Early

Human

Development,

29 (1992)

339

339-343

Elsevier Scientific Publishers Ireland Ltd. EHD 01300

Fortified preterm human milk for very low birth weight infants K. Itabashi, T. Hayashi, T. Tsugoshi, H. Masano and K. Okuyama Department

of Pediatrics,

Showa

University

School

of Medicine,

I-5-8

Hatanodai.

Shinagawa-ku,

Tokyo

(Japan)

We studied the nutritional effects of low birth weight infants. These studies nuritional advantages for very low birth and phosphorus with supplementation density. Key wor&: human milk fortifier; disease of prematurity

two types of human milk fortifiers suggest that fortified human milk weight infants. However, providing is necessary for the improvement

for very provides calcium of bone

very low birth weight infants; metabolic bone

Introduction Human milk has the advantages of easy digestability, bio-available nutrients and the presence of host-resistance factors. Human milk is the safest and preferred diet for term infants. For very low birth weight (VLBW) infants, milk of mothers who deliver the preterm infants (preterm human milk) is widely acceptable, but whether preterm human milk provides the optimal nutrients is a controversial issue. Nutritional problems such as hypoproteinemia, hyponatremia and metabolic bone disease of prematurity are common in VLBW infants fed preterm human milk. Therefore, nutrient supplementation for VLBW infants may be advocated in order to enhance the nutrient contents of preterm human milk. We studied the effects of two types of human milk fortifiers for VLBW infants from the growth and biochemical aspects. The first type was human milk protein and the other was a commercial human milk fortifier. Correspondence to: K. Itabashi, Department of Pediatrics, Showa University School of Medicine, l-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan. 0378-3782/92/%05.00 0 1992 Elsevier Scientific Publishers Ireland Ltd Printed and Published in Ireland

340

Fortified preterm human milk Fortified preterm human milk with human milk protein Human milk protein was provided from pooled human milk. The human milk concentrate was prepared by removal of fat in a milk separator and by ultrafiltration of the skimmed milk. Each 1.5 g of concentrate mainly contains 0.51 g of human milk protein and a small amount of minerals. To prepare the fortified preterm human milk, 1.5 g of this fortifier were added to, each 100 ml of preterm human milk (protein/energy ratio = 2.45-2.55 g/100 kcal) Fortification of human milk protein was started after 3 weeks of postnatal age after the consumption of VLBW infants received 150- 160 ml kg-’ day-’ of preterm human milk. The aim of this study was designed to evaluate how the addition of human milk protein may influence growth, bone density and biochemistries in VLBW infants fed preterm human milk during the first 2 months of life. A weight gain rate in the foritifed group was significantly greater than the unfortified group (17.6 g kg-’ day-’ versus 15.4 g kg-’ day-‘), but body length and head circumference gains were not significantly different. In comparing blood biochemical data, the serum levels of total protein, albumin, calcium and blood urea nitrogen in the fortified group were significantly’ higher without any metabolic disturbances. However, the phosphorus level was lower than the unfortified group. The serial changes of bone density were not significantly different between both groups during study period. After fortification, urinary calciumcreatinine ratio in the fortified group was significantly increased and was higher than the unfortified group. These changes, such as serum low phosphorus level and hypercalciuria, were due to the relative deficiency of phosphorus in the fortified group. The reason is speculated that the tissue needed much more phosphorus to coincide with the increase in body weight.

TABLE I Nutrient contents of Enfamil human milk fortifier (four packets) Energy (kcal) Protein (g) Fat (g) Carbohydrate (g) Na (mg) CI (m3) K (mg) Ca (mg) P (mf4) Mg Owl Fe (md cu w

Zn (pg)

14 0.1 0.05 2.7 7 17.7 15.6 90 45 4 80

Vitamin A (IU) Vitamin D (IU) Vitamin E (IU) Vitamin K (pg) Ascorbic acid (mg) Thiamine (mg) Ribofrabin (mg) Niacin (mg) Pyridoxine (mg) Vitamin B-12 (ag) Folic acid (ag) Pantothenic acid (pg)

