The relationship between creamatocrit and cumulative percentage of total milk volume: a cross-sectional study in mothers of very preterm infants in Bangkok, Thailand

Abstract

Background: Human hindmilk contains higher concentrations of fat than foremilk and is more desirable for growth in preterm infants who can tolerate limited volumes of breastmilk. There is currently no clear demarcation between foremilk and hindmilk. This study characterized the change in breastmilk's fat content from the start to end of milk flow and defined this demarcation.

Methods: Mothers of infants born at ≤ 32 weeks gestational age and ≥ 14 days after childbirth in a University hospital in Bangkok, Thailand between July, 2011, and April, 2012 were included in this cross-sectional study. Breastmilk samples were sequentially collected from the start to end of milk flow in 5-mL aliquots using breast pumps. The fat content of each aliquot from each breast was determined through creamatocrit. The average creamatocrit of foremilk and hindmilk were compared in predefined foremilk to hindmilk ratios of 20:80, 25:75, 33:67, and 50:50. Creamatocrit of the first and last aliquots were compared for mothers who expressed low- (≤ 25-mL per breast) and high-volumes (> 25-mL per breast) of breastmilk.

Results: Of the 25 mothers enrolled, one was excluded due to unsuccessful creamatocrit measurement. The last aliquot of breastmilk had a significantly higher creamatocrit than the first from the same breast (median [interquartile range] of 12.7% [8.9%, 15.3%] vs. 5.6% [4.3%, 7.7%]; test statistic 1128, p < 0.001). Mean creamatocrit in hindmilk portions (9.23%, 9.35%, 9.81%, and 10.62%, respectively) was significantly higher than foremilk portions (6.28%, 6.33%, 6.72%, and 7.17%, respectively) at all predefined ratios. Creamatocrit increased by 1% for every 10% incremental increase in expressed breastmilk volume until the breast was emptied. Low-volume mothers had a significantly higher creamatocrit in the first aliquot compared with high-volume mothers (U = 437, p = 0.002). No significant difference in breastmilk volume was observed between mothers with and without breastfeeding experience.

Conclusions: Fat content in breastmilk increased on an incremental basis. More fluid definitions of foremilk and hindmilk should be adopted. Mothers should prepare their breastmilk into aliquots based on the required feeding volume of their infant. Hindmilk aliquots can be prioritized over foremilk aliquots to ensure infants obtain optimal caloric intake.

Keywords: Creamatocrit; Foremilk; Hindmilk; Preterm infants; Thai.

Fig. 1

Breastmilk sample collection process. Illustrated above is a demonstration of how a 40-mL (8 tubes) volume of breastmilk from one breast would be processed after collection in 5-mL aliquot. The cumulative percentage of total milk volume (CP-MV) was calculated as an example

Fig. 2

Foremilk to hindmilk ratios. Illustrated above is a continuation of how the previous 40-mL volume of human breastmilk from one breast would be used to calculate the cumulative percentage of total milk volume (CP-MV) as predefined ratios of 20:80, 25:75, 33:67, and 50:50 of foremilk:hindmilk

Fig. 3

Flow diagram. Thirty-two participants were assessed for eligibility and 25 were enrolled. Sequential breastmilk samples were assessed for 24 participants, with one mother excluded from analyses due to unsuccessful creamatocrit measurements

Fig. 4

Relationship between creamatocrit (%) and the cumulative percentage of total milk volume (CP-MV). A spaghetti plot was used to visually explore the relationship between creamatocrit and CP-MV. The bold line represents the fit regression line from the final mixed model (Model 2.1)