Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Human milk feeding and fortification of human milk for premature infants

Richard J Schanler, MD
Section Editor
Steven A Abrams, MD
Deputy Editor
Alison G Hoppin, MD


Premature infants have greater nutritional needs to achieve optimal growth in the neonatal period than at any other time of their life for several reasons:

They have low nutrient stores because they missed the surge in nutrient deposition that normally occurs during the last trimester.

They are susceptible to medical problems including infection, respiratory disorders, hypoxia, acidosis, and surgery, which increase the infant's metabolic energy requirements and nutrient needs [1]. Certain therapies such as glucocorticoids specifically impair growth.

Their gastrointestinal tract is physiologically immature with decreased gastrointestinal motility and reduced intestinal enzyme activity.

Nutritional support helps to correct growth restriction at birth and to achieve an appropriate rate of weight gain, which is almost twice that of a term infant [2,3]. Parenteral nutrition is necessary for infants whose immaturity or medical condition precludes enteral feeding.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Jan 2017. | This topic last updated: Wed Jan 25 00:00:00 GMT+00:00 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Hay WW Jr, Lucas A, Heird WC, et al. Workshop summary: nutrition of the extremely low birth weight infant. Pediatrics 1999; 104:1360.
  2. Schanler RJ, Garza C, Nichols BL. Fortified mothers' milk for very low birth weight infants: results of growth and nutrient balance studies. J Pediatr 1985; 107:437.
  3. Butte NF, Garza C, Smith EO, Nichols BL. Human milk intake and growth in exclusively breast-fed infants. J Pediatr 1984; 104:187.
  4. Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2012; 129:e827.
  5. Narayanan I, Prakash K, Bala S, et al. Partial supplementation with expressed breast-milk for prevention of infection in low-birth-weight infants. Lancet 1980; 2:561.
  6. Contreras-Lemus J, Flores-Huerta S, Cisneros-Silva I, et al. [Morbidity reduction in preterm newborns fed with milk of their own mothers]. Bol Med Hosp Infant Mex 1992; 49:671.
  7. Lucas A, Cole TJ. Breast milk and neonatal necrotising enterocolitis. Lancet 1990; 336:1519.
  8. Levy I, Comarsca J, Davidovits M, et al. Urinary tract infection in preterm infants: the protective role of breastfeeding. Pediatr Nephrol 2009; 24:527.
  9. Furman L, Taylor G, Minich N, Hack M. The effect of maternal milk on neonatal morbidity of very low-birth-weight infants. Arch Pediatr Adolesc Med 2003; 157:66.
  10. Sisk PM, Lovelady CA, Dillard RG, et al. Early human milk feeding is associated with a lower risk of necrotizing enterocolitis in very low birth weight infants. J Perinatol 2007; 27:428.
  11. Schanler RJ, Lau C, Hurst NM, Smith EO. Randomized trial of donor human milk versus preterm formula as substitutes for mothers' own milk in the feeding of extremely premature infants. Pediatrics 2005; 116:400.
  12. Cristofalo EA, Schanler RJ, Blanco CL, et al. Randomized trial of exclusive human milk versus preterm formula diets in extremely premature infants. J Pediatr 2013; 163:1592.
  13. O'Connor DL, Gibbins S, Kiss A, et al. Effect of Supplemental Donor Human Milk Compared With Preterm Formula on Neurodevelopment of Very Low-Birth-Weight Infants at 18 Months: A Randomized Clinical Trial. JAMA 2016; 316:1897.
  14. Quigley M, McGuire W. Formula versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev 2014; :CD002971.
  15. Corpeleijn WE, Kouwenhoven SM, Paap MC, et al. Intake of own mother's milk during the first days of life is associated with decreased morbidity and mortality in very low birth weight infants during the first 60 days of life. Neonatology 2012; 102:276.
