NICU Nutrition - can a sub 1000g baby grow on breastmilk alone?

This is my first post. I may be slow to keep posting here as I also focus on the Butterfly Project and work with parents. But, please stick with me, and help me share what you know, and your insights on NICU nutrition, to the Global Majority.

I want to share content for all things NICU nutrition related especially with a view for global collaboration. I want YOU to help me make a difference to the sick newborns in LMICs.

I want to learn how best to translate knowledge to, and share good practice and evidence with less well resourced settings. I want to find out what works in your settings, and what ideas and solutions you have. Our practice in High-income country (HIC) settings is guided by systematic reviews, RCTs and years of experience, but translating that to resource limited settings is challenging. The risks and benefits of faster/slower feeding is context dependant and impacted by population differences (higher rates of IUGR), baseline infection rates and available resources (e.g. PICCs). Let’s be honest, we are all guided by Cochrane etc. but 90% of what we practice is experiential. Show me a single successful RCT powered on a primary of NEC and I’ll buy you lunch. An intervention that is beneficial in HICs (high quality probiotics) could be lethal in LMICs.

My clinical career (qual. MBBS 1990) has been in a well resourced setting - the UK, where we care for babies from 22 weeks and 400g with unrestricted access to PN, intravenous lipids, supplements, minerals and fortifiers, as well as biochemistry, dieticians and high nurse:patient ratios.

I’ve published hundreds of papers, many of which individually probably made little difference to clinical care, but cumulatively I hope added to our understanding of nutritional needs and practice.

I then imagined that in resource limited settings where I’ve been fortunate to visit, such as Kenya, Latin America, Philippines, most preterm babies <28 weeks or <750g wouldn’t survive. However, even in settings such as Kenya, where there were no ventilators or surfactant, no PN, no fortifiers, I saw babies born at 25-26 weeks weighing 600-800g surviving just on Mother’s Own Milk, MOM and good nursing care (warmth, infection control, Kangaroo and milk).

However, a lack of access to routine biochemistry (sodium), supplements (calcium but no phosphate) and fortifiers results in universal growth faltering. Whilst I strongly believe that slower growth on MOM is preferable to faster weight gain on formula, there will be a point at which slow growth is a marker of inadequate nutrients for optimal brain growth. Humans are naturally innovative, and there are many local approaches that have been developed, but most have not been rigorously tested. Studies have explored high volume feedings (200-240ml/kg/day), energy supplements such as olive oil, MCT etc. and in some settings where access to breastmilk fortifiers is expensive, formula milk powder is added although of course the final milk composition given is always sub-optimal. In other settings, in-hospital access to formula and fortifier is effectively prohibited because of rigid adherence to BFI. We can all see the benefits of BFI culture, but the adverse growth impact on individual VLBW feels wrong.

There may be many babies 1250-1500g who will do fine with high volume MOM, some extra sodium and lots of KMC, below that I’m not so sure.

Is it really possible for a <1000g baby to grow optimally just on breastmilk?

Also posted here on Substack.