Formula / Breast Milk Fortification and Protein Supplements

300g · May 28, 2009

I was wondering how you all handle the fortification process in your units. Do you have a seperate room / area in the unit to do it all in? Do you use HMF? Formula? A combination of the 2 when the calories get big? When using powdered formula to fortify, do you measure it out (using teaspoons...) or weigh it using a gram scale? If you measure it out, how do you clean the teaspoons and the other measuring equipment?

We use HMF, usually 1 pack/25ml so no measuring equipment involved. We have a separate room, but it's very small so sometimes the BM/HMF is mixed at the bedside.

I know one of the current "trends" in neonatal nutrition right now is protein content. How has your unit been dealing with this new push? Our standard TPN / HA starts off at 3g of protein per kg. (the custom TPN/HA then goes off of that / lab values). We just started our Similac roation (6mo Similac, 6mo Enfamil). For our babies on premature formula, we are now exclusively using their high protein (3.3g vs 3g of protein) 24cal forumla. We are in the process of trying to decide how to best make sure that our babies on breast milk (which is most of them) are getting all the protein that they need as well. Do any of you routinely add Beneprotein (or a different protein supplement) to breast milk? Currently we only use protein supplements when babies aren't growing very well despite all other measures.
Thanks a bunch!

I believe our standard initial TPN/HAL is also 3g/kg protein... I'll have to double check that. Our formula fed premies also start exclusively on 24cal. We don't generally fortify BM initially, but when they aren't growing well, like you mentioned. We also use Beneprotein (1/8 tsp/30ml).

Those are the doses I've seen used in our unit. There may be others but I don't work with those patients that advanced in their feeding very frequently.

Hope that helps!

RainDreamer, BSN, RN · May 29, 2009

All of the formula is mixed up in the formula room by the techs. We use HMF or formula powder to fortify EBM. The formula room also sends us packets of weighed out powder for each baby, depending on the calories that need to be added, so we just add one packet per oz of EBM.

I have seen the high protein formula used a few times, but only a handful of times so far. We rarely ever use Beneprotein.

Imafloat, BSN, RN · May 29, 2009

We have a formula room where we do the mixing.

We use SHMF or powdered formula to enrich EBM. The SHMF is pre-measured. We have measuring spoons for each patient to measure what is needed into the EBM when we use powdered formula.

We use Beneprotein when a baby has poor linear growth. That is mixed up in dietary and sent up in jugs.

We use Similac and the new SSC 24 we use is high protein.

Allison T · Sep 16, 2009

I am a former NICU RN/current lactation consultant who covers NICU. Many RNs at the hospital where I work use infant formula even in breastfed babies. For example, they squirt infant formula onto the mother's nipple to "entice" the baby to latch on.

Recently, our amazing pro-breastfeeding neonatologist told our breastfeeding committee that she is piloting a new "minimal enteral feeds" option for preemies, in which babies whose mothers are pumping and/or intend to breastfeed will not have enteral feeds introduced until there is sufficient available mother's milk. I was thrilled and told her so. Then I asked what about the "rinsing with formula" practice. Many NICU RNs at this hospital add some formula to "help the breast milk get out of the bottle," like if the pumped milk is low volume and not very liquid (as is the case with much colostrum). Obviously this exposes the babies to infant formula. The neonatologist did not know about this "rinsing with formula" RN practice; I guess she has not observed it.

My questions for you current NICU RNs are:

(1) Do you do this rinsing with formula?

(2) Do your coworkers do this?

(3) Has your hospital educated RNs about avoiding formula exposure in breastfed infants?

(4) Do many NICU moms ask about avoiding formula so they can exclusively breastfeed?

(5) Is anyone using donor breast milk (from a certified human milk bank) in NICU?

Thanks!

TiffyRN, BSN, PhD · Sep 17, 2009

My questions for you current NICU RNs are:

(1) Do you do this rinsing with formula?

Yes I do, our unit does not have a policy of withholding enteral feeds until sufficient mom's EBM is available. We do however really push the use of donor EBM for mother's trying to establish or failing to maintain sufficient EBM, so many times the "rinsing" is done with donor milk. But not every RN does the rinsing, some simply don't feed that pesky sludgy

(2) Do your coworkers do this?

Many do, some do as I outlined above.

(3) Has your hospital educated RNs about avoiding formula exposure in breastfed infants?

Yes, in favor of using mom's EBM, followed by donor EBM (though only with premature infants, rarely with some gut kid also). Our neos tend to do this for preemies

(4) Do many NICU moms ask about avoiding formula so they can exclusively breastfeed?

Very very few, but we work with a population that we have to "strongly encourage (read push)" to even consider breastfeeding vs. formula feeding.

(5) Is anyone using donor breast milk (from a certified human milk bank) in NICU?

Yes, extensively. Thankfully we never see preemies get formula anymore as their first feedings. We change them over to it before they go home if mom was unable or unwilling to establish her own supply. Many of our extreme preemies are on donor EBM for 2-3 months until they reach 34-36 weeks adjusted age.

