HM (DHM) if MOM is insufficient and safe, affordable milk-banking facilities are available. 7 Commercially available milk formula diets are discouraged when MOM is available due to the immunonutritional value of MOM and the increased risk of necrotizing enterocolitis (NEC) associated with formula. The lack of equipoise is such that no randomized clinical trials have compared MOM with exclusive formula use. 8 Milk formula does demonstrate improved linear growth compared with DHM but at a cost of increased rates of NEC. 9 When formula is used, if standard infant formula does not provide for adequate weight gain, PTF has the added advantage of being energy enriched to meet the additional needs of LBW infants.Several HM fortifiers (HMFs) have been developed to meet the relatively high nutrient requirements of VLBW infants and reduce the need for milk formulas. However, fortification cannot be pursued without limits, as its use must be carefully balanced against the potential risk of feed intolerance and NEC with its potentially catastrophic sequelae. In LMICs, HMF is recommended only for LBW and VLBW infants who fail to gain weight despite adequate MOM or DHM to augment their nutrient intake. HMFs, while effective at augmenting the nutritional content of breast milk, are relatively expensive in LMICs.The focus on optimizing nutrition for preterm infants is timely, as global rates of prematurity are increasing. 10 The economic burden associated with prematurity is also projected to increase with improved survival of younger infants. Costeffective nutritional interventions therefore have the poten- (Pilkington, Brindle)