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Corrected fortification approach improves the protein and energy content of preterm human milk compared with standard fixed-dose fortification
  1. Anish Pillai1,2,
  2. Susan Gail Albersheim2,3,4,
  3. Kaitlin Berris2,4,
  4. Arianne Y Albert5,6,
  5. Horacio Osiovich2,3,4,
  6. Rajavel Elango2,3,4,5
  1. 1Neonatology, Surya Hospitals, Mumbai, Maharashtra, India
  2. 2Neonatal Perinatal Medicine, Department of Pediatrics, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
  3. 3British Columbia Children's Hospital Research Institute, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
  4. 4Department of Pediatrics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
  5. 5Women's Health Research Institute, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
  6. 6Department of Obstetrics and Gynaecology, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
  1. Correspondence to Dr Rajavel Elango, Department of Pediatrics, Faculty of Medicine, The University of British Columbia, Vancouver, BC V6T 1Z4, Canada; relango{at}


Objective To evaluate whether a pragmatic corrected fortification (CF) model achieves recommended target protein and calorie content of human milk (HM) for preterm infants when compared with standard fixed-dose fortification (SF).

Design In this prospective non-interventional study, we enrolled mothers of infants with birth weight ≤1500 g fed exclusive HM. Infants with chromosomal or intestinal disorders were excluded. A total of 405 HM samples from 29 mothers and 45 donor milk samples were analysed for macronutrient content using a real-time HM analyser. A stepwise CF model was derived based on published data on HM calorie and protein content corrected for lactation stage and milk type. We applied both models to the measured protein and calorie content for all HM samples and compared the proportion of samples achieving target nutrient requirement in each group.

Results Target protein and calorie content of feed was achieved in 68% of HM samples with CF, compared with 5% samples with SF model (p<0.0001). For mother’s own milk, none of the samples met the target macronutrient range with SF fortification during later lactation periods (≥week 5). With SF, over 40% of infants had poor growth (decline in weight z-score ≥0.8 SD) by 8 weeks. The final feed osmolality was acceptable for all fortification steps of the CF model.

Conclusion The proposed CF model significantly improved the final protein and calorie content of HM with acceptable osmolality. It provides a proactive option to improve nutrient intake in premature infants.

  • very low birth weight
  • mother's own milk
  • nutrition
  • neonatology
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  • Contributors AP, SGA and RE contributed to study design. AP oversaw patient enrolment, acquired data, sample size calculation, data analysis and interpretation and wrote first draft of the manuscript. AP and KB were involved with consent process, coordination of milk sample collection, storage and transport. KB assisted growth assessment and monitoring nutrient intake. AP, SGA, RE and HO were responsible for reviewing data, manuscript drafts and critical appraisal.

  • Funding The study was funded in parts from grants held by RE (BC Children’s Hospital Research Institute) and Division of Neonatology, Neonatal-Perinatal Program, BC Women’s Hospital and Health Centre, Vancouver, Canada.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Research approval was obtained from the University of British Columbia/Children’s and Women’s Health Centre of British Columbia Research Ethics Board (#H17-00077).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. Data regarding individual milk sample macronutrient analysis could be available on reasonable request.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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