Dr. Sheila Mathai , DM, MD, DNB *
Associate Professor (Pediatrics) & Neonatologist, Armed Forces Medical College, Pune. *
There is on doubt that human milk is the most optimal nutrition for term babies. That it is also adequate for the Low Birth Weight (LBW) baby in sufficient quantities is now becoming more and more evident (1). These babies may not require any other supplements other than calcium, phosphorous, vitamins (till 3 kg weight) and iron (till 1 year). The problems arise in Very Low Birth Weight (VLBW) and the Extremely Low Birth Weight (ELBW) babies. Can breast milk fulfill the nutritional requirements of these tiny babies? A significant proportion of protein, minerals, iron and other nutrient accretion occur during the third trimester of gestation. By virtue of their untimely birth, premature infants are relatively deficient in some nutrients. They also have greater requirements for protein, minerals and other nutrients for growth. Delayed onset of feedings, volume restriction and variable composition of mother's milk are but a few of the factors posing limitations in the exclusive use of human milk for preterm infants. The nutritional requirements of these babies have been based on the assumption that postnatal growth curves should follow intrauterine accretion rates. This may not be true considering the many adaptations that the fetal infant has to make in an extrauterine environment. The composition of preterm breast milk depends on the stage of gestation. Higher concentrations of nitrogen, immune proteins, medium chain fatty acids, vitamin A and E, calcium, sodium, zinc and copper have been identified in preterm milk suggesting that it is suited for that particular age of gestation. The protein content, however, decreases significantly after 4-6 weeks of birth. There is also a great variation in the nutritive values of preterm milk in different studies, with some showing no difference as compared to mature milk (2). Even at maximum levels of feeding (200 ml/kg/day) the calcium and phosphorus in human milk represent only 25% of the amount thought to be required for normal bone mineralization of a preterm baby (3). Hence, the role of exclusive human milk in premature infants as regards nutritive adequacy is still controversial, though its other benefits remain undisputed. The host of short-term and long-term benefits from human milk including improved immunity, protection from NEC, improved neurodevelopment and beneficial cell programming suggest that it should be the obvious first choice for use in this group of babies as well, with some additions.

FORTIFICATION OF HUMAN MILK: It seems reasonable, given the existing evidence, that some amount of supplementation of protein, calcium, phosphorus, sodium and certain vitamins like vitamin A, D and folic acid is required for VLBW babies fed adequate quantities of breast milk (180-200 ml/kg/day). Trace elements, zinc and vitamin B and C may be required if these are deficient in the milk of malnourished mothers. Commercially produced multicomponent fortifiers provide additional nutrients to human milk in the form of protein, calcium, sodium, phosphate, and minerals as well as vitamins and trace elements. Considering the convenience of an "all in one" fortifier that contains all the extra requirements (except iron), many NICUs the world over use these in the hospital setting or till the baby is 1.8 kgs of weight. Fortified human milk positively affects protein intake and protein retention in preterm infants (4). Total serum protein and BUN levels are higher, approaching normal, in infants fed fortified human milk. Commercial human milk fortifiers have been shown to boost weight gain, length increase, and head growth and to improve bone mineral content and nitrogen balance in the short term (5). Controlled trials have not shown fortifiers to be responsible for persistent GI intolerance, increased gastric residuals, bilious gastric residuals, abdominal distention, or blood in. Human milk fortification increases milk osmolality but does not increase feeding intolerance or NEC (6). However, it must be remembered that the composition of fortifiers vary and it is prudent to calculate the exact amounts being supplemented so as not to give any nutrient either in excess or inadequate quantities. In India, Lactodex HMF of Raptakos, Brett & Co., is the only Human Milk Fortifier available and though no scientific studies have been published on it's use, anecdotal evidence suggests that it is effective in improving short-term growth in preterm babies. Though adverse effects of fortification do not appear to be significant, there is still insufficient data evaluating its effect on long-term neurodevelopment and growth outcomes. Fortification is usually started when feeds reach 100 ml/kg by adding 1 sachet (2 grams) to 50 ml of Expressed Breast Milk (EBM). This can be fed over 4-6 hrs if kept at 4C. Alternatively ½ sachet is added to 25 ml of EBM. Usually 3-4 sachets of HMF/day suffice even for the smallest babies once they are on full feeds. This works out to an expense of Rs.1000/- per month.

