Maternal breast milk is the optimal nutrition for preterm infants, supporting immune and gut maturation. When unavailable, alternatives include infant formulas or pasteurized donor milk, the latter conferring greater protection against feeding intolerance and necrotizing enterocolitis. This study examined the impact of cow's milk-derived extensively hydrolyzed proteins (eHP), widely used in formulas and human milk fortifiers, on intestinal barrier function and gene expression in fetal human intestinal organoid-derived monolayers, modeling premature epithelium. Monolayers were exposed to free amino acids (AA), intact cow milk proteins (WP), or eHP at different concentrations, followed by inflammatory cytokines or commensal bacteria, to mimic physiologic gut conditions. Barrier integrity, permeability, and viability were measured using FITC-Dextran diffusion and LDH release. RNA-seq assessed transcriptional changes. eHP at low and high concentrations decreased epithelial permeability at baseline, AA showed no effect, and WP only at high concentrations. Under inflammatory conditions, eHP significantly reduced epithelial barrier permeability; both eHP and AA improved cell viability at low concentrations. Transcriptomic analysis revealed modulation of proliferation- and regulation-related pathways, including NOTCH and WNT signaling. In this gut model, eHP enhanced barrier function under baseline and inflammatory conditions, supporting their role in nutrition, though further validation is needed. Extensively hydrolyzed proteins (eHP) derived from cow's milk improve intestinal barrier function and cell viability in a fetal organoid-derived model of premature human intestine. This is the first study to assess the functional and transcriptomic impact of eHP on primary intestinal epithelial cells derived from fetal organoids, a highly relevant model for preterm gut physiology. It demonstrates that eHP-unlike intact proteins or free amino acids-can mitigate inflammation-induced permeability and modulate pathways involved in epithelial proliferation and repair (e.g., NOTCH, WNT, E2F, G2M checkpoint). These findings highlight the potential of eHP as a nutritional strategy to enhance gut integrity and limit inflammatory damage in preterm infants, who are at high risk of intestinal complications such as NEC. This study paves the way for further mechanistic and clinical research on how peptide-based formulas might support immature gut function and reduce extraintestinal risks.

Fortification of human milk for very preterm infants (VPIs) with alternatives to conventional bovine milk-based fortifiers remains minimally studied. This trial tested whether fortification with protein-rich bovine colostrum (BC) improves feeding intolerance and clinical variables in VPIs receiving enteral nutrition with a relatively slow advancement. In this unblinded, two-centre, randomised, controlled trial (FortiColos CN), VPIs (gestational age, 26 + 0 to 31 + 6 weeks) were fed human milk fortified with BC (n = 74) or a conventional fortifier (CF, FM85, Nestlé, n = 72) for at least two weeks, starting when enteral feeding volume reached 80-100 mL/kg body weight/d. Incidence of feeding intolerance, nutrition intake, body growth, morbidities and clinical biochemical parameters were compared between the two groups. No statistically significant difference was found in the incidence of feeding intolerance or in most of the nutritional or body growth parameters (p > 0.05). All recorded morbidity incidences and haematological and blood biochemical parameters were also similar between groups. Amino acids (Phe, Pro, Ser, Tyr, Val) showed higher levels in the infants receiving BC. BC appeared safe when used as a fortifier to human milk for VPIs with slow feeding advancement, but did not improve feeding tolerance or clinical variables. Fortifying human milk with bovine colostrum (BC) in very preterm infants (VPIs) is safe but did not improve feeding tolerance, growth or clinical outcomes, compared with a conventional fortifier (CF), when used during slow enteral feeding advancement. This study adds to the limited clinical evidence on the use of BC as a human milk fortifier in VPIs receiving enteral feeding with different feeding protocols. The findings support the safety of BC as a human milk fortifier in VPIs but suggest limited short-term clinical benefits over currently used fortifiers.

