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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.

  • 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

    • 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. 

    • 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.

    • Potential Costs Associated with Application

      There is variability in the cost of available human milk fortifiers. 

    • 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.

    • 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. 

    • Minority Opinions

      Consensus reached.