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Individualizing fortification of human milk using real time human milk analysis

Individualizing fortification of human milk using real time human milk analysis
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  319 ou m ;!l of N<.: on' ll,- d-P   r in al, [l Medicine 6 (2013) 319-323 DOr 1O :< 3 (N1 ~ I I13 [OS P   : Original Research Individualizing fortification of human milk using re al time human milk analysis P.O. Radmacher"*, S.L. Lewis b and D.H. Adamkin a aDeparlment o Pediatrics, University o Louisville School o Medicine, Louisville, KY USA bNeonatallnlensive Care Unit, Kosair Children's Hospilal, Louisville, KY USA Received 07 June 2013 Revi sed 13 September 20 13 Accepted 27 September 2013 Abstract. On mcnVE : 'fb use real-time human milk macronutrie nt analysis to calculate final composition foHowing fortiflcation. STUDY DESIGN : Pretenn HM (PHM) and pooled donor human milks (OHM) were analyzed by mid-infrared spectroscopy fo r protein, f at and lactose. Ene rgy content was calculated from macronutrienr re sults. Three lactation s tages were constructed. HM was compared to PHr v1. Four milk ~ arnple profiles we re selected to demonstrate individualized fortifica tion re s ults. REc LTS : Lactose was similar in PHM and OHM. Protein in I HM showed the expected decline as lactation progress ed. O HM protein was significantly lower vs. PHNI F at was highly variable and lowest in DHM. Using standard fortification proto c ols. not all fortified milks met targets for protein and energy. Individualizcd fortification rcoulLed in milks closer to target reCOllllTIendatioJl s. CO CLUSI0 : Real-time analysis of HM provides assessment of the macronutrient content of the milk and can guide fortification. Individualized protocols, based on actual milk macranutrient praftles, may necd to be considered to avoid unexpected nutrie nt conlent. Keywords: Human milk analysis, human milk fortification 1  lJl l ro duction woman, within a feeding, a day and over the entire lactation period [7, 8, 15-18]. The nutrient profile and Human milk (HM) is the preferred feeding for volume of milk produced on any given day can be human infanlS, including those born prctcrm [1-6]. influenced by a number of factors, including materWhile the milk from a woman delivering very pre nal nutritional status, parity, gestation at delivery, and maturely has some nutritional limitations [7-10], the stage of lactation [[7]. The time of day, length and immunological and many other benefits of human method of expression (mechanical pump, hand expresmilk, are very important for the overall health of the sion), volume or milk expressed and method of storage infant [11-14]. all impact the profile. The macronulrientcontent ofHM Human milk is a complex biological fluid composed has bcen studied in women from various cultures and of thousands of compounds which vary from woman to with different types of diets [7, 14, 19-24]. The concentration of important nutrients such as Vitamin D can " Co rresponding aut ho r: Dr. Pa u la G. Radnlacha, Ne oll fH aJ Nutri· be affected by diet and geography [ 5] while others, Lion Res ea rch Laboratory. 