Recommendations Summary
VLBW: Human Milk Fortification (2020)
Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.
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Recommendation(s)
VLBW: Human Milk Fortification
Healthcare practitioners should fortify human milk fed to very low birth weight preterm infants because fortification increases weight gain and head circumference growth compared to human milk alone.
Rating: Weak
Imperative-
Risks/Harms of Implementing This Recommendation
Very low birth weight (VLBW) preterm infants receiving human milk fortification in comparison to human milk alone experienced improved growth in hospital (weight gain and head circumference) and post discharge (weight, length, and head circumference). No potential risks or harms (including necrotizing enterocolitis) were identified with human milk fortification.
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Conditions of Application
Health care practitioners should use professional expertise and individual assessment to select an appropriate human milk fortifier (Ganapathy et al 2012, Guest et al 2017, Knake et al 2019, WHO 2011)
Implementation Considerations
- Consider offering human milk fortification to VLBW; preterm infants to improve growth.
- Evaluate commercially available human milk fortifiers and consider stocking one or more to add to expressed human milk.
- Provide a suitable area and staff education for safe handling and preparation of enteral feedings (Pediatric Nutrition, Steele, Collins et al 2018)
- Encourage the development of a feeding protocol that is accepted and used by key stakeholders in the NICU and that specifies when human milk fortification is started, how it is advanced and when it is stopped.
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Potential Costs Associated with Application
There is variability in the cost of available human milk fortifiers.
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Recommendation Narrative
Human milk is the preferred food for nearly all infants, however, fortification is often necessary for VLBW infants (Guest et al 2015, Ramaswamy 2019, Johnston et al 2012). Improved medical care and technology have resulted in improved survival for VLBW preterm infants and an urgency to improve nutrition care for this population. Healthcare practitioners need unbiased guidance on the use of fortifiers, and type of fortifiers for human milk-fed VLBW preterm infants.
Two separate analyses were conducted to evaluate effect of human milk fortification on identified health outcomes. Only studies that evaluated fortifiers with both macronutrients and micronutrients were included in this review.
The first analysis compared infants receiving human milk and fortification vs. human milk alone. No studies were identified that met these criteria and evaluated fortification vs. none and impact on mortality, morbidities, development, gastrointestinal health, bone mineral content, or protein utilization. With regard to growth, evidence with low certainty found that VLBW preterm infants receiving fortification had improved growth in hospital (weight gain and head circumference) and post discharge (weight, length, and head circumference).
The second analysis compared different types of fortifiers (liquid vs. powdered, and varying nutrient content) among VLBW preterm infants. Low-certainty evidence indicated no significant difference between type of fortifier on mortality, necrotizing enterocolitis, sepsis, weight gain or gastrointestinal health. Moderate-certainty evidence indicated that a fortifier with added protein, iron and essential fatty acids decreased the odds of blood transfusions, compared to a standard powdered fortifier. However there was no effect on hematocrit or ferritin levels. Moderate-certainty evidence also indicated that fortifiers with increased protein and micronutrient levels may result in higher blood urea nitrogen (BUN) levels compared to BUN levels when a standard fortifier was fed. Effect of type of fortifier was unable to be analyzed on length and head circumference growth due to heterogeneity and on bone mineral content due to lack of reported data. In summary there was insufficient evidence to recommend one fortifier over another.
Results of the human milk fortification analyses have limitations due to heterogeneity amongst studies, lack of reported data, and lack of information regarding the nutrition composition of the human milk received by study population.
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Recommendation Strength Rationale
Fortification versus None
- Limited/weak certainty evidence for weight gain, lenght, gain, and head circumference.
Type of Fortifier
- Limited/weak certainty evidence for mortality.
- Moderate certainty evidence for anemia.
- Limited/weak certainty evidence for mortality, necrotizing enterocolities and sepsis, weight gain, lenght gain, head circumference, gastrointestinal health, bone mineral content, protein utilization, and adverse events.
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Minority Opinions
Consensus reached.
