Enjoying the varied comments about the need for Human milk fortifier.  Dr
Nancy wrote, "Mature breastmilk does not have enough (calories) to ensure
optimal growth rates for very low birth weight premies... I wish we had a
better product."

Then Dr Jack wrote, I was tired of being the only one to ever rail about the
"need" to "fortify" human milk... My experience is from Africa .. we were
able to give them 200, 250, even 300 cc/kg/day by ng tube, slow drip (like
intrautero--*continuous* nutrition), and they grew fine.  I didn't
know about the fat sticking to the tubing, but it worked anyway."

When Roz Escott was here visiting an NNU in one of Harare's private
hospitals she asked about Human Milk Fortifier, and received a blank stare -
it is unknown here.  Even the smallest babies (600g and 700g are the
smallest I have worked with, survivors of a 26 week triplet pregnancy)
receive EBM as soon as the mother can express it, every two hours by
naso-gastric tube as soon as their condition permits, and up to 280
ml/kg/day once they are doing well.  Bigger premies are fed every three
hours. I don't think anyone has ever thought about "hindmilk" - moms simply
express and feed the milk as it comes.  They *do* express immediately before
the baby needs feeding in the day (every 2 or 3 hours) so maybe the shorter
interval provides milk with a higher fat content, although some of the
mothers do not express at night after they get home.  Nevertheless, this
would not affect the protein content (which Human Milk Fortifiers are
supposed to "improve"). The *only* supplement is Vit D. The babies thrive.
They are also discharged home at 1800g exclusively breastfed.  So it would
seem that "just" human milk *can* provide sufficient nutrition for even
extremely low birth-weight infants and that simply increasing the volume the
baby receives, rather than the (foreign) protein content, or the fat
content, does the job.

Pamela Morrison IBCLC, Zimbabwe