Human milk fortifiers are products that can be added to expressed breast milk to increase its nutritional content for premature infants. There are three main approaches to fortification - standard fixed dosage, adjustable based on blood urea nitrogen levels, and targeted fortification using human milk analysis. Fortifiers provide additional protein, calories, and minerals to help premature infants achieve adequate growth. While fortification benefits growth, high osmolality from fortifiers can cause feed intolerance and risks like necrotizing enterocolitis. Careful monitoring of infants on fortified breast milk is needed to optimize nutrition and growth.

1. HUMAN MILK FORTIFIERS
Dr Jo Martin Kuncheria
JR, Pediatrics

2. DEFINITION
Human milk fortifiers are commercially available
products that can be added to EBM to increase its
nutritional composition to meet the high nutritional
requirements of premature baby.

3. INTRODUCTION cont
• Human milk is recommended as the first choice for
feeding all infants
• Benefits include nutritional, immunologic,
developmental ,psychological, social, and economic.
• Reduction in three widely occurring morbidities,
necrotizing enterocolitis (NEC), bronchopulmonary
dysplasia (BPD), and retinopathy of prematurity
(ROP)

4. INTRODUCTION cont
• Human milk alone is insufficient to meet the nutritional
needs of preterm infants, especially protein and
minerals.
• Infants born early in the third trimester miss the
placental transfer of nutrients which would normally
create stores for use in the postnatal period.
• Commercial fortifiers can meet the protein needs of the
rapidly growing preterm infant. protein
recommendation for a VLBW infant would be about
3.5-4.4 g/kg/d.

8. COMPOSITION OF HMF
• HMF available in international market contain similar
amounts of protein, energy, calcium & phosphorus
• Difference is in type of protein and amounts of lactose,
sodium & vitamins
• Human milk fortifier is available in India as 2gm pack
(Lactodex HMF).
• The powder is added to 50ml human milk.
• Provides additional 0.2gm protein, 0.19g fat, 1.2g
carbohydrate & significant amount of calcium, phosphorus,
vitamins, minerals and trace elements.

9. Composition of HMF

11. INDICATIONS
• Low birth weight of less than 1500gm
• Less than 30wks gestation
• Late preterms SGA/IUGR
Continued till the infant is successfully shifted to breastfeeding
Fortification started as half strength for 2 days if tolerated full
strength given.

12. ADVANTAGE
Provide increased protein, energy and minerals
Short term increase in weight gain, linear and head
growth.

14. STRATEGIES FOR FORTIFICATION
Three approaches for fortifying human milk
• Standard fixed dosage or “blind fortification,”
• Adjustable fortification using the blood urea nitrogen
• Targeted, individualized, fortification that may
be based on periodic human milk analysis (HMA), and
then modifying the fortification plan

15. STANDARD FORTIFICATION
• Most widely used strategy and is based on the assumption that the human milk being
fortified has a protein content of 1.5 g/dL.
• A fixed dosage of fortifier is added to milk over the entire fortification period.
• This method does not account for any changes in caloric and nutrient content of the milk
being fortified.
• Therefore, the nutrient content variation in milk, the stage of lactation, and the
characteristics of the milk sample (whether a full expression or an overrepresentation of
foremilk or hindmilk), are not factored into the plan.
• The resulting fortified milk probably has less protein and energy than the labelled content
suggests from the Fortifier
• At recommended dosages, these products may provide an additional 1-1.5 g/dL of protein,
up to 1 g/dL of fat, and 0.4-3.4 g/dL of carbohydrates
• Protein levels <3.5 to 4gm/kg/d at intakes of 150ml/kg/d with standard fortification
• Studies suggest that fixed dosage fortification of breast milk may not meet the
recommended intake in about 25-40% of VLBW infants.

16. ADJUSTABLE FORTIFICATION
The amount of additional fortifier or modular protein
added to human milk is based on changes in serial BUN
measurements
It assumes that the changes in the BUN are a surrogate
for assessing adequate protein supply.
If the BUN is below a critical threshold, additional
fortifier and, perhaps, a protein supplement are added.
If the BUN is above a level considered to suggest
excessive protein, the amount of fortifiers is reduced.

