A READY RECKONER HUMAN MILK FORTIFIER

To ensure long-term health and development of preterm infants, early nutritional support is of utmost importance. Breast milk is undoubtedly an ideal food for a preterm infant. However, human milk fortifiers protein, calcium, phosphorus, carbohydrate, vitamins, and minerals. All infants with a birth weight below 1800g would benefit from the additional fortification of breast milk as per ESPGHAN recommendations 2009. The said fortification of breast milk aims to increase the optimum level of concentration of nutrients to meet the requirements of all nutrients for preterm infants including those who are at the customary feeding volumes. As no classification of infants who should receive fortified human milk (FHM) has been recommended by any study in India and abroad, there is a general worldwide consensus amongst the Neonatologists to prefer the above-mentioned recommendation of ESPGHAN 2009.

The results of a systematic review of ten randomized controlled trials1 generally support the use of HM fortification as a common practice in neonatal intensive care units. Other trials2, 3 have not come out with any significant differences.

Caution is also required as feeding these enriched diets may lead to disproportionate growth. Rapid Catch-

Up growth has been proposed as a potential contributor to a “metabolic syndrome” that results in long-term adverse cardiovascular outcomes.

Composition of LCI-HMF 1gm (HMF) Sachet

 

Brief Analysis of Contents

Protein: The most common approach is multi-nutrient packaged powdered fortifiers. Protein replacement in VLBW poses the most difficult challenge. Preterm infants accrete protein at a higher rate than term infants and, therefore, the protein requirements of preterm infants are higher. ESPGHAN Committee on Nutrition recommends aiming at 4.0 to 4.5 g kg/day protein intake for infants up to 1000 g, and 3.5 to 4.0 g for infants from 1000 to 1800 g that will meet the needs of most preterm infants. However, human milk alone provides inadequate amounts of protein, energy, and minerals to meet the high needs for preterm infant growth. It has been shown that adequate protein intake has an impact not only on short term growth but also on long term neurological outcomes. A Cochrane analysis showed that protein supplementation of human milk in preterm infants lead to increase in short term weight gain (WMD 3.6 g/kg/day, 95% CI 2.4 to 4.8 g/kg/day), linear growth (WMD0.28cm/week, 95% CI 0.18 to 0.35 cm/week) and head growth (WMD 0.15 cm/week,95% CI 0.06 to 0.23 cm/week).

As HM shows variability in protein content, it often results in unpredictable nutrient intake. Actual intakes of protein by preterm infants fed fortified human milk are substantially lower than assumed intakes. The discrepancy may in part explain why preterm infants who are fed fortified HM also frequently show postnatal growth failure.

Individualized fortification is now emerging as the best solution to the problem of protein undernutrition with the standard fortification of HM. Given the large variability in the nutrient composition of breast milk, it is difficult to know how much fortifier to provide. Some have proposed analyzing individual aliquots of breast milk it is difficult to know how much fortifier to provide. Some have proposed analyzing individual aliquots of breast milk but this technique is not routinely available. Adjusting fortification uses periodic determinations of serum urea as a guide to protein intake, and adjusting the intake of fortifier and supplemental protein accordingly. This technique resulted in better weight gain and head growth compared to a control group receiving standard fortification.

Also, protein and energy needs should be considered concurrently. Protein to energy ratio (P: E ratio) should be in the optimal range. It has been recommended that 2.8g/100 kcal to 3.4 g/100 kcal should be the minimum and maximum and maximum P: E ratio. The energy content of HMF could influence the gastric emptying, with implications for the management of premature infants at greater risk of feed intolerance.

Carbohydrate: The expert panel for LSRO has based its carbohydrate intake recommendations in relation to the needs of other macronutrients and has recommended a minimum of 9.6 g/100 kcal and a maximum of 12.5g/100 kcal. So the fortifier should aim to provide this amount of carbohydrate.

