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Recommendations Summary

VLBW: Human Milk (Mother's and Donor) (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 (Mother's and Donor)

    Health care practitioners should provide fortified human milk regardless of source (mother's or donor) to very low birth weight (less than or equal to 1, 500g) infants when available. Growth should be monitored by practitioners and the nutrition care plan should be adjusted as appropriate.

    Rating: Weak

    • Risks/Harms of Implementing This Recommendation

      Results of the systematic review indicate that VLBW preterm infants who received at least 75% human milk had less weight gain compared to infants who received formula exclusively. Results of the review also indicate that infants receiving human milk had less absolute nitrogen retention.

    • Conditions of Application

      This recommendation is limited to scenarios in which mother’s own milk or donor milk is available. 


    • Potential Costs Associated with Application

      Some studies have shown no difference in total cost between donor milk and formula. However, cost comparison likely differs by institution, region, country, cost of donor milk, rate of necrotizing enterocolities (NEC), and the cost of NEC for a specific institution (Treng et al 2018, Fengler et al 2019, Buckle and Taylor 2017).


      Practitioners should use a multidisciplinary approach when implementing donor human milk programs in Neonatal Intensive Care Units.  Implementation teams should consider development of policies and protocols, and a process for tracking human milk. The Food and Drug Administration (FDA) recommend against feeding infants donor milk obtained directly from individuals or the internet. Donor milk should only be obtained from a source that has screened its milk donors and taken other precautions to ensure safety such as the Human Milk Banking Association of North America (FDA, 2018).

    • Recommendation Narrative

      Many studies and international and national organizations promote mother’s own milk, or donor milk when mother’s milk is not available for VLBW preterm infants (WHO 2011, ESPGHAN 2013, Committee on Nutrition 2017). Two systematic reviews were conducted to evaluate available evidence for human milk (mother’s own or donor) intake for VLBW preterm infants in developed nations. 

      The first systematic review evaluated 75% intake or more from human milk, in comparison to exclusive formula and association with identified outcomes. Each of the conducted systematic reviews resulted in Grade III evidence (limited or weak). No evidence was found for mortality, gastrointestinal health, bone mineral content or development. The systematic review on morbidities identified one prospective multicenter cohort study,  which found that infants who received infant formula, compared to infants who received human milk exclusively, had higher risk of bronchopulmonary disease, retinopathy of prematurity (ROP) and necrotizing enterocolitis (NEC). The systematic review on weight found that human milk-fed infants had less weight gain than formula-fed infants. Human milk-fed infants were also found to have less nitrogen retention than formula fed infants. The remaining reviews did not find a significant difference in length, head circumference, or skin-fold measurements.

      The second systematic review evaluated dose-response of higher vs. lower human milk intake and association with identified health outcomes. No evidence was found meeting systematic review criteria except for weight gain. Higher portions of fortified human milk resulted in greater decreases in weight Z-scores from birth to discharge. 

    • Recommendation Strength Rationale

      Low certainty evidence (grade III):  ROP, NEC, and BPD; Anthropometrics; Protein Utilization

    • Minority Opinions

      Consensus reached.