- Add 1 teaspoon of level, unpacked Neosure powder to 130 ml or 4 1/3 ounces of breast milk. …
- Add 1 teaspoon of level, unpacked Neosure powder to 70 ml or 2 1/3 ounces of breast milk. …
- Add 1 teaspoons of level, unpacked Neosure powder to 46 mL or 1 ½ ounces of breast milk.
Contributions include: HF, data collection, interpretation of the work, revising, final approval, agreement that the work is appropriately done; MSES, design, revision, final approval, agreement that the work was appropriately investigated; KS, design of the study, drafting, analysis, revision, final approval, agreement that the work was appropriately investigated. Presentation at a conference: An abstract of this study was made at the “Pediatric Nutrition Conference” in New Orleans, USA, in August 2016. The authors state that there is no potential conflict of interest. ©.
The goal of this study is to identify the growth parameters, nutritional biochemical markers, and complications associated with the post-discharge formula fortification of human milk in preterm very low birth weight (VLBW) newborns. The study included 50 preterm infants who were less than 37 weeks gestation and weighed less than 1500 g. They received parental nutrition and feeding according to our protocol. Infants were randomly divided into two groups when enteral feeding reached 100 cc/kg/day: group I, Cases, n=25, with post-discharge formula (PDF) added for fortification; group II, Controls, n=25, with no fortification. Both groups’ infants received 50% of the necessary enteral feeding as premature formula. This protocol was used until infants’ weight reached 1800 g. Daily weight, weekly length and head circumference were recorded. Clinical complications as well as hemoglobin, albumin (Alb), electrolytes, and blood urea nitrogen (BUN) levels were recorded. Better growth and weight gain were the results of adding PDF to human milk 16 8 and 13. 78 g/kg/day (P=0. 0430), length 0. 76 and 0. 58 cm/week (P=0. 0027), and head circumference of 0. 59 and 0. 5 cm/week (P=0. 0217) in cases and controls respectively. Duration of hospital stay was less in cases (22. 76 versus 28. 52 days in Controls), P=0. 02. Between the two groups, there were no discernible differences in serum electrolytes, BUN, or Alb. Hemoglobin was significantly higher in Cases, P=0. 04. There were no significant clinical complications. In preterm, very low birth weight newborns, our feeding protocol of fortifying human milk with PDF led to better growth and a shorter hospital stay. In developing nations with limited resources, the use of PDF could be an alternative method of boosting mothers’ milk for preterm VLBW infants.
The preferred enteral feeding for preterm infants is their mother’s human milk. Compared to infant formula, full enteral feeding occurs sooner in preterm infants fed human milk. In addition to providing nutrition, human milk contains immunologic and antimicrobial components that support infant health and development. Reduced infections, less necrotizing enterocolitis, and reduced feeding intolerance are a few of the reported advantages of human milk for preterm infants. 2,3 There are several barriers to providing preterm infants with exclusively human milk, including the mother’s insufficient milk supply, volume restrictions, and the infant’s intake restrictions. 4.
When compared to milk from mothers of term infants, biochemical analysis of the milk from mothers of preterm infants, particularly during the first two weeks after delivery, reveals higher levels of energy and higher concentrations of fat, protein, and sodium but slightly lower concentrations of lactose, calcium, and phosphorus. 2 To match the intrauterine rates, postnatal growth must happen quickly. The majority of preterm infants’ protein needs cannot be met by most preterm infants’ milk, especially by the end of the first month. 5,6.
Human milk fortifiers give preterm infants the extra protein, minerals, and vitamins they need for the best possible growth and development. The nutrient, mineral, and vitamin concentrations produced when these supplements are added to human milk in the first month after delivery are comparable to those of formulas made for feeding preterm infants. If discharge occurred before 1800 g, fortified milk from mothers of preterm infants may be used to meet the needs of the preterm infant’s growth after discharge for infants with very low birth weight (VLBW). 7.
This study’s goals were to determine whether post-discharge formula (PDF) is a viable substitute for fortifying preterm mothers’ milk in underdeveloped nations without access to human milk fortifiers (HMF) and to look for any potential complications.
This was a prospective case-control study. From November 2012 to April 2014, it was carried out at the Neonatal Intensive Care Unit (NICU) of the Ain Shams University Maternity Hospital. This study was approved by Pediatric Department Ethical Review Board. Our NICU provides level III care and has access to surgical specialists and pediatric sub-specialists for consultation. It has the ability to provide assisted ventilation at various ventilation frequencies, ranging from low to conventional.
Preterm and very low birth weight (birth weight 1500 g) infants, no enteral feeding intolerance, an enteral feeding volume of 100 mL/kg/day, and mothers willing to express breast milk manually were the inclusion criteria.
