The use of fortifiers in breast milk was a topic highlighted in “Controversies and Challenges”, in a talk given by Neena Modi, professor of neonatal medicine at Imperial College London. Learn more about number 137 of the Medical Journal.
In her intervention, Neena Modi, also a researcher and president-elect of the European Association of Perinatal Medicine, began by recalling the objectives of fortification, referring to the recommendation, based on the consensus on protein requirements, of 2010 [Agostoni C, et al. Nutr. 2010 Jan;50(1):85-91] which says that “a weight gain close to that in utero can be obtained with a non-protein energy intake of 90 kcal/day and a protein intake of 3.0 g/kg/day” and that “protein supplementation must compensate protein accumulation deficit observed in almost all premature babies, which can be increased to a maximum of 4.5 g/kg/day, depending on the size of the accumulated deficit, recommending a protein intake of 4.0 to 4.5 g/kg/day for babies weighing 1000g and 3.5-4.0 for babies weighing between 1000g and 1800g”. Well, according to the researcher, “fortunately, in the update of 2022, still only available in preprint, these recommendations have changed, with protein intake reduced to 3.5-4.0 g/kg/day for very preterm babies”.
Then, the speaker continued, “there is another statement from 1977, from the American Academy of Pediatrics, which has influenced practice over the years, which asserts that the goal of diets for low birth weight babies birth is to achieve rapid replacement of postnatal growth at a rate approximating intrauterine growth”. But, according to Neena Modi, “this statement has been widely interpreted to mean that it is ideal for a very premature baby to reach the size of a full-term baby”, which she says is “a misinterpretation “.
For the professor of neonatal medicine, “birth weight charts should not be used as growth charts, because they force a premature baby to follow a trajectory to reach the size of a full-term baby at the same time. “. Additionally, we know that “babies born prematurely generally weigh less than they would have had they remained in the womb and, therefore, are generally stunted”.
For these reasons, according to Neena Modi, two crucial questions arise: “Do we want to reach the weight the baby would have had if it had remained in utero, or do we want to reach the weight rate the baby would have had? in the womb?” As he replied, “we still don’t know the answer, because in the first case the weight gain will be rapid and will exceed the fetal speed and, in the second case, the baby will weigh less at term than that of a pregnancy “which has been carried to term”. As such, “it is a serious uncertainty that we do not know how quickly premature babies should gain weight”, noted the specialist, noting that “on the other hand, we know that the anthropometry of the baby term does not predict later”. neurological development and that breastfed babies gain weight more slowly than formula-fed babies and have better neurodevelopmental outcomes. Moreover, as he noted, “the evidence supporting routine fortification is totally inadequate, with small studies and flimsy methodology, and clinical practice is also variable around the world.”
Consequences of routine use of tonics “can be dangerous”
In the opinion of the researcher, “the consequences of the systematic use of fortifiers can be dangerous”, in particular because “we know that a premature baby who ingests 200 ml/kg/day of non-fortified breast milk will have an average intake in protein of 3 g/kg/day ranging from 1.4 to 4.8 g/kg/day, and commercial human milk fortifiers have been known to provide 1.1 to 2.4 g of protein/100 ml of milk In other words, routine fortification means that some babies will have a protein intake of more than 5 g/kg/day.” On the other hand, “there is reasonable evidence that there is a dose-benefit response for fresh breastmilk and that reducing breastmilk intake seems unwise,” he added. [Semin Fetal Neonatal Med. 2021 Jun;26(3):101216].
In short, and according to Neena Modi, “the enthusiastic use of fortification, supported by the literature and observational research, raises many concerns, which show us that excessive protein intake increases the risk of sepsis, compromises the neurological development, elevates urea, leads to ventilation, bronchopulmonary dysplasia, obesity, abdominal adiposity, renal failure and increased mortality,” adding that “early exposure to cow’s milk protein complex may improve responses β-cell autoimmunity associated with type 1 diabetes in children genetically at risk” and that “avoiding the consumption of bovine products in the first 14 days is associated with a reduction in necrotic enterocolitis”.