Many preterm infants need nutrition beyond 24 kcal/oz (standard fortification) to support growth. Individualized targeted fortification improves growth but is labor-intensive. Universal enhanced fortification to presumed 26 kcal/oz for very low birth weight infants was clinically implemented. We determined how often donor breast milk (DBM) and preterm maternal breast milk (MBM) met nutritional targets with enhanced fortification. MBM/DBM samples were collected for a prospective cohort study of infants born <1500 g and <33 weeks. Macronutrients were measured using a mid-infrared analyzer. The frequency at which MBM/DBM samples met intake goals (4.8-8.1 g/kg/day fat, 11.6-13.2 g/kg/day carbohydrate, 3.5-4.5 g/kg/day protein) with enhanced and standard fortification was compared. Among 198 MBM samples and 168 DBM samples, MBM had higher protein, fat, and energy (p < 0.0001). Regardless of fortification method, MBM samples met lower and mid-range fat goals more often (p < 0.01 and p = 0.03, respectively). Collectively, more samples achieved protein targets with enhanced fortification: all samples reached 3.5 and 4 g/kg/day, 56% (147 MBM, 58 DBM) attained 4.5 g/kg/day. With standard fortification, 11% achieved 4 g/kg/day protein; none attained 4.5 g/kg/day. Enhanced fortification is an efficient method that meets enteral nutrition goals for preterm infants and delivers desired protein intake more consistently. Enhanced fortification is a feasible and efficient alternative to targeted fortification that can also achieve enteral nutrition goals for preterm infants. Enhanced fortification delivers desired protein intake more consistently than standard fortification, especially with donor breast milk. Regardless of fortification strategy, maternal breast milk is more likely to reach fat intake goals, although additional enrichment may be needed, depending on the fortifier product.

Food and Drug Administration Expert Panel on Infant Formula "Operation Stork Speed" June 2025: Part 3, Marketing of Infant Formulas, Breastfeeding Support, Hypoallergenic Formulas, and Nutrition for Preterm Infants.

Background/Objectives: Food protein-induced allergic proctocolitis (FPIAP) is a non-IgE-mediated gastrointestinal food allergy. Although tolerance to the culprit food is usually achieved within the first year of life, late acquisition occurs and remains poorly predictable. This study aimed to analyze clinical characteristics and explore factors that may potentially function as predictors of late tolerance acquisition to cow's milk (CM). Methods: We conducted a cross-sectional study at two Italian pediatric clinics (2020-2024), including infants diagnosed with FPIAP. Clinical, dietary, and immunological variables; onset and duration of rectal bleeding (visible blood in the stools); and time to CM tolerance were analyzed. Late tolerance was defined as acquisition after 19 months according to the distribution of tolerance achievement in our population. Statistical analyses included χ2, Mann-Whitney U, Spearman's correlation, and logistic regression. Results: Ninety-four infants were included (median age at onset 2.9 months [IQR 1.9-4.7]); 58 (62%) were exclusively breastfed and 18 (19%) were born preterm (<37 completed weeks of gestation). CM was the culprit food in all cases; tolerance was achieved in all infants at a median age of 12 months. Family history of atopy and atopic dermatitis were reported in 44% and 19% of infants, respectively. Late CM tolerance was associated with preterm birth, fortification of human milk, early antibiotic exposure, growth faltering, and recurrent infections. Logistic regression identified family history of atopy (OR 5.4 [95% CI 1.2-25.4]; p = 0.031), atopic dermatitis (OR 8.2 [1.7-40.7]; p = 0.010), rectal bleeding >18 days before elimination diet (OR 5.9 [1.3-27.7]; p = 0.023), and IgE sensitization (OR 6.4 [1.2-35.0]; p = 0.034) as factors that may potentially function as predictors of late tolerance acquisition to CM. Conclusions: Identification of factors that may potentially function as predictors of late tolerance acquisition to CM in infants with FPIAP may help providing a personalized clinical management for these patients.

