Improving Outcomes in Premature Infants:  “Exclusive Human Milk Diet”

An exclusive human milk diet is exactly that:  giving nothing to a newborn but human milk.  We preach it. We tell everyone who will listen that the American Academy of Pediatrics, the CDC, the WHO, and even the Joint Commission {small shiver up my spine- if you are in healthcare, you’ll get that} want us to help each new mother exclusively breastfeed for 6 months. 

The key word there is exclusive.  Hospitals are measuring exclusive breastfeeding rates because of the Joint Commission Perinatal Core Measure that asks them to start paying attention to what is, right now, an abysmal number. The CDC has and continues to measure exclusive breastfeeding rates at several time points from birth to 6 months.  Exclusive breastfeeding for 6 months!  What a task that is in the United States.  

However, many more decision-makers are starting to see that the daunting prospect of exclusive breastfeeding for 6 months is not just the responsibility of that new mother. We have an army of people helping on so many fronts, ready with toolkits, education and enthusiasm. We have dedicated (and probably frustrated) people lobbying for extended maternity leave.  All of this effort is to establish an infrastructure around a new family, helping them to achieve their breastfeeding goals, to remove obstacles and to help increase exclusive breastfeeding duration rates.   All of the good things we know happen because of human milk feeding are related to how long a baby is breastfed.  No other population needs this help and support more than the family of the extremely premature infant (those infants born before 28 weeks of gestation). 

Premature infants are at risk for a host of problems. Among others, premature infants are at risk for feeding intolerance, late-onset sepsis, and necrotizing enterocolitis (NEC). NEC is an awful inflammation of the gut, which can lead to surgery, sepsis and death.  I used to play a neonatologist on TV (I did not complete my fellowship in neonatal-perinatal medicine, but I learned a lot during the time I was there) and I have a healthy fear of what that disease does to the baby and the family.

Human milk decreases gastric pH, improves gut flora, decreases gut permeability, matures the mucosal immune system, prevents invasion of bacteria. All of those properties help prevent NEC in premature infants. Premature infants getting human milk at discharge from NICU have increased IQ points and growth of brain white matter.  Obviously, the early diet of these babies affects their long-term outcome; the more human milk they get, the less risk of serious complications.

Great, but often the mothers of those preterm infants cannot provide enough milk for their babies.  A 2005 study showed that about 30% mothers of premature infants were able to give all of the milk their premature baby needed. Enter donor human milk, donated by breastfeeding mothers to human milk banks to be pasteurized and most often used to help fill the gap between mother’s own milk and that premature baby’s needs.

Again, great, but even if that premature infant could get all their feedings from their mother’s own milk, human milk protein content decreases over time, which is fine in healthy, term newborns, but not for preemies who need more protein than human milk has in order to grow. Preemies also need more fat, sodium, calcium, and phosphorus. Hence, human milk given to extremely premature infants needs to be fortified. However, many concerns about fortifiers (ex: powdered ones have potential for contamination) exist.  The fortifiers are also concerning because they are cow’s milk based. Early studies looking at the benefits of donor milk in the NICU and found that it was of limited value may have been confounded by the use of fortifiers that were cow’s milk based.

What if we were to give nothing but human milk, with human milk based fortifiers rather than those based on cow’s milk? That would be the very definition of an exclusive human milk diet and it works really well. This study concluded that for “extremely premature infants, an exclusively human milk-based diet is associated with significantly lower rates of NEC and surgical NEC when compared with a mother's milk-based diet that also includes bovine milk-based products.”

The results intuitively make sense. This is really exciting news for all of us who really care about the health and outcomes of extremely premature infants. 


A post-script…Currently, the only manufacturer of the human-milk based human milk fortifier is Prolacta, which was and really had to be a part of the study. When I first heard of them, they had sales reps that didn’t know anything about the product, had no research to support the work they were doing and in general were pretty clueless. Now, they have great research to support their fortifier.  They have severed their ties with Similac maker, Abbott, and they are a safe and credible place to donate breast milk. What I am saying is that they are not the Prolacta of the past and a knee jerk response of dismissing them now is uninformed.

If you are a mother looking to donate extra breast milk, yes!  Thank you.  You have many choices to help those fragile premature infants including any one of HMBANA’s growing number of milk banks, and yes, Prolacta.  (And no, they didn’t pay me.)


Jenny Thomas, MD, MPH, IBCLC, FAAP, FABM


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