  16. Meinzen-Derr J, Poindexter B, Wrage L, et al. Role of human milk in extremely low birth weight infants' risk of necrotizing enterocolitis or death. J Perinatol 2009; 29:57.
  17. Eibl MM, Wolf HM, Fürnkranz H, Rosenkranz A. Prevention of necrotizing enterocolitis in low-birth-weight infants by IgA-IgG feeding. N Engl J Med 1988; 319:1.
  18. Spiegler J, Preuß M, Gebauer C, et al. Does Breastmilk Influence the Development of Bronchopulmonary Dysplasia? J Pediatr 2016; 169:76.
  19. Zhou J, Shukla VV, John D, Chen C. Human Milk Feeding as a Protective Factor for Retinopathy of Prematurity: A Meta-analysis. Pediatrics 2015; 136:e1576.
  20. Bharwani SK, Green BF, Pezzullo JC, et al. Systematic review and meta-analysis of human milk intake and retinopathy of prematurity: a significant update. J Perinatol 2016; 36:913.
  21. Fang JL, Sorita A, Carey WA, et al. Interventions To Prevent Retinopathy of Prematurity: A Meta-analysis. Pediatrics 2016; 137.
  22. Lewandowski AJ, Lamata P, Francis JM, et al. Breast Milk Consumption in Preterm Neonates and Cardiac Shape in Adulthood. Pediatrics 2016; 138.
  23. COMMITTEE ON NUTRITION, SECTION ON BREASTFEEDING, COMMITTEE ON FETUS AND NEWBORN. Donor Human Milk for the High-Risk Infant: Preparation, Safety, and Usage Options in the United States. Pediatrics 2017; 139.
  24. ESPGHAN Committee on Nutrition, Arslanoglu S, Corpeleijn W, et al. Donor human milk for preterm infants: current evidence and research directions. J Pediatr Gastroenterol Nutr 2013; 57:535.
  25. Moro GE, Arslanoglu S, Bertino E, et al. XII. Human Milk in Feeding Premature Infants: Consensus Statement. J Pediatr Gastroenterol Nutr 2015; 61 Suppl 1:S16.
  26. Wojcik KY, Rechtman DJ, Lee ML, et al. Macronutrient analysis of a nationwide sample of donor breast milk. J Am Diet Assoc 2009; 109:137.
  27. Boyd CA, Quigley MA, Brocklehurst P. Donor breast milk versus infant formula for preterm infants: systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2007; 92:F169.
  28. Sullivan S, Schanler RJ, Kim JH, et al. 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; 156:562.
  29. Hair AB, Peluso AM, Hawthorne KM, et al. Beyond Necrotizing Enterocolitis Prevention: Improving Outcomes with an Exclusive Human Milk-Based Diet. Breastfeed Med 2016; 11:70.
  30. Chowning R, Radmacher P, Lewis S, et al. A retrospective analysis of the effect of human milk on prevention of necrotizing enterocolitis and postnatal growth. J Perinatol 2016; 36:221.
  31. Assad M, Elliott MJ, Abraham JH. Decreased cost and improved feeding tolerance in VLBW infants fed an exclusive human milk diet. J Perinatol 2016; 36:216.
  32. Cohen RS, Xiong SC, Sakamoto P. Retrospective review of serological testing of potential human milk donors. Arch Dis Child Fetal Neonatal Ed 2010; 95:F118.
  33. Lepri L, Del Bubba M, Maggini R, et al. Effect of pasteurization and storage on some components of pooled human milk. J Chromatogr B Biomed Sci Appl 1997; 704:1.
  34. Koenig A, de Albuquerque Diniz EM, Barbosa SF, Vaz FA. Immunologic factors in human milk: the effects of gestational age and pasteurization. J Hum Lact 2005; 21:439.
  35. Ewaschuk JB, Unger S, O'Connor DL, et al. Effect of pasteurization on selected immune components of donated human breast milk. J Perinatol 2011; 31:593.
  36. Van Gysel M, Cossey V, Fieuws S, Schuermans A. Impact of pasteurization on the antibacterial properties of human milk. Eur J Pediatr 2012; 171:1231.
  37. Keim SA, Hogan JS, McNamara KA, et al. Microbial contamination of human milk purchased via the Internet. Pediatrics 2013; 132:e1227.
  38. Lindemann PC, Foshaugen I, Lindemann R. Characteristics of breast milk and serology of women donating breast milk to a milk bank. Arch Dis Child Fetal Neonatal Ed 2004; 89:F440.
  39. Keim SA, Kulkarni MM, McNamara K, et al. Cow's Milk Contamination of Human Milk Purchased via the Internet. Pediatrics 2015; 135:e1157.
