Table 4. Factors Influencing the HM Lipid Received by the Preterm Infant.

Data from Meier PP, Patel AL, Bigger HR, et al. Human milk feedings in the neonatal intensive care unit. In: Rajendram R, Preedy VR, Patel VB, eds. Diet and nutrition in critical care. New York: Springer-Verlag; 2015:807–822 and Meier PP, Rossman B, Patel AL, Johnson TJ, Engstrom JL, Hoban R, Patra K, Bigger HR. Human milk in the neonatal intensive care unit. In: A state-of-the-art view about human milk and lactation. Stuttgart: Thieme; in press.

Factor	Impact	Best Practices
Pumping
Long intervals between pumpings yield a low-lipid, high lactose HM	Longer intervals between pumpings (such as during sleep or return to employment) result in low-lipid HM in the first pumping after the longer interval, whereas Shorter intervals (such as every two hourly pumpings during a visit to the NICU) result in a high-lipid HM in the first pumping after the interval	If sufficient HM volume, freeze low-lipid HM for use after NICU discharge, and Feed HM collected after shorter inter-pump intervals HM can be pooled over a 24 hour period in the same storage container to decrease this within-mother variability
Not emptying breasts thoroughly yields a low-lipid, high lactose HM	HM that flows from the first few minutes of a pumping is low-lipid (foremilk), whereas Following milk ejection and through to thorough breast emptying, the HM lipid increases significantly	Do not teach mothers to use a standard time to complete pumping such as 10 or 15 minutes. Emphasize that time to complete breast emptying is individual Teach mothers the concept of foremilk and hindmilk so that they understand the importance of complete breast emptying
Inadvertently separating foremilk and hindmilk with small pumping/storage receptacles	Container filled from the earlier part of the pumping will be low-lipid HM, whereas Container filled from the later part of the pumping will be high-lipid HM and These differences may translate into calories that are 3 times higher in the last versus first pumped receptacle	Avoid the use of these products for mothers whose pumped HM volume exceeds the capacity of the receptacle. Teach all mothers the importance of not separating HM during pumping (unless used as a strategy to concentrate hindmilk lipid)
Storage
HM is not homogenized so lipid separates and rises to the top of the storage container Freezing disrupts the HM fat globule membrane	Mothers may think there is something wrong with the pumped HM if not informed about separation of lipid Lipid becomes difficult to thoroughly mix	Teach mothers that lipid rises to the top of the storage container and that it is a different color from the rest of the HM Develop and implement protocols that assure the HM is thoroughly mixed Recognize that this process takes extra time for the bedside RN
Handling
Lipid adheres to crevices of storage containers, lids and is not transferred to feeding receptacles	Lipid is not delivered to the infant This is a commonly overlooked contribution to slow weight gain	Assure that HM feeding protocols include guidelines for transferring as much HM lipid as possible by thorough checking and mixing Do not use HM storage bags in the NICU because lipid is very difficult to remove from corner crevices
Feeding
Lipid is poorly delivered with slow-infusion gavage feedings	Lipid is trapped in infusion tubings The slowest infusion rates yield the greatest lipid trapping (loss)	Avoid continuous infusions of HM Use intermittent, gravity gavage feedings when possible If intermittent gavage feedings are administered by infusion pump, use the most rapid rate that is safe Use creamatocrit or HM analysis to diagnose/manage the degree of lipid trapping if continuous infusions must be used
Lipid rises to the top of HM infusion instruments and is poorly delivered in a horizontal position	Significant lipid loss can occur over a 24-hour period Infant receives equivalent of defatted HM with a greater proportion of calories from lactose This problem is a significant source of caloric loss	Place the infusion syringe so that the bevel is pointing up so as much lipid as possible is moved from the syringe into the infusion tubing
Lipid is trapped in infusion tubing if not flushed post-feed with air	Even when intermittent gavage feedings are administered by infusion pump, lipid is trapped in the infusion tubing This is worsened when the nurse adds “extra” HM to the prescribed feed volume, knowing that a final 2 mLs will remain in the tubing at the end of the feeding (which is discarded) The infant does not receive the trapped lipid	Do not add extra HM to compensate for the volume remaining in the tubing at the end of the infusion. Instead, Flush the remaining HM from the infusion tubing using a slow air purge
During breastfeeds the preterm infant may not consume sufficient volume to remove lipid- rich hindmilk	Mothers often have more HM in the breast than the preterm infant can consume Infants can consume sufficient HM volume (as measured by test weights) and still gain weight slowly if the intake reflects low-lipid foremilk that flows at the beginning of the feeding Failure to remove hindmilk at the end of the feeding also impacts the feedback inhibitor of lactation with resultant downregulation of HM volume	Until the preterm infant is able to effectively and efficiently consume all of the HM from a single breast, bottle supplements of pumped HM can consist of fractionated hindmilk, as needed Recognize that slow weight gain when consuming an adequate volume of HM from the breast does not mean that the infant needs extra fortification or formula products. This scenario is easily diagnosed and managed using a combination of creamatocrits with pumped HM and test-weights
Frequent switching the infant between breasts potentiates low-lipid foremilk intake	Due to weak suction pressures the preterm infant may not consume an adequate HM volume at breast Consuming an adequate HM volume is facilitated when maternal HM flow is rapid, such as with post-milk ejection. The common strategy of switching breasts after 5 minutes of sucking is meant to facilitate intake at breast, but It potentiates low-lipid, high volume feedings In extreme circumstances infant may demonstrate symptoms of lactose intolerance, including explosive stools and slow weight gain	Do not recommend this approach with recently discharged preterm infants It is preferable to provide some pumped HM (as hindmilk as necessary) to provide sufficient HM intake until the infant is capable of exclusive at-breast feeding