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Breast Milk Fortifier

by Richard J. Schanler, MD

In 1998, the American Academy of Pediatrics noted that human milk is very beneficial in managing very low birth weight (VLBW) infants. The beneficial effects are generally related to improvement in the child’s host defenses, digestion and absorption of nutrients, gastrointestinal function, and neurodevelopmental outcomes, and the mother’s psychological well-being. Human milk contains specific bioactive factors such as sIgA, lactoferrin, lysozyme, oligosaccharides, nucleotides, cytokines, growth factors, enzymes (eg, acetylhydrolase), antioxidants, and cellular components.

However, the VLBW infant’s special needs that result from metabolic and gastrointestinal immaturity, immunologic compromise, and associated medical conditions must be considered so adequate nutrition can be provided to meet the needs for intrauterine growth rates and nutrient accretion. Exclusive feeding of unfortified human milk to VLBW infants has been associated with poor growth rates and nutritional deficits, during and beyond hospitalization. Unfortified human milk may not supply sufficient quantities of nutrients to meet the needs of the VLBW infant, in part because of the large variation in the energy and protein content of human milk. These nutrient deficits can be corrected with nutrient supplements.

Human milk should be fortified with multinutrient preparations designed to achieve optimal growth and nutrient retention. Only additional iron should be supplied since commercial fortifiers are otherwise complete nutrient mixtures. Growth and biochemical assessments, including any potential adverse effect on morbidity, should be conducted on any new product entering the market. When the infant demonstrates feeding tolerance to unfortified human milk, human milk fortifiers should be started and continued until the infant is about 2 kg body weight and 35 weeks’ postmenstrual age. When compared with preterm formula alone, feeding fortified human milk may provide significant protection from infection and necrotizing enterocolitis.