5! IS. Floyd St. Room 107, U nrVc.rsilY of such as Vitamins C and K are not dependent on mater  [ 502852 8 K2 6; E-mail: [1aula.radmacher @l nal dietary intake [17,26,27]. While HM is sufficient Lcuisvi l k. Lo uisville. KY 40292. U SA Tel.: 15028525532: Fax: 1934-5798113/ 27.50  © 2013 -lOS Pr ess and the authors. A ll rights reserved  320 c Rad1ll  u.  hu er al. / Re {(i -l im c lil li/W I m lk ma .c ronUlri e nt allalysis to support the grow th and development of the nonnal term inf ant, pretelm human milk (PHM) may be inade quat e to m ee t the nutrient requirements of th e ve ry low birth weight in fant (<l50 0 gBW; VLBW) who se n ee ds ar e dynamic and related to severity of illness, postnatal age and need for catch-up growth [28-34]. Since enteral feeding is often delayed for medical reasons in th e first days after birth, human milk should be fed in the chronol og ic or der it was expressed to maximize the hi gher protein content found in early milk. While popula ti on-de ri ved nutritional profiles of human milk are ava il ab le, individual mothers m ayor may not be producing milk th at mirr ors those norms [7, 8, 16, 18, 35]. Th e ref ore specific data on the individual mo th er s milk salllple at the time it is being fed may enhance the ability to match intake with requir ements and to promot e catch-up growth. Fortifi cat ion of PHM is one way to compen sate for its macr onutrient inadequacies and to enhance protein/energy ratio [10, 36-38 ]. Additives can be either sterile liquid or no n- sterile powder. These product s ha ve been d es igned ba se d on assumptions of sta ti c nutrient content of pr eterm human milk. Donor human milk, which is predominantly term in compos ition, is signifi ca nliy diff e rcnt than PHM and rarely mccts the needs of the rapitlly growing YLRW infant without fortification r81 The purpo ses of this study were: to analy ze macronutri ent content of discrete human milk samples in real time and to investigate opportunities for individualized f ort ific at io n. 2. Methods Milk sample s (mother's own pre term milk [pHM] or purchased donor human milk [DHM]) wer e obtained after thawing enough for the day s preparation and before any fortifier pr oducts were added. Analysis was perform ed by mid-infrared spectrometry (Calais Human Milk An alyzer, Melron Instruments. Solon, OH) the s ame day as milk was thawed. 2 1. Mid infrared spec/ro m r y Infrared energy with wavelengths 3-10 microns radiates from an in candescent source lamp and pas  ies through six filters mo u(lt<:ci on a disk. This allows r ea dings at six wavelengths (3 for fat., one eac h for protein, lactose and so lids). Absorption at each wavelength is m os t se nsitive to a partic ul ar comp onent in the sa mple to determine th e a mount of prote in , fat, and carbo hydrate ba se d on the absorp ti on o flR energy by specific chemical bonds: CH groups in fatty aci ds chains of fat molecules, carbonyl groups in ester linkages of far molec ul es, peptide linkages between amino acids of prote in Ino1ecules, and OH gr oups in lactose molecule s. A det ector converts the IR energy into an electrical signal processeJ by a comp uter to generate a va lu e for each macronutrient. 3. Sample handling Ea ch infant s date of birth and the dare milk was expre ssed were used to calculate day of l actat ion, which was th en orga ni zed into three epoch s: less than 2 week s (early), 2-4 weeks (transitional) and more than 4 weeks ( matur e). Concentrations of t ota l pro tein, lactose and fat were expre sseJ in g/d L Ener gy (kcalloz.) was calculated by s ummin g the energy valu es from eac h macronutrient and co nverting i"rom kcal/dL to kcal/o z: l actos e (4 kcal/g), protein (4 k ca l/g) and fat (9 kcal/g). R es ul tS