A Ready Reckoner : Human Milk Fortifier
- Part 2 -

Pankaj Garg / Hijam Rajendra Singha *

Comparison of content with other available Brands.

Nutrient ESPGHAN Human milk Similac Enfamil Lactodex HIJAM-HMF (/kg/ day)
(100 ml) (4 Pkts) (4 Pkts) (2 Pkts) (4 Pkts) Energy,
Cal 110-135 67 14 14 15 14 Protein,
g 3.5-4.5 1.1 1 1.1 0.4 1 Fat,
g 4.8-6.6 3.5 0.36 1 0.2 1 Linoleic Acid,
mg 385-1540 - 140 - Carbohydrate,
g 11.6-13.2 7.0 1.80 0.2 3 0.2 Vitamin A,
IU 1320-3300 48 620 950 240 620 Vitamin D,
IU/day 800-1000 8 120 150 76 400 Vitamin E,
IU 2.2-11 3.2 4.6 2.5 2.48 Vitamin K,
mcg 4.4-28 8.3 4.4 2.2 2.2 Vitamin C,
mg 11-46 25 12 10 10 Calcium,
mg (mEq) 120-140 25.3 117(5.48) 90 100 100 Phosphorus
mg (mEq) 60-90 14.5 67(2.16) 50 50 50 Iron,
mg 2-3 0.35 1.44 - 1.44 Sodium,
mg (mEq) 69-115 15(0.65) 16 3.5 16 Potassium,
mg (mEq) 66-132 63(1.61) 29 7.8 7.8 PRSL,
mOsm 11.2 9.7 Osmolality (mosm/kg water) +95 + 35 Not known +25

Frequently Asked Questions (FAQs)

1. What is the optimum condition requiring HMF to an infant?

Are there any national and international guidelines on the use of (HMF)? The preterm infants <32 weeks gestation or <1500g birth weight, who fail to gain weight despite full volumes of breast milk feeding, are the best suited for use of additional fortification of breast milk. However, in absence of sufficient data to categories a particular infant who should receive fortifier human milk, there is a general consensus that all infants with birth weight below 1800g would benefit from additional fortification as per ESPGHAN 2009. The existing WHO and NNF guidelines somehow also support the abovementioned condition for use of additional multi component fortification of breast milk.

2. What are the short and long term benefits of HMF?

A systematic review of ten randomized controlled trials (more than 600 infants with birth weight less than 1850 g multi-component fortification of HM compared with the feeding of unfortified HM was associated with small but statistically significant short-term improvements in weight gain (+2.33 g/kg/d; 95%CI 1.73, 2.93), linear growth (+0.12 cm/week ; 95%CI 0.07, 0.18), and head growth (+0.12 cm/week; 95%CI 0.07, 0.16)(1) .

Only two trials have evaluated long-term growth effects of HM fortification and did not demonstrate any difference in weight, length or head circumference at 12 and 18 months of corrected age(2, 3).

Only one trial looked at developmental performance at 18 months: at this age test scores were higher in the fortifier in the fortified group by 2.2 points for the Bailey Mental Development Index, by 2.4 points for the Psychomotor Development Index, and by 3.1 points for social maturity, but these differences were not significant. 3. What are the pros and cons of adding Iron to HMF? In Indian context with high prevalence of Iron deficiency in Indian mothers and more SAG status in preterm and LBW neonates, addition of 1mg Iron/100ml of human milk would meet up with ESPGHAN guidelines and would go a long way in reducing Iron deficiency anaemea in Indian infants.

4. Discuss importance of protein content of HMF?

Adequate protein intake has impact not only on short term growth but also on long term neurological outcome. Cochrane analysis showed that protein supplementation of human milk in preterm infants leads to increase in short term weight gain (WMd 3.6g/kg/day, 95CI 2.4 to 4.8g/kg/day), linear growth (WMD 0.28cm/week, 95% CI 0.38cm/week) and head growth (WMD 0.15 cm/week, 95% CI 0.06 to 0.23cm/week) 5. What are the various types of fortification used? The three different forms of fortification are standard, tailored and adjustable. {4,5}

(1) Standardized:- Adding a constant amount of fortifier without taking into account the initial milk composition from each individual mother.

