Neonatologist Dr Evelyn Rider talks about the benefits of early fortification with human milk–based fortifiers in babies born weighing <1250 grams and how Prolacta’s fortifiers reduced the overall cost of care in her neonatal intensive care unit (NICU).
Dr Evelyn D Rider is a neonatologist in Anchorage, Alaska. She received her medical degree from the University of Hawaii Manoa John A. Burns School of Medicine and underwent her neonatology training at Harbor-UCLA Medical Center. She has been a practicing neonatologist for nearly 30 years. She is the medical director of the Children’s Hospital at Providence Alaska Medical Center. She is also the practice director for Alaska Neonatology Associates, an affiliate of Pediatrix Medical Group with MEDNAX. This is the only neonatology group in Alaska.
Huston, R, Lee M, Rider E, et al. Early fortification of enteral feedings for infants <1250 grams birth weight receiving a human milk diet including human milk based fortifier. J Neonatal Perinatal Med. 2020;13(2):215-221. doi: 10.3233/NPM-190300
The full potential of human milk has yet to be realized. Speaking of Human Milk provides healthcare professionals with information on the latest science and clinical research. Each episode features an interview with a thought leader passionate about uncovering the unknown potential of human milk or better understanding the science of neonatal nutrition.
In addition to hosting Speaking of Human Milk, Keli Hawthorne is the director for clinical research for the Department of Pediatrics at the University of Texas Austin, Dell Medical School. In her current role, she trains faculty and staff on effectively executing high-quality protocols for research. She has authored more than 40 peer-reviewed publications on neonatal nutrition.
Keli Hawthorne (KH): Hey y’all, welcome to Speaking of Human Milk, where we give you bite-size episodes on the latest science and innovation surrounding human milk. This podcast is brought to you by Prolacta Bioscience, a company dedicated to Advancing the Science of Human Milk®. The results and outcomes described in this episode are anecdotal and specific to the institution and its protocol. For a list of published studies of exclusive human milk diet, go to Prolacta.com. I’m your host Registered Dietitian Keli Hawthorne. Today, we will be speaking with neonatologist Dr. Evelyn Rider. She has been a practicing Neonatologist for nearly 30 years and is the medical director of the Children’s Hospital at Providence NICU at Providence Alaska Medical Center. She is also the practice director for Alaska Neonatology Associates, an affiliate of Pediatrix Medical Group with MEDNAX.
Today, we’ll be talking about the role of early fortification for very small premature infants receiving an exclusive human milk diet in the NICU. Thanks for joining us today Dr. Rider.
Evelyn Rider (ER): Thanks for having me on the podcast, Keli. It’s a pleasure to be here.
KH: For our listeners who don’t know you, tell us a little bit about how you got into neonatal care and your experience in the NICU.
ER: Well, so as you mentioned I’ve been a practicing Neonatologist since 1990, so I’ve seen a lot of changes in the field over the past 30 years. As a pediatric resident, I loved ICU medicine and opted for the Neonatal ICU where I felt everything we did in caring for these most fragile patients made a difference. Over my career, I have seen our care of these babies become more sophisticated, including how we provide nutrition. When I started in neonatology, we did not hesitate to offer formula alternatives to maternal breast milk. And of course, back then, we had no options but cow’s milk-based fortifiers to supplement breast milk for these babies. Today, I can no longer say that there is a safe alternative to breast milk feedings for very premature babies.
KH: First of all, why do premature babies struggle so much with achieving adequate growth?
ER: Keli, babies born prematurely struggle with achieving adequate growth because we have yet to figure out how to support these babies as well in an incubator as the placenta and the mother’s womb during pregnancy. A baby born prematurely is at a distinct disadvantage from the growth standpoint because not only can we not match the nutrient delivery from the placenta, but the baby’s metabolic needs are also higher than it is in the womb. Therefore, it is very important to avoid nutritional deficits from the very beginning of a baby’s hospital stay. As neonatologists, it is important to recognize that premature babies are very much at risk for nutritional crisis and we must avoid the vicious cycle that results when they don’t grow because babies who don’t grow get sick and sick babies do not grow.
KH: As a NICU dietitian, it was always important for me to work with the nurses to make sure they correctly measured length and head circumference weekly. What have you done in your NICU to help ensure these measurements are done properly?
ER: Accurate length and head circumference measurements are certainly more challenging to obtain than a baby’s weight Keli. We now use a special measuring tape for the head circumference, one that is made of a non-stretch Teflon synthetic material and encircles the baby’s head. Length is measured using a recumbent length board with a stationary head rest and a movable footplate that can measure a baby’s fully extended length more precisely. Both of these were implemented in our NICU in the last year. Having reliable measurements are important when we are trying to determine impact of nutrition on growth parameters.
KH: I know you were involved in a multi-center study a while back that compared differences in babies who were started on human milk fortification at different time periods. Can you tell us about how you got involved in that study and why you thought it was a worthwhile research question for you to answer?