from 4 speci fic milk analyses were selectee to represe nt different macronutrient profiles. These dat a w ere then used to calculate lhe resulting protein and energy content that would re sult if a com mercial fortilie rw ere adde d. using manufactur er  s label values f or currently ava il able fortifi ca ti on pro du cts: 30 kcal/oz pretenn formula ( PTF ; Simila e® Sp ecial Care 30 r Abbott Nutrition, Columbus , OH]). E nf amil® Hum an Milk Fortificr Acidified Liquid (AC-LF ; M ead John so n Nutritionals, Evansv ill e, IN), I'rolactPlu s™ Human Milk Fortifier (HM F +4; Prolacta Bio sc ience, Monrovia. CAl, Enfam il® Human Milk Fortifier pow der (Mead John son Nutritionals, Evansville, IN). Data were analy zed by ANOYA (SPSS v. 19) and statistical significance set at p 0.05. 4 Results Eighty-three discrcte milk salllples f or V LBW infants and 6 donor HM sample s from a rc gional. mil.k bank were analy z.e d.  RC  i ul ts from macronutrient ana l yses, organized by st age of lact.ation are shown in Table I Lactose con ce ntrations were relatively con stant in all sampl es, although l actose concentrations in OHM were sign.ificantly lower than PHM. Fat con cent rations showed wide va ri ahility a nd the m ean  pc RadlJU1 ..-he r el al / Ne al lime human milk macr 1IUlriel1l analys is 32 1 Tab le 1 '\1acronuuic llI analysis results (mean ± SU) S w. ge of lac ta tion 0 2 ~e k 5 Prot e in 1.7 ±0.3 (l'JdL) (range) 1.3 - 2.8 Fat 3.0 ±0.9 (gJ dL ) (range) 10- 5.7 L1 ClO SC 6.5 ±05 (g1dL) (range) 5.1 -7.9 Energy 17 . 2± 2.4 (kca1l0l.) (range) 1 2. 4- 24 .5 2 -4 we eks 1. 5± O.2 1. 2-2.0 3.6± 1. 1 IX-6.2 6.6 ± 0.3 6 .4 -7 .5 18.6 ± 2.9 13. (;-25.7 wed :! tJ : :0 .4 0. 9- 1. 9 3.8 ± O.9 2. 1-5 .5 6 5 ±O l 5.9-7.1 18.9 0:0 1.6 1 4. 2-23.6 Donor hll rna n milk (t erm) 1. 0± 0.1 0 .8 - 1.1 2.5 ± 0.3 2.2- 3. 0 6. 1 ± 0.4 5.5-6.7 1 4.6± 1 .4 LJ .I- 16 .6 p <0.0 2 (DHM vs. all stages) S O.0 15 (DHM vS 0-2 wks and ? 4 wks) <0.005 (D HM vs. a ll stages) 0.021 (DHM vs 0-2 wks and :;: 4 wks) DH1vt: donor human milk . Table 2 P ro fil es of fo ur milk samples to be fonified 0 24 kcaV ol PrOtem (gldL) En er gy fkcaUoz.) Low protein 1.0 1.1.6 Low energy Ex pe ct ed rrote in 1. 5 18.6 E-xpc C ted ener gy Ex rected rrotein IA 24.2 H.i gh energy Hi gh prot60 1.9 16. 9 Margi nal en ergy trended to increase over time. DHM fat content was significantly lower than that observed in th e first 2 weeks of la ctation and beyo nd 4 weeks. Prot e in co n- centrations showed the expec ted decline over the first weeks of lactation and. at a ll pe ri ods, were significantly nigher than in thc DHM samples [7]. Energy co n ce ntrations also showed wide variations across time periods, most likely due to differences io fat co ntent. Table 2 shows the protein and energy profiles of the unfortified milk samples selected for modeling 24 kcal/oz. fortificalion outcome s. Fig ures I a nd 2 depict the ca   l~L Ccl results for prote in and energy, respect iv el y, whcn fed at 1 50 mL and include refercn ce lin es for current prote in and energy recommendation s. Figure I shows that none of the samples ac hi eved the recommended prote in re quirement without fortification and only the high protein sample reached the protein reqltircme nt with the 4: 3 HM to PTF 30 mixture. Using th e acidi fi ed liquid HM fortifier (4 vials added to 100 mL human milk), 3 of4 s amp les exceeded 4.5 g/kgld of prote in with one sa mple grcater than 5 g/kg/d. Us in g both the powder and human-derived fortifier options. 