Breastfeeding the premature baby: Part 3

What about “fortifiers”?

I will start off by saying that when I finished my pediatric training at the Hospital for Sick Children in Toronto in 1981, I was a believer, more or less, in the way we did things with regard to breastfeeding the babies in the neonatal intensive care unit (NICU).  It was obvious that we were putting obstacles in the way of mothers and babies, ensuring breastfeeding failure for most. The illnesses these babies had, such as respiratory distress syndrome of the premature (RDS) usually requiring ventilator support because of their immature lungs. Another common illness, necrotizing enterocolitis (NEC), which could lead to perforation of the baby’s gut, also made breastfeeding difficult if not impossible for most mothers and their babies.  While the babies were being mechanically ventilated, it was assumed that babies could not be breastfed or even be held in skin to skin contact.  Necrotizing enterocolitis, if it occurs, does still require any oral feeding to be suspended, but we now know that breastfeeding and even breastmilk decreases the risk of NEC.

On top of that, the restraints on the access mothers had to their babies was a large factor in the difficulties they ran into.  Mothers were not allowed access to their babies during physician rounds, or if a baby in the same room was undergoing a procedure, and during nursing shift changes.  And many reasons were good enough reasons to keep the mothers away.

And so, I thought, well, it’s unfortunate, but there is nothing to be done. The thinking at the time was that saving the babies’ life somehow prevented them being in skin to skin contact and breastfeeding as if the two were mutually exclusive.  And so, of course, saving the baby’s life came first.  As it turns, very good work from Columbia and Scandinavia has shown that we can do everything to save the baby’s life while at the same time encouraging mothers to do skin to skin contact and Kangaroo Mother Care and as a result help get the mother and baby breastfeeding successfully.

The thinking, in those days, came from thinking of breastfeeding as something “extra”, a bonus that the mother and baby can have when and if the baby is well enough and big enough, but only then. However, in spite of the many studies demonstrating, without doubt, the benefits of Kangaroo Mother Care on the general wellbeing of the premature (and full term) baby, including the increased success of breastfeeding, many neonatal intensive care units have just not come on board. “What we’ve always done works well” seems to be the mindset, and “Please don’t confuse me with facts”.

These articles Breastfeeding the premature baby Parts 1 and 2 discuss some of the advances in the care and breastfeeding of premature babies that occurred over the last 35 or more years.

My (Jack Newman’s) experience in Africa

My first “real” job after finishing my training was as a pediatrician in the “Black Homeland” of the Transkei, an artificial country made to advance the Apartheid policy of the Republic of South Africa.  Any Black Africans not supporting the economy of South Africa (by working at jobs not that different from slavery) were to be made to live in several scattered, generally very poor areas, where the land was infertile, rainfall sparse and no source of any sort of riches at all, not even mineral wealth for which South Africa is known.

I was the only pediatrician in the “country” where the infant mortality rate (death before 1 year of age) was outlined by an epidemiologist not long after I arrived.  He presented the results of a study that showed that 250 of 1000 of all babies born in the Transkei died before the age of a year.

Of course, part of my responsibilities was to manage the “special care” unit.  The unit was very poorly equipped compared the ones of my experience in Toronto, and we not infrequently had 3 or 4 premature babies in the same incubator (they seemed to keep each other warmer, lying side by side in the incubator, than the frequently malfunctioning incubators).  There were no infant ventilators in the hospital at all.  The mothers did stay with the babies much more than what I was used to in Toronto, but most had other children at home and so this made their being there most of the day difficult.  When they could, they slept on the floor in an adjoining room and would come to breastfeed their babies whenever the babies showed readiness to feed.

And to my surprise, though formula and bottles were not allowed in the hospital, I had somehow expected that premature formula would be available for the premature babies, as “medicine”, so to speak.  But no, “No formula meant no formula”.  In my training, I was taught the idea that premature babies should grow at the same rate as they would have, had they stayed in the uterus.  So, what could I do? I “knew” that breastmilk alone could not make babies grow at the desired rate. How did I know this?  I was taught this and believed it, just as many doctors believe the unspoken message in their training that breastfeeding cannot make full term babies grow at the desired rate. Yes, such doctors are not rare.