As a side note. In the last few years our unit has strongly advocated early establishment of enteral feedings as a preferred way of nourishing premature infants. Our neo's are not fond of the idea of TPN feeding an infant any longer than is absolutely necessary. We start enteral feeds on all infants, regardless of gestational age within 12-24 hrs of age unless they have absolute clinical signs of inability to tolerate it. It would make them cringe to put this off until mom can establish milk supply. Of course, they would undoubtedly give donor EBM since our unit has ready and easy access to a local milk bank.

FlutterbyNurse · Sep 18, 2009

Our unit uses milk techs. We have two to three techs a day dedicated to making and mixing all of the breastmilk in our unit. They have their own room and are required to wear surgical hats while in the room. They only work on one patient's milk at a time.

The milk fortifiers we currently use are HMF 1:25 or 1:50, Prolacta in several different concentrations-the mixing instructions vary according to the guidelines given to us from Prolacta, and powdered Similac Neosure 1 tsp to 90 mL of breastmilk for 24 cals and 1/2 tsp to 90 mL for 22 cals. We clean the measuring spoons with Super Sani-Cloths between each patient's milk. We do not use Enfacare to fortify with as we were instructed by our Diaticien that they do not want their product to be used in this manner.

texas2007, BSN, RN · Sep 24, 2009

Our unit also has milk techs that make up all the special formulas and any fortified EBM daily. I think to make 24 cal EBM they will use HMF. To make 27 cal EBM, they will mix the 24 cal FEBM with 30 cal formula to make 27 calorie FEBM. We rarely use 30 cal. in general and I don't think I've ever seen it just by itself. The docs will also write for 1-1.5 g Beneprotein/100 ml to be added and if the weight gain is still poor, then they will also want corn oil with each feed (not mixed with the formula).

In response to Allison's questions..

1) Do you do this rinsing with formula?

Never heard of it

(2) Do your coworkers do this?

Don't think so

(3) Has your hospital educated RNs about avoiding formula exposure in breastfed infants?

nope

(4) Do many NICU moms ask about avoiding formula so they can exclusively breastfeed?

Very rarely. This is mainly in the term TTN or rule out sepsis crowd. With the preemies, I think the parents just hope the baby survives at all.

(5) Is anyone using donor breast milk (from a certified human milk bank) in NICU?

Nope.

BabyLady, BSN, RN · Sep 24, 2009

In our unit the human milk fortifier is in a small packet that is mixed to 50 ml.

We ONLY mix in 50 ml amounts. So there is no measuring. So Mom must have the breast milk volume available in order to do this.

So we just put it in the measured bottle, we have been told by Lactation to gently rock the bottle back and forth, to NOT vigorously shake it as it breaks down the milk.

We do not use donor milk at our facility.

RM-RN · Sep 28, 2009

We do have a formula prep room. We're not supposed to prepare any feedings at the bedside.

For additives, we use the Enfamil HMF at either 1:25 or 1:50, beneprotein, and Prolacta. If we fortify with formula, we typically use the ready-to-feed and mix per ratio. If we do use the powdered to fortify, each baby gets their own measuring cup/spoon that's sterilized or disposed of when finished. We seem to be hot on the high protein stuff lately, too.

I've never seen anyone doing the "rinsing" with formula. We routinely use donor breast milk. We don't use formula for anyone under 34 weeks. We do start with minimal feeds, but it's not for mom's milk supply.....it's to allow the baby's gut some time for adjusting to feeding. Mom's milk supply just usually falls right into place.

We do have some people who are very anti-formula. They tend to be the "birth plan" crowd, who hasn't yet accepted that their baby has a different plan. We try to accomodate their wishes, if at all possible.

lvnurs9 · Oct 5, 2009

We have a million different recipies for breastmilk... for babies under a certain weight, we fortify with HMF up to 24 cal. If we need more calories, we add neosure powder, beneprotein, and/or MCT oil. There are so many different combos, I can't keep them straight Most kids that are on 24 cal have added beneprotein and for 26 cal beneprotein and MCT oil.

Jerico, BSN, RN · Oct 7, 2009

My questions for you current NICU RNs are:

(1) Do you do this rinsing with formula? No

(2) Do your coworkers do this? Not that I have seen.

(3) Has your hospital educated RNs about avoiding formula exposure in breastfed infants? Yes, is a most excellent NICU. I've been in three previous to this NICU and it is a breath of fresh air.

(4) Do many NICU moms ask about avoiding formula so they can exclusively breastfeed? A few, but we encourage EBM and DEBM.

(5) Is anyone using donor breast milk (from a certified human milk bank) in NICU? Yes.

Our NICU attempts to use EXCLUSIVELY breastmilk; we have fantastically up to date neos who hold the staff to high standards.

I have not seen a case of NEC in this NICU (65 bed); and in ALL the others I saw NEC and the others did not hold breastmilk at a premium.

The policy of breast milk or donated breast milk is a GREAT policy, in my opinion. :up: :up: :up: