Adding Fortifier ??

MishlB · Feb 7, 2005

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.

Wow...two packs per 25 cc's for 24 cal??? We do two per 50cc's. As the calories go up we add Neosure powder as well as HMF. I am also surprised to hear of the place that DOESN'T charge for the HMF. Our facility is very strict as to who needs it, must have an order etc. People actually sell it for cash...VERY expensive stuff.

Gompers, BSN, RN · Feb 7, 2005

Wow...two packs per 25 cc's for 24 cal??? We do two per 50cc's. As the calories go up we add Neosure powder as well as HMF. I am also surprised to hear of the place that DOESN'T charge for the HMF. Our facility is very strict as to who needs it, must have an order etc. People actually sell it for cash...VERY expensive stuff.

We also do one packet per 25cc's, two per 50cc's...don't know if it makes the feeding 22 or 24 cal per ounce, but we just do it because the kids tolerate BMF better than BM+NS24 at first. Once they're tolerating the full feeds on BMF for a week or so, we'll transition them to BM+NS24 (or BM+NS27 for those who need it).

I can't imagine having to mix up the formulas ourselves - we're so spoiled that our dietary department does it under a "hood" during the day and puts it all in the fridge for us drawn up into syringes or poured into little jugs.

dawngloves, BSN, RN · Feb 7, 2005

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?

It was more of a "Do you like powder or liquid better? What kind of packaging do you like?" type of session. I think they got $100 for their opinon.

Gompers, BSN, RN · Feb 7, 2005

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!

In answer to the original question...

Even though we don't mix it ourselves, we still have problems with "clumpy" BMF at times, because dietary mixes 24 hours worth of feedings for us. It seems to dissolve the best if we really warm up that milk, not hot, but nice and warm. Then gently shake, more like turning the syringe or bottle upside down and right side up, over and over again. The heat seems to work better than really shaking it.

prmenrs, RN · Feb 7, 2005

I think it is 1 pkt/50ml=22cal, and 2pkts/50ml (or 1/25)=24cal; I don't like adding formula powder because the measurement is so inaccurate, and I don't have anything that holds 75ml or whatever. They didn't even have measuring spoons till I bought some and brought them in. So when I have to mix in formula, it's a total guessing game: Here, this has 22cals/oz because I SAID SO!!!

I do think that warming the breast milk makes it easier to dissolve. And, remembering that it's not just calories, it's extra Ca++ and Phosphorous for their bones, which they need. I believe in fortifying, I just wish it weren't so imprecise.

MishlB · Feb 7, 2005

I am curious how many have dietary mixing their breast milk??? Our dietary makes many mistakes with our special formulas, so I can't imagine trusting them with EBM.

prmenrs, RN · Feb 7, 2005

Our dietary did a good job, the formula was mixed daily by a Registered Dietician, not a "food service worker"; she came up and reviewed the order w/the nurse and took a copy down. If you needed changes, you had till 1pm to make a call; the stuff was delivered around 3pm.

I don't think having them do the breast milk would be a good thing at all. You'd have some body fluids down in the kitchen--I think that would be asking for a problem.

Gompers, BSN, RN · Feb 7, 2005

Our dietary did a good job, the formula was mixed daily by a Registered Dietician, not a "food service worker"; she came up and reviewed the order w/the nurse and took a copy down. If you needed changes, you had till 1pm to make a call; the stuff was delivered around 3pm.
I don't think having them do the breast milk would be a good thing at all. You'd have some body fluids down in the kitchen--I think that would be asking for a problem.

Oh, definitely wouldn't want any of our formulas, especially with EBM, prepared in the kitchen. Yuck! We have our own dietary staff, with a registered dietician and a tech on each day shift. They go over the orders and then make the formula or EBM mixtures under a hood in our dietary room. They actually lock the door so people can't walk in while they're mixing, to limit exposure to germs. The dietician also does weekly analysis of each baby's nutrition, whether they're on all TPN or full enteric feeds. She also does the discharge teaching with the parents who have to make up complicated formulas.

nekhismom · Feb 8, 2005

Wow...two packs per 25 cc's for 24 cal??? We do two per 50cc's. As the calories go up we add Neosure powder as well as HMF. I am also surprised to hear of the place that DOESN'T charge for the HMF. Our facility is very strict as to who needs it, must have an order etc. People actually sell it for cash...VERY expensive stuff.

I've always fortified with 1 pack HMF to 25 mls EBM= 22cal/oz, 2 packs = 24 cal/oz. Or, 2 packs HMF to 50 mls EBM= 22 cal/oz. That's just what I've always been taught. I've worked in 4 different NICU/Intermediate nurseries, and that is how I've always seen it done. And I've never worked anywhere that charges for HMF. I can't imagine people actually WANTING to buy HMF!!! YUCK!!