Our study did not include any infants with congenital abnormalities, intolerance to enteral feedings, or any medical conditions such as hyperbilirubinemia requiring phototherapy, hypoglycemia, hyponatremia, or respiratory illnesses requiring any type of assisted ventilation () ()
Parents gave their informed consent to have their child participate in the study. For each newborn infant, a clinical examination and perinatal history were conducted. Daily weight, weekly length and frontal-occipital circumference were measured. Blood urea nitrogen (BUN), hemoglobin level (Hb), hematocrit, albumin (Alb), and electrolytes such as sodium (Na), potassium (K), calcium (Ca), and phosphorus (P) were examined in particular. Certified lactation consultants offered advice on how to express, store, and transport breast milk to the NICU.
On the day of delivery, parenteral nutrition was started as soon as possible with glucose 5% at a rate of 3 g/kg. Up until a maximum of 12 g/kg/min, the rate started at 5 g/kg/min and increased by 1-2 g/kg/min/day. Amino acids were started as 3. 5 g/kg/day and increased to 4 g/kg/day. Calcium 650 mg/dL, multivitamins, zinc and selenium were added.
A separate line was used to administer intra-lipid, which was then increased to 2-3 g/kg/day. Within the first two days following birth, enteral feeding was initiated. 10–20 mL/kg/day of maternal breast milk that was not fortified primed the gastrointestinal tract (GI). Feeding was advanced by 10–20 mL/kg/day after a few days of GI priming. The desired daily fluid intake was achieved by reducing total parental nutrition (TPN). TPN was stopped when enteral feeding reached 120 mL/kg/day. By day 10 of life, a full enteral intake of 150 mL/kg/day was intended.
Because manual breast pumps were the only ones available in Egypt, mothers expressed their breast milk using them. Despite the fact that mothers could receive breastfeeding consultation from certified breastfeeding consultants, the amount of expressed breast milk could only meet about 50% of daily enteral needs. So we administered premature formula (PMF) for 50% of the total volume of enteral milk. The post-discharge formula was Similac Neosure by Abbott Laboratories, while the premature formula was Babelac Premature 24 cal/fl oz by Danone Baby Nutrition.
Randomly divided into two groups, Group I (intervention group or PDF fortified human milk group) and Group II (controls or non-intervention group) with no fortification of breast milk and Bebelac Premature Formula, were infants who tolerated 100 mL/kg/day enteral feeding. In our unit, the infant’s discharge weight was set at 1800 g, so fortification began with 22 calories per fluid ounce for two to four days, followed by 24 calories per fluid ounce and, if tolerated, 27 calories per fluid ounce. When enteral feeding reached 150 cc/kg/day, iron was prescribed along with the start of vitamin D supplementation.
According to the PDF’s manufacturer’s instructions, 1 teaspoon of level powder added to 130 mL of term human milk has 22 calories, 1 teaspoon of level powder added to 70 mL of term human milk has 24 calories, and 1 teaspoon of level powder added to 40 mL of term human milk has 27 calories. However, rather than using term human milk, we used mothers’ preterm human milk. We used clinical criteria such as overall clinical status, abdominal examination, emesis, characteristics of gastric residue, or any change in stools frequency to evaluate feeding intolerance. Further investigations were available if necrotizing enterocolitis was suspected. To evaluate feeding intolerance, a feeding tolerance algorithm was used. Infants receiving >40 mL/kg of enteral feedings had their gastric residual volume (GRV) checked every three hours. Additional testing, such as an abdominal x-ray, a sepsis workup as a complete blood count (CBC), and C-reactive protein, were conducted if the GRV was greater than 50%, there was a noticeable and persistent increase from the usual residual, there was abdominal distension, or the baby appeared sick. With minimal symptoms and normal physical examinations, newborns were refed, but at half the previously tolerated volume, and serially monitored. Those who had abnormal exams were given nil per os and received necrotizing enterocolitis protocol treatment. The study excluded infants with feeding intolerance and infants who could not advance on enteral feeding. The nutritional components of human milk fortified by PDF and PMF as described by the manufacturers are
We used SPSS version 24 for statistics. For continuous data, mean±SD and Student’s t-test were used. When necessary, the non-parametric Mann Whitney U test was applied if the data were not normally distributed. For categorical variables, the percentage (%) and Chi Square test were employed. Pearson test was used when appropriate. A P-value of <0. 05 was considered statistically significant.
Fifty low birth weight preterm infants completed the study. Group I (Cases, n=25), in which mothers’ breast milk was fortified using PDF, and group II (Controls, n=25), in which no fortification was added There was no difference between the two groups at the beginning of the study in terms of gestational age, gender, birth weight, length, or occipital-frontal circumference (P>0). 05. Maternal pre-eclampsia, multiple pregnancies, antepartum, and unintentional hemorrhage were the main causes of prematurity in both groups.
