LCI HMF – FAQs
1. What is the optimum condition requiring HMF to an infant? Are there any national and international guidelines on the use of (HMF)?
The preterm infants <32 weeks gestation or <1500g birth weight, who fail to gain weight despite full volumes of breast milk feeding, are the best suited for use of additional fortification of breast milk. However, in absence of sufficient data to categories a particular infant who should receive fortifier human milk, there is a general consensus that all infants with a birth weight below 1800g would benefit from additional fortification as per ESPGHAN 2009. The existing WHO and NNF guidelines somehow also support the abovementioned condition for use of additional multi-component fortification of breast milk.
2. What are the short and long term benefits of HMF?
A systematic review of ten randomized controlled trials (more than 600 infants with birth weight less than 1850 g multi-component fortification of HM compared with the feeding of unfortified HM was associated with small but statistically significant short-term improvements in weight gain (+2.33 g/kg/d; 95%CI 1.73, 2.93), linear growth (+0.12 cm/week; 95%CI 0.07, 0.18), and head growth (+0.12 cm/week; 95%CI 0.07, 0.16)(1). Only two trials have evaluated long-term growth effects of HM fortification and did not demonstrate any difference in weight, length, or head circumference at 12 and 18 months of corrected age(2, 3). Only one trial looked at a developmental performance at 18 months: at this age test scores were higher in the fortifier in the fortified group by 2.2 points for the Bailey Mental Development Index, by 2.4 points for the Psychomotor Development Index, and by 3.1 points for social maturity, but these differences were not significant.
3. What are the pros and cons of adding Iron to HMF?
In Indian context with a high prevalence of Iron deficiency in Indian mothers and more SAG status in preterm and LBW neonates, the addition of 1mg Iron/100ml of human milk would meet up with ESPGHAN guidelines and would go a long way in reducing Iron deficiency anemia in Indian infants.
4. Discuss importance of protein content of HMF?
Adequate protein intake has an impact not only on short term growth but also on long term neurological outcomes. Cochrane analysis showed that protein supplementation of human milk in preterm infants leads to increase in short term weight gain (WMD 3.6g/kg/day, 95CI 2.4 to 4.8g/kg/day), linear growth (WMD 0.28cm/week, 95% CI 0.38cm/week) and head growth (WMD 0.15 cm/week, 95% CI 0.06 to 0.23cm/week)
5. What are the various types of fortification used?
The three different forms of fortification are standard, tailored, and adjustable.{4,5}
· Standardized:- Adding a constant amount of fortifier without taking into account the initial milk composition from each individual mother.
· (2) Tailored (“a Ia carte”):– Based on milk analysis. The amount of fortifier is adjusted according to weekly determinations of milk protein content to achieve target protein intakes at all times.
· Adjustable:- Based on the metabolic response of the infant. The amount of fortifier is adjusted after determining blood urea nitrogen as an index for the adequacy of protein intake.
6. What are adverse effects of HMF feared of?
Osmolality is a critical determinant of feed tolerance. Rise of Osmolality observed can be explained by the fact that polysaccharides present in HMF, are broken into constituent mono and oligosaccharides. So we expect an ideal fortifier to alter Osmolality to a minimum. The Cochrane review, on the basis of the small number of infants for whom this outcome was reported, showed a non-significant trend toward an increased risk of feed intolerance in treated infants (RR2.85, 95% CI 0.62 to 13.1)(1). Among the reasons used to advocate HM feeding for VLBW infants is the belief that it is advantageous in reducing infections when compared to preterm formula. HM is a highly complex secretion with live cells and a wide variety of biologically active factors; it has anti-infective properties due to the high content of lgA, lysozyme, lactoferrin, and interleukins. A possible concern with HMF is that the added nutrients may affect these unique qualities. Adding HMF was reported to be associated with some lysozyme and lgA reduction but this observation was not replicated in later studies. Total bacterial colony counts in milk stored at refrigerator temperature are significantly greater in fortified than in unfortified milk; however, the magnitude of this difference may not be of biological importance. From a clinical point of view, a systematic review comparing infants fed unfortified and fortified HM did not show any significantly increased risk of NEC in infants receiving FHM (RR 1.33, 95%CI 0.7 to 2.5)
7. When Should HMF be stopped?
There are no standard evidence-based guidelines for the same. If the baby is on direct breastfeeds at the time of discharge, HMF fortification is usually discontinued as it interferes with direct breastfeeds. If the baby is on expressed breast milk, then HMF should be continued till the baby achieves its birth percentile on growth charts. Conventionally in such cases, HMF is continued till 40 weeks.
8. What is the energy Value of HMF?
Human milk has an average of 67 Cal /100ml and the addition of LCI-HMF/100ml human milk provides an additional 14 calories, thus, making it a total of 81 Cals/100ml. the Calories in LCI-HMF come from FAT and PROTEIN and not from carbohydrates. It adds value to the product and at the same cuts down the Osmolar Load.