It's amazing how different things are from one unit to the next!

TiffyRN, BSN, PhD · Feb 8, 2005

I checked out the Enfamil site to see if it confirmed what I thought I had read on the packets. So I am copy and pasting a page on instructions from the Enfamil site (to give proper credit). It also had a lot of good instructions on handling. Interestingly the manufacturer of this product reccommends to "agitate" to mix the product (though I know the integrity of the EBM is not their primary concern). Also, they specifically say NOT to add more than 1pkt per 25mls. I know when our kids need more than 24cals/oz we will use HMF 1pk/25mls then to add additional cals we will use microlipids or another formula powder (such as Enfacare or Neosure) to acheive 26, 27 or 29cals/oz.

Enfamil Human Milk Fortifier

Preparation of Feedings

Follow hospital rules for safe handling of human milk.

To aid mixing, agitate the human milk well. Pour the desired amount into a sterile container and warm to feeding temperature.

Add the powder to the human milk according to the following schedule:

Additional

Calories Desired Human Milk Enfamil Human Milk Fortifier

2 Calories/fl oz 50 mL 1 packet

4 Calories/fl oz 25 mL 1 packet

1. Fortified human milk should be fed immediately or covered, refrigerated, and used within 24 hours. Agitate before each use.

2. For tube feeding: Once fortified human milk is prepared, it should remain at room temperature for no longer than a total of 4 hours.19

3. For bottle feeding: Pour only the amount of fortified human milk to be fed into a feeding container and feed immediately. Discard any fortified milk within 1 hour after feeding begins. Do not leave human milk at room temperature for more than a total of 2 hours.

4. DO NOT USE MICROWAVE OVEN to warm the mixture-- serious burns may result.

Suggestions When Using This Product:

1. Monitor and regularly assess blood levels such as serum calcium, sodium, urea nitrogen, albumin, and others. In case of an elevated level, reduce the amount of Enfamil Human Milk Fortifier used to supplement breast milk. In case of deficiency, additional supplementation with the deficient nutrient may be indicated.

2. Do not administer other nutrient supplements in addition to Enfamil Human Milk Fortifier unless appropriate tests indicate a need for further supplementation with a particular nutrient.

3. Do not add Enfamil Human Milk Fortifier to breast milk in a ratio greater than 1 packet/25 mL.

4. Preterm breast milk collected less than 2 weeks postpartum is particularly rich in nutrients, so fortification with Enfamil Human Milk Fortifier is generally not required.

If more than 25 packets daily are used, the infant should be monitored for evidence of excessive vitamin A and D intake.

Caution

Not nutritionally complete. To be used only under the supervision of a physician.

Use product by date on container.

Neither expressed human milk nor nutritional powders are sterile.

Warning: Do not use a microwave oven to prepare or warm formula. Serious burns may result.

Use only as directed. Improper dilution, preparation, handling, or storage may be harmful.

Regarding use in extremely-low-birth-weight infants (ELBW-1 kg or less): Hypercalcemia has been reported in some of these infants on full enteral feeds of mother's milk supplemented with human milk fortifiers

nekhismom · Feb 21, 2005

Yikes! I actually read the Similac HMF box at work the other night, and it does say 1 pack to 25 ml=24cal!! I asked some of the other nurses about this, and they were all surprised, too. So, I was wrong, I've been adding extra calories to milk for some time now! I'm planning on doing a short training on the fortifier asap!

Mimi2RN, ASN, RN · Feb 21, 2005

Enfamil Human Milk Fortifier

Preparation of Feedings

Follow hospital rules for safe handling of human milk.

To aid mixing, agitate the human milk well. Pour the desired amount into a sterile container and warm to feeding temperature.

Add the powder to the human milk according to the following schedule:

Additional

Calories Desired Human Milk Enfamil Human Milk Fortifier

2 Calories/fl oz 50 mL 1 packet

4 Calories/fl oz 25 mL 1 packet

1. Fortified human milk should be fed immediately or covered, refrigerated, and used within 24 hours. Agitate before each use.

2. For tube feeding: Once fortified human milk is prepared, it should remain at room temperature for no longer than a total of 4 hours.19

3. For bottle feeding: Pour only the amount of fortified human milk to be fed into a feeding container and feed immediately. Discard any fortified milk within 1 hour after feeding begins. Do not leave human milk at room temperature for more than a total of 2 hours.

This says we should warm the milk to feeding temp, mix it, then refrigerate it for up to 24 hours. Maybe we just pasteurize it when we heat it?I've never heated it that much before mixing.

Why is it fine to leave fortified milk for 4 hours and unfortified milk for only 2 hours?

I've used this stuff for years, we do continuous feeds for 4 hours, although I don't bring that to room or feeding temp first. We are usually using small quantities, and it won't be cold when it reaches the stomach.