Pam, I completely agree, with one exception.... hospitalized NICU micropreemie babies.  Increasing calories by decreasing free water volume usually results in less residuals in the enteral fed NICU baby who has slower gastric emptying due to immaturity.  The low volume helps, and the team makes up the fluids by providing them via IV, monitoring the fluid balance by an IVPO rate to avoid dehydration/overhydration.  

That does not take away the fact that formula addition will decrease the quality of the milk, so in a perfect world, every NICU baby who needed more calories in lower volume, would have access to high calorie breastmilk manipulated via addition of actual breast milk fat.  Some of my neonatal RD friends might be opposed to it (and might want to strip me of my "RD card") since adding fat does not add the extra protein or the higher provision of phosphorous and calcium that the micropreemie needs, but the truth is... we talk about increased needs for those nutrients, not fully understanding the difference in bioavailability of them from breast milk versus formula.  Oh, I can go on... 

For our late preterms, we have been able to avoid the addition of formula to increase calories, by acquiring a crematocrit.  Literature says they usually overestimate calorie density, but even if they do by a little bit, once we provide that test result to the MD, they usually agree to let the baby take exclusive breastmilk - and time (and growth), ends up proving our point: even with all technological advances (formula, HMF, crematocrits, etc), mom's body is still the best "milk expert".

Regards,
Tina Schallhorn, RD LDN CLC

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