I don't think milk fortifiers (or diluters as I call them) are a given
at all.  Indeed, many of the larger premies can do fine without them.
The intrauterine growth rate as the ideal rate of growth for premies
is intellectually satisfying, but there is not one stitch of evidence
to suggest that at 20 years, these children are any better off for
growing at intrauterine growth rates.  As soon as you question the
need for this rate of growth, the whole question of fortifiers becomes
moot.  Calcium can be given as added calcium, if that's necessary; so
can phosphorus.  You can feed well premies much more than the usual
180 cc/kg/day.  In Africa we often fed them 300 cc/kg/day.  And they
did fine, but that was because in those days I was enamoured by
"intrauterine growth rates".

I think the first thing to remember is that babies grow faster and
nurse better in Kangaroo care.  That babies should be sucking earlier
than what is done in most NICU's.  That babies can get continuous flow
feeding (as in intrauterine times), and that story about fat sticking
to the tube doesn't seem to make that much of a difference.  That
babies can be fed hindmilk as in Dr. Schanler's study.  The trouble in
NICU's is that very few people are willing to take the time.

Jack Newman, MD, FRCPC