Human milk (HM) is a dynamic and bioactive fluid that provides essential nutrients and immunological components tailored to infant developmental needs. The composition of HM varies significantly depending on gestational age, maternal nutrition, genetic background, and environmental factors. This review aims to systematically compare the macronutrient and micronutrient composition of HM from preterm and term infants, and to evaluate the implications of these differences for neonatal growth, immune function, and clinical nutrition strategies. Preterm milk differs markedly from term milk, particularly in protein quality, free amino acid content, fatty acid profile, vitamin concentrations, and immunological factors. It is enriched with α-lactalbumin, lactoferrin, sIgA, lysozyme, and medium-chain triglycerides, offering enhanced support for immune function and neurodevelopment. However, it is often lower in key nutrients such as glutamine, DHA, and minerals like iron and phosphorus, necessitating targeted fortification. Maternal dietary intake significantly affects the levels of vitamins (e.g., A, D, B12, and C) and fatty acids, while genetic polymorphisms also influence the lipid and oligosaccharide composition of HM. Understanding the compositional differences between preterm and term HM is essential for guiding individualized nutritional interventions. Clinically, fortification of preterm HM and alignment with the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), the American Academy of Pediatrics (AAP), and the World Health Organization (WHO) guidelines are critical to ensure adequate nutrient delivery and optimal neurodevelopmental outcomes. Future research should focus on the long-term effects of variable DHA and HMO levels, and the influence of maternal nutrition and genetics on milk composition.

Nutritional quality of fatty acids from donated human milk, infant formulas and human milk fortifier

Severity of Bronchopulmonary Dysplasia in Infants Born Extremely Preterm and Randomized to Early Human Milk Fortification with a Donor Milk-Derived Fortifier for 2 Weeks.

Preterm infants require human milk fortification to achieve adequate growth. Most fortifiers are bovine-derived and may trigger feeding intolerance or immunological reactions. We describe a 25+5 week, 720 g male infant who developed recurrent apnea, reflux, and dependence on respiratory support soon after initiation of bovine-based human milk fortifier (HMF). Investigations excluded sepsis and necrotizing enterocolitis. Stool calprotectin was markedly elevated, and eosinophilia was noted. Symptoms resolved rapidly after discontinuation of bovine HMF and initiation of a human milk-derived fortifier, with dramatic improvements in weight gain and respiratory stability. This case highlights cow’s milk protein intolerance (CMPI) precipitated by bovine fortifier and the therapeutic benefit of human milk-based HMF.

ABSTRACTPreterm infants have higher energy and nutrient needs compared to term infants, with human milk recommended as the primary feeding choice and infant formula as the secondary option. This study aimed to evaluate the concentration of essential trace minerals (manganese, copper, iron, and zinc) in preterm human milk and infant formulas in Qatar, and assess their nutrition label accuracy and compliance with nutritional requirements. Mineral analysis was performed using Inductively Coupled Plasma Mass Spectrometry (ICP‐MS). Samples included 50 liquid human milk samples from lactating mothers of preterm infants, 42 powder infant formulas from local markets and pharmacies, and 10 water samples commonly used in Qatar. All human milk and infant formulas were below the recommended zinc and iron ranges as per the American Society for Parenteral and Enteral Nutrition (ASPEN). Additionally, 96% (48/50) of human milk and 95% (40/42) of infant formulas were below the recommended copper range. Furthermore, 34% (17/50) of human milk samples for manganese were below the recommended range, whereas 86% (36/42) of infant formulas exceeded it. Water samples showed mineral levels below detection limits, and thus had no contribution to mineral levels in reconstituted formulas. Significant differences were found between label and laboratory‐tested values for copper (p = 0.0039) and zinc (p = 0.0000), with label values higher than laboratory results. No significant differences were observed for manganese (p = 0.7564) or iron (p = 0.1966). Reconstituted formulas had significantly higher manganese, zinc, and iron laboratory levels (p < 0.001) than human milk, whereas copper showed no significant difference (p = 0.324). These findings highlight mineral imbalances in both human milk and infant formulas for preterm infants, demonstrating the need for human milk fortifiers, improved nutrient formulation, accurate labeling, and further research to ensure optimal health outcomes.