(2) Tailored (“a Ia carte” ):- Based on milk analysis. The amount of fortifier is adjusted according to weekly determinations of milk protein content to achieve target protein intakes at all times.

(3) Adjustable :- Based on the metabolic response of the infant. The amount of fortifier is adjusted after determining blood urea nitrogen as an index for adequacy of protein intake.

6. Which Calcium salts should be used as HMF constituent and why?

Insoluble calcium salts such as calcium phosphate tribasic and calcium carbonate should be used as these optimize fat absorption. Whereas, calcium salts bind fatty acids in milk, thus impairing fat absorption.

7. What are adverse effects of HMF feared of? Osmolality is a critical determinant of feed tolerance.

Rise of Osmolality observed can be explained by the fact that polysaccharides present in HMF, are broken into constituent mono and oligosaccharides. So we expect an ideal fortifier to alter Osmolality to minimum. The Cochrane review, on the basis of the small number of infants for whom this outcome was reported, showed a non-significant trend toward an increased risk of feed intolerance in treated infants (RR2.85, 95% CI 0.62 to 13.1)(1).

Among the reasons used to advocate HM feeding for VLBW infants is the belief that it is advantageous in reducing infections when compared to preterm formula. HM is a highly complex secretion with live cells and a wide variety of biologically active factors; it has anti-infective properties due to the high content of lgA, lysozyme, lactoferrin, and interleukins.

A possible concern with HMF is that the added nutrients may affect these unique qualities. Adding HMF was reported to be associated with some lysozyme and lgA reduction but this observation was not replicated in later studies. Total bacterial colony counts in milk stored at refrigerator temperature are significantly greater in fortified than in unfortified milk; however, the magnitude of this difference may not e of biological importance.

From a clinical point of view, a systematic review comparing infants fed unfortified and fortified HM did not show any significantly increased risk of NEC in infants receiving FHM (RR 1.33, 95%CI 0.7 to 2.5)

8. When Should HMF be stopped?

There are no standard evidence based guidelines for the same. If the baby is on direct breast feeds at the time of discharge, HMF fortification is usually discontinued as it interferes with direct breast feeds. If baby is on expressed breast milk, then HMF should be continued till baby achieves its birth percentile on growth charts. Conventionally in such cases HMF is continued till 40 weeks.

9. Energy Value Human milk has an average of 67 Cal /100ml and addition of HIJAM-HMF/100ml human milk provides additional 14 calories, thus, making it a total of 81 Cals/100ml. the Calories in HIJAM-HMF come from FAT and PROTIEN and not from carbohydrates. It adds value to the product and at the same cuts down the Osmolar Load.

Bibliography

1. Kuschel CA, Harding JE. Multicomponent fortified human milk for promoting growth in preterm infants (Cochrane Review). Cochrane Library 2004;3

2. Lucas A, Fewtrell MS, Morley R, al. Randomized outcome trial of human milk fortification and development outcome in preterm infants. Am J clin Nutr 1996;64:142-51.[40]

3. Wauben IPM, Atkinson SA, Shah JK, et al. Growth and body composition of preterm infants: influence of nutrient fortification of mother’s milk in hospital and breastfeeding post-hospital discharge. Acta Paediatr 1998; 87:780-5.

4. More GE, Minoli I, Ostrom M, Jacobs JR, Picone TA, Raiha NC, et al. Fortification of human milk: evaluation of a novel fortification scheme and of a new fortifier. J Pediatr Gastroenterol Nutr 1999;20:162-72.

5. Arslanoglu S, Moro GE, Ziegler EE. Adjustable fortification of human milk fed to preterm infants: does it make a difference? I Perinatol 2006;26:614-21

Concluded.....