Human Milk Fortifiers (HMFs)

What are Human Milk Fortifiers

Commercial human milk fortifiers (HMFs) are available to increase the nutrient density of human milk and correct or minimize nutrient deficits in premature neonates whose nutritional needs exceed the content of human milk for calories, protein, fat, and many micronutrients.

HMFs provide enhanced nutrition to the premature infant while still allowing them to receive human breast milk and all its benefits.

Metabolic complications associated with long-term use of unsupplemented human milk in preterm infants include hyponatremia at 4—5 weeks, hypoproteinemia at 8—12 weeks, osteopenia at 4—5 months, and zinc deficiency at 2—6 months.

Fortification of human milk historically has provided additional protein, calories, fats, and other micronutrients and vitamins in a powdered form.

Two commercial powdered HMFs have been available for approximately 15 years. These 2 products were similar in form and nutritional composition with the exception of iron content.

Powdered HMFs have represented a major improvement in the nutrition of the preterm infant over the last decade.

However, there remained several areas that demanded improvement to meet the clinical and safety needs of the preterm infant. First, the products are a powder and are not sterile. Both the Centers for Disease Control and the Academy of Nutrition and Dietetics recommend the use of liquid products in the Neonatal Intensive Care Unit (NICU) to prevent infection due to bacterial contamination.

Second, despite improved growth compared to unfortified human milk, infants fed fortified human milk often develop extrauterine growth restriction (EUGR). Third, powdered versions of HMFs do not meet the current estimates of protein necessary for the extremely low birth weight infant and for larger infants who require catch-up growth.

Therefore, new liquid versions of HMFs have emerged to confer the same beneficial properties of the powdered versions but without the aforementioned concerns. Furthermore, there is a liquid HMF derived from donor human milk, and a human milk cream fortifier is also available.

Indications

• nutritional supplementation

General nutritional information:

• Preterm infants fed unfortified human milk grow more poorly than preterm infants fed preterm or even term formula. Studies have repeatedly demonstrated that protein and multi-nutrient fortification of human milk is associated with short-term growth advantages (weight, length and head circumference) for infants < 34 weeks gestation or birth weight < 1800 g when fortified human milk is given both during and after the infant’s initial hospitalization. A Cochrane review of studies using HMFs concluded that there is no clear effect on bone mineral content (BMC); some studies have shown no effect on BMC while others have shown increased BMC in infants receiving HMFs compared with those receiving unsupplemented milk. It also concluded that there are insufficient data to evaluate long term neurodevelopmental and growth outcomes in infants receiving HMFs, although there appears to be no effect on growth beyond one year of life. It is suggested that infants in any of the following categories be fed fortified human milk 
  • Infants <= 34 weeks gestation
  • Infants weighing <= 1500 g at birth
  • Infants weighing > 1500 g on PN for > 2 weeks, as PN does not provide adequate calcium and phosphorus intake
  • Infants weighing > 1500 g with suboptimal growth
  • Infants weighing > 1500 g with limited ability to tolerate increased volume
  • Infants weighing > 1500 g with high acuity, which increases risk of nutritional deficiencies
• Clinical conditions that should be considered when evaluating the need for fortification include growth history, fluid tolerance, energy requirements, protein requirements, risk of osteopenia from long-term PN, low intake of calcium and phosphorus, and the use of diuretics or steroids. The goals of human milk fortification are:
  • Meet the nutritional needs of the patient
  • Continue the beneficial properties of human milk at the cellular macrophage humoral level to protect sIgA, lactoferrin, and lysozymes
  • Preserve the human milk as a ‘live’ solution
• General daily caloric requirements are approximately 110—130 kcal/kg for neonates and 85—105 kcal/kg for infants < 6 months; however, specific patient circumstances will dictate individual requirements.

Monitoring Parameters

• serum albumin
• serum creatinine/BUN
• serum electrolytes
• weight

Contraindications

• breast-feeding
• dehydration
• galactosemia
• immunosuppression
• milk protein hypersensitivity
• nutritionally incomplete
• phenylketonuria
• pregnancy
• renal impairment
• severe combined immunodeficiency (SCID)
• soya lecithin hypersensitivity

Interactions

No information is available regarding drug interactions associated with Human Milk Fortifiers