Preterm babies, supplementation, and counseling families

On behalf of babies, let's move past "That's just how we do it here"

“NICU ‘graduate’ families I work with, who have moved to at-breast feeding primarily, often find it frustrating that formula supplementation has to continue for ‘x’ length of time...but without much reason why other than "they were preterm". Any language guidance to support families through this? Or any resources for what is evidence-based supplementation? Good questions these parents can ask as they work with their providers?” - from Q&A at my recent talk for Inland Empire Breastfeeding Coalition, titled “Milk & More: Nurturing Connection in Preterm Dyads

{First - look for official/standardized recommendations

Second - what problems problems health care providers are trying to solve when they make recommendations for formula, fortifiers, etc. 

Third - what we can encourage families to ask}

Unfortunately, what you are describing is common, and it stems from a complex set of misunderstandings. Let’s pick it apart to figure out how we can talk to families about this. 

First, where is the official guideline that preterm babies have to have formula supplementation for “x” amount of time? It doesn’t exist - that’s because it should be by individual need. Just because it’s common doesn’t mean it’s actually supported by evidence OR recommended by any health authorities. The ABM protocol #12 lists multiple options for feeding the preterm post-discharge, and all encourage individual assessment and as much human milk feeding as possible, as well as at-chest/breast supplementation whenever required. It also lists trial of exclusive breastfeeding as one of the options. 

* Be aware that the protocol also lists information about adding preterm infant formula (powdered) to expressed human milk, a practice which directly contradicts all official guidance regarding the safe preparation of powdered infant formula and the avoidance of powdered infant formula for infants born preterm and/or vulnerable. The reference used to support this option is not valid. *

Let’s be clear: we ALL want to see preterm babies grow optimally. Parents, lactation care providers, and others on the health care team are working toward the same goal. As lactation care providers, we are naturally seeking the MOST lactation-supportive methods to do that, and though we sometimes feel frustrated at having to constantly advocate for something that is so clearly demonstrated in the research, that’s our role. It’s what we do. We have the expertise to add in the gentle reminders about how we can integrate - or in some cases introduce - at chest/breastfeeding and human milk into the feeding routine. I know it sometimes feels like others view us as ONLY thinking about breastfeeding and ignoring the rest, but when we communicate clearly that we share the same goals, we can hopefully be more respected on the team.

Let’s take a moment to consider what types of feeding products are often discussed in the world of preterm infants.

Formula = substitute fed to babies when human milk is not available; a safe, whole food when reconstituted with water that has been boiled, then cooled to 70degrees C

Fortifier = commercial product to be added to human milk; not a whole food, even when reconstituted with water; comes in powder (not sterile) and liquid (bovine-based or human milk-based)

Following the rationale, fortifier may be used temporarily when a preterm and/or low birthweight baby is unable to A)absorb enough micronutrients from human milk due to immaturity of the gut, and/or B)take in a large enough volume of human milk to obtain enough macronutrients to grow at a rate equal to what would have been in-utero growth 

Preterm formula is a slightly different product than standard term formula because its macronutrients have been altered to get more of them to the baby in a volume that the baby can tolerate. 

So why are we seeing so many babies being given formula, preterm formula, and fortifiers?

It’s pretty simple, actually. It’s mainly because human milk is rarely analyzed for its macronutrient content. Everyone uses an average or an estimate, and human milk macronutrient composition varies widely from day-to-day and even hour-to-hour. 

When providers don’t know how to calculate how much nutrition a baby is getting (because the baby is breastfeeding and they don’t know to assess it or because they are simply estimating the macronutrient content of expressed human milk), they feel it is easier to recommend formula (standard or preterm) because the calculations are simple. 

The bottom line is that when breastfeeding and human milk are part of the picture, an IBCLC should be part of the team for the families of preterm babies. Each baby needs individual assessment of both growth AND biomarkers of mineralization in order to determine if they need anything other than expressed human milk. Each family needs individual assessment and discussion of how they will access ANYTHING recommended to be given to their preterm infant at home - fortifiers, preterm formula, etc.

What families can ask about? - Safety, for one thing. When we educate them about the need and rationale for preparing powdered infant formula using boiled-then-cooled-to-70C water, it will become clear to them that adding powdered formula to expressed human milk does not conform to that safety precaution. Powdered infant feeding products are not sterile and can cause illness. 

They can ask for individual assessments, like IBCLC evaluation of breastfeeding/milk transfer, blood testing to check for mineralization iron levels, and frequent weight checks to empower them to monitor their baby for growth progress. 

Essentially, families should be encouraged to ask for individual care, rather than a “standard” or “how we do it here” approach, and they should ask for frequent assessment and determination of when they can discontinue any types of supplementation, fortification, and use of breastmilk substitutes. 

Many thanks to Susan for asking this question and to IEBFC for inviting me to speak. If you are interested in learning more about human milk fortification, I have an extensive learning module inside my Evolve Lactation Community where we explore fortification in detail. Learn more here.