Breastmilk Fortification Method and Breastmilk Feeding Rates Among NICU Graduates

CQ #215 – January 19, 2021

by Anne Eglash MD, IBCLC, FABM

#LACTFACT

Among NICU graduates, fortification by adding formula powder to expressed breastmilk is associated with continued breastmilk feedings at 4 months as compared to supplementation with bottles of formula.

Comparison of Types of Breast Milk Fortification at Discharge from the Neonatal Intensive Care Unit and Breast Milk Feeding Rates and Growth at 4 Months Corrected Age

Breastfeeding Medicine 15(10) 2020; 955-661

What is the difference between fortifying breastmilk with formula powder versus supplementing with a few bottles of formula a day for premature infants upon hospital discharge?

In the United States, approximately 50% of premature infants are discharged with any breastmilk feedings, vs 83% of term infants. Breastmilk fortification at the time of NICU discharge is very common among very low birthweight (<1500g) or very preterm (<32 weeks gestation) infants. Needing to add supplementation may further decrease breastmilk feeding duration postpartum.

At the time of NICU discharge, lactating parents often provide bottles of expressed breastmilk, and breastfeed a few times a day, with the eventual goal of increasing breastfeeds over time. Parents are often advised to fortify their breastmilk by either adding formula powder to the bottles of breastmilk or feeding a few bottles of formula a day in lieu of breastmilk. Fortification is recommended to increase various nutrients such as calcium, phosphorus, protein, and fat.

The researchers for this week’s CQW were interested in comparing breastfeeding rates at 4 months corrected age based on these 2 methods of breastmilk fortification.

They followed 285 very premature or very low birth weight infants after NICU discharge, until they were 4 months corrected age. One hundred forty-seven (52%) were discharged on breastmilk feeds fortified with formula powder (BM-F), and 138 (48%) were discharge with bottles of formula (BM-S).

The 2 groups were similar in maternal age. The mothers in the BM-F group were less likely to be Caucasian, more likely to have private insurance, and less likely to have multiple gestation.

Among all infants, 34% were receiving breastmilk at 4 months corrected age.

The researchers found that infants receiving bottles of breastmilk with added formula powder were 3.9 times more likely to be receiving breastmilk at 4 months corrected as compared to infants who were receiving a few bottles of formula a day. What else? Check the question!

What do you think are accurate statements based on this study regarding the differences in growth between those who received breastmilk with formula powder supplementation vs those who received bottles of breastmilk? Choose none, 1 or both:

The premature infants who received bottles of breastmilk with formula powder weighed less at 4 months compared to those who received bottles of formula.
The premature infants who received bottles of breastmilk with formula powder had a higher likelihood of growth restriction as compared to those who received bottles of formula.
The infants who received bottles of formula were more likely to have weights above the 50th%.

See the Answer

Correct Answers: A and C (not B)

Comparison of Types of Breast Milk Fortification at Discharge from the Neonatal Intensive Care Unit and Breast Milk Feeding Rates and Growth at 4 Months Corrected Age

Breastfeeding Medicine 15(10) 2020; 955-661

Brigitta Gehl, Elizabeth Brownell, Kimberly Power, Richard Feinn, Kathleen Haines, Mary Lussier, James Moore, and Shabnam Lainwala

Abstract

Background

Effects of breast milk (BM) enhancement on long-term BM feeding in preterm infants discharged from the neonatal intensive care unit (NICU) have not been examined previously. This study compares any BM feeding rates at 4 months corrected age (CA) in preterm infants discharged from the NICU on BM enhancement by fortification of expressed BM with infant formula additives (BM-F) versus BM supplemented with infant formula feeds (BM-S).

Subjects and Methods

We compared infants born between January 1, 2013, and December 31, 2017, with gestational age <32 weeks or birth weight <1500 g, discharged home on BM-F or BM-S from two NICUs and followed at 4 months CA. Multivariate logistic regression with propensity scoring estimated the adjusted associations between nutrition at discharge and any BM feeding at 4 months CA.

Results

Two hundred eighty-five infants were followed at 4 months CA. Infants discharged on BM-F were more likely to have mothers with multiple gestation, private insurance, and not Caucasian, initiate feeds of human milk, be discharged from NICU-1, and receive any BM at 4 months CA (p < 0.03). No significant difference in growth parameters <10th percentile at 4 months CA was observed between the two groups. After adjusting for confounding factors, discharge from the NICU on BM-F was significantly associated with BM feeding at 4 months CA (odds ratio: 3.89, 95% confidence interval 1.66–9.14, p = 0.002).

Conclusion

In this observational study, preterm infants receiving BM fortified with formula powder additives at discharge from the NICU had better BM feeding outcomes without poor growth at 4 months CA relative to those infants receiving BM supplemented with infant formula feeds.

IABLE Comment by Anne Eglash MD, IBCLC, FABM

The premature and very low birth weight infants who received bottles of breastmilk with formula powder were NOT at higher risk for growth restriction as compared to the infants who were given bottles of formula. They had lower growth parameters compared to the infants given infant formula, who had grown larger. Infants given bottles of formula had a higher risk of being over the 50th % for weight, and there was a trend towards the 85% for weight at 4 months corrected age. They raised the concern as to whether such rapid growth would be associated with a higher risk of obesity and metabolic diseases due to overweight.

This study did not include a comparison group of infants who received unenhanced breastmilk, nor did the authors discuss parameters that would determine whether the NICU graduates needed fortification by using the NICU Graduate Going Home Protocol outlined by the Academy of Breastfeeding Medicine.

Jeannie Manthe

January 20, 2021 at 7:16 PM

Do any of the studies take into account Nils Bergman’s work? He said they never (or maybe rarely) fortify breastmilk in his clinics/work, yet administer micronutrients and vitamins needed. They do not alter the breastmilk. That is what he said when he was last in Wisconsin, to speak.

Anne Eglash

January 20, 2021 at 7:57 PM

These authors simply compared the 2 methods of fortification. The authors didn’t discuss NOT fortifying. In their background they discussed the need to fortify breastmilk for VLBW and very premature infants. You, I, and many others, know that much more work is needed to identify who really needs this fortification.

January 20, 2021 at 8:45 PM

Formula fed infants grow faster than breastmilk fed infants, right? And I would ask how much milk did mom have stored up in the freezer prior to discharge, which would impact how long her milk lasted; so many variables. I do think that the nutrient benefits from using 2 bottles of PDF fortified to 24 and then unadulterated breastmilk for all other feedings if volumes are > 180cc/kg/day do grow post discharge infants. and makes it easier to transition to breastfeeding which for my mom’s is usually the goal. Just thoughts.