New Ways to Provide a Human Milk Fortifier during Breastfeeding

Abstract

Providing a human milk fortifier once the preterm infant has started to suckle at the breast can be challenging for the mother and might shorten duration of the breastfeeding period. Fortification is recommended up to term for the normal-growing infant and up to 3 months in growth-retarded infants. After hospital discharge, some mothers may not want to pump, fortify, and bottle-feed the fortifier-milk mixture any longer. They desire to breastfeed their infants directly from the breast, but unfortunately, fortification often interferes with direct breastfeeding. Cup feeding is the most researched fortification method and appears to be safe but cannot be applied during nursing. Another alternative is the supplemental nursing systems, but only a few low-quality studies investigated the method, which is difficult to handle and requires a lot of nursing experience. The use of a finger feeder to administer a fortifier to preterm infants is a new method that enables mothers to exclusively breastfeed their infants and meet their nutritional needs. Mothers reported easy preparation and han-dling of the fortifier. More than 67% of the infants accepted the device and fortifier application during nursing very well. However, the development of further methods to augment preterm infant nutrition that does not interfere with breastfeeding is of great interest. Future efforts to enable fortification during breastfeeding must be linked to the development of ready-to-use devices containing liquid human milk fortification mixtures. 

The supplementation of human milk with human milk fortifiers (HMF) is a standard therapy for preterm babies during their stay in the neonatal units up until discharge. Breastfeeding is usually initiated as soon as possible but a coordinated sucking-swallowing-breathing pattern is not usually present before the infant's gestational age is 32 weeks [1] - at this time point, preterm infants start to take their first small-volume meals on the breast. Milk- and breastfeeding volumes increase with the strength and endurance of the infant which goes with neurological maturation that enables a more sufficient sucking-swallowing co-ordination. Breastfeeding should be encouraged at any time, but concurrent fortification while breastfeeding is challenging for mothers and their preterm infants especially during the early learning phase. Full breastfeeding is usually established around the term, which is also often the time point of discharge from the hospital. After discharge, the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) recommends fortification of breast milk following the postnatal growth trajectory of the preterm infant. If weight gain after discharge continues to be above the 10th percentile, breast milk should be fortified until term gestational age. In the case of growth restriction, which is defined as weight gain below the 10th percentile, breast milk should be fortified up to 52 weeks' postconceptional age [2].

Cup Feeding

Cup feeding as a supplemental, alternative feeding method in the neonatal inten-sive care unit is a well-documented and safe method to apply HMF, but it affects direct breastfeeding [3]. A recent review investigated 12 studies on the safety and efficacy of cup feeding as an alternative, supplemental feeding method for breast-fed preterm infants [3] and found the method to be viable. When examining physiologic factors with cup feeding, it was illustrated through the 7 studies that cup feeding did not cause more physiologic distress than bottle feeding. The use of cup feeding resulted in a more stable heart rate and oxygen saturation than bottle feeding with similar weight gain. Additionally, breastfeeding rates were higher at discharge with continued higher rates at 3 and 6 months post-discharge for cup-fed infants [3]. Length of stay for cup feeding infants was found to be not significantly different between cup feeders and bottle feeders in 2 of the 3 studies that examined this variable. However, compliance to the intervention remains a challenge as cup feeding can not be applied during nursing [4] - the mother has to pump her milk, enrich it with a fortifier and feed it with a rather impractical cup device. Nevertheless, cup feeding may have some benefits for late preterm infants and improve breastfeeding rates up to 6 months of age [4].

Supplemental Nursing System and Supplemental Feeding Tube Devices

The supplemental nursing system (SNS) is a feeding tube device to provide babies with long-term supplemental feedings at the breast. When a baby is at the breast over a period of days or weeks, a hormonal mechanism is triggered that causes milk to be produced. It is used for inducing lactation, weak or ineffective “nursers,” low milk supply, and premature babies [5].

Human milk fortification via an SNS has not been investigated yet, but forti-fiers often attach to the walls of syringes and tubes, which might also be a problem here. Many mothers who used the device felt that it was difficult to use, and they needed assistance with it [6]. They also reported that the use of the device was time-consuming and cumbersome. Most women reported receiving help from the product instructional booklet beyond what they received from the lactation consultants and nurses. The other sources of assistance were from an experienced user or from the person who provided the device. Overall, the women had a strong desire to breastfeed and found the SNS an acceptable alternative method of supplementation, but these were mainly mothers of term infants [5].

Fortification Directly at the Breast by the Finger Feeder Method

Only a few studies investigated HMF application while breastfeeding in preterm infants after discharge. Each used a different method to administer the fortifier, one adding the entire dose into one bottle per day [7] with no adverse gastroin-testinal symptoms reported, another was by the bottle but given spread out over the day [8], and the third by cup twice a day [9]. Again, these methods required pumping of breastmilk, which is uncomfortable for the mother and might hamper direct breastfeeding but none of the studies reported any adverse effect on breastfeeding rates in the fortified group. Fortifying breast milk for infants fed directly from the breast is logistically difficult and has also the potential to inter-fere with breastfeeding.

Recently, we investigated the acceptance, adherence, and feasibility of fortifier administration by finger feeder during breastfeeding [10]. Mothers were instructed (Fig. 1) and trained in fortifier application during breastfeeding by a lactation consultant before discharge and documented their experience via a self-reported feeding diary at home. Results of the observational study showed that the method was well accepted by 67% of the mothers. Mothers did not report problems in preparation or handling of syringes and finger feeder, but 33% of the infants stopped latching on or drooled milk during finger feeder use. Also, problems due to the bitter taste of the water-fortifier mixture were reported.


However, there was no effect on weight gain or growth of the infants in the group which used the fortifier (67%) in comparison to the group who stopped to use it due to problems (33%), which was surprising (Fig. 2). One can speculate that this observation is related to a lower milk intake induced by the higher caloric density of the fortified breastmilk, but this has to be investigated in further studies. Mothers who use feeder method positively remarked that they could stop pumping and feed directly from the breast. Medications such as multivitamin or iron supplements, among others, could also be administered simultaneously with the finger feeder, which was also tolerated very well. The method appeared to be cost-effective because finger feeders and syringes are reusable products.



Fortification of breast milk directly during breastfeeding via the finger feeder method is an opportunity to cup or bottle feeding and does not interfere with breastfeeding. However, not all of the infants accepted the method. To avoid ir-ritation for the infant, improvement in the flavor of the fortifier would be helpful. Multivitamin supplements, which are often prescribed, have a sweet taste. Splitting the daily dose of supplements into small portions might help sweeten the fortifier solution and make it tastier for the infant.

New Developments

Although the finger feeder method during breastfeeding is a further step towards exclusive breastfeeding in combination with fortifier application, there are still unsolved problems. The development of more user-friendly, ready-to- use devices or already prepared liquid fortifiers is of great interest. An already portioned and tastier product, which does not have to be pre-prepared is required. The need is to design a ready-to-use, disposable vial that contains one
 
portion of liquid fortifier with an application tip so that the portion can be ad-ministered directly during breastfeeding.
In conclusion, the application of HMF during breastfeeding by finger feeder is a safe and feasible method, but further studies should evaluate effects on efficacy and growth. Future efforts should be linked to the development of ready- to-use, liquid HMF mixtures, which can be directly fed during breastfeeding.

Conflict of Interest Statement

N.H. receives honoraria for lectures from Nestlé, Baxter, Danone, Novalac, and MUM. No other conflicts of interest to declare.
F.H. receives honoraria for lectures from the Nestlé Nutrition Institute and different nutrition companies. No other conflicts of interest to declare.

References

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