Linda

You've written a very compelling mini-review.  Great info!  Many 
thanks indeed.  I've written again and again to describe how all 
preterm babies - from 600g - 1800g in the neonatal nurseries in 
Zimbabwean hospitals received no HMF at all - it was unknown - but 
only Vit D and extra calcium on a case by case basis, and extra iron 
much later.  Ordinary formula was used for those babies whose mothers 
were not making quite enough colostrum, but the amounts were tiny and 
completely phased out by Day 2-3 when EBM was the only food/fluid 
given.  Once stable, the babies would receive exclusively their 
mothers' own EBM in gradually increasing quantities - up to 280 - 
300ml/kg/day, and they would gain and grow well - the highest gain 
I've worked was a 34-weeker  who started gaining 76g/day on exclusive 
breastmilk-feeding.  There was no manipulation of the milk, siphoning 
off the cream etc - it was fed as it was produced, foremilk and 
hindmilk simply shaken up and fed via NGT, spoon, or cup - bottles 
and pacifiers were prohibited.  Well babies were discharged home at 
1800g exclusively breastfeeding if they gained 20-30g/day showing 
that they were thriving. Several people on LACTNET have warned about 
long-term health, bone mineralization etc, but I never heard any of 
these concerns from the paediatricians.  Now your review queries the 
risks vs benefits to HMF based on cow's milk, particularly in the 
long term.  I think this is really important.  Could you let us have 
the full refs, please, for the studies you cite?

Gross 1987
Lucas 1996
Bishop 1996
Kuschel in 2001 Cochrane review
Mead Johnson 2004
Kuschel 2004
Funkquist 2006
Premji 2006


Pamela Morrison IBCLC
Rustington, England

At 05:00 26/04/2009, you wrote:
>Date:    Sat, 25 Apr 2009 17:49:04 -0400
>From:    Linda Palmer <[log in to unmask]>
>Subject: Re: New formula being promoted in our NICU - help!
>
>More studies are needed on exclusive breastmilk vs any non-human fortifie=
>r in=20
>the NICU. Funkquist 2006 (small study) shows more morbidity and longer=20=
>
>hospital stays for LBW with fortifier vs exclusive BM, and less successfu=
>l full=20
>breastfeeding after release for fortified infants. Lucas 1996 shows more=20=
>
>infections with fortifier use, while a 2004 Mead Johnson study reports "n=
>o=20
>more" NEC or sepsis with fortifier than typically seen with breastmilk fe=
>d.
>
>What kind of fortification do we want? Protein? Premji 2006 in a meta-ana=
>lysis=20
>of 5 studies concludes about higher protein (comparing formulas in=20
>LBW): "Accelerated weight and nitrogen accretion were noted with higher=20=
>
>protein intakes in 'healthy' formula-fed low-birthweight infants. This be=
>nefit=20
>could not be weighed against the adverse consequences of elevated blood=20=
>
>urea nitrogen levels and increased metabolic acidosis and neurodevelopmen=
>tal=20
>abnormalities."
>
>Calcium/Phos? Bishop 1996 shows that 5 years later, preterms fed=20
>predominantly human milk, (mother's and donor), had greater bone density=20=
>
>than those who received formula supplements to mother's milk. Kuschel in=20=
>
>2001 Cochrane review of available studies finds no support for the=20
>supplementation of Ca+/Phos. Gross 1987 reported: "The lack of any=20
>significant effect of early maternal milk supplementation on bone mineral=
>ization=20
>by 44 weeks postconceptional age suggests that these methods of=20
>supplementation of maternal milk may not be warranted for healthy preterm=
>=20
>infants."
>
>Multi-component fortification? Kuschel 2004 makes this very unfortunate=20=
>
>conclusion: "Multicomponent fortification of human milk is associated wit=
>h=20
>short-term improvements in weight gain, linear and head growth. Despite t=
>he=20
>absence of evidence of long-term benefit and insufficient evidence to be=20=
>
>reassured that there are no deleterious effects, it is unlikely that furt=
>her=20
>studies evaluating fortification of human milk versus no supplementation =
>will be=20
>performed."
>
>Vitamin fortifications seem to be OK. Iron is a "no" in studies. Studies =
>also=20
>show no benefit from glutamine, iodine, or lactase supplementation. Basic=
>ally,=20
>while we know that those preterms receiving exclusive breastmilk end up w=
>ith=20
>less morbidity, slightly higher IQ's/better neurological development, eve=
>ntually=20
>greater bone density, and more successful breastfeeding, the fact that=20=
>
>fortifiers do increase weight gain (what all the formula sales people foc=
>us on)=20
>seems, to me personally, a little irrelevant.
>
>linda palmer, dc

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