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protect the preterm infant from infection. After additional phosphorus and sodium. Beyond this,
2–3 days the milk goes through a transitional phase many will require additional protein as the breast
for about 15 days and then becomes mature milk. milk levels decrease over time.
The composition varies during the course of an Breast milk fortifiers
expression/feed and also depends on:
Breast milk fortifiers may be added to expressed
●● time since birth breast milk in the neonatal unit if the infant is not
gaining sufficient weight on breast milk alone. These
●● the time of the day are powdered supplements which are added to the
maternal breast milk to increase the nutrient and
●● expressing technique energy content to aid growth. They contain protein,
sodium, potassium, calcium and phosphate, trace
●● how much the milk is handled after expressing. minerals and vitamins, but in the UK provide no iron.
Energy Infants on breast milk fortifier require iron as a
As the transitional and mature milks increase in fat separate supplement and some neonatal units also
and energy throughout the feed, mothers are give an extra vitamin supplement.
encouraged to ‘empty’ both breasts each time they
express to include the high-fat, high-energy There is no consensus on the stage at which to
content at the end of the feed. add breast milk fortifiers, however, they are
probably not required in early breast milk while the
Protein protein level is high.
The maternal protein is of a higher bioavailability
compared to formula milk and so is better absorbed There are also no current recommendations on
by the preterm infant. The protein content is higher when breast milk fortifiers should be added to
at 1.8 g/100 mL in the transitional milk from the expressed breast milk. Manufacturers recommend
mothers whose infants were born 31 weeks gestation. that they can be added to each batch of milk feeds
It then falls to about 1.3 g/100 mL in mature milk for the next 24 hours. Local policies vary but ideally
– similar to that of mature milk in mothers of term they should be added to the breast milk just prior to
infants. The higher content in transitional milk feeding if possible.
promotes better growth.
Most units use multicomponent breast milk
Calcium and phosphorus fortifiers but single components are available.
These are also better absorbed from breast milk Disadvantages to adding protein, phosphorus,
than from formula milk. However, phosphorus can sodium, calcium and trace elements all separately
become a limiting nutrient for bone development include a higher risk of contamination, unacceptably
and is therefore always given to the infant as a high osmolarity and poor use of nursing time.
supplement.
Breast milk fortifiers are usually discontinued
Vitamin and iron before discharge from the neonatal unit.
The vitamin and iron content of breast milk is
lower than preterm requirements so preterm Oral Feeding
infants feeding only on breast milk need a vitamin
supplement once on full enteral feeds and then an Feeding development in the preterm infant is
iron supplement from around 4 weeks of life. Local individual and dependent on many factors,
policies for supplementation can vary. including gestation and size at birth, the medical
condition and history of the baby.
Most infants less than 1500 g grow satisfactorily
on maternal breast milk and vitamin supplements Breastfeeding
for the first weeks of life, however, some may need
With appropriate support preterm infants may be
able to start breastfeeding attempts from as early as
