HMF.pptx

HMF.pptx

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.

5. 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.

6. Composition of HMF

7. 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.

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

9. 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

10. 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.

11. 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.

12. 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.

13. 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

14. 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

15. 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 }

16. 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 2 nd and 3 rd 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

17. 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.

18. 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

19. Thank you