Iron: The quantity of iron in human milk fortifiers differs and directly affects the activity of lactoferrin. Lactoferrin is a glycoprotein that binds iron so bacteria cannot use it for metabolism. If lactoferrin binds to iron, it is rendered inactive; thus, lactoferrin needs to be in a state that is not found to be active. A few studies have shown that the addition of iron decreases the antimicrobial property of the human milk and therefore, iron supplementation should be given separately from HM feedings.

However, it has also been demonstrated that using the iron-fortified product may reduce the need for blood transfusions in VLBW infants. This study also demonstrated low rates of suspected and confirmed NEC and sepsis and refuted the premise that the inclusion of iron in fortifiers will increase the incidence of sepsis and NEC. So further research is needed regarding the optimum content of iron in HMF.

Mineral: Human Milk fortifiers contain different quantity and quality of minerals and their effect on bone mineral content is still unclear. Calcium absorption is dependent on the quantity and the source of calcium salt and the quality and quantity of fat content of the diet. In using human milk fortifiers, it has been suggested that soluble calcium salts bind the fatty acids in the fortified human milk, thus impairing fat absorption, lowering energy intake, and decreasing the rate of growth. Schanler and Abrams reported that preterm infants receiving that powdered HMF containing highly soluble calcium and phosphorus demonstrated poorer at absorption, compared with similar infants fed powdered HMF containing insoluble calcium and phosphorus. So insoluble calcium salts like calcium phosphate tribasic and calcium carbonate should be used to optimize fat absorption. As per WHO guidelines, there is low-quality evidence that routine calcium and phosphate supplementation reduces the risk of metabolic bone disease in preterm VLBW infants. Also, there is no evidence of a reduction in the risk of rickets of prematurity. So, fortification with minerals, trace minerals, and vitamins presents few problems. Although the exact requirement for many of these nutrients is unknown, aiming at a meeting or, more often, exceeding the presumed requirements has proved successful. This is so because neither a modest degree of shortfalls nor of excesses of these nutrients appear to pose any problems. None of these nutrients are limiting growth.

Osmolality: Osmolality is a critical determinant of feed tolerance. Cochrane meta-analysis has shown an increased tendency to feed intolerance with fortified milk. Various studies have demonstrated that the Osmolality of breast milk increases significantly on fortification with HMF and LBW formula. The rise of Osmolality observed in human milk supplemented with HMF can be explained by the fact that polysaccharides, present in the HMF, are broken down into their constituent mono and oligosaccharides and the difference observed between the various HMF could be related to the different carbohydrate content and the use of dextrin of different origin and equivalent glucose content. So we expect an ideal fortifier to alter the Osmolality of human milk to a minimum. The lower Osmolality may improve feeding tolerance, thereby providing indirect benefits to growth. Some fat may be used in place of carbohydrates to reduce the Osmolality of the fortifier.

The commonly used fortifiers are powdered products that are different from liquid fortifiers in that they do not further dilute maternal milk when added. Recently liquid ultra-concentrated fortifier has been used. This new LHMF with higher protein has been shown to enhance both lengths as well as weight growth in preterm infants with birth weight less than 1250 g, with minimal metabolic and host defense impact compared with currently available powdered fortifier.

Comparison of content with other Brands.

#Nutrients per 4 sachets (to be mixed with 100ml of Mother’s milk)

 

LCI-HMF is an ideal HMF and most advanced formulation that meets the urgent nutrients requirement of Preterm, LBW and ELBW infants.

LCI-HMF 1gm per Sachet is the most Pioneers in India.

Dosage: One LCI-HMF 1gm sachet well mixed with breast milk 25ml for single feed to infants. The same method may be repeated for each next feed in a day at required intervals as directed by Neonatologists/Health Expert. The optimum frequency of feed within 24 hours 4 to 8 times or more as advised by a neonatologist.

Direction for use

Mix well the entire content of one sachet with 25 ml of mother’s milk. Now LCI-HMF is ready for a feed.

Repeat for each next feed in a day at required intervals as directed by Neonatologists/ Health Expert