Target fortification of breast milk with fat, protein, and carbohydrates for preterm infants

J Pediatr. 2013 Oct;163(4):1001-7. doi: 10.1016/j.jpeds.2013.04.052. Epub 2013 Jun 12.


Objectives: Fortification of breast milk is an accepted practice for feeding very low birth weight infants, however, fixed dosage enhancement does not address variations in native breast milk. This could lead to deficiencies in calories and macronutrients. We therefore established the infrastructure for target fortification in breast milk by measuring and adjusting fat, protein, and carbohydrate content daily. We analyzed nutrient intake, growth, and safety variables.

Study design: Each 12-hour batch of breast milk was analyzed using near-infrared spectroscopy. Macronutrients were individually added to routine fortification to achieve final contents for fat (4.4 g), protein (3 g), and carbohydrates (8.8 g) (per 100 mL). Fully breast milk fed healthy very low birth weight infants (<32 weeks) were fed the fortified breast milk for at least 3 weeks. Matched pair analysis of 20 infants fed routinely fortified breast milk was performed using birth weight, gestational age, and postnatal age.

Results: All 650 pooled breast milk samples required at least 1 macronutrient adjusted. On average, 0.3 ± 0.4 g of fat, 0.7 ± 0.2 g of protein, and 1.2 ± 0.2 g of carbohydrate were added. Biochemistry was normal in the 10 target fortified infants (birth weight: 860 ± 309 g, 26.3 ± 1.6 weeks gestational age); weight gain was 19.9 ± 2.7 g/kg/d; and milk intake was 147 ± 5 mL/kg/d (131 ± 16 kcal/kg/d). Osmolality of fortified breast milk was 436 ± 13 mOsmol/kg. Matched pair analysis of infants indicated a higher milk intake (155 ± 5 mL/kg/d) but similar weight gain (19.7 ± 3.3 g/kg/d). No adverse event was observed. The linear relationship between milk intake and weight gain observed in study babies but not seen in matched controls may be related to the variable composition of breast milk.

Conclusions: Daily target fortification can be safely implemented in clinical routine and may improve growth.

Trial registration: NCT01305642.

Keywords: BUN; Blood urea nitrogen; ESPGHAN; European Society for Pediatric Gastroenterology, Hepatology, and Nutrition; L2; Level 2; NICU; Neonatal intensive care unit; VLBW; Very low birth weight.

Publication types

  • Clinical Trial

MeSH terms

  • Algorithms
  • Body Weight
  • Breast Feeding
  • Dietary Carbohydrates / administration & dosage*
  • Dietary Fats / administration & dosage*
  • Dietary Proteins / administration & dosage*
  • Food, Fortified*
  • Gestational Age
  • Humans
  • Infant Nutritional Physiological Phenomena*
  • Infant, Newborn
  • Infant, Premature
  • Infant, Very Low Birth Weight / growth & development
  • Milk, Human / chemistry*
  • Prospective Studies
  • Spectroscopy, Near-Infrared


  • Dietary Carbohydrates
  • Dietary Fats
  • Dietary Proteins

Associated data