P 0 analysis revealed a significant difference in weight, length, and head circumference gains between the intervention group and the controls. 05 ( ).
Days of only TPN, mixed feeding (TPN+enteral feeding), days of only enteral feeding, and age at 100 mL/kg/day of enteral intake did not statistically differ between Cases and Controls, P>0. 05 ( ). Compared to the Control group, infants in the Intervention group spent 22 fewer days in the hospital. 76 versus 28. 52 days, P=0. 02 ( ).
Despite the fact that Cases (n=3) had more feeding intolerance than Controls (n=1), this was not statistically significant (P>0). 05. Other issues like reflux and sepsis did not statistically differ between the two groups. Infants who developed complications were excluded from the study.
The correlation between serum Ca, P, Alb, BUN, and hematocrit, P>0, was not statistically significant. 05. While Hb was statistically higher in Cases than Controls, P=0. 03 ( ). The beginning of the study and discharge were compared for these biochemical parameters. The majority of the babies in our NICU were healthy preterm VLBW, so routinely checking these parameters wasn’t necessary.
Because human milk has been shown to have both short- and long-term advantages, the American Academy of Pediatrics advises it for all premature infants. But to satisfy the rapidly growing preterm infant’s protein and mineral needs, human milk must be fortified with nutrients. Commercial bovine or human milk fortifiers are readily available in developed nations. While post-discharge formula is affordable and simple to obtain, none of these milk fortifiers are offered in Egypt.
To our knowledge, this is the first study to compare the fortification of preterm VLBW infants’ mothers’ milk with the control group. In the current study, adding PDF to breast milk led to cases where there was a greater increase in weight, length, and head circumference, P 0. 5. We discovered that cases and controls differed significantly (P=0), with cases having younger age at full intake. 04). In the current study we reported shorter hospital stay, P=0. 02.
One recent study from Thailand was the only one to use PDF for very low birth weight preterm infants. The study, however, contrasted the fortification of human milk with either PDF or HMF. They found no discernible differences between the intervention group and the control group in terms of growth parameters, age at full enteral feeding, or length of hospital stay. This could be explained by the fact that our control group received no fortification, whereas in their study, the control group received HMF.
Prior studies of HMF did not include PDF, likely because they were all conducted in developed nations where HMF are widely available. According to Martins and Krebs’17 research, HMF led to better growth in the intervention group. More increases in weight, length, and head circumference were discovered; P=0 075, 0. 003, and 0. 0001 respectively. Di Natale and colleagues18 showed that using fortified human milk results in adequate growth in premature infants and meets their unique nutritional needs. Martin and Kreb17 demonstrated that, up to 1800 g, the intervention group’s length of hospital stay was longer than the control group’s. They provided an explanation based on the intervention group’s initial study’s lower mean weight. However, this did not show statistical difference. Additionally, they spent less time in the hospital during the intervention than the control group, but this difference was not statistically significant.
We measured serum electrolytes (Na, K, Ca, and P) in both groups at admission and discharge in this study. There was no discernible difference between the two groups, according to our findings. Infants who consumed unfortified human milk had progressive increases in serum calcium and decreases in serum phosphorus, according to Heiman and Schanler19. However, Lucas and associates20 discovered that there was no age-related difference in plasma phosphorus between groups. While we used PDF, those studies had used HMF to fortify human milk.
In the current study, controls had significantly lower hemoglobin and hematocrit levels. This could be attributed to the Cases having nutrient additives like iron while the Controls did not. When infants in either group reached their maximum intake of 150 mL/kg/day, iron supplements were given to them. Alb or BUN did not significantly differ between groups in our study, but Heiman and Schanler19 demonstrated that indicators of protein nutritional status, such as g. Total protein, serum Alb, and BUN were all lower in the interventional group. Their study’s findings may differ from ours because they used a different human milk fortifier. Only three (12%) cases of feeding intolerance and one (4%) case of sepsis were found in this study. None of the newborns in interventional group had reflux. Four infants (16%) in the control group had reflux, but only one (4%) had feeding intolerance. 1). There was no statistical significance between these clinical complications. There was no discernible difference between the interventional group using PDF and the control group using HMF, according to Khorona and colleagues16.
Despite the fact that gram-negative bacteria (Coronobacter sakazakii) may contaminate powdered human milk fortifiers because they are not sterile, we had not observed any related infections in infants fed PDF. 21,22 Reali and colleagues had described customized human milk fortification based on analysis of maternal milk. It had better growth results, but it was costly and required milk sample analysis.
For the mother of a preterm infant to successfully initiate and maintain breastfeeding, she needs education, supplies, and encouragement. One of the study’s limitations was the mothers’ insufficient supply of breast milk. Only 50% of the infant’s enteral intake had to be in the form of PDF-fortified breast milk. To increase milk production, pharmacological galactagogues like domepridone were not prescribed; instead, we advised mothers to use natural galactagogues like dates and fenugreek. Because breast milk banks are not allowed in Egypt, donor breast milk is not an option.
