Fats First in Enteral Feeding Human Milk Delivery

Kathleen Quellen, RN, BSN / June 2018


Delivering an enteral feed of human milk with important nutritional fat is a priority in the NICU. Our patients gain so much value from a human milk feed. But how do we ensure fat is delivered first? How do we avoid losing fat during the feeding? Let’s take a closer look.

The recommendations to avoid losing breast milk fat when giving enteral feedings on a pump are to tilt the pump at a 180-degree angle to allow fats to rise to the top. This allows for “fats first” delivery.  Some of these regulations are highlighted below from the American Society for Parenteral and Enteral Nutrition (ASPEN), the Academy of Nutrition and Dietetics (formerly the American Dietetic Association, or ADA), and Human Milk Banking Association of North America (HMBANA):

  • HMBANA: Use of a feeding pump system with the syringe tip pointed up, reduces fat loss from 48% to less than 8%.1
  • Academy of Nutrition and Dietetics: In addition to loss of fat, loss of protein may also occur. Tilting the delivery system so that the exit point of the feedings is elevated minimizes the loss of fat.2
  • ASPEN: Tilting of the pump to an angle with the syringe tip elevated will prevent loss of fat.3

The pump delivery method can result in loss of fat (macronutrients and protein) with the separation of the fat layer within the container and adherence of fat to the sides of the syringe.  All this information has been around for several years, and many manufacturers have provided “enteral only” pumps that are meant to be tilted at 180-degree angle to avoid fat loss.

The importance of process and the right enteral pump

Despite the recommendations and research, tilting at 180-degree angle for delivering fats first is not always used. It’s important to review current process and make improvements where possible.

It’s also good to note that not all pumps are meant to be tilted, and many “enteral pumps” are actually old IV syringe pumps that have been “refurbished” with new faceplates to now be called “enteral only.” But these old IV syringe pumps were never meant to be tilted at an angle, because with IV use, air would rise to the top – and we all know that air rising to the top is only good for pushing it out of the syringe before connecting to a patient. Now syringes, unlike pumps, are universal in how they will allow fats to rise to the top. Fats will rise to whichever way the syringe is tilted and flow evenly out the tip. When it’s tilted at 180-degree angle, fats will go first, which is why it’s the recommended method.

New research on fats first

ASPEN recently published a new study that also appears to confirm the benefits of this “fats first” delivery method.4 The study was done in August 2017, with NICU patients and human milk – but delivered in bags, not syringes. I still found the information compelling, because the fat loss was significant, and the recommendation to tilt 180-degrees for optimal fat loss still applied.

The study wanted to demonstrate that fat delivery is best when human milk is delivered from the top of a feeding bag. This would confirm most of the already known and recommended methods.

The ASPEN study considered that many NICU studies have been done in this area, and that they already demonstrated fat and calorie losses with human milk tube feedings. They also recognized that the losses were greatest with longer tube lengths and continuous feedings. But this study looked at the NICU patient that has been transferred out of the NICU and into rehab or onto inpatient floors and when feeding bags must be used because the feeding rate had increased past what the syringe could deliver.  The feedings were usually longer, 8-12 hours or overnight, so they looked at 4-hour portions.

A few of the study highlights that make a powerful case for “fats first” are:4

  1. Significant fat losses were observed at all hours 1-4 averaging to 73% at 5ml/hr
  2. Horizontal positioning and continuous agitation of the feeding bag only partially limited fat losses
  3. Fat delivery at 5ml/hr was significantly enhanced to 87% when the feeding bag was placed in an inverted position and improved up to 98% with higher infusion rates
  4. No carbohydrate and proteins losses were seen
  5. Conclusions: “Enabling the delivery of human milk from the top of the feeding bag optimizes fat delivery and limits losses”
  6. Conclusions: “Human milk delivered in a continuous fashion using conventional feeding bags connected to a pump results in high fat and total calorie losses and puts the infant at risk for growth failure and prolonged hospital stay”
  7. They further recommend: “Such top infusing feeding bags should be developed and could decrease healthcare costs for intestinal rehabilitation programs”

The results of this study, combined with what is already known and recommended, reminds us that as clinicians we need to be aware of how important it is to deliver human milk properly when on a pump. The tried and true method of tilting the pump at a 180-degree angle is the best way to deliver fats and nutrients, especially on an enteral-only feeding pump which is not originally an IV pump. Look to these and other studies to guide your best practices.


Learn more about the Medela Enteral Feeding Pump and its rotating pole clamp for those 180-degree “fats first” feedings.



  1. HMBANA Guidelines (2011) Best Practices for Storing and Handling Human Milk in Hospitals, Homes, and Child Care Settings. p. 4
  2. American Dietetic Association: Infant Feedings: Guidelines for preparation of human milk and formula in health care facilities. (2011), Page: 99-101
  3. ASPEN Enteral Nutrition Practice Recommendations. Journal of Parenteral and Enteral Nutrition. (2009), Page: 152,157 #9

Improved Delivery of Fat from Human Breast Milk via Continuous Tube Feeding, ASPEN, Mokha & Davidovics, Volume 41, #6, August 2017


About the Author

Kathleen Quellen, RN, BSN, has been a NICU/PICU RN since 1981. She has worked in hospitals all over the U.S., including Georgetown University Hospital, DC Children’s, Cedars Sinai and Children’s Hospital of NJ.  She worked as a Clinical Specialist for Abbott Labs/Hospira and has been a NICU Clinical Specialist for Medela LLC since 2014. She covers hospitals all throughout the western United States.