Jeannette,
I just wanted to add a few comments about preemie breastmilk and commercial
fortifiers. Many preemies do not need commercial fortifiers to maintain their
15g/kg/day average weight gain. If they can do this on 180ml/kg/day of
breastmilk this is wonderful. If, however, they are on fluid restrictions or
their growth needs exceed the nutrient content of their mother's milk, then
breastmilk can be fortified. It's what is used as fortification that raises
the blood pressure of many of us who must deal with the outcomes of some of
this fortification. Sometimes other clinical factors slow the rate of the
baby's growth and need to be assessed, rather than blaming it on breastmilk.

In the Scandinavian countries, human milk or its fractions are given to
preterm infants. Infant formula use is rare in most of the NICUs. They
practice lactoengineering (extracting from human milk the necessary protein,
etc) or using higher fat donor milk. In the US it is common to routinely
fortify breastmilk, whether or not the baby needs all of the stuff that is in
these little packets. The commercial fortifier is made from cow's milk and
adds a shotgun full of ingredients that the baby may or may not need. The
infant formula companies make these fortifiers. There are side effects to
their use beginning with intolerance and ending with higher disease rates
caused by interference with the anti-infective properties of the breastmilk.

Quan et al: The effect of nutritional additives on anti-infective factors in
human milk. Clinical Pediatrics 1994; June:325-328
This study showed a 41%-74% decrease in lysozyme activity when either regular
or premature liquid formulas were added to breastmilk. Fortifiers reduced
lysozyme activity by 19%.

Some nurseries check each baby to see what he or she actually needs in the
breastmilk (often calcium and phosphorus) and add the nutrients as needed.
This individualized fortification helps prevent under- or overnutrition.
Polberger S, Lonnerdal B: Simple and rapid macronutrient analysis for human
milk for individualized fortification: basis for improved nutritional
management of very low birth weight infants? Journal of Pediatric
Gastroenterology and Nutrition 1993; 17:283-290.

Helping babies gain weight can also be accomplished by using pumped hindmilk
which may or may not need fortification. The lipid content of hindmilk can be
2-3 times greater than foremilk. Valentine C et al: Hindmilk improves weight
gain in low birth weight infants fed human milk. Journal of Pediatric
Gastroenterology and Nutrition 1994; 18:474-477.

Sometimes it is healthier for the baby and spends less health care dollars to
give the baby what he really needs rather than have him suffer through
feeding intolerance and extended stays in the hospital for growth problems. I
get numerous calls each month regarding poor outcomes of babies whose
breastmilk diet was augmented by formula. Parents and professionals often
call wondering what the mother ate that is causing the baby gastrointestinal
distress. When I ask them what else baby has been receiving, there is usually
a laundry list of stuff that the baby was fed.

Mothers are often told it is their breastmilk which is causing the problem
and the baby is put on full formula feeds. The last call I had describing
this scenario was a long distance consultation regarding  a baby who
developed NEC (necrotising enterocolitis) and had several feet of bowel
removed with a colostomy now in place. The baby is on Alimentum and the
mother wanted to relactate after 2 months of no pumping because the baby is
not doing real well on Alimentum either. I suggested along with a referral to
a local lactation consultant, that this mother consider the use of banked
human milk for her baby. What does it take to get across to NICU staff that
human milk is still the best for these babies, even if it needs an extra
boost?