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protein than the milk from the baby’s own mother,
so it has the lowest protein, around 1 gm/dL of
protein or even a little bit less, whereas the mother’s
own milk, at least early on in lactation, has about
1.5 grams per deciliter.
We do know, however, that even the mother’s own
milk, which starts out with more protein than donor
milk has, actually decreases as lactation continues.
So that the mother’s own milk delivering a premature
baby, the protein in that milk declines, and over time
may look more similar to donor or term milk.
Therefore, human milk provided to extremely low
birth weight infants, babies less than a kilogram,
is likely to have inadequate protein content.
In eNeonatal Review, the article reviewed from Sauer
and Kim talks about analyzing human milk with a
spectrophotometer. 4 We also do that here at the
University of Louisville. It allows us to examine in real
time the content of the mother’s milk each day before
it’s provided to the baby. This technology takes about
20 seconds after a human milk sample is provided to
the device and prints out the macronutrient content
of that milk that’s being fed to the baby that day
including the amount of energy. That allows us to
individualize and customize the human milk that that
baby is receiving.
For this particular baby, the 120 ml/kg/day of donor
milk could be providing as little as 1 gm/kg/day to
1.2 gm/kg/day in an infant whose protein
requirement is 4 gm/kg/day. So it is not hard to
understand that this baby is not going to grow very
well. And I believe that we’ll talk more about
fortification in a moment.
MR. BUSKER: Actually, Doctor, let’s take that
moment right now. Tell us more about adjustable
fortification and human milk macronutrient analysis.
DR. ADAMKiN: Sure, thank you. There are two ways to
go about fortifying human milk with a fortifier. One is
an adjustable method. The adjustable method tries to
make up for the changing protein that is decreasing by
analyzing the baby’s BUN as a surrogate for protein
adequacy. So if the BUN is below a certain level — 9
was used in the study that analyzed this strategy —
if the BUN is less than 9, they added more fortifier;
if the BUN was greater than 14, they took away some
fortifier or protein powder.
The method that I alluded to would be called targeted,
or individualized, fortification, where we measure
the protein in the milk, the energy in the milk, and
then we can adjust the nutrient intake based on the
results of the analysis. And again, the paper from
Sauer and Kim in eNeonatal Review showed how to
go about using the point of care spectrophotometry
in the nursery. 4
MR. BUSKER: Thank you for that explanation,
Doctor, and for presenting today’s case discussion.
I want to switch gears now and ask you to look into
the future for us. What upcoming advances do you
see regarding nutritional support for these very low
birth weight infants?
DR. ADAMKiN: I think there is going to be a lot of
excitement about the relationship between nutrition
provided to these very low birth weight babies and
their cognitive outcomes and their risk of adult
diseases later on in life. The so-called programming
of disease that may occur early in life and express
itself later.
The things that I’m referring to for our tiny babies is
methodologies to look at body composition of these
babies. To look at whether or not our feedings are
making them fat or lean. We know that body
composition of these babies may be associated with
the risk later on in life of cardiometabolic diseases.
Another technology that may become available to
use at the bedside in a standard fashion would be
measuring energy expenditure: how are the babies
using the nutrients that we’re giving them, how many
calories are they burning, can we tailor their nutrition
more for the individual baby than simply feeding all of
these babies the same amount of fuel and seeing how
they do. I think measuring body composition and
learning more about their energy expenditure will be
part of the future in optimizing management and
outcomes of these babies.
MR. BUSKER: Thank you for sharing those thoughts,
doctor. To wrap things up, let’s review the key points
of today’s discussion in light of our learning
objectives. So to begin: the importance of starting
parenteral nutrition in the first hours of life in very
low birth weight infants, even in the face of critical
illness.
eNeonatal Review Podcast Transcript, Volume 9: Issue 14
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