*2.2. Comparison and Use of Human Milk Fortifiers*

Maternal breast milk (MBM) was fortified according to manufacturer directions. Ingredient and estimated nutrient compositions of fortified preterm human milk were obtained from online nutritional references [16,17]. Table 1 provides a composition comparison for key nutrients and ingredients.


**Table 1.** Comparison of ingrediants and key nutrients using powder and liquid HMF.

**24-Calorie-Per-Ounce Fortified Premature Human Milk [16,17]** 

Enteral feedings are initiated in this NICU within the first one to three days of life with Human Milk (MBM as available or donor milk form the Milk Bank of Austin) at 20 mL/kg/day, trophic feedings are continued for three to five days at the discretion of the attending neonatologist, and then feedings are advanced daily by 20 mL/kg/day with human milk fortification beginning at 80–100 mL/kg/day enteral volume. A protein modular is utilized to improve protein intake to approximately 4 g/kg/day enteral protein once caloric density is 24 kcal/oz. While using the ALHMF, no additional protein modular was utilized. There were no other nutrition differences during the two time periods. Nutrition is managed closely per unit protocol and is very consistent from provider to provider.

According to unit policy, infants receiving the PHMF also received supplementation with a protein modular to provide approximately 4 g protein/kg/day when fed at goal volumes.

Sole use of the ALHMF was initiated on April 1, 2011. Infants receiving the PHMF before this date of fortification change were included in the control group (PHMF, *n* = 46). Infants receiving the ALHMF following this date were included in the study group (ALHMF, *n* = 23). Infants transitioned from the PHMF to the LHMF on the date of fortification change were excluded.
