Dear all:

Nancy pointed out the protein issue which has been driving my curiousity to the point of 
obsession, but not currently having a University affiliation after leaving my former profession as a 
Director of International Nutrition Programs --- I can't do the megasearch I would have done 
because the $12/article makes it totally unaffordable.  I hate abstracts because I never trust them 
and always find I come to different conclusions or glean some points that the authors don't 
discuss from reading the whole article.

If you look at all the results in this study - the most striking and substantial result to me is the 
fact that 17 infants (21%) in the donor milk were switched to PF.  This means that the actual rate 
of gain shown in Table 4 of 17.1+/- 5.0 g/day may have been even LOWER had these infants not 
been given PF.  This finding is more SUBSTANTIAL than any other difference found in the study 
including the differences in NEC between the donor milk group and the formula group for which 
the sample size is inadquate to detect the satistical signficance. I don't have a calculator at hand 
right now to work this out for sure, but my number crunching experience suggests to me that if 
did a statisical test on the differences between the groups in terms of those that "failed to thrive", 
this would most likely be significant. 

Knowing how journals work, I understand that there is only so much data that is allowed in an 
article.  Schanler sites his protocol for ensuring tha tmilk advancement and parenteral nutrition 
were consistent - but this is in a book, not a journal. Otherwise I might spent the extra $12 to 
read it cover to cover.  

What I would have liked would have been side by side tables of actual analyses of the actual 
nutritional content of the donor's milk, the mother's milk with and without the fortifier as well as 
the formula.  All that is mentioned is that the donor milk group received more acetate and 
sodium.  The mother's milk group received less oil, protein or glucose supposments for energy.

So, here are the questions I have:

1) Were there differences in the protein content of the donor milk and the mother's milk groups 
BEFORE fortifier?  The authors claim that they used donor milk from women who delivered 
prematurely, but did they actually measure the differences in protein content?

2) Did they compensate for differences in protein content of the donor milk and the mother's milk 
groups?  That is, did they measure these before adding the fortifier?  

3) Nancy Wight discusses the importance of protein for optimal growth - but growth is measured 
by two parameters - weight and crown-heel length.  And she's suggesting fat (& I'm assuming 
she's considering weight/length) unhealthy babies are not good.   So, I really do want to know the 
criteria that was used for putting the DM group on the PF treatment.  Was it a failure in length 
gain?  A failure in weight gain? or a failure in weight/length?  

4) If the protein were really controlled between all three groups, could their actually have been an 
issue of adequate caloric content?  Was there more transfer of milk from container to container 
with a loss of fat as one IBCLC I know suggested to me?  While adequate fat without the protein & 
other nutrients is not healthy, you also will not have adequate growth if the fat is insufficient. Both 
are needed.  This potential explanation is not terribly satisfactory to me. 

More than anything else I want to know why there was such a huge failure in the effectiveness of 
the donor milk "treatment" for growth and exactly what impact it did have on growth.  I'm not 
coming up with explanations that seem plausible to me.

Perhaps Nancy Wight (if she isn't tired of this topic already) can speculate on why this would crop 
up in such a carefully controlled study that on the fact of things, tried to equalize the nutrient 
content.

Susan E. Burger, MHS, PhD, IBCLC

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