Background
While in the clinic with my sick 5yo daughter (bacterial
pneumonia...UGH), I pulled off the shelf the following publication:
_Nutritional Insights_: Highlights from the 5th National Conference on
Advances in Pediatric Nutrition, Johns Hopkins University School of
Medicine, December 2002
On the cover:
"In this issue:
-Maintaining Breastfeeding
-Infant formula and polyunsaturated fatty acids
-Calcium and bone health
-Nutritional management of intestinal and metabolic diseases"
Fortifying breastmilk for preemies:
The article "Nuts and bolts of NICU nutrition" is by Jeanne Cox, Senior
Pediatric Clinical Dietitian in the Division of Pediatric Gastroenterology
and Nutrition at Johns Hopkins. This is her paragraph on breast milk:
"Along with its many nutritional advantages, breast milk improves digestion
and has immunologic benefits and psychosocial advantages. [the only
positive sentence breastmilk gets] Breast milk provides inadequate levels
of some nutrients the premature infant needs, however, particularly
protein, vitamins, and minerals for the baby who weighs less than 2,000 g
and was born after fewer than 33 weeks' gestation. These babies require
the addition of fortifiers to their breast milk diet. While it is a good
idea to encourage mothers of premature infants to supply breast milk for
their baby, some will be unable to or choose not to do so (see "Lactation
101" on page 6)."
In contrast she describes preterm formula as "tailored to the special needs
of the preterm infant". Her explicit comparison is to term infant formula,
but the implied comparison to human milk is very strong, especially given
the lack of any comment in the previous section on the differences between
preterm and term human milk -- the reader is left thinking human milk is
static.
Richard J. Schanler, MD, wrote an article called "Human milk for premature
infants in and after the NICU." The first two sections of his article are
headed "Benefits of human milk for the premature infant" (2+ columns) and
"Limitations of human milk" (about 1+ columns).
Included under human milk's limitations are the possibility that the mother
may be unable to supply it, or that storage and handling may destroy
nutrients. The availability of formula is unquestioned -- hurricanes,
power outages, interruption of water supply are not envisioned, but
maternal unwillingness/inability to give her milk is considered likely. I
am particularly impressed that the potential for loss of vitamins etc.
through handling of human milk is listed as an intrinsic flaw in the milk.
The other limitations given are variable composition and low nutrient
content. "Levels of certain nutrients, most significantly calcium and
phosporus, are too low in breast milk to supply the needs of the premature
infant."
"Several strategies can be used to compensate for deficiencies in human
milk in the premature infant." These are listed as "Increase milk intake"
(one sentence), "Provide hindmilk" (two sentences, including "If hindmilk
is not available, corn and safflower oils are appropriate substitutes"),
and "Provide human milk fortifiers" (three paragraphs). There is a table
showing the results of a meta-analysis of 13 studies of 596 infants
altogether, showing that compared to babies on pure human milk, those on
human milk with fortifier had higher gains in weight, length, head circ.,
bone mineral content, nitrogen balance, and BUN (??), with "no
statistically significant difference" in the rates of necrotizing
enterocolitis or feeding tolerance. (I would love to see the *actual*
numbers for those last categories....which are *not* given.)
The last paragraph on HMF states "I recommend the use of human milk
fortifiers in all tube-fed infants who weigh less than 1,500 g at
birth. We begin when the baby tolerates about 100 mL/kg of unfortified
milk, maintaining this amount if the baby is still hospitalized until he
weighs about 2 kg."
I should add that the _Core Curriculum for Lactation Consultant Practice_,
ed. Marsha Walker, includes (pgs 265-268) five different published preterm
infant feeding regimes, two from J Hum Lact. Two of them (incl one from J
Hum Lact) specify using human milk fortifier. The others mention
"supplement" but don't specify what it is.
More on HMF, also calcium and Vit D:
Finally, Dr. Steven Abrams in "Calcium issues in infants and toddlers"
asserts that "Human milk fortification should be continued almost until
discharge" for premature babies and adds "The premature infant with a birth
weight of less than 1,250 g, who is fed exclusively with human milk, must
be followed up after discharge with labs every 2 weeks" for blood levels
and growth. Not the formula-fed babies. He goes on to say "infants who
are fed cow's milk-based formulas are likely to accrete and form more
calcium in their bones than infants who are breastfed. ... However, there
are absolutely no data to support any long- or short-term benefit to
exceeding the calcium retention in the human milk-fed infant... I believe
human milk remains the gold standard for infants..." And he means
*infants*: "As for vitamin D, the upswing in rickets in the United States
is almost certainly related to prolonged breastfeeding without vitamin D
supplementation and inadequate sunshine exposure. ... I believe it should
be public policy for all breastfed infants to be supplemented with vitamin D."
What I haven't been mentioning so far:
At the bottom of the front cover is a Nestle Nutrition Institute logo and
in small caps: "Sponsored through an educational grant from the Nestle
nutrition institute of Nestle USA, Inc. Produced by Rogers Healthcare
Communications."
Inside front cover is a full-page GoodStart ad. Inside back cover is a
full-page Nestle Ad showing little girl gratefully kissing beautiful mom
and the words: "Nurture. Nourish. Nestle."
No ads in the body of the pamphlet. There is a tear-out centerfold
questionnaire including the questions "How often do you discuss infant
nutrition/formulas with parents?" and "Do you expect to make any changes in
your clinical practice based on the information presented in this special
publication?" (Which I read as "how much of our stuff are you in a
position to sell?" and "have we convinced you to buy/sell more of our stuff?")
What "they" say about sources of DHA and ARA:
Craig Jensen, MD in an article on "Should long-chain polyunsaturate fatty
acids be in infant formula?" says:
"...an algae-derived product is the only source [of DHA] the Food and Drug
Administration (FDA) currently has no objections to using in infant
formulas. Likewise, for ARA ... a fungus-derived product is the only
source the FDA currently approves for use in infant formulas."
Elise Morse-Gagne, IBCLC
Bath NH
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