The use of human milk (mother’s own milk and/or donor milk) in ill or medically compromised infants frequently requires some adaptation to address medical diagnoses and/or altered nutrition requirements. This tutorial describes the nutrition and immunological benefits of breast milk as well as provides evidence for the use of donor milk when mother’s own milk is unavailable. Several strategies used to modify human milk to meet the medical and nutrition needs of an ill or medically compromised infant are reviewed. These strategies include (1) the standard fortification of human milk to support adequate growth, (2) the novel concept of target fortification in preterm infants, (3) instructions on how to alter maternal diet to address cow’s milk protein intolerance and/or allergy in breast milk–fed infants, and (4) the removal and modification of the fat in breast milk used in infants diagnosed with chylothorax.
CritchJN.Nutrition for healthy term infants, birth to six months: an overview. Paediatr Child Health. 2013;18(4):206-209.
2.
American Academy of Pediatrics. Breastfeeding and the use of human milk. Section on Breastfeeding. Pediatrics. 2012;129(3):827-841.
3.
World Health Organization (WHO). Infant and Young Child Feeding: Model Chapter for Textbooks for Medical Students and Allied Health Professionals. Geneva, Switzerland: WHO; 2009.
Medoff-CooperBNaimMTorowiczDMottA.Feeding, growth, and nutrition in children with congenitally malformed hearts. Cardiol Young. 2010;20(suppl 3):149-153.
6.
O’ConnorDLUngerS. Post-discharge nutrition of the breastfed preterm infant [published online May21, 2013]. Semin Fetal Neonatal Med.
7.
IpSChungMRamanG. Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (Full Rep). 2007;(153):1-186.
8.
MonastaLBattyGDCattaneoA. Early-life determinants of overweight and obesity: a review of systematic reviews. Obes Rev. 2010;11(10):695-708.
9.
AndersonJWJohnstoneBMRemleyDT.Breast-feeding and cognitive development: a meta-analysis. Am J Clin Nutr. 1999;70(4):525-535.
10.
WalfischASermerCCressmanAKorenG.Breast milk and cognitive development—the role of confounders: a systematic review. BMJ Open. 2013;3(8):e003259.
11.
KramerMSAboudFMironovaE. Breastfeeding and child cognitive development: new evidence from a large randomized trial. Arch Gen Psychiatry. 2008;65(5):578-584.
12.
O’ConnorDLPiccianoMF. Lactation. In: RossACCaballeroBCousinsRTuckerKLZieglerTR, eds. Modern Nutrition in Health and Disease. 11th ed.Philadelphia, PA: Lippincott Williams & Wilkins; 2014.
13.
BallardOMorrowAL.Human milk composition: nutrients and bioactive factors. Pediatr Clin North Am. 2013;60(1):49-74.
14.
GidrewiczDAFentonTR.A systematic review and meta-analysis of the nutrient content of preterm and term breast milk. BMC Pediatr. 2014;14:216.
15.
LeySHHanleyAJSermerMZinmanBO’ConnorDL.Associations of prenatal metabolic abnormalities with insulin and adiponectin concentrations in human milk. Am J Clin Nutr. 2012;95(4):867-874.
AllenLH.B vitamins in breast milk: relative importance of maternal status and intake, and effects on infant status and function. Adv Nutr. 2012;3(3):362-369.
18.
Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington, DC: National Academies Press; 1998.
19.
Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium and Carotenoids. Washington, DC: National Academies Press; 2000.
20.
Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington, DC: National Academies Press; 2001.
21.
Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids. Washington, DC: National Academies Press; 2005.
22.
InnisSM.Impact of maternal diet on human milk composition and neurological development of infants. Am J Clin Nutr. 2014;99(3):734S-741S.
23.
ChiricoGMarzolloRCortinovisSFonteCGasparoniA.Antiinfective properties of human milk. J Nutr. 2008;138(9):1801S-1806S.
24.
Hosea BlewettHJCicaloMCHollandCDFieldCJ.The immunological components of human milk. Adv Food Nutr Res. 2008;54:45-80.
25.
