Extrauterine Growth Restriction: What Is the Evidence for Better Nutritional Practices in the Neonatal Intensive Care Unit?

Dana Lunde, DNP RNC APRN NNP-BC

Disclosures

NAINR. 2014;14(3):92-98. 

In This Article

Liquid Human Milk Fortifier

Chan[43] also reported that contamination with Enterobacter sakazakii is well known with powdered infant formula use in the hospital setting and has led to infection and death. So, more recently Abbott Nutrition® and Mead Johnson Nutrition® have produced bovine-based liquid human milk fortifiers to further reduce the use of powder for enteral feedings in the hospital setting. Due to the recent evidence supporting the need for higher protein intake in small premature infants, both manufacturers reformulated their human milk fortifiers to include additional protein. Just like in the bovine powdered human milk fortifiers, the nutritional composition of both products is similar but some distinct differences do exist (Table 3). The Similac® liquid human milk fortifier[44] contains less protein, fat and carbohydrates but has higher amounts of calcium, phosphorus, and magnesium. Enfamil® liquid human milk fortifier[45] contains higher protein, fat and carbohydrates as well as more iron, and is acidified with a pH of 4.3–4.7.

Little evidence exists on the use of liquid human milk fortifiers and its effect on premature infants. Moya and associates[46] conducted a multi-center RCT that included 150 VLBW infants who received either the standard powdered human milk fortifier or the new liquid human milk fortifier (Enfamil® acidified liquid human milk fortifier) for 28 days. The liquid human milk fortifier was noted to provide 20% more protein than the standard powdered human milk fortifier. Infants who received the liquid human milk fortifier were noted to have a significant increase in weight, length and head circumference with no differences in feeding intolerance or days to reach full feedings. Albumin, prealbumin and BUN levels were noted to be significantly higher in infants who received the liquid human milk fortifier, which is consistent with the findings from the early amino acid RCTs discussed previously. Based on these findings, the authors concluded that the administration of liquid human milk fortifier was safe and prevented the use of powdered human milk fortifier.

Rochow et al.[47] designed and completed a double blind RCT to determine if an increased incidence of metabolic acidosis was associated with the use of a new commercially available liquid human milk fortifier and whether modification of the liquid human milk fortifier (Enfamil® acidified liquid human milk fortifier) would decrease the incidence of metabolic acidosis. Seven out of 8 infants who received the commercially available liquid human milk fortifier developed metabolic acidosis in comparison to 1 out of 7 infants who received the standard human milk fortifier. This finding resulted in the study being interrupted and the liquid human milk fortifier being modified. Metabolic acidosis continued to occur after modification and the authors noted in the overall analysis that the infants with metabolic acidosis had lower mean weight gain and a lower bone mineral content at discharge.[47]

Thoene and colleagues[48] had similar findings in their retrospective chart review of 69 human milk fed premature infants with a birth weight < 2000 g. Infants who received the new liquid human milk fortifier (Enfamil® acidified liquid human milk fortifier) had a significantly higher incidence of metabolic acidosis, and poor weight gain resulting in an increase in fortification of feedings to greater than 24 calories/ounce. Infants who received the liquid human milk fortifier also had increased incidence of NEC but the retrospective study was not powered to study the incidence of NEC as a primary outcome.

The use of liquid human milk fortifier may improve growth in premature infants provided that the composition is appropriate and does not lead to adverse outcomes. A limitation of the available evidence is that only one of the commercially available liquid human milk fortifiers (Enfamil® acidified liquid human milk fortifier) has been studied. Therefore, additional research involving both commercially available liquid human milk fortifiers should be conducted in order to make an evidence-based decision on the use of liquid human milk fortifiers.

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