Comparison of the effect of two human milk fortifiers on clinical outcomes in premature infants

Melissa Thoene, Corrine Hanson, Elizabeth Lyden, Laura Dugick, Leslie Ruybal, Ann Anderson-Berry, Melissa Thoene, Corrine Hanson, Elizabeth Lyden, Laura Dugick, Leslie Ruybal, Ann Anderson-Berry

Abstract

The use of human milk fortifiers (HMF) helps to meet the high nutritional requirements of the human milk-fed premature infant. Previously available powdered products have not met the protein requirements of the preterm infant population and many neonatologists add powder protein modulars to help meet protein needs. The use of powdered products is discouraged in neonatal intensive care units (NICU) due to concern for invasive infection. The use of a commercially available acidified liquid product with higher protein content was implemented to address these two concerns. During the course of this implementation, poor growth and clinically significant acidosis of infants on Acidified Liquid HMF (ALHMF) was observed. The purpose of this study was to quantify those observations by comparing infant outcomes between groups receiving the ALHMF vs. infants receiving powdered HMF (PHMF). A retrospective chart review compared outcomes of human milk-fed premature infants<2000 g receiving the ALHMF (n=23) and the PHMF (n=46). Infant growth, enteral feeding tolerance and provision, and incidence of necrotizing enterocolitis (NEC), metabolic acidosis, and diaper dermatitis were compared between the two groups. No infants were excluded from this study based on acuity. Use of ALHMF resulted in a higher incidence of metabolic acidosis (p=0.002). Growth while on HMF as measured in both g/kg/day (10.59 vs. 15.37, p<0.0001) and in g/day (23.66 vs. 31.27, p=0.0001) was slower in the ALHMF group, on increased mean cal/kg/day (128.7 vs. 117.3, p=0.13) with nearly twice as many infants on the ALHMF requiring increased fortification of enteral feedings beyond 24 cal/ounce to promote adequate growth (48% vs. 26%, p=0.10). Although we were not powered to study NEC as a primary outcome, NEC was significantly increased in the ALHMF group. (13% vs. 0%, p=0.03). Use of a LHMF in an unrestricted NICU population resulted in an increase in clinical complications within a high-acuity NICU, including metabolic acidosis and poor growth. Although further research is needed to assess outcomes among infants with a variety of clinical acuities, gestational ages, and weights to confirm these findings, based on this experience, caution is urged to avoid potential risks.

Figures

Figure 1
Figure 1
CO2 levels between groups after Day of Life 14. The lowest CO2 levels after DOL 14 were collected from metabolic panels. The mean level in the powder group was 23, the mean level in the liquid group was 18.5. Laboratory clinical reference range 22–32 mmol/L. The difference is statistically significant (p = 0.002).
Figure 2
Figure 2
CO2 levels between groups after Day of Life 30. The lowest CO2 levels after DOL 30 were collected from metabolic panels. The mean level in the powder group was 25, the mean level in the liquid group was 20. Laboratory Clinical reference range 22–32 mmol/L. The difference is statistically significant (p = 0.002).
Figure 3
Figure 3
The growth pattern of infants receiving powder differs from the growth pattern of infants receiving liquid on fortified feed days. The plot shows the growth pattern for each infant and the fitted line by group. Based on the plot, infants on powder grow at a faster rate than infants receiving liquid. Evaluation of growth in gm/kg/day for the days infants were fed fortified breast milk, based on the mixed effects model, shows a significant interaction between day and group (p = 0.0022). Truncating the analysis at 45 days did not attenuate the results.