AdamkinDH.Mother’s milk, feeding strategies, and lactoferrin to prevent necrotizing enterocolitis. JPEN J Parenter Enteral Nutr. 2012;36(1)(suppl):25s-29s.
26.
Cabrera-RubioRColladoMCLaitinenKSalminenSIsolauriEMiraA.The human milk microbiome changes over lactation and is shaped by maternal weight and mode of delivery. Am J Clin Nutr. 2012;96(3):544-551.
27.
HuntKMFosterJAForneyLJ. Characterization of the diversity and temporal stability of bacterial communities in human milk. PLoS One. 2011;6(6):e21313.
28.
BodeL.Human milk oligosaccharides: every baby needs a sugar mama. Glycobiology. 2012;22(9):1147-1162.
EinarsonKDArthurHM.Predictors of oral feeding difficulty in cardiac surgical infants. Pediatr Nurs. 2003;29(4):315-319.
32.
Medoff-CooperBIrvingSY.Innovative strategies for feeding and nutrition in infants with congenitally malformed hearts. Cardiol Young. 2009;19(suppl 2):90-95.
33.
StrychowskyJERukholmGGuptaMKReidD.Unilateral vocal fold paralysis after congenital cardiothoracic surgery: a meta-analysis. Pediatrics. 2014;133(6):e1708-e1723.
34.
RobbinsSTMeyersR, eds. Infant Feeding: Guidelines for the Preparation of Human Milk and Formula in Health Care Facilities. 2nd ed.Chicago, IL: American Dietetic Association, Pediatric Nutrition Practice Group; 2011.
35.
KleinmanRE, ed. Pediatric Nutrition Handbook. 7th ed.Elk Grove Village, IL: American Academy of Pediatrics; 2014.
Academy of Breastfeeding Medicine Protocol Committee. ABM Clinical Protocol #9: use of galactogogues in initiating or augmenting the rate of maternal milk secretion. Breastfeed Med. 2011;6(1):41-49.
39.
WinterfeldUMeyerYPanchaudAEinarsonA.Management of deficient lactation in Switzerland and Canada: a survey of midwives’ current practices. Breastfeed Med. 2012;7:317-318.
Human Milk Banking Association of North America. HMBANA website. https://www.hmbana.org/. Accessed April 13, 2015.
44.
Human Milk Banking Association of North America. Guidelines for the Establishment and Operation of a Donor Human Milk Bank. Fort Worth, TX: HMBANA; 2013.
ColeSZLanhamJS.Failure to thrive: an update. Am Fam Physician. 2011;83(7):829-834.
53.
RomanB.Nourishing little hearts: nutritional implications for congenital heart defects. Nutrition Issues in Gastroenterology. 2011;98:11-34.
54.
KingCDavisT.Nutritional treatment of infants and children with faltering growth. Eur J Clin Nutr. 2010;64(suppl 1):S11-S13.
55.
HairABBlancoCLMoreiraAG. Randomized trial of human milk cream as a supplement to standard fortification of an exclusive human milk-based diet in infants 750-1250 g birth weight. J Pediatr. 2014;165(5):915-920.
56.
RobbinsSTBekerLT eds. Infant Feeding: Guidelines for the Preparation of Human Milk and Formula in Health Care Facilities. Chicago, IL: American Dietetic Association, Pediatric Nutrition Practice Group; 2004.
57.
De CurtisMCandussoMPieltainCRigoJ. Effect of fortification on the osmolality of human milk. Arch Dis Child Fetal Neonatal Ed. 1999;81(2):F141-F143.
58.
BasukiFHadiatiDRTurnerTMcDonaldSHakimiM.Dilute versus full strength formula in exclusively formula-fed preterm or low birth weight infants. Cochrane Database Syst Rev. 2013;11:CD007263.
59.
FentonTRKimJH.A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants. BMC Pediatr. 2013;13:59.
60.
SullivanSSchanlerRJKimJH. An exclusively human milk–based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk–based products. J Pediatr. 2010;156(4):562-567.e561.
61.
