Is It Safe to Give Human Milk Fortifier to Premature Baby?

Human Milk Fortifier for Preterm Babies

Medically Reviewed By
Dr. Shruti Kainth (Gynecologist/Obstetrician)
View more Gynecologist/Obstetrician Our Panel of Experts

Breast milk forms the perfect and complete diet for newborn infants. Sometimes the protein and mineral content found in human milk might be insufficient for premature babies, though they are enough for term babies. If the baby is very small, then these deficits are a cause of concern, which is why he will require an additional amount of minerals and proteins necessary for his growth.

What Is Human Milk Fortifier?

Commercially produced multi-nutrient fortifiers that supplement the breast milk of the mother are called human milk fortifiers (HMF). These are usually cow-milk based. They are slowly becoming available everywhere as these multi-nutrient fortifiers contain the right amount of calcium, protein, carbohydrate, phosphate, and even vitamins with some trace elements. These are mostly given to babies that were born prematurely or have low birth weight.

Why Do Premature Babies Require a Human Milk Fortifier?

We all know that breast milk provides superior nutrition to premature babies. However, some studies indicate that babies with the least birth weight might be in need of some additional nutrients, those that breast milk cannot provide. For example, the baby might need extra phosphorus and calcium to prevent osteopenia. This is a condition where there might be a risk of fractures due to a low density of the bones. No matter what the case is, the baby’s long-term health can be affected due to poor growth. In order to prevent conditions that could affect preterm babies, human milk fortifiers are added to the mother’s breast milk to provide extra nutrients and meet the needs of growing preterm babies.

Nutrient Requirements of Preterm Babies and Intakes Provided by Unfortified and Fortified Human Milk

Nutrients Nutrient Requirements of Preterm Infants<1500g Unfortified

20 kcal/oz

Breast Milk

24 kcal/oz

Breast Milk+ HMF

27 kcal/oz

Breast Milk+ HMF

30 kcal/oz High protein Breast Milk+ HMF
Calcium (mg/kg) 100-200 50 214 277 218


120 120 120 120 120


180 150 133 120


60-140 25 120 156 122


2-4 1.9 4 4.8 4.2


4 1.8 3 3.4 4.1


Guidelines to Use a Human Milk Fortifier

Given below are a few basic guidelines that you must stick to while using a human milk fortifier:

1. Babies weighing less than 2 kg

Ideally, human milk fortifier (24 kcal/oz) is indicated for all breastmilk-fed infants weighing less than 2000 g.

2. Check if the baby can take more than 25ml of breast milk

Human milk fortifier (24 kcal/oz) should be given if the infant can tolerate breast milk feeds of more than 25 ml per day. On the first day of the feeds, if the infant receives only 25 ml of breast milk, then it is advised to wait for a few days before starting human milk fortifiers.

3. NPO Babies

NPO babies are the ones who are fed intravenously as they are too premature to breastfeed or bottle-feed. Such babies who can tolerate human milk fortifier feeds should again start with human milk fortifiers and breast milk.

Human Milk Fortifier

4. Calcium and phosphate content in the fortifier

If a baby taking breast milk concentrated with human milk fortifier (27 kcal/oz or 30 kcal/oz) develops hyperphosphatemia (phosphorus > 7.5 mg/dl) or hypercalcemia, (ionized calcium greater than 6.5 mg/dl) then he should be given a nutrient consult and must switch into a reduced mineral recipe to decrease mineral content.

5. The weight of the infant

Human milk fortifier (24 kcal/oz) can be given to all infants weighing less than 2000g. If the weight of the infant is between 2000- 2500g, then he might benefit from the addition of human milk fortifiers especially if he shows poor growth.

6. Babies with poor weight gain and bone problems

Indications when using concentrated breast milk feeds (27 kcal/oz or 30 kcal/oz high protein) in babies include:

  • Fluid restriction is below 140 ml/kg
  • Poor weight gain (below 10-15 g/kg/d) on 120 kcal/kg of 24 kcal/oz breast milk with human milk fortifier.
  • A need for increased intake of phosphate and calcium because of metabolic bone disease (alkaline phosphate greater than 600 U/L) with poor bone mineralisation on x-ray.

