Target Fortification

Target fortification is the process where Mom’s Own Milk (MOM) or Donated Breast Milk (DBM) is analyzed to assess its macronutrient content, and then fortified to meet the macronutrient target for the premature baby (1).

The nutritional content of human milk changes over time and differs between mothers. It is therefore impossible to accurately estimate the milk’s nutritional content (2; 3; 4).

The nutritional content of human milk changes over time and differs between mothers, so it is not possible to correctly guess the milk’s nutritional content. Fortifying blindly, without knowing the milk’s macronutrient content (so-called standard fortification), more often than not misses the nutritional target, leaving the infant at risk of over- or undernutrition (4; 1; 5).

The risk of using standard fortification is either malnutrition, in the short term associated with poor growth and in the long term with complications such as visual impairment, developmental disorder or cardiovascular disease (6; 7; 8), or overnutrition resulting in increased body fat, larger waist circumference or impaired glucose homeostasis (9).

Yes, many NICUs analyze the macronutrient content of MOM/DBM and use target fortification for all preterm babies. For instance in Sweden target fortification is standard of care for all babies born before GA 32.

Yes, it is possible to create the 24h pool necessary for analysis by extracting 0.5 - 1 ml from every pumping during 24h, and then pool these samples to obtain a 24h average of the MOM needed for macronutrient analysis.

It is up to your NICU to decide. Research shows that in order to compensate for the macronutrient changes in the milk, it is recommended to analyze once or twice a week (10; 11).

Adjusting the fortification based on the metabolic response of the infant, for example blood urea nitrogen (BUN), means that you need to wait for a decrease in BUN and therefore expose the infant to some degree of malnutrition before the fortification is changed. Also, it does not provide the important information on energy and fat intakes. The protein-to-energy ratio is important to achieve growth of lean body mass with limited fat mass deposition (15; 16; 17). An energy intake of 115–120 kcal supports a protein intake of 3.5–4.0 g/kg/day (18). To actively reach this target you need to perform milk analysis.

1. Rochow N, Fusch G, Choi A, Chessell L, Elliott L, McDonald K, Kuiper E, Purcha M, Turner S, Chan E, Xia MY, Fusch C. Target fortification of breast milk with fat, protein, and carbohydrates for preterm infants. J Pediatr. 2013, Årg. 163, s. 1001-7.

2. Weber A, Loui A, Jochum F, Buhrer C, Obladen M. Breast milk from mothers of very low birthweight infants: variability in fat and protein content. Acta Paediatr. 2001, Vol. 90, pp. 772-5.

3. Wojcik KY, Rechtman DJ, Lee ML, Montoya A, Medo ET. Macronutrient analysis of a nationwide sample of donor breast milk. J am Diet Assoc. 2009, Årg. 109, s. 137-40.

4. de Halleux V, Rigo J. Variability in human milk composition: benefit of individualized fortification in very-low-birth-weight infants. Am J Clin Nutr. 2013, Årg. 98, s. 529S-35S.

5. Embleton NE, Pang N, Cooke RJ. Postnatal malnutrition and growth retardation: an inevitable consequence of current recommendations in preterm infants? 2001, Årg. 107, s. 270-3.

6. Singhal, A, Cole, TJ, Fewtrell, M, Kennedy, K, Stephenson, T, Elias-Jones A, et al. Promotion of faster weight gain in infants born small forgestational age: is there an adverse effect on later blood pressure? Circulation. 2007, Årg. 115, s. 213-20.

7. Stoltz Sjöström E, Lundgren P, Öhlund I, Holmström G, Hellström A, Domellöf M. Low energy intake during the first 4 weeks of life increases the risk for severe retinopathy of prematurity in extremely preterm infants. 2016, Årg. 101, s. F108-13.

8. Susanna Klevebro, Vera Westina, Elisabeth Stoltz Sjöströmd, Mikael Normana, Magnus Domellöff, Anna-Karin Edstedt Bonamy, Boubou Hallberg. Early energy and protein intakes and associations with growth, BPD, and ROP in extremely preterm infants. Clin Nutr. 2018, Årg. [Epub ahead of Print].

9. Kerkhof GF, Willemsen RH, Leunissen RW, Breukhoven PE, Hokken-Koelega AC. Health profile of young adults born preterm: negative effects of rapid weight gain in early life. J Clin Endocrinol Metab. 2012, Årg. 97, s. 4498-506.

10. Rochow N, Fusch G, Zapanta B, Ali A, Barui S, Fusch C. Target fortification of breast milk: how often should milk analysis be done? Nutrients. 2015, Årg. 7, s. 2297-310.

11. Stoltz Sjöström E, Ohlund I, Tornevi A, Domellöf M. Intake and macronutrient content of human milk given to extremely preterm infants. J Hum Lact. 2014, Årg. 30, s. 442-9.

12. The national board of health and welfare. Statistics on Pregnancies, Deliveries and Newborn Infants 2016. http://www.socialstyrelsen.se/publikationer2018/2018-1-7. [Online] Socialstyrelsen, 2018.

13. EXPRESS Group, Fellman V, Hellström-Westas L, Norman M, Westgren M, Källén K, Lagercrantz H, Marsál K, Serenius F, Wennergren M. One-year survival of extremely preterm infants after active perinatal care in Sweden. JAMA. 2009, Årg. 301, s. 2225-33.

14. The National Board of Health and welfare. Care of extremely preterm infants. Guidlines for treatment of infants born before 28 gestational weeks [Swedish]. https://www.socialstyrelsen.se/Lists/Artikelkatalog/
Attachments/19503/2014-9-10.pdf. [Online] Socialsyrelsen.

15. J, Rigo. Protein, amino acid and other nitrogen compounds. [forfatter] Uauy R, Koletzko B, Zlotkin S Tsang R. Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines. 3. s.l. : Digital Educational Publishing, 2005, s. 45-80.

16. Thureen PJ, Hay WW. Intravenous nutrition and postnatal growth of the micropremie. Clin Perinatol. 27, 2000, s. 197-219.

17. Kashyap S, Forsyth M, Zucker C, Ramakrishnan R, Dell RB, Heird WC. Effects of varying protein and energy intakes on growth and metabolic response in low birth weight infants. J Pediatr. 1986, Årg. 108, s. 955-63.18. Hay WW, Brown LD, Denne SC. Energy requirements, protein-energy metabolism and balance, and carbohydrates in preterm infants. World Rev Nutr Diet. 2014, Årg. 110, s. 64-81.