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 *********************************************** To temporarily stop your subscription: set lactnet nomail To start it again: set lactnet mail (or digest) To unsubscribe: unsubscribe lactnet All commands go to [log in to unmask] The LACTNET mailing list is powered by L-Soft's renowned LISTSERV(R) list management software together with L-Soft's LSMTP(TM) mailer for lightning fast mail delivery. For more information, go to: http://www.lsoft.com/LISTSERV-powered.html