Expressed breast milk: fortification  

Positive effects of breastfeeding on the health of infants include:

• Breastfeeding reduces the risk of acute infections such as diarrhoea, pneumonia, ear infection, haemophilus influenza, meningitis and urinary tract infection (WHO 2007).

• Lower risk of developing necrotising enterocolitis in preterm and low birth weight infants (King 2005; Boyd et al 2007).

• Breastfeeding has a preventative effect on the early development of asthma, allergic rhinitis, atopic dermatitis and food allergy symptoms (Schanler & Atkinson 2005). 

• Breastfeeding improves cognitive development (Kramer et al 2008).

• It promotes the maternal-infant relationship (Kramer et al 2008).

• It also protects against chronic conditions in the future such as type 1 diabetes, ulcerative colitis and Crohn's disease (WHO 2007).

• Breastfeeding during infancy is associated with lower mean blood pressure and total serum cholesterol, and with lower prevalence of type 2 diabetes, overweight and obesity during adolescence and adult life (WHO 2007).

• It is always available, at the right temperature and free!

Background

The World Health Organisation (2007) recommends exclusive breastfeeding for the first six months of life.

It is recognised that the health of preterm babies benefits greatly from the ingestion of their mothers breastmilk due to a number of factors including the presence of active enzymes that enhance the maturation of the underdeveloped gut, anti-infective properties which protect the newborn from infection and earlier tolerance of full enteral feeding (Boyd et al 2007).

Despite the benefits of breast milk, the nutrient levels in  breast milk may not fully meet the increased nutritional needs of the preterm infant, particularly energy, protein, sodium, calcium, phosphorus and some vitamins (King 2005; Edmond and Bahl 2007; McCormick et al 2009).

Preterm infants who have accumulated deficits in calcium and phosphate by the time of hospital discharge have a higher risk of low bone mineralisation, metabolic bone disease and slow skeletal growth compared to infants born at term.

Fortification of expressed breast milk (EBM) can minimise these deficiencies in preterm infants <32 weeks gestation and infants with a birth weight <1500g (Edmond and Bahl 2007)(Rationale 2).

Other babies may benefit from having their EBM fortified but their requirements will be different to those of the preterm infant (Rationale 3):

• Infants who are fluid restricted, eg those with cardiac or renal anomalies.

• Infants who are failing to thrive due to increased requirements or losses, eg in malaborptive states.

When fortification is required, an aseptic technique must be used when handling the EBM (Shaw & Rathwell 2010)(Rationale 4).

Methods of increasing the nutritional intake of the preterm infant

The first step to improve nutritional intake should be to slowly increase the volume of EBM given (Rationale 5). Well preterm infants >1500g can tolerate up to 220ml/kg (King 2005) although an iron supplement will be needed.

If the maximum volume of EBM tolerated provides inadequate nutrition for growth, then fortification should be considered. A commercial breast milk fortifier (BMF) has the advantage over suplementing with a liquid preterm formula (Rationale 6).

Supplementation with a source of energy alone is not advised (King 2005)(Rationale 7). A multi-nutrient BMF is recommended.

How to add breast milk fortifier to EBM on the ward

This procedure should be carried out as an aseptic non-touch technique in a clean area of the ward. (Shaw & Rathwell 2010)(Rationale 8). Use the ward milk kitchen when available (Rationale 9). It should be done as close to the feed time as possible (Rationale 10).

The decision to fortify EBM for a preterm baby must be made by the medical consultant (Rationale 11).

The breast milk fortifier must be prescribed by the medical staff on the infant's prescription chart (Rationale 12). Urea and electrolyte levels must be carefully monitored (Rationale 13). Serum copper and zinc levels should be checked when starting BMF (Rationale 14).

Repeat serum levels of copper and zinc after two weeks and then monthly thereafter (Rationale 15).

Fortification of EBM should be performed by a trained member of staff. In certain circumstances, this may also be done by the mother under supervision (Rationale 16).

Check the following:

• The EBM is for the correct infant (Rationale 17).

• The EBM is used in the correct rotation (Rationale 18)

• The frozen EBM is defrosted correctly (Shaw & Rathwell 2010) (Rationale 19).