Abstract Objectives We aimed to gather insights from physicians regarding feeding practices for premature infants in the Middle East and North Africa. Methods An online survey was distributed among physicians who managed premature infants. Descriptive analyses were used to evaluate the responses. Results In total, 1000 out of 1300 participants from Egypt, Iraq, Kuwait, Qatar, Saudi Arabia, Syria, and the United Arab Emirates completed the survey. As reported, the participants included neonatologists ( n = 678), general pediatricians ( n = 258), and pediatric gastroenterologists ( n = 14). Nearly half the participants ( n = 466; 49.2%) had over 10 years of experience. Overall, 53.4% of participants followed available feeding protocols, 16.8% inconsistently adhered to available protocols, and 14.8% reported unavailability of feeding protocols in their practice. Some participants (36%) had concerns about feeding‐related complications with early initiation of enteral feeding. We observed variations in feeding practices as well as the management and monitoring of feeding‐related complications in preterm infants among the participants. Additionally, awareness of human milk fortifiers was variable and correlated with clinical experience. Conclusion There is a need for training healthcare professionals, standardizing feeding protocols, and optimizing care for preterm infants across the region to reduce feeding‐related complications and improve long‐term health outcomes.

We aimed to analyze vitamin A content in pooled donor human milk (DHM) and determine enteral vitamin A intake after fortification (NCT05742815). We analyzed pooled DHM (n = 15) from seven commercial milk banks for vitamin A (retinol) content. Retinol was directly quantified by ultra-high-performance liquid chromatography. Enteral retinol intake was calculated for several commercial liquid human milk fortifiers (HMFs) at standard fortification according to each manufacturer's instructions. The mean retinol concentration in commercial DHM was 120 ± 30 international units (IU)/dl (range, 49-158 IU/dl). Retinol content correlated with fat content in DHM (R2 = 0.37; P = 0.01). Standard fortification of DHM with HMF (150 ml/kg/day; 24 kcal/ounce) results in variable enteral retinol intake (range, 200-1600 IU/kg/day). Vitamin A content in DHM approximates mature term human milk, but vitamin A intake may be insufficient for some preterm infants provided an exclusive human milk diet.

ObjectiveThe objective was to explore variation of macronutrient and bioactive content between levels of human milk-derived human milk fortifier (HM-HMF), and between donor human milk (DHM) from commercial vs non-profit banks.Study DesignWe analyzed the concentration of macronutrients, Immunoglobulin A (IgA), and cortisol in multiple lots of each HM-HMF product (20, 24, 26, 28, and 30 kcal/oz) using multiple methods.ResultAt each level of caloric density (p<0.0001), protein, carbohydrate, and caloric concentration in HM-HMF increased with minor exceptions while fat and cortisol concentrations did not differ. Total IgA concentrations differed by product type (p <0.0001). Protein concentration did not differ between commercial and non-profit donor milk banks while carbohydrates, fat, calories, and cortisol were higher, and IgA was lower. Lot-to-lot variability of all DHM components was lower in commercial DHM.ConclusionThis study expands data on the variability in the composition of DHM originating from various sources.

Background/Objectives: Freeze-dried high-temperature short-time pasteurized human milk fortifiers offer potential for exclusive human milk feeding in preterm infants while providing necessary nutritional supplementation. However, clinical data on safety, tolerability, and growth outcomes remain limited. This study evaluated donor milk fortification compared to conventional bovine protein-based fortification. Methods: We conducted a prospective non-interventional observational cohort study with a retrospectively matched comparison cohort at University Children’s Hospital of Nuremberg. Preterm infants ≥ 30 weeks gestational age requiring mother’s own milk fortification were included. The exposed cohort (n = 32) received freeze-dried high-temperature short-time pasteurized donor milk fortifier at 1.6–4.8 g/100 mL of mother’s own milk; the matched comparison cohort (n = 32) received bovine protein-based fortifier. Primary outcomes included feeding tolerance, safety parameters, and anthropometric measurements. Cohorts were matched for birth weight (±10%), gestational age (±5 days), and fortified feeding. Results: Baseline characteristics were not significantly different: gestational ages 32.8 ± 1.0 versus 33.0 ± 1.2 weeks; birth weights 1900 ± 380 g versus 1840 ± 370 g. Excellent feeding tolerance was demonstrated across >3100 feedings. No necrotizing enterocolitis, abdominal complications, or serious adverse events occurred. Blood glucose, triglycerides, and urea remained normal. Birth weights, lengths, and head circumferences showed no significant differences. Discharge parameters including weight, length, head circumference, and length of stay were also not significantly different. Conclusions: Freeze-dried human milk fortification demonstrates excellent safety and tolerability in preterm infants ≥ 30 weeks gestational age, achieving anthropometric outcomes not significantly different to bovine protein-based fortification. However, the suboptimal protein-to-energy ratio may limit applicability for very low birth weight infants. Therefore, freeze-dried high-temperature short-time pasteurized human milk fortification is suggested to provide appropriate nutritional supplementation for preterm infants with a birth weight over 1500 g.