3 of 4 met the suggested intake. Figure 2 shows [he wide variation in energy related :g ~ • 1 ~ c 2 Prettrm M PTF 30(4:3} AC LF HM  +4) Powder Fi g. 1. Prclerrn human milk ( HM ) rrotein (g) aL: h ic vcd with four di ffe rent fort ifi er slra tcgi c s* when fed a.t 1.';0 [n1 a nd compared to e st imated go als. Low P 0: b pected P 0; Ex pected I D ; ni gh P • . "Fortifier st ra tegies: P1T: PretCfm fo nnula (Similac Special Care 30 '10 . Ab bou Nutrition, Co lu rnbus. OIl : AC-LP: Acidified liq· uid fo ndi ;; r (Mead J oh nson Nu tritionals, EVaJ l sv iJl e. TN); lIM F +4 : P ro J UCLa Bioscience (l\: lonrovia. CA): P ov¥' dcr: Enfarnil Human Milk Fortifier (Mead Johnson NULrit ionals. Evansvi ll e. TN), to the variation among the samples rortified. Figure 3 shows th e resulLing milk profiles after individua li z in g fortification based on th e data from real time hum an rni Ik analysi s. S. Discus si on Hum an milk is unique to eac h woman that lactates. Maternal diet. lime since parturition, co -existing medical co nditions, expression t ec hnique and eve n time of day arc factors thaL affect the compo sition of any individual milk sample. The natural decline in protein content in PHM occurs despite the prete nn infant's ear ly weight loss, need for catch-up growth, reeov  32 2 20 . R admll C her J/ ai / I? n tl t i me lIl1/(11/ m il k tl/(Jcrmllltr ie l/1 analys i J 160 140 ~ uo}---   ~   ------   ----   ----   - E ~100 ~ so f : Pr et erm HM PTF 30(4: 1) A C- lf HMFI ) Powder Fi g. 2. Prctcrm human milk en er gy (ken1) ac hieved with four fo rti  fi er : trategic s· whc. /l fcd at 150 TI L an d comp a. re d to l i Tlla t cd g< H s. Low l' : Expected P 0 : Expe Cled P . : H ig h P • . ' Funificr str at egies: PT F: Pr elcrm fOnllllla (Si milac Special Care 30 ~   bbotl utri~ i G n   Colu mb u s. 01-1 ): AC-LP: Acidi fi ed li q ui d fo rt i fi er ( ('ad John so n N lH rition al s. ~\ an s \   l e . iN ): H MF +4: P rula cta Bioscience (M o nr ovia. C A) : Powdc r: En r amil Human Milk ror1 i1i a ~1 ead Johnson NUritlonals, Eva ns vi ll e. IN), E o • .< . = ~ - Ii 3 ~ .5 2 j '---, AC·LF 3 vi als HMFI+61 Powder (S pltt l Fig. 3. Pr Cle nn hu rn an milk cne rh'Y (k ca l) ach i ~   ved w it h ahemate fo niti cr strat eg. l es- when fed 31 15 0m L and Co mpar ed 10 es limat ed goals, Lo w P ; Expected P : Expected P _ ; Hi gh P · Fortifk r s II 1 1 cg H;   ; ; AC-LF; A cid iiicd l iquid foni r1 er (3 vialsJ IOO m .1 . human tlll lk ) O v1ead Johnson Nutritionals, Ev nn ~v i ll e . IN); H;\ l F +6: Pro lacta Bios ci ence (Mon rov i a, r'\ ); P owd cr(5 P il CkCI <J IOO InLhum an Inilk  : Enf am il Hu ma n ;o .. 1 lk r' ortifier (f\ ' kad Johnson NU lnt lO nal   , Evans vi lle. IN). ery of illness, and ongo in g medical co m[llicati ons . A broad, o nc-r ecipe-fits- aJ l st ra te gy ca nnot m eet the n eed s of infan ts with a variety of growth re quir eme nts and an i Ll-d efined m il k ba se. Ln dividuali /.c d  fo rtifica tion strategies ca n ad dr ess these variables and better match an i nf ant's n eeds . On- s it e, real-time analysis of pret er m hum an milk with new devi ce s is eas y and ca n be informa ti ve. Result s fr om th es e P HM s ampl es s howed that while l acto se rema in ed relatively co nstant ov er more th an 4 wee ks of l acta tion, prote in and fat vary consider ab ly over time. Protein, ge nerally th e rate-limiting Hutrient fo r the rapidly grow ing V LB W infant, fo J/ owed the