Diehl-JonesWLAskinDFFrielJK.Microlipid-induced oxidative stress in human breastmilk: in vitro effects on intestinal epithelial cells. Breastfeed Med. 2007;2(4):209-218.
62.
FrielJKDiehl-JonesBCockellKA. Evidence of oxidative stress in relation to feeding type during early life in premature infants. Pediatr Res. 2011;69(2):160-164.
63.
Assessment of nutrient requirements for infant formulas. J Nutr. 1998;128(11)(suppl):i-iv, 2059S-2293S.
64.
MehtaNMCompherC.A.S.P.E.N. clinical guidelines: nutrition support of the critically ill child. JPEN J Parenter Enteral Nutr. 2009;33(3):260-276.
65.
Groh-WargoSThompsonMHovasiCJ, eds. Nutritional Care for High Risk Newborns3rd ed.Chicago, IL: Precept Press; 2000.
66.
KanmazHGMutluBCanpolatFE. Human milk fortification with differing amounts of fortifier and its association with growth and metabolic responses in preterm infants. J Hum Lact. 2013;29(3):400-405.
67.
FomonSJ.Potential renal solute load: considerations relating to complementary feedings of breastfed infants. Pediatrics. 2000;106(5):1284.
68.
FentonTRPremjiSSAl-WassiaHSauveRS.Higher versus lower protein intake in formula-fed low birth weight infants. Cochrane Database Syst Rev. 2014;4:CD003959.
69.
KoletzkoBPoindexterBUauyR, eds. Nutritional care of preterm infants: scientific basis and practical guidelines. World Rev Nutr Diet. 2014;110:i-xii.
70.
KentRMFitzgeraldGFHillCStantonCRossRP.Novel approaches to improve the intrinsic microbiological safety of powdered infant milk formula. Nutrients. 2015;7(2):1217-1244.
World Health Organization. Safe Preparation, Storage and Handling of Powdered Infant Formula Guidelines. Geneva, Switzerland: WHO Press; 2007.
74.
AnderssenSHLovlundEENygaardEASelbergTRStordalK.Expressing breast milk at home for 24-h periods provides viable samples for macronutrient analysis. Acta Paediatr. 2015;104:43-46.
75.
CzankCSimmerKHartmannPE.A method for standardizing the fat content of human milk for use in the neonatal intensive care unit. Int Breastfeed J. 2009;4:3.
76.
de HalleuxVRigoJ. Variability in human milk composition: benefit of individualized fortification in very-low-birth-weight infants. Am J Clin Nutr. 2013;98(2):529S-535S.
77.
FuschGMitraSRochowNFuschC.Target fortification of breast milk: levels of fat, protein or lactose are not related. Acta Paediatr. 2015;104:38-42.
78.
RadmacherPGLewisSLAdamkinDH.Individualizing fortification of human milk using real time human milk analysis. J Neonatal Perinatal Med. 2013;6(4):319-323.
79.
VieiraAASoaresFVPimentaHPAbranchesADMoreiraME.Analysis of the influence of pasteurization, freezing/thawing, and offer processes on human milk’s macronutrient concentrations. Early Hum Dev. 2011;87(8):577-580.
80.
ArslanogluSMoroGEZieglerEE, The Wapm Working Group on Nutrition. Optimization of human milk fortification for preterm infants: new concepts and recommendations. J Perinat Med. 2010;38(3):233-238.
81.
PolbergerSRaihaNCJuvonenPMoroGEMinoliIWarmA.Individualized protein fortification of human milk for preterm infants: comparison of ultrafiltrated human milk protein and a bovine whey fortifier. J Pediatr Gastroenterol Nutr. 1999;29(3):332-338.
82.
RochowNFuschGChoiA. Target fortification of breast milk with fat, protein, and carbohydrates for preterm infants. J Pediatr. 2013;163(4):1001-1007.
83.
StellwagenLMVaucherYEChanCSMontminyTDKimJH.Pooling expressed breastmilk to provide a consistent feeding composition for premature infants. Breastfeed Med. 2013;8:205-209.
84.
RochowNFuschGZapantaBAliABaruiSFuschC.Target fortification of breast milk: how often should milk analysis be done?Nutrients. 2015;7(4):2297-2310.