  40. Agostoni C, Buonocore G, Carnielli VP, et al. Enteral nutrient supply for preterm infants: commentary from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition. J Pediatr Gastroenterol Nutr 2010; 50:85.
  41. Kumar SP, Sacks LM. Hyponatremia in very low-birth-weight infants and human milk feedings. J Pediatr 1978; 93:1026.
  42. Atkinson SA, Bryan MH, Anderson GH. Human milk feeding in premature infants: protein, fat, and carbohydrate balances in the first two weeks of life. J Pediatr 1981; 99:617.
  43. Atkinson SA, Radde IC, Anderson GH. Macromineral balances in premature infants fed their own mothers' milk or formula. J Pediatr 1983; 102:99.
  44. Tönz O, Schubiger G. Feeding of very-low-birth-weight infants with breast-milk enriched by energy, nitrogen and minerals: FM85. Helv Paediatr Acta 1985; 40:235.
  45. Cooper PA, Rothberg AD, Pettifor JM, et al. Growth and biochemical response of premature infants fed pooled preterm milk or special formula. J Pediatr Gastroenterol Nutr 1984; 3:749.
  46. Gross SJ. Growth and biochemical response of preterm infants fed human milk or modified infant formula. N Engl J Med 1983; 308:237.
  47. Schanler RJ, Shulman RJ, Lau C. Feeding strategies for premature infants: beneficial outcomes of feeding fortified human milk versus preterm formula. Pediatrics 1999; 103:1150.
  48. Polberger SK, Axelsson IA, Räihä NC. Growth of very low birth weight infants on varying amounts of human milk protein. Pediatr Res 1989; 25:414.
  49. Greer FR, McCormick A. Improved bone mineralization and growth in premature infants fed fortified own mother's milk. J Pediatr 1988; 112:961.
  50. Schanler RJ, Abrams SA. Postnatal attainment of intrauterine macromineral accretion rates in low birth weight infants fed fortified human milk. J Pediatr 1995; 126:441.
  51. Lucas A, Fewtrell MS, Morley R, et al. Randomized outcome trial of human milk fortification and developmental outcome in preterm infants. Am J Clin Nutr 1996; 64:142.
  52. Miller J, Makrides M, Gibson RA, et al. Effect of increasing protein content of human milk fortifier on growth in preterm infants born at <31 wk gestation: a randomized controlled trial. Am J Clin Nutr 2012; 95:648.
  53. Brown JV, Embleton ND, Harding JE, McGuire W. Multi-nutrient fortification of human milk for preterm infants. Cochrane Database Syst Rev 2016; :CD000343.
  54. Schanler RJ, Garza C, Smith EO. Fortified mothers' milk for very low birth weight infants: results of macromineral balance studies. J Pediatr 1985; 107:767.
  55. Horsman A, Ryan SW, Congdon PJ, et al. Bone mineral accretion rate and calcium intake in preterm infants. Arch Dis Child 1989; 64:910.
  56. Kashyap S, Schulze KF, Forsyth M, et al. Growth, nutrient retention, and metabolic response of low-birth-weight infants fed supplemented and unsupplemented preterm human milk. Am J Clin Nutr 1990; 52:254.
  57. Abrams SA, Schanler RJ, Tsang RC, Garza C. Bone mineralization in former very low birth weight infants fed either human milk or commercial formula: one-year follow-up observation. J Pediatr 1989; 114:1041.
  58. Schanler RJ, Garza C. Improved mineral balance in very low birth weight infants fed fortified human milk. J Pediatr 1988; 112:452.
  59. Schanler RJ. VII. Fortification of Human Milk With Human Milk Components. J Pediatr Gastroenterol Nutr 2015; 61 Suppl 1:S9.
  60. Jocson MA, Mason EO, Schanler RJ. The effects of nutrient fortification and varying storage conditions on host defense properties of human milk. Pediatrics 1997; 100:240.
  61. Santiago MS, Codipilly CN, Potak DC, Schanler RJ. Effect of human milk fortifiers on bacterial growth in human milk. J Perinatol 2005; 25:647.
  62. Ovali F, Ciftçi I, Cetinkaya Z, Bükülmez A. Effects of human milk fortifier on the antimicrobial properties of human milk. J Perinatol 2006; 26:761.
  63. American Academy of Pediatrics. Pediatric Nutrition Handbook, 7, Kleinman RE, Greer FR. (Eds), American Academy of Pediatrics, Elk Grove Village 2014.