Protecting the Fat in Human Milk for the Most Vulnerable Infants

Why is the Fat in Human Milk Such a Critical Component for Vulnerable Infants?

Human milk is a vital first food for infants and the cornerstone for infant survival. As nurses and lactation professionals, we recognize the value and importance of informing an exclusive human milk diet in the first 6 months of life, especially focused on those infants born premature and who are spending their early days in the hospital. Preterm infants have unique nutritional needs. Up to 17 weeks of their final growth occurs outside of the womb rather than intrauterine and they are vulnerable to postnatal nutritional deficits, including fat. These last couple of weeks are a period of rapid growth and maturity for major organ systems. Fetal weight will double, length increases by 25%, and 70% of every calorie is used for brain growth. The mom is no longer able to do the work for them; they are outside the protective environment of the womb and responsible for managing the energy expenditure of the extrauterine world. Due to these circumstances, they require higher fat intake compared to those born at full-term to reach adequate growth and development.

So, how do we help ensure the expressed milk that mom has worked so hard to collect for her baby is provided in a way that offers the best clinical outcomes? Here are a few of the key findings I discovered while looking further into this topic:

To minimize fat and nutrient loss during gavage feedings (HMNANA, 2019):

• Use shortest length feeding tube possible
• Provide bolus feeds where appropriate
• Deliver feeding over the shortest time period possible
• Use a milk infusion system with the syringe pointed up

“Use of a feeding pump system with the syringe tip pointed up, reduces fat loss from 48% to less than 8%.”  (HMBANA Best Practice for Expressing, Storing, and Handling Human Milk, p. 109)

Whenever possible, the following should be considered for tube feeding human milk (Academy of Nutrition and Dietetics, 2019):

• Use a small-bore short feeding tube and connecting set
• Completely empty the syringe at the end of each feeding
• Aim for early initiation of bolus feeds

“The position of the syringe or feeding bag affects the delivery of fat during continuous feeds because the fat rises to the top, which results in it being administered towards the end of the feeding. Tilting the enteral syringe upward in a more vertical position can be useful in reducing fat losses during continuous feedings.” (Academy of Nutrition and Dietetics Infant and Pediatric Feedings, p. 209)

To prevent the loss of fat and protein along with separation of a fat layer (ASPEN Guidelines, 2009):

• Use of syringe pump versus bag, as the use of conventional enteral feeding pumps has resulted in fat adherence to the enteral bags.
• Tilting of the pump at an angle with the syringe tip elevated will prevent loss of fat.

I found a consistent trend in recommendations for the rotation of enteral syringe pumps into the vertical position or “tip up” feedings in effort to reduce fat loss. This means there is something we can do to help ensure the expressed milk that mom has worked so hard to collect for her baby is provided in a way that offers the best clinical outcomes - and it’s as easy as turning the pump!

How Can Medela Help Maximize the Fat in Human Milk for Enteral Feeds?

The Medela Enteral Feeding Pump is the only true enteral feeding pump that is designed to be rotated upright to maximize fat delivery.

• Fats are only given first if the syringe if in a vertical position.
• Fats rise to the top of both off-center and center tip syringes in both horizontal and vertical positions.
• When syringes are in a horizontal position, fats rise to the top or sides of the syringe and are given along with milk in both center and off-center tip syringes.
• It is recommended to tilt enteral pumps in a vertical position to allow fats to rise to the top of a syringe (not sides) and be given first.
• Not all syringe pumps are meant to be tilted. For example, with IV syringe pumps this could mean air to the top.

As clinicians, we have the opportunity to make small modifications to our practice that equate to life-changing outcomes for our patients. This is just one small example of the true impact we have as caregivers.

To all my fellow nurses out there, keep up the great work! You’ve got this!

References

Bankhead, Robin & Boullata, Joseph & Brantley, Susan & Corkins, Mark & Guenter, Peggi & Krenitsky, Joseph & Lyman, Beth & Metheny, Norma & Mueller, Charles & Robbins, Sandra & Wessel, Jacqueline. (2009). A.S.P.E.N. Enteral Nutrition Practice Recommendations. Journal of parenteral and enteral nutrition. 33. 122-67. 10.1177/0148607108330314.

Jones, Frances (2019). Best Practices for Expressing, Storing, and Handling Human milk in Hospitals, Homes, and Child Care Settings. (4th ed.). Fort Worth, TX: Human Milk Banking Association of North America (HMBANA)

Steele C, Collins E. (Eds). (2019).  Infant and Pediatric Feedings: Guidelines for Preparation of Human Milk and Formula in Health Care Facilities. (3rd ed.). Chicago, IL: Academy of Nutrition and Dietetics.