It should be mentioned at the outset that one of the flaws of getting babies to gain at “intrauterine growth rate” is that overall gain in weight does not necessarily mean that the babies are actually getting the nutrients they need.  Weight gain is a very crude measure of what adequate nutrition is.  So, for example, lots of weight gain in a developing premature baby may mean that much of that weight is actually fat, not necessarily lung growth or brain growth. The notion that premature babies, once out of the uterus should grow as if they were still in the uterus is based on no science at all, but really based on “It seems like a good idea”.  But studies show that the push for more weight gain often leads to long term problems such as overweight, higher blood pressure, higher cholesterol and insulin resistance in adolescents born prematurely.

Furthermore, nobody knew in 1981 at Toronto’s Hospital for Sick Children whether babies should be fed enterally (through the intestinal tract) for the first 7 to 10 days.  The opinion shifted back and forth and sometimes every month, depending on which neonatologist was in charge for that month.  “Fasting” the babies for 7 to 10 days is part of the reason for the enthusiastic introduction of fortifiers, to catch up on what the baby didn’t get during that time.  It is now believed that early enteral feeding is a good thing.

How could I get the premature babies to gain weight at the intrauterine rate?

I couldn’t use formula; I couldn’t use a relatively new technique at the time called “total parenteral nutrition” which was a way of getting nutrients into the baby with an intravenous infusion of nutrients.  It was beyond the money available, in a health system starved for funds for adequate care of anyone, never mind premature babies.  And we didn’t have the expertise to make up the solutions and monitor the results.

So I decided that instead of using the standard amounts of milk given to babies in affluent countries, I would give the premature babies more breastmilk.

Usually it is said that premature babies can take only up to 180 to 200 cc/kg/day fluid total in 24 hours (by enteral methods + intravenous). In some neonatal intensive care units (NICUs), the “rule” is even less. If the baby is on an intravenous, that may mean little is given orally. In an NICU this may make sense since the babies are sick, often on ventilators and some babies on ventilators may go into heart failure if they receive larger amounts of fluid. If the baby goes into heart failure while on a ventilator it may become difficult to wean the baby from the ventilator. But, the well premature baby can take more, especially if given by continuous gastric tube feeding, drop by drop into the baby’s stomach.

We started gingerly, slowly increasing the amount of milk the baby received. We ended up giving 300+ cc/kg/day (4.6+ ounces/pound/day) with no trouble except occasionally babies would get watery bowel movements. But what is the meaning of watery bowel movements in the exclusively breastfed (or breastmilk fed) baby?  This could be normal with large volumes of breastmilk and is seen in full term, healthy babies as well.

In any case, the babies thrived, we had no evidence of osteopenia (low levels of calcium in the bones).  Okay, these were babies who were not very sick, not like many babies we frequently see in NICUs. They were generally bigger (babies born at 24 weeks gestation rarely, if ever, survived).  But the point is that we could make them grow at rates that were similar to how they would have grown had they stayed in the uterus. And we did it with breastmilk only.

With the limited numbers of laboratory tests we could use, the babies were fine and biochemically did not show signs of osteopenia except unusually, but then we could add calcium and phosphorus, not a fortifier, to the milk.

What is the lesson for NICUs in resource-rich countries?

I think we can say a few things:

1. Problems with breastfeeding babies in the NICU are very much caused by current NICU routines and by the fact that breastfeeding is presumed in many hospitals, not to be a priority and often even seen as impossible. Vital steps are not taken to ensure premature babies can be given opportunities to breastfeed and can be breastfed. Here is an email from a mother: “One day my baby was skin to skin with me and she latched on my breast and began breastfeeding. A nurse noticed and said I should not allow her to do that as she is not yet strong enough. Since then, every day when I went to have my one hour of skin to skin contact with my baby, I would let her breastfeed in secret and made sure the nurse did not see us.”

Here is a list of NICU routines that make breastfeeding premature babies difficult and promote the “need” for fortifiers:

• No skin to skin contact of the mother and baby or skin to skin contact being limited to an hour or so a day. But Kangaroo Mother Care is much of the day, not a couple of hours.
• The notion that babies need to first learn to bottle feed before they can be allowed to breastfeed.
• The routine use of pacifiers presumed to “teach babies how to suck”.
• The routine use of nipple shields thought to be necessary and helpful for premature babies and the bizarre notion that a baby gets more milk through a nipple shield than latched on directly to the breast.