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Risks/Harms of Implementing This Recommendation
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Supporting Evidence
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of human milk fortification vs. none via enteral nutrition on morbidities and mortality?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of human milk fortification vs. none via enteral nutrition on weight gain?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of human milk fortification vs. none via enteral nutrition on weight gain post discharge?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of human milk fortification vs. none via enteral nutrition on length gain?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of human milk fortification vs. none via enteral nutrition on length gain post discharge?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of human milk fortification vs. none via enteral nutrition on head circumference?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of human milk fortification vs. none via enteral nutrition on head circumference post discharge?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of human milk fortification vs. none via enteral nutrition on development, gastrointestinal health, bone mineral content, protein utilization or adverse events?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of human milk fortifier type via enteral nutrition on mortality?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of type of human milk fortifier via enteral nutrition on blood transfusions and anemia indices?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of type of human milk fortifier via enteral nutrition on necrotizing enterocolitis or sepsis?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of type of human milk fortifier via enteral nutrition on weight gain?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of type of human milk fortifier via enteral nutrition on length gain?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of type of human milk fortifier via enteral nutrition head circumference gain?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of type of human milk fortifier via enteral nutrition on development?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of type of human milk fortifier via enteral nutrition on gastrointestinal health?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of type of human milk fortifier via enteral nutrition on bone mineral content?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of type of human milk fortifier via enteral nutrition on protein utilization?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of type of human milk fortifier via enteral nutrition on adverse events?-
References
Carey D, Rowe J, Goetz C, Horak E, Clark R, Goldberg B. Growth and phosphorus metabolism in premature infants fed human milk, fortified human milk, or special premature formula. Use of serum procollagen as a marker of growth. American Journal of Diseases of Children 1987; 141:511-5
Modanlou H, Lim M, Hansen J, Sickles V. Growth, biochemical status, and mineral metabolism in very-low-birth-weight infants receiving fortified preterm human milk. Journal of Pediatric Gastroenterology and Nutrition 1986; 5:762-7
Nicholl R, Gamsu H. Changes in growth and metabolism in very low birthweight infants fed with fortified breast milk. Acta Paediatrica 1999; 88:1056-61
O'Cnnor D, Khan S, Weishuhn K, Vaughan J, Jefferies A, Campbell D, Asztalos E, Feldman M, Rovet J, Westall C, Whyte H. Growth and nutrient intakes of human milk-fed preterm infants provided with extra energy and nutrients after hospital discharge. Pediatrics 2008; 121:766-76
Aimone A, Rovet J, Ward W, Jefferies A, Campbell D, Asztalos E, Feldman M, Vaughan J, Westall C, Whyte H, O'Connor D. Growth and body composition of human milk-fed premature infants provided with extra energy and nutrients early after hospital discharge: 1-year follow-up. Journal of Pediatric Gastroenterology and Nutrition 2009; 49:456-66
Willeitner A, Anderson M, Lewis J. Highly Concentrated Preterm Formula as an Alternative to Powdered Human Milk Fortifier: A Randomized Controlled Trial. Journal of Pediatric Gastroenterology and Nutrition 2017; 65:574-578
Berseth C, Van Aerde J, Gross S, Stolz S, Harris C, Hansen J. Growth, efficacy, and safety of feeding an iron-fortified human milk fortifier. Pediatrics 2004; 114:e699-706
Kim J, Chan G, Schanler R, Groh-Wargo S, Bloom B, Dimmit R, Williams L, Baggs G, Barrett-Reis B. Growth and tolerance of preterm infants fed a new extensively hydrolyzed liquid human milk fortifier. Journal of Pediatric Gastroenterology and Nutrition 2015; 61:665-71
Maas C, Mathes M, Bleeker C, Vek J, Bernhard W, Wiechers C, Peter A, Poets C, Franz A. Effect of Increased Enteral Protein Intake on Growth in Human Milk-Fed Preterm Infants: A Randomized Clinical Trial. JAMA Pedatrics 2017; 171:16-22
Moya F, Sisk P, Walsh K, Berseth C. A new liquid human milk fortifier and linear growth in preterm infants. Pediatrics 2012; 130:e928-35
Porcelli P, Schanler R, Greer F, Chan G, Gross S, Mehta N, Spear M, Kerner J, Euler A. Growth in human milk-fed very low birth weight infants receiving a new human milk fortifier. Annals of Nutrition and Metabolism 2000; 44:2-10
Moyer-Mileur L, Chan G, Gill G. Evaluation of liquid or powdered fortification of human milk on growth and bone mineralization status of preterm infants.Evaluation of liquid or powdered fortification of human milk on growth and bone mineralization status of preterm infants. Journal of Pediatric Gastroenterology and Nutrition 1992; 15:370-4 -
References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
- Ganapathy V, Hay JW, Kim JH. Costs of necrotizing enterocolitis and cost-effectiveness of exclusively human milk-based products in feeding extremely premature infants. Breastfeed Med. 2012;7(1):29-37.
- Guest JF, Moya F, Sisk PM, et al. Relative cost-effectiveness of using a liquid human milk fortifier in preterm infants in the US. Clinicoecon Outcomes Res. 2017;9:49-57.
- Johnston M, Landers S, Noble L, Szucs K, Viehmann L. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-841.
- Knake LA, King BC, Gollins LA, et al. Optimizing the use of human milk cream supplement in very preterm infants: growth and cost outcomes. Nutr Clin Pract. 2019.
- Pediatric Nutrition Practice Group, Steele C, Collins E. Infant and Pediatric Feedings: Guidelines for Preparation of Human Milk and Formula in Health Care Facilities. Chicago 2018.
- Ramaswamy VV. A randomized controlled trial comparing the effect of fortification of human milk with an infant formula powder versus unfortified human milk on the growth of preterm very low birth weight infants. J Matern Fetal Neonatal Med. 2019:1.
- World Health Organization. Guidelines on optimal feeding of low birth-weight infants in low and middle income countries. World Health Organization. http://www.who.int/maternal_child_adolescent/documents/infant_feeding_low_bw/en/. Published 2011. Accessed 2019.
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References