Pragmatism vs idealism in preterm human milk fortification

Abstract

In this volume of The Journal, Schanler et al report the results of a randomized trial of an acidified human milk fortifier, compared with a non-acidified human milk fortifier, in premature infants weighing 700-1500 grams at birth. The authors hypothesized that infants fed the acidified human milk fortifier would have more acidosis and consequently, poorer growth than infants fed a non-acidified fortifier. To address this, the primary outcome of the study was the rate of weight gain. Other outcomes of interest were feeding tolerance and basic biochemical assessments including electrolytes and bicarbonate levels. Although the study showed significant differences in feeding tolerance and biochemical assessments between the groups, there were no differences in the primary outcome of weight gain for study days 1-29. Although the same nutrition protocol was described for all sites, some aspects of the trial were pragmatic and clinical teams were able to individualize nutritional management. As is typical in clinical practice, some infants received mostly donor milk, and some received non-study fortifiers, formula, or protein supplements that may have been prescribed to help with feeding tolerance and weight gain. This heterogeneity prompted the authors to perform extensive secondary and post-hoc analyses. From these analyses, we see that only about one-half of the infants received the ideal combination of >50% mother's own milk and the study fortifier, but this subgroup showed better weight gain with the non-acidified liquid fortifier. Although the investigators were not able to show a difference in the primary study outcome, the results of this study should be helpful to neonatologists as the trial reflected the “real world” use of human milk fortifiers and reaffirmed that in clinical practice, optimizing weight gain in preterm infants may be more complicated than the choice of a human milk fortifier. Article page 31 ▶ Improved Outcomes in Preterm Infants Fed a Nonacidified Liquid Human Milk Fortifier: A Prospective Randomized Clinical TrialThe Journal of PediatricsVol. 202PreviewTo compare growth, feeding tolerance, and clinical and biochemical evaluations in human milk-fed preterm infants randomized to receive either an acidified or a nonacidified liquid human milk fortifier. Full-Text PDF