previously recognized [laltern of decl in e ove r the iir st weeks of lactation, with D HM reflec ti ng the lowe st ,rO lein content , c on,istent wilh term m il k [7 ]. How eve r. with in each lactation st age , pr ot ein content vari ed from - 20 to +50% of the mean. Energy (ome nt abo flu ctuat ed ae ross lactarion stages. most likely due to variable fat conten t. Co ll ection and storage co nditi on s can also alfeet nutrient compos ition. The r efo re J-lM A wi ll provide more accur at e data. These differen ces m ay be i m[lona nt co nsi de rations in the ove ra ll nutritional support plan. Fortilicati on of PHM for VL R W infa nts is ba s ed on ge neral a%ulllptions of co nsistent ener gy and prote in co ntent. These data show that when indivi dual m il k pro fi les deviate fr ont those a ss umptions, the rc :; ulting fort il ie d milk m ay not co nt ain the desired co n ce ntration of nutrients. As women progress th rough th e first weeks of lacta ti on, alt eration s in forti fi ca ti on proto co ls lJlay be r eq uir ed to mc t: t the indivi du al ne eds of the convales ce nt infant. Know in g the maeronu trient profile of milk s ample s p ri or to fortifica ti on ma y avoid potentia ll y in adeq uate or excessive nutr i ent intake. Blind fortifica ti on assumcs the HM prol il e is c onstan t There are 2 strategies, ter m ed Iaeto-engi neering , that can more closely tar ge t the nutritional needs (prima ril y protein) of the inf ant. Arslan og lu , M oro and Zi egler [3 9] used a BUN va lue of 9 to 14 mg /dL to disc ri minat e an infant 's n eed for additional pr ote in in th eir study. In fants were fed forti fied HivI per ll :; ll al rout inc. If a HUN was betwcen 9 and 14, no chan ge s w ere nmde. If the BUN was less than 9, additional fortifier (± addi ti onal pro tein p owder) was added to Ih e m i>;. If the BUN was above 14, the am ount of fo rt ifier was reduced. In our a[lproach. milk can be analyz ed prior to the initialio ll of fortification and the mlio of fortificr to H 'v l ca n th en be adju >1 cd to the d es ired nutrient co mposition to more closely match the gr ow th need s or an in fa nt. Ad ju s tment s can conlinnc to be made as bot h the milk pro fil e and th e infa nt "s gr owth needs cha nge. Wh ile analysis of individua ll y e xprc sscd milk sam ples provides ouly a nutrient s nap sho t: ' this pro ce ss can bc ap [lli cd to 24 -hour poo ls of milk to bet ter characterize a J1lothe r' s unique tnilk profile and to synchronize it s c ontent with d es ir ed growth outcomes. Frn an c. ial. di s cl os ure s tatem e nt The author s declar e no co nOi et of inter es t.  323 RaJma cher ef l / Real- time JlJlman milk  tnaL:rrmltlri e nf analysis References II J Academy of Pediarric, A. BreaS lreeding and th e use of human milk. Ped iaLrics20 12: 129(3):e827 l (2] $chao l er RJ . T' hc use of hllm an milk for premalure:: infants . Podi alfCli n North Am Feb 2001 :4 8(1):207-1 9. \ [JJ Sisk PM, UJvelady CA, Di ll ard RG, Gruber KJ , Q'Sho TM. f Early human milk fcetling is associated wi th a lower ns k of nccro t i7i ng enterocolitis in very l ow bi n.h weig ht infants. J Perinalol l ui 2007:27( 71: 428-_3. [41 Seh an ler R, Evaluation of th e ev idence to suppo rt cur rrot rccommcndallolls to m eet th e need s of prema lUr c inrant ~: The role of hum an milk. Am J C li n Nurr 2007; 85(, uppkmenl :S25 - 8. [5J Vohr BR. P oind er BP, Dusick AM, el al. 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