Date of Award

May 2018

Degree Type


Degree Name

Doctor of Philosophy



First Advisor

Teresa Johnson

Committee Members

Sarah Taylor, Kris Barnekow, Michele Polphus, Sandeep Gopalakrishnan


calories, fat, human milk, premature infants


Premature birth affects 8-18% of all infants worldwide and is the leading cause of death in children less than the age of 5 years. The premature birth rate has been on the rise between 2014-2016 in the United States and 1 in 10 infants are born prematurely. Infants who are born prematurely are at considerable risk of serious infections, visual impairments and neurodevelopmental problems. Human milk, specifically mother’s own milk (MoM), is associated with decreased rates of necrotizing enterocolitis, pneumonia, chronic lung disease and late onset sepsis. MoM is also associated with improved neurodevelopmental outcomes in premature infants.

Although MoM is considered the gold standard of nutrition (with current fortification guidelines), it places the hospitalized premature infant at risk of insufficient postnatal growth due to maternal individual variability in the fat and caloric content of MoM. Premature hospitalized infants are already at risk of insufficient caloric intake due to iatrogenic factors in the storage, handling and delivery of human milk. Fat loss can also occur during the freezing, thawing and handling process and during gavage feedings.

Obstetrical, antepartum, postpartum and neonatal nurses play an integral role in supporting mothers to provide breast milk for their premature hospitalized infant. With a greater understanding of the numerous advantages infants have when provided with MoM and when evidence-based collection, handling and feeding methods are well understood, vulnerable premature infants are provided with practices that can optimize their health, growth and development.

Three key areas are presented in this dissertation. Chapter 1 summarizes the main study (Fat and Caloric Content of Breast Milk of Mothers of Premature Hospitalized Infants: Comparison of High vs. Average to Low Volume Producers and the Impact of Volume in the Breast at Single Pumping Sessions and the Interval Between Pumping Sessions). This chapter also introduces the second manuscript (Chapter 2: Collection Techniques of Colostrum in the Postpartum Period from Mothers of Hospitalized Infants for Oropharyngeal Care and Trophic Feedings) that discusses the composition of colostrum and techniques that nurses can employ to collect this highly viscous dense bioactive fluid from mothers in the postpartum period for early enteral feedings to improve neonatal gut maturation.

Chapter 3 (Creamatocrit Measurement of the Fat and Caloric Content of Mother’s Own Milk in the Neonatal Nursery: Clinical Pearls to Achieve Accurate and Reliable Results) summarizes the research available on the accuracy, reliability and validity of the instrument used in this study. It also provides useful clinical pearls to achieve accurate and reliable results with the primary measurement instrument of this study (the Creamatocrit Plus, Separation Technology, EKF). This manuscript was written to describe best practices in the measurement and caloric content of MoM and in response to numerous questions I receive from NICU staff members throughout the world about how to use this instrument in the neonatal nursery setting.

Chapter 4 is the results manuscript of the main dissertation study. This study was developed based upon a review of the literature and our clinical experience that many mothers who produced high volumes of breast milk (>900 ml/day) had a premature infant with inadequate weight gain.

Separation or fractionation of breast milk (hind milk feeding) is a common practice in neonatal nurseries in the United States (US) that involves pumping the initial low fat breast milk, stopping the pumping session and then saving this low fat milk for later use. The mother then continues the pumping session to collect higher fat breast milk that is collected and fed to her infant. Although this may result in improved weight gain in the infant, it can involve wastage of MoM and is an arbitrary process if the MoM is not tested by a validated measurement instrument at several points in the day and after the separation of the higher fat portion of the maternal pumping session. Also, mothers who have a daily supply of breast milk that does not exceed the volume needs of their infant cannot participate in hind milk separation and feeding. This limits this feeding intervention to only infants of mothers with sufficient daily breast milk production. The main study of this dissertation (Chapter 4) attempted to answer key factors that may influence the fat and caloric content of MoM to provide baseline information to problem-solve inadequate or slow growth and inform best practices for this vulnerable population of infants.