780 210 3.4 9.1 24 0.187 0.250 3.1 0.193 0.81 23 790

710

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To sum up this portion of our study, the rate of weight gained by VLBW infants fed protein fortified preterm human milk was similar to the fetus of same gestational age. However, much more phosphorus and calcium might be needed in order to improve bone density. Fort$ed preterm human milk with a commercial human milk fortifier In this study, nutritional balances, intestinal flora and composition of weight gained as well as somatic growth, radial bone density and status of blood chemistries were compared with VLBW infants fed fortified preterm human milk with a commercial human milk fortifier (Enfamile Human Milk Fortifier) and unfortified preterm human milk. The nutrient and energy contents of this human milk fortifier is demonstrated in Table I. The macronutrients are also shown in this table. Four packets of this fortifier were added to each 100 ml of preterm human milk. When intake of preterm human milk reached 150-160 ml kg-’ day-‘, fortification was started (mean: 6 weeks of postnatal age) until their body weight reached 2500 g. Nutritional balance studies were done at 8 weeks of postnatal age. The weight and body length gained by the VLBW infants fed fortified preterm human milk were greater than the VLBW infants fed unfortified preterm human milk (15.5 g kg-’ day-’ versus 14.2 g kg-’ day-‘, 0.90 versus 0.67 cm week-‘). Head circumference in the fortified group increased similar to that of the unfortified group. Results of nutritional balance studies is shown in Table 2. As shown in the table, nitrogen and energy retention in the fortified group was greater than the unfortified group. The composition of weight gained by the two groups and reference fetus during 28-36 weeks of gestation [l] is demonstrated in Fig. 1. The protein accretion in the unfortified group was lower than the fortified group and the fetus. The fat deposition in study groups was greater than the fetus.

TABLE II Nitrogen and energy balance (mean f S.D.)

Nitrogen (mg-’ kg-’ day) Intake Excretion Urine Feces, Retained Absorption (%) Retention (%) Energy (kcal kg-’ day-‘) Gross intake Energy losses Metabolizable Metabolic rate Retained

Preterm human milk

Fortified preterm human milk

303

l

451

f 72

34 74 196 88.6 64.4

f 6 f 22 zt 45 zt 2.3 f 7.8

29 69 354 91.4 77.6

ztz9 12 f 71 f 4.5 zt 4.0

109.2 6.5 102.7 55.4 47.4

zt f zt f f

127.7 9.5 118.2 65.7 52.5

f 14.3 f 2.7 zk 16.7 f 9.5 f 16.2

50

6.3 2.1 6.4 2.9 4.7

l

342

18.0 16.0 14.0 12.b IO.0 8.0 6.0 4.0 2.6 0I Preterm

Human

Fortified Preterm Human milk

Milk

Fetus (28-36wks)

Fig. 1. Composition of weight gained by the preterm human milk group, the fortified group and the reference fetus.

preterm

human

milk

Serum total protein, albumin, calcium, phosphorus, blood urea nitrogen in the fortified group were higher than the unfortified group without any metabolic disturbances. The bone density in the fortified group increase after fortification (Fig. 2). Analysis of intestinal flora at the end of this study showed that bifidobacterium was dominant in both groups. In summarising this study, the protein accretion and body weight gain in the VLBW infants fed fortified preterm human milk with the commercial human milk

l.“I. lIO.90.80.70.60. li0.4’

, o-13

I 14-Z

28-41 postnatal

42-55

56-69 age

70-83

84-97

Cd)

Fig. 2. Serial changes of the bone density analyzed by microdensitometry in the fortified group. The shadowed area represents the pretenn human milk group (mean * SD.); 0, before fortification; l , after fortification.

343

fortifier achieved levels similar to that of the fetus. And the bone density was also improved. Fortified preterm human milk with the commercial human milk fortifier might not have any affect on the intestinal flora. Conclusion In order to compensate the nutritional disadvantages of preterm human milk without compromising the superiority of preterm human milk, protein fortification of preterm human milk is advisable for very low birth weight infants. Our two studies suggest that daily protein intake of 2.25-2.55 g 100 kcal-’ may achieve the weight gain rate similar to that of the fetus without any metabolic disturbances. But, providing calcium and phosphorus with protein supplementation is necessary for the improvement of bone density. Reference 1 Ziegler, E.E., O’Donnell, A.M., Nelson, SE. et al. (1976): Body composition of the reference fetus Growth. 40, 329-341.

Fortified preterm human milk for very low birth weight infants.

We studied the nutritional effects of two types of human milk fortifiers for very low birth weight infants. These studies suggest that fortified human...
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