1. Customized Fortification of Human Milk for the VLBW Infant HOT TOPICS in NEONATOLOGY Washington, D.C. Dec 2014 David H Adamkin Professor of Pediatrics, Director of Division of Neonatology, University of Louisville

2. Disclosures Consultant and Investor in Medolac Laboratories I will not discuss any off-label use and/or investigational use in my presentation

3. AAP Recommendations on Breastfeeding Management of Preterm Infants ( Ped 2012) The potent benefits of human milk are such that all preterm infants should receive human milk Mother’s Own Milk, fresh or frozen, should be the primary diet, and it should be fortified “appropriately” for the infant born < 1500g. If mother’s milk is unavailable despite significant lactation support, pasteurized donor milk should be used

4. VLBW Does Human Milk Meet The Nutritional Requirements

5. 5 Human Milk Alone Does Not Meet the Nutritional Needs of VLBW Infants Human milk requires fortification to provide nutritional needs of preterm infants VLBW = very low birth weight. 1. Premji SS, et al. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD003959; 2. Carlson SJ, Ziegler EE. J Perinatol. 1998;18:252-258; 3. Zeigler EE, et al. In: Suskind RM, Lewinter-Suskind L, eds. Textbook of Pediatric Nutrition. 1981:29-39. (g/kg/d) Preterm human milk Term human milk Recommended (for VLBW)

6. Protein, Calcium, and Sodium Requirements for VLBW Infants and Human Milk Fomon SJ 1977 Groh-Wargo S 2000 Ziegler E 2007 *0.9g/dl @ 200ml/k/d **1.5g/dl @ 150ml/k/d

7. Human Milk Nutrients The high variability in nutrient content in human milk makes meeting nutrient recommendations inherently inaccurate. Milk composition varies with volume of milk expressed, the type of milk obtained (foremilk or hindmilk), and the stage of lactation. For example, two to three fold differences in protein, fat and hence energy have been demonstrated regardless of stage of lactation. The creamatocrit accuracy has been challenged and the creamatocrit does not measure carbohydrate or protein.

8. Fortification Strategies Standard, Fixed Dosage Enhancement Adjustable Fortification Based on BUN Targeted Customized, Individualized – Daily or triggered by defined need

9. Human Milk Protein and Fortification Recommended Intake 3.5 – 4.4 g/kg/d Schanler, 1980 FORTIFICATION Industry Standard Donor Milk

10. Assumed and Actual Protein, Fat and Energy Content of the Fortified Human Milk and Assumed and Actual Protein, Energy Intakes of the Infants STD ADJ (BUN 14) Assumed values Actual values Assumed values Actual values Intakes Protein intake (g/kg/d) First week 3.4±0.1 2.9±0.4 3.7±0.1 2.9±0.3 Second week 3.5±0.1 2.9±0.3 4.0±0.4 3.2±0.4 Third week 3.5±0.1 2.8±0.2 4.2±0.3 3.4±0.5 Energy intake (kcal/kg/d) First week 126.1±5.2 125.9±7.9 132.2±1.8 127.2±12.1 Second week 128.4±2.4 126.6±11.8 135.2±4.2 125.6±11.6 Third week 127.6±2.4 120.5±8.3 135.9±2.7 128.0±8.3 Protein Δ STD 0.5 to 0.7g/k/d Wt gain 14 vs 18g/k/d, HC 0.7vs 1.0 cm/wk p=0.001 Protein Δ ADJ 0.8g/k/d Arslanos, Ziegler et al J of Peri 2009 1 gram

11. Mid Infrared Spectrophotometry (MIRSA) Point-of-care Accurate Measures Protein, Fat, Energy and Carbohydrates Uses relatively small volume of milk Affordable $$ Fast Small footprint Commercially available - validated for goat, donkey, and bovine milk Lacto-engineering

12. Breast Milk Analyzer Results 99 discrete PT samples from 24 women were analyzed (mean ± SD; range) Fat (g/dL) Protein (g/dL) Lactose (g/dL) Energy (kcal/oz) 3.3 ± 1.21.6 ± 0.38.0 ± 0.520.1 ± 4.1 0.9, 7.43 Range 0.9, 2.56.2, 10.111.2, 32.3 Range Radmacher, Adamkin et al J Invest Med 2010

13. Stage of lactation 0-2 weeks2-4 weeks≥4 weeksDHM* (term)p Protein (g/dL) 1.7 ± 0.31.5 ± 0.21.3 ± 0.41.0 ± 0.1<0.02 (DHM vs. all stages) Fat (g/dL) 3.0 ± 0.93.6 ± 1.13.8 ± 0.92.5 ± 0.3≤0.015 (DHM vs 0-2 wks and ≥4 wks) Lactose (g/dL) 6.5 ± 0.56.6 ± 0.36.5 ± 0.26.1 ± 0.4<0.005 (DHM vs. all stages) Energy (kcal/oz) 17.2 ± 2.418.6 ± 2.918.9 ± 2.614.6 ± 1.40.021 (DHM vs 0-2 wks and ≥4 wks) DHM: donor human milk Radmacher, Adamkin JNPM 2014 Macronutrient Analysis (mean ± SD) HUMAN MILK Analyzer * Foremilk protein = hindmilk protein Foremilk energy < hindmilk energy Unpublished observations with HMA