Precautions to Take While Giving Human Milk Fortifier to a Premature Baby

Here’s a list of precautions that you must consider while giving HMFs to premature babies:

  • HMFs should be mixed with human milk only. Water or no other liquid should not be added.
  • Offer small volumes of unfortified human milk to check and confirm if the baby is tolerant before starting to feed him.
  • When you finally establish enteral feeding, you can add the powder of human milk fortifier to human milk.
  • After the low birth infant reaches the weight of 3600g, it is not intended to feed them. You can either follow this or as directed by the doctor.
  • These powdered formulas are not sterile, so unless it is directed and supervised by a physician, it should not be fed to preemies that are susceptible to immune problems.
  • Microwave ovens should never be used to warm the feelings as it might result in serious burns.

Human Milk Fortifier


Many questions arise when the baby is given human milk fortifiers. A few of them are below:

1. Do all preemies need fortifiers?

No, not all preemies need fortifiers. It has been found that for babies with very low birth weight, breast milk alone was not enough; especially if the baby’s weight group is between 1251-1500g. It has also been found that for the babies that are extremely premature exclusively feeding them human milk-based diet had lower rates of necrotising enterocolitis than a diet of the cow milk products.

2. How does bovine milk fortifier improve health and help growth and development?

It is very hard to establish if the health of a baby improves when fortifiers are added to his diet. Various studies show benefits and many others show risks in premature babies. Short-term increases in length, head growth, and weight are seen when premature babies are given multi-nutrient fortifiers with breast milk. However, no difference was found between babies receiving fortified breast milk and the babies who were receiving unfortified breast milk by the age of 12 months. A study also indicates that when breast milk fortifiers are taken they only help with short-term growth and its long-term advantages have never been proven.

3. Are there any risks of adding bovine based fortifiers to human milk?

Some human milk fortifier risks that link health issues and bovine fortifiers are:

Increased Risk of Gastrointestinal Disease

  • Many premature babies are affected by necrotising enterocolitis (NEC). For premature babies, this is the most dangerous gastrointestinal disorder.
  • Urinary tract infections and diarrhoea are also seen with increased antibiotic therapy.
  • An increase in the risk of gastrointestinal disease including bowel obstruction or NEC and morbidity is seen when increased osmolarity (concentration) of the feed is given.
  • There is also an increase in gastroesophageal reflux.

Increase in Infection

  • Bovine fortifiers affect a few anti-infective properties of the human milk like lysozyme, lactoferrin, and IgA specific to E coli. Recent studies have also found that bovine fortifiers reduce 76 per cent of the white blood cells and 56 per cent of lipase activity which is the enzyme digesting fats. A decrease in the total protein is also seen.
  • Compared to human milk-derived fortifiers, bovine fortifiers do not have the ability to protect the baby from bacterial infection.
  • There is an increase in the risk of contamination of breast milk when using bovine fortifiers because human milk fortifier powder is not sterile and the human milk fortifier liquid dilutes the anti-infective properties of the breast milk.

Increased Risk of Allergy and Diabetes

  • An increase in the risk of diabetes mellitus and allergies is seen when premature babies are introduced to cows’ milk protein.
  • Artificial feeding causes an increase in the gut permeability and a decrease in lactase activity (which is a marker of intestinal maturity)

It is important to bear in mind that your baby needs extra care because of the prematurity and not because there is a problem with breast milk. Many infants require fortification for some time after being discharged weeks before they were due to be born. Remember to keep an eye on the side effects of human milk fortifiers if you are giving it to your infant.

Also Read:

Common Health Problems of Premature Babies
When and How to Wean a Premature Baby
Tips on Taking Care of Premature Baby at Home

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