Adding Fortifier ??

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Does anyone have any suggestions for "effectively" dissolving fortifier into breast milk?? We always used to "shake vigorously" - until we learned that shaking destroys the cells in milk. Gently swirling just seems to leave us with lumpy milk- yuck!! Also, how far ahead of time to you add your fortifier? The package says you can store it for up to 24 hours but I think it starts to look a little funny after a few hours in the frig. Thanks for your input!

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Specializes in NICU.

We've always shaken the milk with the fortifier. I'd never heard of the cells being destroyed and I've never heard of a different way to mix it. It does turn a funny color after a few hours, but it doesn't deteriorate. We usually mix enough for three or four feedings at one time.

Do you charge your patients for the fortifier? Our hospital has a charge, which seems strange to me, most patients have meals included in their room rate, we have mom provide the food and then charge extra for the forifier!

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Specializes in Nurse Scientist-Research.

We've been told about the cells being destroyed. I still shake gently but what I try to do if I can is dissolve the fortifier in a small amount of the EBM then add the rest of the milk to the total amount. We are supposed to place a small amount of of breast milk in a medicine cup, gently mix the fortifier with a tongue blade then pour this mixture back to the total EBM. It doesn't mix that way, it clumps. That's why I prefer when the docs order a formula powder to add to the EBM like Enfacare powder, it dissolves almost instantly though I understand it's not formulated specifically for that purpose.

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linda smith is a very well known lactation consultant. she lectures and holds lactation consultatant exam prep course on a yearly basis. people who have heard her speak say she's great- extremely knowledgable. anyways- she has a web site that has lots of great articles about breastfeeding. she also has alot of articles by jack newman md - another breastfeeding consultant guru. if you go to her web site, check out the article entitled "don't shake the milk". it explains how shaking breaks up the amino acid chains, leaving only pieces - thus ruining many of the beneficial properties of breast milk. the link to her site with that article is:

http://www.bflrc.com/ljs/ls-arts.htm

i only recently learned about the problems with shaking the milk. i used to "shake vigorously" to get the fortifer to dissolve. now i feel torn between maintaing cellular components or serving my babies a lumpy meal !

we don't charge for fortifier but i do know that it is very expensive. i wish someone would come up with a liquid additive! i've never heard of enfacare powder- what is it?

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Specializes in Nurse Scientist-Research.

Enfacare is a 22 calorie formula specifically designed for preemies, it's an Enfamil product. The powder form is mixed similar to other formulas, something like 1 scoop to 2 oz to make a 22 cal formula. Our docs however will use it as a fortifier though generally on the more stable feeder grower types. It's something like 0.5tsp per 100mls EBM to add 2cals/ounce. It's easy to send parents home on this for the kids who still need their milk fortified to 22 or 24 cal. I'm not sure HMF is available commercially so using formula powder is a solution.

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Specializes in NICU.

I have never heard of that shaking could be a preblem, though it does make sense. I've always found that adding the HMF powder to a bottle that's not full helps, but that's because it has more room to slosh around when I shake it!

We have something called "Natural Care" by Similac that supposedly is a fortifier for breast milk but we never use it since it is liquid and will mess up our volumes. I don't know whether it actually fortifes minerals and such or whether it only fortifies calories. I think the only reason we have it is because Similac gives it to us. So it sits on our shelves indefinitely and I assume just goes away when it expires (at which time we get more).

When a baby approaches discharge, we change their fortifier from HMF to Neosure powder, since it is available at the grocery store and HMF is not.

I've always thought that Enfacare 22 was a "term" 22cal formula, not a "premature" 22cal formula? Similac has their Neosure 22cal and their Similac Special Care 22cal, and I thought the Special Care was the "premature" 22cal formula and the Neosure was the "term" 22cal formula. Enfamil only has the one 22cal formula right? The Enfacare? Is it actually "premature" formula? I ask because we've gone to the trouble of mixing Premature Enfamil 20 with Premature Enfamil 24cal to make Premature Enfamil 22cal (supposedly because Enfacare 22 wasn't for preemies).