All these routines combined with the notion that faster weight gain is better pushes the use of fortifiers in the NICUs. And parents then also agree as weight gain is linked to their being able to take the baby home.

There is an issue that arises when the “fortifiers” are called “human milk fortifiers”. This gives the impression to many parents that the babies are not getting formula, but that is what fortifiers are – formula. Mothers of premature babies who come to our clinic for help with breastfeeding usually say that their babies received only breastmilk when they were in the NICU, presumably because the “fortifiers” are called “human milk fortifiers”.

2. “Fortifiers” just like any other formula are frequently overused, used unnecessarily and for much too long, without proof that they are necessary. “Fortifiers” are not always necessary for premature babies. They are presumed necessary because formulas are the accepted, “scientific” way to feed babies and breastmilk and breastfeeding are seen as unreliable. This assumption also causes health professionals not to prioritize breastfeeding and not look for ways in which babies can be breastfed exclusively or receive only breastmilk.

3. In some NICUs, babies of 34 weeks gestation and even older, weighing 1500 grams (3lb 5oz) or even more at birth are routinely given “fortified” breastmilk.  This is usually completely unnecessary especially if the mother has the baby in Kangaroo Mother Care (skin to skin much of the day), is taught how to put the baby to the breast so that the baby has a good latch and gets more milk while at the same time preventing the mother from getting sore.  Mothers should also be taught breast compression to get the baby to take in more milk.  It is the pre- and post- weights that are done without teaching the mother the above important techniques, while believing that pre- and post-weights actually tell us something, that often results in the “need” for “fortification”. Another reason is the idea, strongly rooted in the NICUs, that babies must be fed every three hours and calculating down to the last millilitre (“drop” in US measure) the amount they must get at each feeding.

4. In some NICUs, mothers are being told that they must “fortify” their breastmilk until the baby is 10 months old. This is madness. This is an approach that truly speaks volumes about how little confidence neonatologists and other pediatricians have in breastmilk and breastfeeding.

5. “Fortification” of breastmilk means that a significant amount of the breastmilk that is given the baby does not come directly from the breast. And usually that means by nasogastric feedings and/or bottles. The result is that most mothers in resource-rich countries go home with their babies not breastfeeding, though the babies may be getting some breastmilk.

Here are some of the reasons why breastfeeding in the NICU is difficult: Babies are fed according to a schedule and they are fed prescribed amounts of milk. Mothers are allowed to come in and feed the baby who may have been overfed before and often has been just fed prior to her coming and a baby who was not in skin to skin contact with her.  And so the baby is fast asleep and difficult to wake up. The mother is then told she is disturbing the baby who needs to sleep to grow and she should put the baby back into the incubator.

6. Very tiny premature babies may need extra calories or calcium and phosphorus in the first days or weeks, but this does not mean they need fortifiers made from cow’s milk and it does not mean they should not be breastfed as soon as they can start oral feedings. Fortifiers made from human milk have been available for many years. True, they are more expensive, even though the one company I am aware of does not pay the breastmilk donors for their milk. But if “fortification” were not practically routine, the cost of “fortifiers” to the hospital would decrease if used only when necessary.

7. In fact, “fortifiers” made from breastmilk, either donated or the mother’s own milk, could be made in any hospital. For extra calories, the fat in the milk could be skimmed off and added to the mother’s own milk and given to the baby. Depending on the baby’s blood levels of alkaline phosphatase (which suggests that the baby’s bones may or may not be “thinning out”) calcium and phosphorus could easily be added to the mother’s milk. It would be important not to use bottles when the baby is receiving fortifiers as there is a superior method to do so if supplementation is truly necessary – using the lactation aid at the breast.

Supplementing a baby at the breast with a lactation aid.

If you need breastfeeding help, make an appointment at the International Breastfeeding Centre

Copyright: Jack Newman, MD, FRCPC, Andrea Polokova, 2017, 2018