Julie, Nancy & Polly

Thank you for the questions and answers on supplementing pre-term infants.
I recently came across a WHO document on feeding pre-terms, at
http://www.who.int/maternal_child_adolescent/documents/infant_feeding_low_bw/en/
 which is apparently used successfully in 100 countries, and which seems to
suggest that there is some caution in developing countries about routine
supplementation of low-gain babies with human milk fortifier. It says,
"VLBW infants who are fed mother’s own milk or donor human milk should not
routinely be given bovine milk-based humanmilk fortifier (recommendation
relevant for resource-limited settings). VLBW infants who fail to gain
weight despite adequate breastmilk feeding should be given human-milk
fortifiers, preferably those that are human milk based."

The key word regarding the quantity of breastmilk fed seems to be
"adequate".  Interestingly, what I've found in recent reading is that the
quantity of breastmilk given to pre-term babies may be really low - as
little as 45ml/kg/day, and not more than 130ml/kg/day and then they are
supplemented with human milk fortifier which needs to be mixed 1:1 with the
small quantity of milk thus bringing the volume up to a reasonable amount.
It almost seems that the quantity of breastmilk used is low _so that_
fortifier can be given. Yet a recent paper by Patel et al, Impact of Human
Milk on Sepsis. J Perinatol 2013 July, 33(7) says, 'For every Human Milk
dose increase of 10 mg/k/day (given to a newborn baby in the NICU) there is
a decrease in sepsis (infection) by 19%."

I wonder, with regard to the concern about low protein intake, why not just
feed these small babies _more_ breastmilk and then - as Polly asks - give
them the calcium and phosphoros, and Vit D, (and later iron) as separate
meds?  In the above WHO document, Recommendations 6, 7 and 8 recommend that
small pre-terms are usually givenVit D, calcium and iron. And these can be
given separately, as separate medications, and don't need to be
administered as being contained in HMF. Recommendation 18 of the WHO
document reads, "In VLBW infants who need to be fed by an alternative oral
feeding method or given intragastric tube feeds, feed volumes can be
increased by up to 30 ml/kg per day with careful monitoring for feed
intolerance".

Recommendation 7 says, VLBW infants who are fed mother’s own milk or donor
human milk should be given daily calcium (120-140 mg/kg per day) and
phosphorus (60-90 mg/kg per day) supplementation during the first months of
life.  Regarding iron, recommendation 8 says, "VLBW infants fed mother’s
own milk or donor human milk should be given 2-4 mg/kg per day iron
supplementation starting at 2 weeks."

A 2006 paper written for WHO by Edmond & Bahl suggests, "a number of
studies reported the beneficial effects of a long period of breastfeeding
on bone mineral status in mineral supplemented pre-term infants. In two
studies, a dose response was apparent; the higher the breastmilk received,
the higher the radial bone mineral content at 8–12 years of age."

So there are questions...

Pamela Morrison IBCLC
Rustington, England

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