Individual supplements may also be added to breast milk in small quantities and given between feeds. It is not recommended to mix these in the entire feed as it may alter fat absorption due to the formation of complexes. Supplementation is usually started in preterm VLBW babies when fortification is stopped at 1.8 kgs of weight and continues till the weight reaches 3.0 kgs. It is also recommended in LBW babies till the same weight as they may not consume enough milk to meet their requirements and also the mothers may be malnourished themselves resulting in a lesser quantity of these nutrients in their milk. Table 1 gives the requirement if supplements in a preterm on adequate (180-200 ml/kg) breast milk. Calcium and phosphorous supplements are most commonly used in the doses of 30-50 mg/kg/day of calcium and 15-30 mg/kg/day of phosphorous. Vitamins that need to be supplemented enterally in the preterm baby being fed human breast milk include Vit A, D and folic acid. Though there is no need to supplement the B group of vitamins, vitamin E or vitamin C routinely (these may only be required if the mother is severely deficient) often these are also given because they are present in "multivitamin" preparation. The Vitamin E to Poly Unsaturated Fatty Acid (PUFA) ratio in preterm human milk is 0.9 mg/gm, which is adequate for Vitamin E absorption and hence Vitamin E supplementation may not be required in those preterms fed adequate human milk. MCT oil (as coconut oil, corn oil or Simyl MCT) may be added to increase calories if weight gain is inadequate. Sodium supplementation may also be required if the baby has late hyponatremia by adding 12 ml/kg of normal saline in divided doses to the feeds. Supplementation with zinc is recommended in babies of malnourished mothers. Iron is started at 4-6 weeks in well preterms at 4-6 weeks of age in the dose of 4-6 mg/kg/day of elemental iron in a single dose. The American Academy of Pediatrics recommends that iron supplementation (as iron-fortified formula or cereal or as iron-containing drops) be given to preterm infants after 2 months of age and to full-term infants after 4 months of age, whether breast or formula fed. Oral iron preparations come in a number of forms and it is sometimes confusing deciding which one to give the baby. Ferrous sulphate or fumarate or colloidal iron are acceptable and effective forms of oral iron supplementation. Iron polysaccharide complex has not been found to be effective and should be avoided. Presently there is no protein supplement available in India suitable for preterm babies. Supplementation is usually started in preterm VLBW babies when fortification is stopped at 1.8 kgs of weight and continued till the weight reaches 3.5 kgs. Alternatively it may given instead of fortification. It is also recommended in LBW babies (both preterm and SGA babies) till the same weight is reached as they may not consume enough milk to meet their requirements and the mothers may be malnourished themselves resulting in a lesser quantity of these nutrients in their milk. However, for SGA babies the quantity supplemented may be less. Table 1 gives the requirement of supplements of common nutrients in a preterm on adequate breast milk.

Preterm formulae:
There are very few preterm formulae available in the Indian market. This may be a blessing in disguise when compared to the developed world where the plethora of products is mind-boggling. It is ironical that it is these countries, which are the most vociferous proponents of breast-feeding! Preterm formulae contain more whey than casein proteins. They also contain maltodextrins or glucose polymers, nucleotides and MCT as easily digestible forms of carbohydrate, protein and fat. In addition they contain vitamins, minerals and trace elements. No preterm formula is adequate Long Chain Polyunsaturated Fatty Acids, which are present in breast milk and are essential for neurodevelopment and retinal maturation (7). A number of preterm formulae contain micronutrients like inositol, choline, biotin, manganese copper and iodine, which the manufacturers claim, improve infant nutrition. These are normally present in breast milk. As it stands, in our country there is very little choice in terms of preterm formulae and occasionally term formulae may need to be used even for preterm babies. Exclusive formula feeding should be the exception rather than the rule due to the inherent dangers of depriving a baby the benefits of breast milk.

Follow up:
Follow up is essential to ensure that adequate nutrition is being given and that the baby is growing normally. Growth in length is as if not more important as compared to weight (8). In an elegant follow-up, study of 103 male and 92 females LBW babies catch-up growth in weight, height, and BMI occurred between 8 and 20 years among VLBW females but not among VLBW males who remained significantly smaller than their controls at 20 years old (9).

Table 1: Nutritional Requirements of Preterm Babies





1.1 gm/dl

2.7-3.7 gm/kg/day

Only if BM<180 ml/kg


4.5 gm/dl

4.5 gm/kg/day



7.1 gm/dl

8-19 gm/kg/day



33 mg/dl

120-150 mg/kg/day

66 mg/kg/day


15 mg/dl

90-110 mg/kg/day

30 mg/kg/day


0.3 mg/dl

2-6 mg/kg/day

2.5 mg/kg/day


.18-.5 mg/dl

1 mg/kg/day

.5 mg/kg/day


0.8 mEq/dl

2-4 mEq/kg/day 1-2 mEq/kg/day


1.4 mEq/dl

2-3 mEq/kg/day



1.1 mEq/dl

2-3 ,Eq/kg/day



100-150 IU/dl

600 IU/kg/day

400 IU/kg/day


8-20 IU/dl

400 IU/kg/day

400 IU/kg/day

VITAMIN E 05 IU/dl 6 IU/kg/day No


5 micro gm/dl

25 micro gm/day

20 micro gm/day


67 cal/100 ml

Max 165 ca/kg/day

If BM<180ml/kg/d

add MCTs

FLUID   Max 200 ml/kg/day No

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