Laurie:
You and Marsha basically said the same thing - we neos don't value 
breastmilk.  I apologize for personalizing the discussion.  You have a good point - 
there are many peds and neos who are not practicing state of the art NICU 
nutrition.  The recommendations are out there: The VON iNICQ toolkit and webcast this 
year, basically reviewed the same literature we did for the CPQCC Toolkits 
2004-5, and came to the same conclusions:
Breastmilk if the first choice, including donor milk when mom's milk is not 
available.
Start TPN within hours of birth for VLBW infants.
Start IL within hours to 1-3 days.
Start feeds within 1-3 days (the earlier the better).
Feed through residuals.
Push feeding volumes up (like they do in Europe) until you get intolerance.
Fortify as needed (esp protein).
 
We need much more research before we "know" the best way to feed premies in 
the hospital or after discharge.  We use the best evidence we have at the time. 
 Assuming that all will be well if we just use enough breastmilk alone is 
just as much an assumption as all fortifiers are needed.  Human milk is 
necessary, but it is not always sufficient for optimal growth and development of our 
smallest, sickest infants.
 
Nancy
Nancy Wight MD, IBCLC, FABM, FAAP



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