Published: 2021-02-23

100% human milk diet: an integral part of nutrition management in NICU: PAN India neonatologist’s survey

Sanjay Wazir, Syed Ershad Mustafa, Vikram K. Reddy


Background: Exclusive human milk diet (EHMD) benefits preterm infants the most, particularly in neonatal intensive care unit. EHMD is dependent on multiple factors consisting of breastfeeding awareness, availability of pasteurized donor human milk, functioning human milk banks and infrastructure. Neonatal nutritional practice varies considerably in India. The aim of this survey was to understand the implementation and benefits of 100% human milk diet through human milk derived nutritional products in preterm infants from NICU experts’ perspective.

Methods: The online survey questionnaire formulated and reviewed by the expert neonatologists was shared with the NICU experts pan India through multiple communication channels and referrals. The survey was constructed on the Google Forms platform, the responses was collected between May 2020 to July 2020.

Results: A total of 100 neonatologists responded to the survey from 79 hospitals and 31 cities across India. All the respondents (100%) opined that EHMD is important for preterm infants, 15% opined that EHMD was ensured to all preterm infants, 80% opined that human milk-based fortifier (HMBF) was safe and well tolerated by premature infants, 17% reported that 51-80% of preterm infants experience feed intolerance issues with bovine milk based fortifiers (BMBF), blood urea nitrogen (49%) was chosen as an optimal biochemical parameter for assessing protein utilization in NICU, 93% opined that post discharge nutritional supplementation is required for preterm infants among which 49% respondents opined that HMBF and human milk 70 calorie sachet would be preferable as post discharge nutritional supplementation.

Conclusions: EHMD unequivocally offers multiple benefits to preterm infants and hence needs to be included in the NICU protocol, availability of human milk derived nutritional products such as HMBF are termed safe and well tolerated and would aid in implementing EHMD in NICUs. Pasteurized donor human milk is vital for ensuring EHMD, thus access to the same needs to be empowered by strengthening the human milk donation and awareness measures.


Human milk, Human milk derived fortifier, Preterm infants, Seventy calories human milk, NICU, Neonatologists

Full Text:



Dicky O, Ehlinger V, Montjaux N, Gremmo-Féger G, Sizun J, Rozé JC, et al. Policy of feeding very preterm infants with their mother's own fresh expressed milk was associated with a reduced risk of bronchopulmonary dysplasia. Acta Paediatr. 2017;106(5):755-62.

Poindexter B. The direct and indirect influence of own mother's milk on bronchopulmonary dysplasia and costs. Arch Dis Child Fetal Neonatal Ed. 2017;102(3):F192-3.

Patel AL, Johnson TJ, Robin B, Bigger HR, Buchanan A, Christian E, et al. Influence of own mother's milk on bronchopulmonary dysplasia and costs. Arch Dis Child Fetal Neonatal Ed. 2017;102 (3):F256-61.

Viswanathan S, Merheb R, Wen X, Collin M, Groh-Wargo S. Standardized slow enteral feeding protocol reduces necrotizing enterocolitis in micropremies. J Neonatal Perinatal Med. 2017;10 (2):171-80.

Cacho NT, Parker LA, Neu J. Necrotizing Enterocolitis and Human Milk Feeding: A Systematic Review. Clin Perinatol. 2017;44(1):49-67.

Maffei D, Schanler RJ. Human milk is the feeding strategy to prevent necrotizing enterocolitis! Semin Perinatol. 2017;41(1):36-40.

Perrine CG, Scanlon KS. Prevalence of use of human milk in U.S. advanced care neonatal units. Pediatrics. 2013;131:1066-71.

Jakaitis BM, Denning PW. Human breast milk and the gastrointestinal innate immune system. Clin Perinatol. 2014;41(2):423-35.

Ballard O, Morrow AL. Human milk composition: nutrients and bioactive factors. Pediatr Clin North Am. 2013;60(1):49-74.

Cristofalo EA, Schanler RJ, Blanco CL. Randomized trial of exclusive human milk versus preterm formula diets in extremely premature infants. J Pediatr. 2013;163(6):1592-5.

Sullivan S, Schanler RJ, Kim JH. An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products. J Pediatr. 2010;156(4):562-7.

Pejaver RK, Maneesha PH, Lingaraju S. Effect of 100% human milk-derived fortifier on growth of premature infants with birth weight of 1000-1500 g. Indian J Child Health. 2020;7(1):33-5.

Halkar MP, Pejaver RK, Shivalli P, Reddy V. Effect of early fortification with 100% human milk–derived fortifier on preterm neonates. Perinatol. 2020;21(2):57-63.

Assad M, Elliott MJ, Abraham JH. Decreased cost and improved feeding tolerance in VLBW infants fed an exclusive human milk diet. J Perinatol. 2016;36(3):216-20.

Froh E, Dahlmeier K, Spatz DL. NICU Nurses and lactation-based support and care. Adv Neonatal Care. 2017;17(3):203-8.

Sahni M, Chandra P, Sharma DM, Pejaver RK, Thomas B, Cardoza F, et al. Benefits of 100% human milk diet in preterm infants: NICU nurses survey. Pediatric Rev Int J Pediatr Res. 2020;7(6): 248-54.

Sachdeva RC, Mondkar J, Shanbhag S, Sinha M, Khan A, Dasgupta R. A landscape analysis of human milk banks in India. Indian Pediatr. 2019: 56:663-8.

Martin CR, Ling PR, Blackburn GL. Review of infant feeding: key features of breast milk and infant formula. Nutrients. 2016;8(5):279

Lönnerdal B. Nutritional and physiologic significance of human milk proteins. AJCN. 2003;77(6):1537S-43S.

Mathes M, Maas C, Bleeker C, Vek J, Bernhard W, Peter A, et al. Effect of increased enteral protein intake on plasma and urinary urea concentrations in preterm infants born at <32 weeks gestation and <1500 g birth weight enrolled in a randomized controlled trial - a secondary analysis. BMC Pediatr. 2018;18(1):154.