Dear all

I'm following the discussions following the report of the death of
the baby twin who received contaminated human milk fortifier shortly
after his pre-term birth and died of complications 5 months later.

 From my experience, NICUs and nursing staff and the specialists who
work in them have protocols that are to be followed in the care and
feeding of pre-term or sick babies.  I'm not questioning the
competence or the dedication of the people who work to perform the
large and small miracles that are achieved every day.  But in this
case I'm questioning the need for powdered HMF, (cow's milk based?)
which was presumably added to the mother's own milk for her very
small baby in the first few days or weeks of life (without her
knowledge or consent, so it seems).

I've written several times to LACTNET describing how in the NICUs
where I used to do consults in in Harare, Zimbabwe (when that country
had a functioning health system ...) the use of HMF was
unknown.  Babies were fed their own mothers' colostrum/EBM from the
earliest time that their mothers could be persuaded to hand-express
it.  If a prem baby needed food in the first 1-2 days before the
mother could provide enough EBM, then they were fed
ordinary  reconstituted powered formula, which I guess was not so
great.  But it was portrayed as less-than-beneficial, and mothers
were encouraged to start expressing to replace it with their own milk
asap for that reason.  Often the very tiny babies would be on a drip
for the first few days, and the mother's milk would be coming in by
the time they could receive milk by nas-gastric tube, so these very
low weight babies (the smallest I worked with was 600g) would never
have any formula at all.

The amounts of EBM would be individually tailored by the
paediatrician according to the baby's condition and how well absorbed
it was (whether undigested milk could be aspirated before the next 2-
or 3-hourly amount was due to be fed).  However, once the baby was
stable and doing well, the quantity of EBM would be increased from
approx 150ml/kg/day from Days 5-10, to 180ml/kg/day at day 10.  After
this, if the baby remained well, then the paediatrician would slowly
increase the amount of EBM by 30ml/kg/day - up to about 280 -
300ml/kg/day.  Individual babies would eventually be prescribed extra
Vit D, and calcium and maybe - later - iron.  These supplements were
not mixed up in a "fortifier" but were given as individual
medications.  Once the babies reached about 1300g they would start
learning to breastfeed, and be topped up with EBM via NGT and later
by cup.  Bottles were also unknown.  Most babies were discharged at
1800g exclusively breastfed, or breastmilk-fed by cup/spoon, and
they'd be gaining at least 30g/day - if the feeding wasn't going
well, then they couldn't go home.

I believe that the rationale behind HMF is to provide additional
protein (and fat?) with the additional micronutrients that pre-term
babies need and were not able to obtain in utero because they were
born 6 - 14 weeks too early.  I know that Nancy has defended the use
of HMF for these reasons, I think mentioning bone mineralization
etc.   I know that Richard Schanler and others have written research
articles apparently demonstrating the need for HMF.

I believe, also, that there are concerns about risks of feeding very
small babies too much fluid.  But I've seen very tiny babies survive
and thrive on "just" super-quantities of EBM and individual
micronutrients.  Not only do they not go into cardiac arrest, or
suffer pulmonary edema, I've known babies who reach 34 weeks
corrected gestational age gain 75/day (2.5 oz a day) when they
receive straight, as-it-comes EBM in the amount of 280ml/kg/day - a
phenomenal amount of intake and gain.  So there's no question that
these babies can grow, and grow well.  And as they gain weight so
much faster, they are strong enough to breastfeed more and more
efficiently, too.  I've also had the opportunity to follow up some of
these babies for years - one was in the top 10% for cognitive
development as tested in his application to a private school at age 6.

My questions are these.
1)  While the research appears to have been done rationalizing the
use of HMF - has anyone actually done any research comparing the use
of HMF with the use of super-feeding with EBM once pre-term babies
have stabilized?  And if not, why not?  Who would be willing to do it?
2) At what age (after birth) would it be recommended currently to
start mixing HMF with the mother's own breastmilk, in order to get
the baby achieving the catch-up gain that I've seen with
super-feeding exclusively with EBM??  My understanding is that for
the first month, premie moms produce premie milk, which contains
higher quantities of several ingredients, specially suited to the
needs of the pre-term infant.  This latest death appeared to have
resulted from a pre-term baby having received powdered HMF
contaminated with E Sakazakii in the first few days after birth - was
this really medically necessary?  Is anyone looking at the
risk-benefit ratio?

Pamela Morrison IBCLC
Rustington, England - formerly in private practice in Harare, Zimbabwe



             ***********************************************

Archives: http://community.lsoft.com/archives/LACTNET.html
To reach list owners: [log in to unmask]
Mail all list management commands to: [log in to unmask]
COMMANDS:
1. To temporarily stop your subscription write in the body of an email: set lactnet nomail
2. To start it again: set lactnet mail
3. To unsubscribe: unsubscribe lactnet
4. To get a comprehensive list of rules and directions: get lactnet welcome