17. TARGETED FORTIFICATION
• Traditional milk analysis using reference chemical analysis which is
time consuming, laborious, and most importantly, not available in real
time has given way to infrared spectroscopy.
• By measuring and adjusting protein,fat and carbohydrate content every
12 hours
• These human milk analyzers (HMAs) permit the clinician to tailor
macronutrient content based on real-time analysis of human milk.
• Therefore, it aims to “standardize” the composition of breast milk and
provide VLBW infants with a constant and defined intake .
• Much of the work with these analyzers has been within research
protocols
• Available for routine clinical use when they are approved by the US
Food and Drug Administration.

18. RECOMMENDATIONS FOR USE OF HMF
• HMF may be initiated in LBW infants less than 1500g. In more
than 1500g its use may be considered
• Fortification is best started when the infant is accepting 100-
150ml/kg/day milk
• Gradually milk volume should be increased to 180ml/kg/day.
• The aim is to achieve at least 15gm/kg/day weight gain
• Fortification should be continued until the infant reaches 2-2.5kg
or corrected age term which ever comes later
• Monitor the adequacy of feeding by clinical and laboratory
parameters in order to adjust the daily requirement and optimize
growth

19. ADVERSE EFFECTS AND SAFETY CONCERNS
Feed intolerance
Neonatal sepsis
Poor fat absorption
Enhanced blood urea level & increased somatic and linear
growth
Associated with later hypertension and obesity

20. INCREASED OSMOLALITY CAUSING
FEED INTOLERANCE
• Breakdown of maltodextrin present in HMF by breast milk
amylase
• Increase osmolality from 300mOsm/kg H2O to 400.
• Hyperosmolar feeds (400mOsm/Kg) are a risk factor for
necrotizing enterocolitis.
• Symptoms: Vomiting, Lethargy ,altered frequency of motions
• Signs:
Abdominal distension, reduction /absent bowel sounds, abdominal
tenderness, cyanosis, bradycardia , metabolic acidosis , poor
weight gain, increased gastric residuals { > 2mL/Kg}

21. ADVERSE EFFECTS OF HMF CONT…
• Neonatal sepsis:
Risk of sepsis being higher with liquid fortifier
Poor Fat absorption: can overcome by providing additional fat.
But additional fat may reduce appetite.
Enhanced blood urea level & increased somatic and linear
growth:
Use beyond 2nd and 3rd weeks cause nitrogen retention,
enhanced blood urea level & increased somatic and linear
growth related to increased protein and energy intake
•SGA infants –faster weight gain may be associated with later
hypertension and obesity

22. GROWTH MONITORING IN HMF FED
INFANTS
CLINICAL
• Daily weight gain: initially a minimal of 15g/kg/day. Subsequently
after reaching 2kg , 20-30gm/day
• Length gain: at least 1cm/week
• Head circumference: at least 1cm/week
LABORATORY/BIOCHEMICAL
• Bone mineral status: serum calcium, phosphorus, alkaline
phosphatase
• X ray of wrist: To detect vitamin D deficiency changes
• Protein status: serum albumin ,BUN
• Electrolytes: Sodium, potassium, bicarbonate, especially in infants
on diuretics
• Hemoglobin and reticulocyte count
• Zn and Cu in post surgical conditions and gut losses.

23. CONCLUSION
• HMF is aimed at obtaining a better weight gain and better
growth and development ,both short term and long term
• HMF may be used in preterm,LBW babies(less than 1500gm
birth weight) after the infant is accepting 150ml/kg/day of milk
• Gradually milk volume should be increased to 180ml/kg/day so
that a minimal 15g/kg/day weight gain occurs
• Growth monitoring is advisable for adjusting daily requirements
and optimizing growth
• Feed intolerance can occur because of increased osmolality and
sepsis
• Causing a hike in osmolality results in feed intolerance and
predispose to NEC

24. Thank you