Human milk, fortification and preterm nutrition

Question 1 (10 marks)

a) What is this infant's nutritional problem, and which ESPGHAN 2022 targets are being missed? (3 marks) This infant is still on unfortified mother's milk at 140 mL/kg/day. ESPGHAN 2022 notes mature human milk protein is about 1 g/100 mL, so 140 mL/kg/day delivers only about 1.4 g/kg/day of protein — below the strong recommendation of at least 3.5 to 4.0 g/kg/day. Energy is also likely below the 115 to 140 kcal/kg/day range unless the milk is unusually energy-dense. Weight velocity of 8 g/kg/day is below Ehrenkranz's observed 14.4 to 16.1 g/kg/day after birth-weight regain and below ESPGHAN foetal guide bands for this gestation. Fortifier should already have been considered: ESPGHAN starts multicomponent fortifier at 40 to 100 mL/kg/day, and this infant is well past that window ^[1].

b) Describe the fortification strategy you would implement. (4 marks) Start a multicomponent human milk fortifier now (ESPGHAN GOR A for use; GOR C for starting at 40 to 100 mL/kg/day). Titrate toward 115 to 140 kcal/kg/day and 3.5 to 4.0 g/kg/day protein. If growth remains slow after protein and micronutrient sufficiency, protein may increase to 4.5 g/kg/day and energy may exceed 140 kcal/kg/day but should not exceed 160. Individualised (adjustable or targeted) fortification may be appropriate. Kuschel: multicomponent fortification produces short-term increases in weight, length, and head growth and does not appear associated with adverse effects, with the caveat of missing data and no proven long-term neurodevelopmental benefit ^[2].

c) What monitoring would you put in place? (3 marks) Plot weight at least several times weekly, and length and head circumference weekly. After the early 7 to 10 percent loss phase, the aim is regain of birth weight by 7 to 10 days and then growth along a centile. Check plasma urea regularly: low urea after the first weeks may allow protein up to 4.5 g/kg/day; urea above 5.7 mmol/L without fluid or renal derangement should prompt considering a protein reduction. Do not use an invented BUN cut-off of 1.5 mmol/L. Alkaline phosphatase is not a fortifier-efficacy marker in Kuschel (no ALP effect) ^[1].