Add the prescribed fortification ie NUTRIPREM BMF to the correct amount of feed (Rationale 20):

• To make ½ strength feed - add one sachet to 100ml EBM.
• To make full strength feed - add one sachet to 50ml EBM.
  

• Shake the bottle vigorously for 30-60 seconds (Rationale 21)

• Label and date the bottle and fed the fortified EBM immediately (Rationale 17).

• Ideally the feed should be given within 10 minutes of fortification (Rationale 22).

• If the fortified feed cannot be given immediately, seal and place in the milk feed refrigerator on the ward. Use within 24 hours (Rationale 23).

• Any excess defrosted EBM that has not been fortified must be discarded if not used within 24 hours (Shaw & Rathwell 2010)(Rationale 24)

• Any fresh EBM should be refrigerated or frozen for later use (Shaw & Rathwell 2010) (Rationale 25).

Rationale

Rationale 1: It is species specific.
Rationale 2: Breast feeding is not usually possible in infants < 34 weeks gestation therefore breast milk must be expressed (Schauler & Atkinson 2005).
Rationale 3: Preterm and term infants have different nutritional requirements.
Rationale 4: To prevent contamination of the EBM.
Rationale 5: Nutritional adequacy can be achieved if sufficient feed volumes are given (King 2005).
Rationale 6: It will allow more of the mother's milk to be used (King 2005).
Rationale 7: It will reduce the protein-energy ratio to an unacceptable level (King 2005).
Rationale 8: To prevent contamination of the feed.
Rationale 9: To avoid loss of immunological factors.
Rationale 10: To prevent a rise in osmolality of the feed which can begin within 10 minutes of fortification (King 2005).
Rationale 11: To ensure that addition of BMF is clinically indicated and safe.
Rationale 12: To ensure the correct dose is given.
Rationale 13: Infants receiving BMF have shown raised urea, calcium and phosphate levels.
Rationale 14: To obtain baseline levels of these nutrients.
Rationale 15: To monitor any decline in copper and zinc status.
Rationale 16: To ensure that the prescription is accurately implemented.
Rationale 17: To ensure that this is a safe procedure.
Rationale 18: To prevent wastage of EBM.
Rationale 19: To prevent contamination of EBM.
Rationale 20: To ensure that the nutrient value of the feed is increased as prescribed.
Rationale 21: To ensure an even distribution of fortifier in the breast milk (manufacturer recommendation).
Rationale 22: To minimise bacterial growth and a rise in osmolality.
Rationale 23: To ensure that the feed is safely stored at the correct temperature.
Rationale 24: To minimise bacterial growth and prevent contamination.
Rationale 25: To ensure safe storage of the EBM.

References

Reference 1:
Boyd CA, Quigley MA, Brocklehurst P (2007) Formula versus donor breast milk for feeding preterm or low birth weight infants. Archives of Disease in Childhood 92: 169-175.

Reference 2:
Edmond K, Bahl R (2007) Optimal Feeding of Low-birth Weight Infants: Technical Review. Geneva, WHO.

Reference 3:
King C (2005) Feeding and Nutrition in the Preterm Infant. Oxford, Churchill Livingstone

Reference 4:
Kramer MS (2008) Breastfeeding and Child Cognitive Development. Archives of General Psychiatry 65: 578-585.

Reference 5:
Meyer R (2009) Feeding practices in the first six months of life. Journal of Family Health Care 19(1): 13-16.

Reference 6:
Schanler RJ, Atkinson SA (2005) Nutrition in Paediatrics. Ohio, Digital Education Publishing Inc

Reference 7:
Shaw V, Rathwell A (2010) Clinical Guideline: Expressing and handling breast milk. London, Great Ormond Street Hospital for Children NHS Trust

Reference 8:
World Health Organisation (2007) Evidence on the Long-Term Effects of Breastfeeding: Systematic Reviews and Meta-analyses. Geneva, WHO

Document control information

Annette Rathwell, Neonatal Nurse Advisor, NICU

Additional authors
Vanessa Shaw, Head of Dietetics, Dietetics

Document owner
Annette Rathwell, Neonatal Nurse Advisor, NICU

Approved by
Clinical Practice Committee 

First introduced: 16 September 2004 
Date approved: 3 October 2011
Review schedule: Two years
Next review: 2 October 2013
Document version: 4.0
Replaces version: 3.0