Extrauterine growth failure is common in the ELBW (extremely-low-birth-weight; <1000 g birth weight) infant, and may be associated with long-term growth failure and neurodevelopmental deficit (4,44–46). HM is often not sufficient on its own to provide the nutrients needed for adequate growth by the ELBW infant, and therefore must be fortified to increase the energy, protein, and minerals. HM is routinely fortified with the assumption it has 20 kcal/oz of energy and 2.1 g/100 kcal of protein. As our study shows, this is not always the case. The macronutrient content is known to vary from mother to mother, within an expression period, and from week to week in lactation (26–28). Individualized fortification for the extremely small premature infant based on an accurate assessment of macronutrient content in HM allows for standardized intakes of macronutrients.
Point of care analysis of HM has been largely limited to a method called the CMCT, developed in the late 1970s by Lucas et al (24) and subsequently used by others in clinical settings (29,30,47,48). This is a simple and inexpensive tool to estimate energy content based on measurement of the percent fat in an HM sample, but assuming constant amounts of protein and lactose. The lipid component in HM has the highest degree of variability within a single feeding/expression among the major macronutrients, and therefore, is the major component in the milk energy calculation by the CMCT method. When planning fortification of milk for the VLBW infants, the provision of adequate protein is one of the most important considerations. The CMCT method cannot provide this information.
We compared fat and energy content as measured by the CMCT and HMA on discrete HM samples and “control” milks. The CMCT method is an extremely gross measurement based on the gravimetric differences between lipid and nonlipid components in the milk sample and visual quantification. The HMA employs measurements that are specific to the chemical bonds of the lipid (as well as other components) and are independent of human estimation. We demonstrated an increasing deviation between the methods for fat and energy as the CMCT increased, sometimes as much as 2-fold. This resulted in much higher estimates of energy content by CMCT when compared to the HMA and laboratory-based results. The use of an external control milk in our protocol checked proper instrument performance. The laboratory analysis confirmed the accuracy and reliability of the HMA results.
Although it was not the purpose of the present study to include measurement of other nutrients, the HMA analyzer provides information about protein content, which is often the limiting nutrient in postnatal growth for this population. Having this information in real time contributes to the ongoing nutritional management of these infants.
The mid-infrared HMA is an excellent option for real-time analysis of the lipid, protein, and carbohydrate content in HM. It is easy to use, and has a process for calibration and instrument reliability. It provides information that can be used to individualize HM fortification for infants at high risk for extrauterine growth failure. The present study demonstrated its greater accuracy versus the CMCT, which overestimates fat and energy content of HM.
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