Diana

Thanks for sending in details of studies on human milk fortifier funded by
industry.  Of particular interest (but little surprise) were the ones by:

Richard J. Schanler, M.D. "An Evaluation of Growth and Blood Biochemistries
of Preterm Infants Fed Preterm Human Milk Fortified with a New Human Milk
Fortifier." Ross Products Division, Abbott Laboratories, $24,292.00.

Richard J. Schanler, M.D. "Feeding Strategies for Low Birth Weight Infants."
NIH, $534,148.00.

Richard J. Schanler, M.D. "Fat absorption in premature infants fed fortified
human milk." NIH, $30,000.00.

I remember feeling a great uneasiness when reading the article written by
this doctor in JHL a while ago, and the recent posts querying the merits
(or not) of the need for human milk fortifier (actually made from cow's
milk and other things, not human milk) would seem to apply.  If "research"
on the apparent necessity of using an additive to mother's milk for
pre-term babies is funded by industry, how unbiased is it, and exactly how
reliable are the conclusions?

Denise referred recently to Lactnet posts sent in by African LCs on the
need, or not, of pre-terms to receive HMF.  I've written a lot about
this.  HMF is unknown in Zimbabwe.  The smallest babies I have ever worked
with, to be sure, were 26-weekers, not 23-weekers, but, once they are
stabilized, they receive the mother's own, raw, expressed breastmilk (2
hourly for the tiniest babies, via naso-gastric tube) and perhaps Vit D,
and later iron.  Plus any medications for any infections.  But nothing
else.  There is no HMF, and no lacto-engineering of the milk.
Often the very tiny ones are on a drip for several days, but as soon as the
paediatrician determines that the baby is well enough for oral feeding he
will start calling for mother's milk, and start with tiny quantities.  The
stomach is aspirated before the next feed to see if all the milk has been
digested.  Often they will "stick" at a very small quantity for several
days, or if there is a complication then the quantity might even be reduced
or stopped altogether until the baby is stable again, then EBM is started
again and very gradually increased as the baby is able to absorb more and more.

The point is taken from various posts on this topic recently that superior
"technology" may well be required, and is capable of keeping these very,
very tiny babies alive today when they would have died without it in days
gone by.  But doesn't this specialized technology in the beginning involve
better ways to keep these little babies' oxygen levels normal, and better
medications to treat the special medical conditions they have in the very
first hours, days and weeks, and improved parenteral feeding?  Am I right
in thinking that HMF is not used right at the beginning for the extremely
low birthweight babies?  It is used a little *later*, once the baby is
taking milk, in order to try and achieve a greater weight gain for a baby
who is already stable and now needs to *grow*, right?  Why are these
mothers not just assisted to provide *more* EBM for their babies?

I can assure everyone that the tiny babies who are stable, and receiving
EBM alone *do* grow well.  The quantities are increased until they receive
150 ml/kg/day, then 180 ml/kg/day then more and more - up to 280 ml/kg/day,
and maybe even more.  And the weight starts to pile on.  The paediatricians
will usually discharge these babies home when they have reached 1800g,
which is usually well before their due dates.  The 26-week gestation babies
mentioned above (born at 600 and 700g) were discharged home after their
mother had provided EBM for them for 100 days (14 weeks) - ie round about
their due date.

Obviously, what we need is a prospective study to be conducted on a
population of babies born into an environment where HMF is *not* added to
the mother's own expressed milk (exclusive breastmilk-feeding) and for
their health and growth to be matched against babies who *have* received
HMF, and to compare the results.  But, in the meantime, anecdotally I have
to report that I have worked with small and very small pre-term babies who
have received only mother's milk, without the addition of this commercially
manufactured cow's-milk-based powder and I have to conclude that it is not
absolutely required to sustain life and achieve good growth and development.

Pamela Morrison IBCLC, Zimbabwe

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