Our objective was to characterize enteral nutrition safety practices and education for pediatric solid organ transplant recipients and compare practices with the 2017 American Society for Parenteral and Enteral Nutrition (ASPEN) Safe Practices for Enteral Nutrition Therapy. A 43-question electronic survey was distributed through the national registered dietitian pediatric transplant listserv. Questions reviewed formula hang-time, preparation, storage during initial transplant admission, and discharge education. Sixty-six of 216 (31%) individuals completed at least one survey section. Forty-one of 47 (87%) reported a standard inpatient policy, and 40/40 (100%) reported ASPEN Safe Practices compliance for nonsterile powder formula with or without additives or unfortified and fortified human milk, whereas 33/39 (85%) complied for sterile liquid formula in an open system. Hospital size, type, and location did not predict compliance practices. Discharge education was primarily provided by dietitians (98%) and nurses (37%). Four-hour hang-time education was provided by 18/42 (43%) respondents for sterile formula in an open system, 31/42 (74%) for nonsterile powder formula in an open system, and 35/42 (83%) for nonsterile formula with additives. Educator type (dietitian vs non-dietitian or nurse vs non-nurse) did not predict compliance for sterile liquid in open system or nonsterile powder formula in an open system. Inpatient policies for formula hang-time are highly compliant with 2017 ASPEN recommendations. However, formula hang-time discharge education varied, particularly for sterile liquid formula in an open system. Standardizing enteral nutrition safety education for transplant patients is critical for minimizing infection risk within this immunocompromised population.

BackgroundNecrotizing enterocolitis (NEC) remains a major cause of morbidity and mortality in extremely low birth weight infants (ELBWIs), despite widespread donor human milk (DHM) use. This study examined NEC cases among DHM recipients to explore potential contributing factors.MethodsWe retrospectively analyzed 1,425 infants registered in Japan's human milk bank database (2018–2023). NEC cases at Bell stage ≥ II were confirmed by attending physicians. Infants who received DHM only after NEC onset were excluded. Cases were categorized by onset timing and associated clinical factors.ResultsAmong 1,324 very low birth weight infants, 21 (1.58%) developed NEC, with 20 requiring surgical intervention. Median gestational age and birth weight were 25.1 weeks and 637 g, respectively. NEC onset was classified as follows: within 7 days of birth (n = 5), after 2 months (n = 5), after formula or fortifier use (n = 6), associated with hemodynamic changes (n = 7), or of unknown etiology (n = 4). Common factors included symptomatic PDA, congenital heart disease, infection, formula exposure, and ophthalmologic procedures.ConclusionNEC can develop despite DHM use, often in association with early infections, PDA, or fortification. Strategies to further reduce NEC incidence should include management of hemodynamic instability, delayed formula introduction, and use of exclusive human milk-based diets. Further research should explore potential roles of ophthalmologic interventions and human milk fortifiers in NEC development.