ER: Yes, we were privileged to be one of four centers invited to participate in this multicenter study led by Dr. Bob Huston from Oregon.1 The study was published in November 2019. The primary purpose was to determine if growth of preterm babies weighing <1250 grams at birth is improved by earlier fortification of their breast milk feedings with the Prolacta human milk-based fortifiers. Our NICU in Anchorage Alaska has used human milk-based fortifiers as part of an exclusive human milk feeding diet for these premature babies since 2012. We followed and monitored our growth and other outcomes as we progressively decreased the volume of feedings at which we added the fortifiers. Because of this, we had babies in both the early fortification and the late fortification arms of the study. No other study had compared early vs. late fortification of breast milk feedings with human milk-based fortifiers.
KH: So tell us what you were looking for – I believe you started some babies earlier than others in receiving a donor human milk-based fortifier.
ER: The babies in the study were in two fortification groups – the group of babies in the early fortification started the human milk-based fortifier at less than 60 ml/kg/day feeding volume and the late group started the fortifier at greater than 60 ml/kg/day feeding volume. Other than when the fortifier was started, the rest of the feeding regimen were the same for both groups. The goal was to see if growth was improved with early fortification and if it is safe to do so.
KH: How different was that from what you were used to doing when it came to starting fortifiers in the NICU for preterm babies?
ER: Well, before human milk-based fortifiers, the only option available was cow’s milk-based protein fortifiers, MCT oil, or formula powders. These are not always well tolerated by these very premature babies and the intolerance could lead to significant complications with intestinal inflammation called necrotizing enterocolitis that can lead to intestinal perforation or death. Maintaining an exclusive human milk diet by using only human milk-based fortifiers has significantly reduced not only these intestinal complications in premature babies but other complications as well. When we started using the human milk-based fortifier, we started at 100 ml/kg/day volume. After proving the safety in our patients, we lowered the volume to 70 ml/kg/day, then to 50 ml/kg/day. For this study, our earlier fortification group were the babies fortified at 50 ml/kg/day and the later fortification were the babies who were fortified at 70-100 ml/kg/day.
KH: And what were your results?
ER: This study showed that earlier fortification at <60 ml/kg/day volume is safe with no increase in intestinal complications, infection or death and that weight gain was improved in these patients compared to the babies who started later fortification at >60 ml/kg/day feeding volume. This is the first study to specifically look at the effect of earlier vs. later fortification of breast milk feedings with the human milk-based fortifiers. In addition, the study also showed that the babies in the earlier fortification group had a lower incidence of chronic lung disease.
KH: Have you been able to adapt this into your current NICU practice?
ER: Absolutely! One center in the study was fortifying babies at 40 ml/kg/day without increase in complications so we have since lowered our fortification volume to that level. We started this lower fortification volume in January 2020 and so far, we have maintained our excellent outcomes in growth, and we have continued to have no cases of Necrotizing enterocolitis since November 2018.
KH: Do you think there are any limitations or barriers to starting the Prolacta fortifier at 60 mL/kg/day that other NICUs might encounter?
ER: A common barrier to many NICUs is the apparent higher cost of the Prolacta fortifiers compared to cow’s milk-based fortifiers and the concern for complications at the lower volume for fortification. Additionally, starting at the lower volume of feedings mean using more of the fortifier; but the return of better growth for babies will be well worth the investment. I hope that results from our study showing that the earlier fortification is safe will reassure others. Showing that earlier fortification is safe is a critical finding because anything we can do to improve nutritional support of these babies in order to avoid deficits is important. The lower rates of necrotizing enterocolitis and other prematurity complications related to having an exclusive human milk diet using these human milk-based fortifiers mean better outcomes for premature babies and lower costs of care. This is important to present when justifying use of these products.
KH: Is there a specific story about a certain baby that comes to mind when you think about how early fortification with an exclusive human milk diet really made an impact?
ER: Keli, I don’t have any one specific baby’s story to share, but what I will say is that since we started earlier fortification of feedings for our babies, growth has improved in our NICU without a single case of NEC in our inborn babies for 2 years. And, knowing the long-term health benefits for these very premature babies in our care is very gratifying.
KH: Thanks so much for your time today Dr. Rider. Early fortification and growth are important topics that have a big impact on babies in our NICU, and I’m glad we could take this podcast time to cover it. Is there anything else you want to make sure our listeners know that I haven’t asked?
ER: Thank you Keli for the opportunity to share this information with your listeners. I feel privileged to care for these very fragile patients and to have human milk-based fortifiers to add to breast milk feedings as part of my tool box to support better and safer growth and to ensure fewer complications and better long term health outcomes. After 30 years of practicing in this field, I continue to feel that everything I do makes a difference for these babies and their families.
KH: Thanks again Dr. Rider. And to our listeners, links to information discussed will be available in the show notes, and as always, we look forward to bringing you future topics on the science of human milk.
Huston, R, Lee M, Rider E, et al. Early fortification of enteral feedings for infants <1250 grams birth weight receiving a human milk diet including human milk based fortifier. J Neonatal Perinatal Med. 2020;13(2):215-221