14. 51.2% fell either below 18 kcal/oz or above 22 kcal/oz / 31% of the samples below 18 kcal/oz 14% were below 16 kcal/oz Variability of human milk calories N=85 Radmacher, Adamkin JNPM 2014

15. Bovine Augmentation vs Exclusive Human Milk Fortification Powder Protein Liquid Liquid Concentrate Human Milk Bovine Antigen Human HMF Donor Conc Human HMF Donor Conc 80:20 24 cal 50:50 30 cal

16. PT HUMAN MILK FORTIFICATION @ 150 ( ) Cal + assumes PTHM @ 1.6 g/100 mL PTHMPTF30/PTH M (24) HM 2 (24) Conc Liq (24) (HP) LIQ (24) Acid K Cal99125120 Prot (g) ˖ 2.43.43.53.6 (4.3) 4.8 Fat (g)6.07.67.26.77.2 CHO (g)10.511.29.811.29.7 Ca (mg)33152120180174 P (mg)21855510596

17. Donor human milk Donor human milk + PTF30* Donor human milk + HMF CL ^ Donor human milk + HMF HP CL ^^ Donor human milk + HMF- Acidified # Donor human milk + HM 2 + 4 @ Kcal 102.00121.80126.07126.97129.97123.6 Protein (g) 1.582.773.414.314.613.06 Fat (g) 5.857.546.476.138.327.38 CHO (g) 10.8011.1813.8413.5010.8011.34 Calcium (mg) 41.85134.67245.46214.86208.86217.98 Phosphorus (mg)21.4573.71137.87119.87112.37113.16 Currently available human milk fortifiers and added nutrients to donor human milk and fed at 150 mL. Fortifiers are mixed according to manufacturers’ instructions to make 24 kcal/oz fortified human milk. *Similac Special Care 30 kcal/oz (Abbott Nutrition, Columbus, OH) ^ Similac Human Milk Fortifier Concentrated Liquid (Abbott Nutrition, Columbus, OH) ^^ Similac Human Milk Fortifier Hydrolyzed Protein Concentrated Liquid (Abbott Nutrition, Columbus, OH) # Enfamil Human Milk Fortifier Acidified Liquid (Mead Johnson Nutrition, Evansville, IN) + Prolact+4 (Prolacta Bioscience, Monrovia, CA) Donor Milk 150ml/k

18. LACTOENGINEERING

19. Four Milk Samples to be “Fortified” Radmacher, Adamkin JNPM 2014 Protein (g/dL) Energy (kcal/oz) Low protein Donor Milk Low energy 1.013.6 Expected protein Expected energy 1.518.6 Expected protein High energy 1.424.2 High protein Marginal energy 1.916.9

20. Preterm Human Milk Protein (g) at 150 mL Achieved with Four Different Fortifiers Powder-Conc Liq 24 24

21. Preterm Human Milk Protein (g) at 150 mL Achieved with Alternate Fortification Strategies Conc Liq (5Pkt)

22. Preterm Human Milk Energy (kcal) at 150 mL Achieved with Alternate Fortifier Strategies

23. Target Fortification of Breastmilk with Fat, Protein and Carbohydrates for Preterm Infants Rochow et al J of Peds 2013 McMaster Ontario Canada Fixed dosage enhancement vs targeted. N=10 vs matched pair analyses (1:2) fed for at least 3 weeks prior to PMA of 36 weeks --- 860g; 26weeks 12 hour milk batch – NIRS ESPGHAN Recommendations for Nutrient intakes: Macronutrients added reach final contents Fat 4.4g/dl (6.6) Protein 3.0g/dl (4.5) Carbohydrates 8.8g/dl (13.2) ( ) At Feedings of 150ml/k/d

24. Intervention Products J of Peds 2013 3.6g Fortifier per 100ml Breastmilk = 0.36g FAT / 1.0g PROTEIN / 1.8g CHO per 100 ml Microlipid : safflower oil for enteral (0.5g fat/ml) Beneprotein: whey protein powder (0.86g protein/ml) Polycose : glucose polymer (0.94g CHO/ml) Step 1 – Analyze native breast milk Step 2 – Routine fortification Step 3 - Additional amounts of fat/protein/CHO to achieve targets (ESPGHAN)

25. RESULTS---Targeted vs Fixed Fortification All 650 pooled breastmilk samples required at least 1 macronutrient adjustment to meet recommendations. Ave 0.3g fat, 0.7g protein, 1.2g CHO, were added Weight gain/ volume/energy – Targeted 19.9 ± 2.7g/k/d ~ 150ml/k/d; 131 ± 16kcal/k/d – Fixed 19.7 ± 3.3g/k/d ~ 155ml/k/d Osmolarity 436 ± 13mosmol/kg with Targeted

26. Take Home Points Human Milk is the preferred feeding for all infants including VLBW infants. Despite its many advantages, human milk does not meet all the nutritional needs of the rapidly growing VLBW infant (specifically protein, calcium and phosphorous). Protein is even lower in donor milk. Newer strategies for fortification of human milk allows nutritional needs to be met despite significant macronutrient variability.