Exclusive Human Milk Diet for Extremely Low Birth Weight Infants

Problem:Despite advances in nutrition, extremely low birth weight (ELBW) infants remain at high risk for extrauterine growth restriction that is correlated with adverse neurodevelopmental outcomes. To provide adequate calories and essential nutrients, fortification of human milk (HM) is necessary. Traditional bovine-based fortifiers are associated with feeding intolerance and necrotizing enterocolitis (NEC) in preterm infants. Evidence supports an exclusive human milk diet (EHMD) using a pasteurized donor HM-based fortifier to decrease adverse outcomes. Purpose:This project aims to compare nutritional outcomes and cost of nutrition for ELBW infants that historically received HM with a bovine-based fortifier to ELBW infants that received an EHMD.Methods:A cohort of ELBW infants received an EHMD until thirty-four weeks postmenstrual age. The EHMD cohort was followed until discharge for nutritional outcomes that included total parenteral nutrition days, nothing by mouth days, and incidence of NEC. Growth outcomes included growth velocity and change in z-score. Data was compared to a historical cohort that received HM with a bovine-based fortifier. Cost of nutrition was determined by comparing the price of 100 mLs of an EHMD to 100 mLs of HM fortified with a bovine-based fortifier. Results:The historical cohort consisted of forty-nine ELBW infants born January 01, 2018 to May 26, 2019. The EHMD cohort included fifteen ELBW infants born May 27, 2019 to December 31, 2019. The EHMD cohort was slightly more mature (28 weeks vs. 26 weeks) with higher birth measurements. A greater percentage of the EHMD cohort was small for gestational age (SGA) (birth weight < 10th%ile) at birth compared to the historical cohort (46.7% vs. 18.4%, p<.041). The total number of NPO days prior to initiation of enteral feeds was significantly lower for the EHMD cohort (2.4 ± 2.75 vs. 7.59 ± 5.53, p<0.0001). The number of NPO days after initiation of enteral feeds was also statistically improved (1.40 vs. 4.63, p<0.002). The changes in z-score from birth to discharge, according to Fenton curves, were significantly worse for the EHMD cohort for both weight (-1.12 vs. -0.26, p<.001) and length (-1.74 vs-0.83, p<.025). More infants in the EHMD cohort required 30 calorie/ounce to achieve growth goals (73.3% vs. 14.3%, p <0.0001). The incidence of death, NEC, and spontaneous intestinal perforation were not statistically significant. The estimated cost of 100 mLs of an EHMD was $250.00, compared to $6.34 for HM with a bovine-based fortifier.Conclusion: Meeting the dietary requirements of ELBW infants presents a difficult challenge from a nutritional and economic standpoint. This project found that an EHMD improves feeding tolerance for ELBW infants. The EHMD cohort had suboptimal growth despite increased caloric feeds. The cost of an EHMD was 40 times higher per 100 mL than HM with a bovine-based fortifier. Because EHMD is potentially associated with inadequate growth and high cost, additional studies are recommended to evaluate the efficacy of an EHMD for ELBW infants