Abstract
For preterm infants, it is common practice to add human milk fortifiers to native breast milk to enhance protein and calorie supply because the growth rates and nutritional requirements of preterm infants are considerably higher than those of term infants. However, macronutrient intake may still be inadequate because the composition of native breast milk has individual inter- and intra-sample variation. Target fortification (TFO) of breast milk is a new nutritional regime aiming to reduce such variations by individually measuring and adding deficient macronutrients. Added TFO components contribute to the final osmolality of milk feeds. It is important to predict the final osmolality of TFO breast milk to ensure current osmolality recommendations are followed to minimize feeding intolerance and necrotizing enterocolitis. This study aims to develop and validate equations to predict the osmolality of TFO milk batches. To establish prediction models, the osmolalities of either native or supplemented breast milk with known amounts of fat, protein, and carbohydrates were analyzed. To validate prediction models, the osmolalities of each macronutrient and combinations of macronutrients were measured in an independent sample set. Additionally, osmolality was measured in TFO milk samples obtained from a previous clinical study and compared with predicted osmolality using the prediction equations. Following the addition of 1 g of carbohydrates (glucose polymer), 1 g of hydrolyzed protein, or 1 g of whey protein per 100 mL breast milk, the average increase in osmolality was 20, 38, and 4 mOsm/kg respectively. Adding fat decreased osmolality only marginally due to dilution effect. Measured and predicted osmolality of combinations of macronutrients as well as single macronutrient (R2 = 0.93) were highly correlated. Using clinical data (n = 696), the average difference between the measured and predicted osmolality was 3 ± 11 mOsm/kg and was not statistically significant. In conclusion, the prediction model can be utilized to estimate osmolality values after fortification.
Highlights
Breast milk is the best source of nutrition for preterm infants but does not alone provide optimal nutrition
To test the impact of components used for target fortification, commercially available macronutrient products were used: Polycose (Abbott Nutrition, Columbus, USA) for carbohydrates, Beneprotein (Protein 1, Nestle HealthCare Nutrition, Minneapolis, USA) and Aptamil Protein (1:1 whey/casein hydrolyzed protein) (Protein 2, Milupa, Lisbon, Portugal) for protein, and Microlipid
The present study systematically investigates the impact of commonly used macronutrient supplements and human milk fortifiers on the osmolality of standard and individually fortified breast milk
Summary
Breast milk is the best source of nutrition for preterm infants but does not alone provide optimal nutrition. Due to inter- and intra-individual macronutrient variations, standard fortified breast milk may still fall short of recommended macronutrient intakes for some preterm infants [1,2,3]. The concept of target fortification has been developed to add deficient macronutrients to each fortified breast milk sample after an analysis of macronutrient components in native breast milk [3]. This fulfills the recommended nutritional requirements for each infant by making up for macronutrient variations in standard fortified breast milk according to international guidelines [4,5]. An upper limit of 450 mOsm/kg (i.e. 400 mOsm/L) has been suggested for enteral feedings though this recommendation is not based on solid scientific evidence [8,9]
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