A common problem among preterm newborns is extrauterine growth restriction, or EUGR. The Evidence-based Practice for Improving Quality (EPIQ) strategy aims to reduce EUGR and enhance growth outcomes in neonatal intensive care units (NICUs). The objective of this study is to assess whether implementing EPIQ-based quality improvement interventions is associated with reduced EUGR among preterm infants (<34 weeks gestation) in a before-after observational study. This study used a before-after design, analyzing retrospective baseline data and prospective postintervention data. A total of 817 preterm infants were included: 231 in the control group (admitted between January 1, 2022, and June 30, 2022; data collected retrospectively) and 586 in the experimental group (admitted between July 1, 2022, and December 31, 2023; data collected prospectively) at Shanxi Children's Hospital. The impact of the interventions was assessed using chi-square and t-tests. There was no significant difference in maternal conditions across groups (p>0.05). The overall incidence of EUGR was significantly lower in the experimental group (37.54%) than in the control group (57.14%) (p<0.01). Breast milk usage increased from 25.97% to 41.12% (p<0.05) and human milk fortifier use increased from 9.09% to 28.84% (p<0.01), indicating significant improvements in average length and weight growth in the experimental group (p<0.05). Implementation of EPIQ-based interventions was associated with a significant reduction in EUGR incidence and improved growth outcomes in preterm infants under 34 weeks, supporting its role in enhancing neonatal care.

IntroductionVery-low-birthweight (VLBW) infants on pasteurized donor human milk (PDHM) have poorer growth compared to infants on fortified mother's milk, suggesting that standard fortification methods for PDHM are inadequate.MethodsWe designed a randomized controlled trial to determine whether an enhanced method of fortification (EF) improved growth in VLBW infants compared to standard fortification (SF). VLBW infants admitted to our tertiary-level neonatal intensive care unit were randomized to receive a bovine powdered human milk fortifier (HMF) added to PDHM (SF), or specially selected high-fat PDHM (fat concentration ≥3.8 g/dL) with bovine powdered HMF and a liquid protein fortifier providing an additional 0.67 g/dL protein (EF). Primary outcome was impaired weight gain defined as weight z-score drop of ≥0.8 from birth at 37 weeks or hospital discharge, whichever earlier. Secondary outcomes included change in length and head circumference (HC) z-scores from birth, requirement for high calorie formula, and rates of bronchopulmonary dysplasia (BPD) and retinopathy of prematurity (ROP).ResultsA total of 61 infants were randomized (31 SF, 30 EF). Impaired weight gain was not significantly different (SF 83.9% vs. EF 73.3%, p = 0.347), with similar declines in weight z-scores from birth in both groups SF −1.27 [interquartile range (IQR) −1.71, −0.87] vs. EF −1.13 (IQR −1.46, −0.78), p = 0.403. However, the EF group had a smaller decline in length and HC z-scores from birth to discharge compared to the SF group [Length z-score change: −0.92 (IQR −1.64, −0.48) vs. −1.64 (IQR −2.21, −0.89), p = 0.007; HC z-score change: −0.08 (IQR −0.74,0.58) vs. −0.86 (IQR −1.81, −0.21), p = 0.014]. The EF group also required less high calorie formula supplementation [0% (IQR 0-4.1) vs. 3.8% (IQR 0 −16.9), p = 0.032]. Rates of BPD and ROP were not significantly different between groups.ConclusionAmong VLBW infants, EF did not improve weight gain, but reduced declines in HC and linear growth compared to SF.

To identify factors affecting macronutrient levels in human milk (HM) from mothers of preterm infants in Thailand by examining maternal diet and body mass index (BMI). HM fortification has become standard care to meet preterm infant's nutritional needs, but macronutrient content varies throughout lactation, leading to challenges in managing HM nutrients. Understanding maternal nutrition factors affecting HM macronutrients should be considered. In this observational study, 47 mothers of premature infants were selected through convenience purposive sampling between October 2023 and March 2024. HM samples were collected at 2 time points: during 1-2weeks of lactation (time point 1) and 3-4weeks of lactation (time point 2) and analyzed using the Miris HM analyzer (Miris HMA™). Maternal dietary intake was assessed using 24-h dietary food recall records from 2 non-consecutive days and food frequency questionnaires (FFQs). Maternal BMI was measured using current body weight and height. Multiple linear regression analysis showed significant positive association between HM macronutrients and maternal dietary intake, including daily intake of carbohydrates, fats, and protein. No association was found between maternal BMI and HM macronutrients. This study supports that maternal dietary intake can affect the nutritional profile of HM. Monitoring and modifying maternal dietary intake during lactation may enhance macronutrient content of HM for preterm infants.

Use of human milk and fortification in the neonatal intensive care unit.