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Specializes in NICU.
I've always thought that Enfacare 22 was a "term" 22cal formula, not a "premature" 22cal formula? Similac has their Neosure 22cal and their Similac Special Care 22cal, and I thought the Special Care was the "premature" 22cal formula and the Neosure was the "term" 22cal formula. Enfamil only has the one 22cal formula right? The Enfacare? Is it actually "premature" formula? I ask because we've gone to the trouble of mixing Premature Enfamil 20 with Premature Enfamil 24cal to make Premature Enfamil 22cal (supposedly because Enfacare 22 wasn't for preemies).

Similac makes two premature baby formulas - Special Care (20 and 24 cal formulas) and NeoSure (22 cal formula). Special Care formula is only available to hospitals, while NeoSure is over the counter. I think Special Care is easier to digest, something like that. We start babies on either plain breastmilk or SCF 20 cal. When they reach full feeds, we add Similac's human milk fortifier to the breastmilk, or if they're on formula, bump them up to SCF 24 cal. When the baby is nearing discharge, we start to fortify the breastmilk with NeoSure to make 24 or 27 cal/oz, or just feed straight NeoSure 24 or 27. A few babies we put on EnfaCare, if NeoSure seems to be giving them painful gas, but we're really more of a Similac hospital.

I believe both NeoSure and EnfaCare are labeled "for conditions such as prematurity."

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Our LC recently attended a product development session on how to make fortifying easier. They may have a "creamer" with liquid fortifier out soon!

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Specializes in NICU, PICU, educator.

We all really hate that powdered fortifier...bleh! I love when it clumps up :uhoh3: We have found that adding it to warmed MBM helps it dissolve a bit better and we usually only mix 50mls at a time. Our nutritionist prefers the powdered over Natural care, but I think the babies tolerate the Natural Care much better . We only use Similac formulas since that is what our WIC contract is for, but the fortifier comes from Enfamil and costs a pretty penny!

We use Special Care 24 or Neosure for the most part. Special Care and Neosure have more calcium and phosporus I believe. Don't quote me on that though LOL I'd have to look it up. We sent kids home sometimes with a case or two of Special Care and then have the parents change over to Neosure after that is gone, or if it is a chronic kid we show them how to mix up 27 cal formula. Breastmilk goes home with Neosure to fortify. We also don't cut the calories for priming feeds anymore, which I am not to sure I agree with.

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Our LC recently attended a product development session on how to make fortifying easier. They may have a "creamer" with liquid fortifier out soon!

Dawngloves-What did your LC learn at the "session"? Any helpful hints for effctively dissolving the Fortifier?

I am currently wrinting a policy for "handling/storage "of EBM. I personally would love to change to some other product than HMF. Its very "user unfriendly"- messy and clumpy and its expensive. We are only a level 2 nursery so we're not dealing with the micro-premies. All of our kiddos are failrly stable. We have 24 cal SCF/ Neosure and Enf 24 cal. Does anyone know the ratio of how much of these products you add to EBM to produce 24 cal EBM?

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Specializes in NICU/Neonatal transport.

My concern with the HMF is also that it has cows milk proteins in it, which also negate some of the benefits of breastmilk, as well as the artificial iron which interferes with the natural iron absorption. But, I don't know of a better way to get the milk fortified :(

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Dawngloves-What did your LC learn at the "session"? Any helpful hints for effctively dissolving the Fortifier?

I am currently wrinting a policy for "handling/storage "of EBM. I personally would love to change to some other product than HMF. Its very "user unfriendly"- messy and clumpy and its expensive. We are only a level 2 nursery so we're not dealing with the micro-premies. All of our kiddos are failrly stable. We have 24 cal SCF/ Neosure and Enf 24 cal. Does anyone know the ratio of how much of these products you add to EBM to produce 24 cal EBM?

EBM is assumed to have 20 cal/0z. So, for 24 cal EBM, add 2 packs of HMF to 25 cc's EBM. I've used the liquid fortifier, and I just add the amount needed to the 25 cc's or 50 cc's of EBM and go from there.

We add 1 tsp. of powder (usually Enf 20 or Enfacare 22-not sure how they can both fortify to the same amount of calories?) to 100 cc of formula/EBM to increase to 24 cal/oz.

We also do 1 tsp. rice cereal to 3 oz. Enfacare 22 to increase to 24 cal.

We have both SCF24 and Neosure, but we dont' use those a lot. We are seeing a rash of Pregestamil 24 right now, some Neocate, and a few other weird ones. But most of our special calories formulas are mixed by dietary.

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