Further research is necessary to determine the reasons why mothers of preterm infants don’t produce enough breast milk. NICUs with preterm mother accommodations may enable them to produce more breast milk. Other research that includes mothers who are exclusively feeding their infants with fortified enteral nutrition may confirm our findings and identify additional complications associated with the use of PDF in this vulnerable population of infants.
PDF fortification of breast milk led to a significant growth boost without any major complications. The cost and complications associated with prolonged NICU stays could be reduced if widespread use of these techniques in our NICUs results in shorter NICU admission times.
Contributions include: HF, data collection, interpretation of the work, revising, final approval, agreement that the work is appropriately done; MSES, design, revision, final approval, agreement that the work was appropriately investigated; KS, design of the study, drafting, analysis, revision, final approval, agreement that the work was appropriately investigated. Presentation at a conference: An abstract of this study was made at the “Pediatric Nutrition Conference” in New Orleans, USA, in August 2016. The authors state that there is no potential conflict of interest. ©.
Days of only TPN, mixed feeding (TPN+enteral feeding), days of only enteral feeding, and age at 100 mL/kg/day of enteral intake did not statistically differ between Cases and Controls, P>0. 05 ( ). Compared to the Control group, infants in the Intervention group spent 22 fewer days in the hospital. 76 versus 28. 52 days, P=0. 02 ( ).
Our study did not include any infants with congenital abnormalities, intolerance to enteral feedings, or any medical conditions such as hyperbilirubinemia requiring phototherapy, hypoglycemia, hyponatremia, or respiratory illnesses requiring any type of assisted ventilation () ()
The goal of this study is to identify the growth parameters, nutritional biochemical markers, and complications associated with the post-discharge formula fortification of human milk in preterm very low birth weight (VLBW) newborns. The study included 50 preterm infants who were less than 37 weeks gestation and weighed less than 1500 g. They received parental nutrition and feeding according to our protocol. Infants were randomly divided into two groups when enteral feeding reached 100 cc/kg/day: group I, Cases, n=25, with post-discharge formula (PDF) added for fortification; group II, Controls, n=25, with no fortification. Both groups’ infants received 50% of the necessary enteral feeding as premature formula. This protocol was used until infants’ weight reached 1800 g. Daily weight, weekly length and head circumference were recorded. Clinical complications as well as hemoglobin, albumin (Alb), electrolytes, and blood urea nitrogen (BUN) levels were recorded. Better growth and weight gain were the results of adding PDF to human milk 16 8 and 13. 78 g/kg/day (P=0. 0430), length 0. 76 and 0. 58 cm/week (P=0. 0027), and head circumference of 0. 59 and 0. 5 cm/week (P=0. 0217) in cases and controls respectively. Duration of hospital stay was less in cases (22. 76 versus 28. 52 days in Controls), P=0. 02. Between the two groups, there were no discernible differences in serum electrolytes, BUN, or Alb. Hemoglobin was significantly higher in Cases, P=0. 04. There were no significant clinical complications. In preterm, very low birth weight newborns, our feeding protocol of fortifying human milk with PDF led to better growth and a shorter hospital stay. In developing nations with limited resources, the use of PDF could be an alternative method of boosting mothers’ milk for preterm VLBW infants.
The preferred enteral feeding for preterm infants is their mother’s human milk. Compared to infant formula, full enteral feeding occurs sooner in preterm infants fed human milk. In addition to providing nutrition, human milk contains immunologic and antimicrobial components that support infant health and development. Reduced infections, less necrotizing enterocolitis, and reduced feeding intolerance are a few of the reported advantages of human milk for preterm infants. 2,3 There are several barriers to providing preterm infants with exclusively human milk, including the mother’s insufficient milk supply, volume restrictions, and the infant’s intake restrictions. 4.
FAQ
How can I make 22 calories of breastmilk?
Add 1/2 teaspoon of regular formula powder to 3 ounces (89 mL) of pumped breast milk to create 22 calories per ounce of breast milk.
Can you mix Similac NeoSure with breast milk?
You can supplement your breast milk with NeoSure® formula powder to give your baby more calories and nutrients.
Can I fortify breast milk with formula?
By mixing powdered formula with breast milk and administering the resulting mixture in a bottle, breast milk can also be fortified. It is inappropriate to fortify breast milk with cow’s milk or any other type of milk substitute.
How do you fortify breast milk to 27 calories with NeoSure?
Add 1 teaspoon of Similac NeoSure Powder to 40 mL (or 113 ounces) of breast milk to make it 27 calories per ounce. The data is meant to be used for general education and informational purposes.
