As a RN who has had over 20 years experience in both NICU and SCN I have
been reading this current thread with interest and I have to agree
wholeheartedly with the postings of Nancy Wight
>I agree that "we know not what we do" when using fortifiers, but I >have
>seen too many premies in tha past with rickets and FTT to go >with with
>human milk alone for the VLBW infant.
>Nancy
The ideal feeding of premature babies is a complex issue and unquestionably
the feeding of breast milk endows enormous benefits on the baby not the
least being substantially reduced risk of Necrotising enterocolitis and
sepsis as well as well as significantly improved IQ (if BF continued for the
first 6 months).  However feeding breast milk alone without some form of
supplemantion (eg milk fortifier) leads to substantial risk of rickets
because of poor bone mineralisation, reduced weight gain and reduced length
and head circumference.  In the  past, particularly, the most premature
babies had significantly stunted growth.  Before the advent of fortifiers,
in the units I worked in, it was quite common for premature babies to be fed
12 hours worth of EBM and 12 hours worth of formula just to try to get
growth rates closer to intrauterine growth rates and as well dose them up
with added Medium Chain Triglyceride oil and Polycose for extra caleries and
the issues of poor bone mineralisation were not properly addressed and long
term follow up showed stunted growth.  The special pre-term formulas were
also not developed. 20 years ago there was not the body of research on
feeding premature babies that there is today and it was a relatively inexact
science.

The research that has followed looked at the  question of balancing the
enormous benefits of breast milk with the added growth and nutrient needs of
premature babies.  In more recent years with the advent of human milk
fortifiers this task has become significantly easier.  I have no doubt in
coming years these fortifiers will continue to be refined.  At the moment
the focus of a lot of research is when it is actually best to cease
fortification and whether there is benefit of conining it in some form, even
  up to 9 months of age, rather than having a relatively short intervention
while the baby is still in  hospital.  This question is particularly
pertintent with early discharge practices in some parts of the world babies
who are still premature (sometimes 34 to 36 weeks) and under 1800 grams are
being transferred home.
For those who are interested in further reading on the topic you may find
these references interesting.  They will give deeper insight into a complex
issue
Canadian Pediatric Society, Nutrient needs and feeding of premature infants,
  http://www.cps.ca/english/statements.N.n95-01.htm

Carver et al. Growth of Preterm Infants Fed Nutrient-Enriched or Term
Formula after Hospital Discharge. Pediatrics Vol 107 No. 4 April 2001

Hall, T & Carrol, R. Infant Feeding "Pediatrics in Review" Vol. 21 No 6 June
2000

Hall, T. Nutritional Follow-Up of the Breastfeeding Premature infant after
Hospital Discharge" Pediatric Clinics of North America. Vol 48 No 2. April
2001

Hay et al.  Workshop summary: Nutrition of the Extremely Low Birth Weight
Infant. "Pediatrics" Vol 104 No 6 Dec 1999

Kuschel, C. Multicomponent fortified human milk for promoting growth in
preterm infants.  "Coichrane Database System Rev" 2000

Lucas et at. Randomized Trial of Nutrient-Enriched Formula versus standard
formula for postdischarge Preterm Infants. "Pediatrics" Vol 108. No 3. Sept.
2001

Reis, et al. Enhanced Growth of Preterm Infants Fed a New Powdered Human
Milk Fortifier: A Randomised, cointrolled trial. "Pediatrics" Volume 105 no.
3 September 2000

Schanler et al Feeding Strategies for Premature Infants:  Beneficial
Outcomes of Feeding Fortified Human Milk versus Preterm Formula.
"Pediatrics". Vol 103 Num 6. June 1999

Schnanler.  The Use of Human Milk for Premature Infants.  "Pediatric Clinics
of North America" Volume 48 no 1 Feb 2001

Warner et al Growth and Metabolic Responses in Preterm Infants Fed Fortified
Human Milk or a Preterm Formula. Int J Clin Pract 1998 June Vol 52 No 4

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