Is Osmolality Pushing the Limit? Considerations for Fortified Infant Feedings

Brian Stansfield, MD
Neonatal-Perinatal Medicine & Research Medical College of Georgia
Augusta University, Augusta, Georgia

Dr. Brian Stansfield is a distinguished physician-scientist and neonatologist, whose research in human milk composition and early growth patterns has been federally supported by the National Institutes of Health. As an associate professor of pediatrics and the vice chair of research at Augusta University, Dr. Stansfield continues to explore the connections between early development and cardiometabolic diseases.

Although breastfeeding is the preferred way of feeding infants, both mother’s milk and pasteurized donor milk do not contain all the necessary nutrients required for the growth and development of premature infants. Preterm infants require more comprehensive supplementation of breast milk to mimic the rapid nutrient accretion that typically occurs in the third trimester. Therefore, specialized multi-nutrient human milk fortifiers (HMFs) have been developed that can be added directly to human milk to provide additional vitamins, minerals, and macronutrients. HMFs are designed to deliver these additional nutrients in a relatively small volume.

It is necessary to use a multi-nutrient liquid HMF to fortify breast milk routinely to ensure proper growth of preterm and very low birth weight infants. The addition of HMF can directly affect the osmolality of enteral feedings and should be considered when selecting an HMF for your NICU. The addition of vitamins, minerals, and medications to fortified breast milk will increase enteral osmolality. However, choosing an HMF that maintains a similar osmolality to expressed breast milk may reduce the increase in osmolality following enteral supplement administration.

The osmolality of human and all mammalian milk is constant. Feeding with high osmolality can result in delayed gastric emptying, increased gastric residual volumes, and slower transit time. Extensively hydrolyzed casein (EHC) HMFs significantly increase osmolality compared to partially hydrolyzed whey (PHW) or human milk-derived (HMD) HMFs. Careful consideration of the type of fortifier and the need for additives and supplements can reduce the risk of a hyperosmolar feeding regimen.

Summary and Key Points:

  • Breastfeeding alone may not provide enough nutrients for premature infants.
  • Multi-nutrient liquid HMF should be used routinely in the NICU to ensure proper growth of preterm and very low birth weight infants.
  • The addition of HMF can affect the osmolality of enteral feedings.
  • Choosing an HMF that maintains a similar osmolality to expressed breast milk may reduce the risk of hyperosmolar feeding.
  • High osmolality can cause gastric issues and slow transit time.
  • EHC HMFs significantly increase osmolality compared to PHW or HMD HMFs.
  • Careful consideration can reduce the risk of hyperosmolar feeding.

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