References

    1. American Academy of Pediatrics . Pediatric Nutrition Handbook. 6th ed. American Academy of Pediatrics; Washington, DC, USA: 2009.
    1. Groh-Wargo S., Thompson M., Cox J.H. In: Nutritional Care for High-Risk Newborns. 3rd ed. Hartline J.V., editor. Precept Press; Chicago, IL, USA: 2000.
    1. Sullivan S., Schanler R.J., Kim J.H., Patel A.L., Trawöger R., Kiechl-Kohlendorfer U., Chan G.M., Blanco C.L., Abrams S., Cotton C.M., et al. An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products. J. Pediatr. 2010;156:562–567. doi: 10.1016/j.jpeds.2009.10.040.
    1. Tsang R.C. In: Nutrition of the Premature Infant: Scientific Basis and Practical Guidelines. 2nd ed. Uauy R., Koletzko B., Zlotkin S.H., editors. Digital Education Publishing; Cincinnati, OH, USA: 2005.
    1. Clark R.H., Thomas P., Peabody J. Extrauterine growth restriction remains a serious problem in prematurely born neonates. Pediatrics. 2003;111:986–990. doi: 10.1542/peds.111.5.986.
    1. Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129:e827–e841. doi: 10.1542/peds.2011-3552.
    1. Hawthorne K.M., Abrams S.A. Safety and efficacy of human milk fortification for very-low-birthweight infants. Nutr. Rev. 2004;62:482–485. doi: 10.1111/j.1753-4887.2004.tb00020.x.
    1. Valentine C.J., Fernandez S., Rogers L.K., Gulati P., Hayes J., Lore P., Puthoff T., Dumm M., Jones A., Collins K., et al. Early amino-acid administration improves premature infant weight. J. Perinatol. 2009;29:428–432. doi: 10.1038/jp.2009.51.
    1. Stephens B.E., Walden R.V., Gargus R.A., Tucker R., Mckinley L., Mance M., Nye J., Vohr B.R. First-week protein and energy intakes are associated with 18-month developmental outcomes in extremely low birth weight infants. Pediatrics. 2009;123:1337–1343. doi: 10.1542/peds.2008-0211.
    1. Maggio L., Costa S., Gallini F. Human milk fortifiers in very low birth weight infants. Early Hum. Dev. 2009;85:S59–S61. doi: 10.1016/j.earlhumdev.2009.08.018.
    1. Kuschel C.A., Harding J.E. Multicomponent fortified human milk for promoting growth in premature infants. Cochrane Database Syst. Rev. 2004;1:CD000343.
    1. Hanson C., Sundermeier J., Dugick L., Lyden E., Anderson-Berry A.L. Implementation, process, and outcomes of nutrition best practices for infants < 1500g. Nutr. Clin. Pract. 2011;26:614–624.
    1. Ehrenkranz R.A., Dusick A.M., Vohr B.R., Wright L.L., Wrage L.A., Poole W.K. Growth in the neonatal intensive care unit influences neurodevelopmental and growth outcomes of extremely low birth weight infants. Pediatrics. 2006;117:1253–1261. doi: 10.1542/peds.2005-1368.
    1. Himelright I., Harris E., Lorch V., Anderson M., Jones T., Craig A., Kuehnert M., Forster T., Arduino M., Jensen B., et al. Enterobacter sakazakii infections associated with the use of powdered infant formula—Tennessee, 2001. MMWR. 2002;51:297–300.
    1. Berseth C.L., Mitmesser S.H., Stolz S., Harris F.M., Sisk P. Growth and safety of premature infants fed a new liquid human milk fortifier. FASEB J. 2011;25:589.3.
    1. Enfamil Enfamil Human Milk Fortifier Acidified Liquid Website. [(accessed on 6 March 2012)]. Available online: .
    1. Similac Human Milk Fortifier Website. [(accessed on 6 March 2012)]. Available online: .
    1. Fenton T.R. A new growth chart for premature babies: Babson and Benda’s chart updated with recent data and a new format. BMC Pediatr. 2003;3:13. doi: 10.1186/1471-2431-3-13.
    1. Fenton T.R., Sauve R.S. Using the LMS method to calculate z-scores for the Fenton premature infant growth chart. Eur. J. Clin. Nutr. 2007;61:1380–1385. doi: 10.1038/sj.ejcn.1602667.
    1. Patel A., Engstrom J., Meier P., Kimura R. Accuracy of methods for calculating postnatal growth velocity for extremely low birth weight infants. Pediatrics. 2005;116:1466–1473. doi: 10.1542/peds.2004-1699.
    1. Kalhoff H., Manz F., Kiwull P., Kiwull-Schone H. Food composition and acid-base balance: Alimentary acid load and clinical implications in neonates. Open Nutr. J. 2008;2:5–8. doi: 10.2174/1874288200802010005.
    1. Manz F., Kalhoff H., Remer T. Renal acid excretion in early infancy. Pediatr. Nephrol. 1997;11:231–243. doi: 10.1007/s004670050270.
    1. Erickson T., Gill G., Chan G.M. The effects of acidification on human milk’s cellular and nutritional content. J. Perinatol. 2013;33:371–373.
    1. Moya F., Sisk P.M., Walsh K.R., Berseth C.L. A new liquid human milk fortifier and linear growth in preterm infants. Pediatrics. 2012;130:928–935. doi: 10.1542/peds.2011-3120.
    1. Cibulskis C.C., Bowles M. Metabolic Acidosis Associated with Liquid Acidified Human Milk Fortifier; Proceedings of the AAP Section on Perinatal Pediatrics Scientific and Educational Program Abstract and Poster Presentations; Orlando, FL, USA. 25–29 October 2013.
    1. Caso G., Garlick B.A., Casella G.A., Sasvary D., Garlick P.J. Acute metabolic acidosis inhibits muscle protein synthesis in rats. Am. J. Physiol. Endocrinol. Metab. 2004;287:E90–E96. doi: 10.1152/ajpendo.00387.2003.
    1. Reaich D., Channon S.M., Scrimgeour C.M., Goodship T.H.J. Ammonium chloride-induced acidosis increases protein breakdown and amino acid oxidation in humans. Am. J. Physiol. 1992;263:E735–E739.
    1. Kalhoff H., Manz F. Nutrition, acid-base status and growth in early childhood. Eur. J. Nutr. 2001;40:221–230. doi: 10.1007/s394-001-8349-y.
    1. Kalhoff H., Manz F., Diekmann L., Kunz C., Stock G.J., Weisser F. Decreased growth rate of low-birth-weight infants with prolonged maximum renal acid stimulation. Acta Paediatr. 1993;82:522–527. doi: 10.1111/j.1651-2227.1993.tb12742.x.
    1. Kalhoff H., Rascher W., Diekmann L., Stock G.J., Manz F. Urinary excretion of aldosterone, arginine vasopressin and cortisol in premature infants with maximum renal acid stimulation. Acta Paediatr. 1995;84:490–494. doi: 10.1111/j.1651-2227.1995.tb13680.x.
    1. Kalhoff H., Diekmann L., Rudloff S., Manz F. Renal excretion of calcium and phosphorus in premature infants with incipient late metabolic acidosis. J. Pediatr. Gastroenterol. Nutr. 2001;33:565–569. doi: 10.1097/00005176-200111000-00010.
    1. Rochow N., Jochum F., Redlich A., Korinekova Z., Linnemann K., Weitmann K., Boehm G., Müler H., Kalhoff H., Topp H., et al. Fortification of breast milk in VLBW infants: Metabolic acidosis is linked to the composition of fortifiers and alters weight gain and bone mineralization. Clin. Nutr. 2011;30:99–105. doi: 10.1016/j.clnu.2010.07.016.

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