85.
MeierPPEngstromJLZulegerJL. Accuracy of a user-friendly centrifuge for measuring creamatocrits on mothers’ milk in the clinical setting. Breastfeed Med. 2006;1(2):79-87.
86.
KimJ.Identifying and addressing infant allergy to cow’s milk protein. Clinical Advisor. 2013;16(11):77.
87.
KoletzkoSNiggemannBAratoA. Diagnostic approach and management of cow’s-milk protein allergy in infants and children: ESPGHAN GI Committee practical guidelines. J Pediatr Gastroenterol Nutr. 2012;55(2):221-229.
88.
Academy of Breastfeeding Medicine. ABM Clinical Protocol #24: allergic proctocolitis in the exclusively breastfed infant. Breastfeed Med. 2011;6(6):435-440.
89.
JonejaJM.Infant food allergy: where are we now?JPEN J Parenter Enteral Nutr. 2012;36(1)(suppl):49S-55S.
90.
KleinmanRE, ed. Pediatric Nutrition Handbook. 6th ed.Elk Grove Village, IL: American Academy of Pediatrics; 2009.
91.
De GreefEHauserBDevrekerTVeereman-WautersGVandenplasY. Diagnosis and management of cow’s milk protein allergy in infants. World J Pediatr. 2012;8(1):19-24.
Klenoff-BrumbergHLGenenLH.High versus low medium chain triglyceride content of formula for promoting short term growth of preterm infants. Cochrane Database Syst Rev. 2003;(1):CD002777.
100.
RamirezMAmateLGilA.Absorption and distribution of dietary fatty acids from different sources. Early Hum Dev. 2001;65(suppl):S95-S101.
101.
LightRW.Chylothorax and pseudochylothorax. In: Pleural Diseases. 6th ed.Philadelphia, PA: Wolters Kluwer Lippincott Williams and Wilkins; 2013.
ChanEHRussellJLWilliamsWGVan ArsdellGSColesJGMcCrindleBW.Postoperative chylothorax after cardiothoracic surgery in children. Ann Thorac Surg. 2005;80(5):1864-1870.
104.
ValentineVGRaffinTA.The management of chylothorax. Chest. 1992;102(2):586-591.
105.
MatsuoSTakahashiGKonishiASaiS.Management of refractory chylothorax after pediatric cardiovascular surgery. Pediatr Cardiol. 2013;34(5):1094-1099.
106.
ZuluagaMT.Chylothorax after surgery for congenital heart disease. Curr Opin Pediatr. 2012;24(3):291-294.
107.
LessenR.Use of skim breast milk for an infant with chylothorax. ICAN. 2009;1(6):303-310.
108.
Soto-MartinezMMassieJ.Chylothorax: diagnosis and management in children. Paediatr Respir Rev. 2009;10(4):199-207.
109.
ChanSYLauWWongWHChengLCChauAKCheungYF.Chylothorax in children after congenital heart surgery. Ann Thorac Surg. 2006;82(5):1650-1656.
110.
DrewniakMALyonAWFentonTR.Evaluation of fat separation and removal methods to prepare low-fat breast milk for fat-intolerant neonates with chylothorax. Nutr Clin Pract. 2013;28(5):599-602.
111.
ChanGMLechtenbergE.The use of fat-free human milk in infants with chylous pleural effusion. J Perinatol. 2007;27(7):434-436.
112.
HamdanMAGaetaML.Octreotide and low-fat breast milk in postoperative chylothorax. Ann Thorac Surg. 2004;77(6):2215-2217.
113.
KocelSLRussellJO’ConnorDL. Fat-modified breast milk resolves chylous pleural effusion in infants with postsurgical chylothorax but is associated with slow growth [published online January5, 2015]. JPEN J Parenter Enteral Nutr.
114.
SpatzDLSchmidtKJKinzlerS.Implementation of a human milk management center. Adv Neonatal Care. 2014;14(4):253-261.
115.
BarbasKH.Mother’s milk technicians: a new standard of care. J Hum Lact. 2013;29(3):323-327.
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