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Contents
Foreword: Our Babies Are What We Feed Them xv
Lucky Jain
Preface: Neonatal Nutrition xix
Brenda Poindexter and Heidi Karpen
Assessment of Neonatal Growth in Prematurely Born Infants 295
Reese H. Clark, Irene E. Olsen, and Alan R. Spitzer
The concept that adequate nutritional status and normal growth are impor-
tant is well-accepted. How to assess the adequacy of nutrition and how to
define appropriate growth remains an area of active debate. Our goal is to
review how growth is assessed at birth and during the hospital stay of pre-
maturely born infants, and to offer a standardized approach.
Linear Growth and Neurodevelopmental Outcomes 309
Katie M. Pfister and Sara E. Ramel
Despite advances in care, preterm infants exhibit disproportionate growth
andneurodevelopmental delay attributable to both nutritional andnonnutri-
tional factors. These infants have prolonged linear stunting and decreased
fat-free mass compared with their termcounterparts. These 2 metrics index
organ growth and development (including the brain) and protein accretion.
Protein, along with carbohydrates, fats, and zinc, plays key roles in brain
development, and deficiencies can lead to linear growth failure, abnormal-
ities in the growth hormone axis, and developmental delay. Optimization of
nutrition, including protein intake, decreasing inflammatory episodes, and
enhancing thegrowth hormone axis will likely improve long-termoutcomes.
Protein Intake and Neurodevelopmental Outcomes 323
Bonnie E. Stephens and Betty R. Vohr
Thereis a compellingbody of literature that suggests that theprovisionof an
inadequate amount of protein to preterm infants in the neonatal period has
detrimental effects on the developing brain with the potential to result in
long-term, neurodevelopmental sequelae. Although a great deal of indirect
evidence implies that the provision of adequate amounts of protein may be
associatedwithbetter neurodevelopmental outcomes, thereremainsapau-
city of direct evidence that would allow us to draw any final conclusions.
Complications Associated with Parenteral Nutrition in the Neonate 331
Kara L. Calkins, Robert S. Venick, and Sherin U. Devaskar
Although parenteral nutrition (PN) is life-sustaining, it is associated with
many complications including parenteral nutritionassociated liver disease
(PNALD) and central lineassociated bloodstream infections (CLABSIs),
which carry a high morbidity and mortality and impose a burden on the
health care system. Evidence has emerged that the dose and composition
Current Concepts in Neonatal Nutrition
of intravenous lipid products may alter the incidence of PNALD. However,
other patient and PN-related factors, such as prematurity, birth weight,
and gastrointestinal anatomy and function, are important. To improve neo-
natal care, future research on optimizing the content of PN and decreasing
the incidence IFALD and CLABSIs is required.
Micronutrient Requirements of High-Risk Infants 347
Steven A. Abrams, Keli M. Hawthorne, Jennifer L. Placencia, and
Kimberly L. Dinh
Micronutrient requirements are well-established for healthy full-term in-
fants. However, few such recommendations exist for high-risk infants, in-
cluding full-term infants with a variety of medical disorders or very preterm
infants. Key micronutrients considered in this review are calcium, phos-
phorus, magnesium, iron, and zinc. The ongoing unresolved shortages,
especially of intravenous forms of these minerals, remain a major problem.
Considered are some aspects of how the nutrient shortages may be man-
aged, recognizing the complexity and changing nature of the supply.
Fatty Acid Requirements in Preterm Infants and Their Role in Health and Disease 363
Camilia R. Martin
Challenges remain in optimizing the delivery of fatty acids to attain their
nutritional and therapeutic benefits in neonatal health. In this review,
knowledge about placental transfer of fatty acids to the developing fetus
is summarized, the potential role and mechanisms of fatty acids in enhanc-
ing neonatal health and minimizing morbidities is outlined, the unique con-
siderations for fatty acid delivery in the preterm population are defined,
and the research questions are proposed that need to be addressed be-
fore new standards of care are adopted at the bedside for the provision
of critical fatty acids to preterm infants.
High-Protein Formulas: Evidence for Use in Preterm Infants 383
Laura D. Brown, Kendra Hendrickson, Marc L. Masor, and William W. Hay Jr
Relatively high amounts of protein are required to achieve normal fractional
protein synthetic rates during the late second through early third trimester
of fetal growth. Once preterm infants achieve higher protein intakes for
sustained periods, growth begins to approximate that of the normally
growing fetus and long-termneurodevelopmental outcomes are improved.
Preterm formulas have been developed that are enriched in protein. This
review discusses several factors when using standard preterm formulas
and high-protein preterm formulas in the neonatal intensive care unit,
with an emphasis on quantity and quality of enteral protein delivery and
risks to insufficient and/or excess protein administration.
Fortification of Human Milk in Very Low Birth Weight Infants (VLBW <1500 g Birth
Weight) 405
David H. Adamkin and Paula G. Radmacher
The American Academy of Pediatrics supports the feeding of human milk
for all infants. Very-low-birth-weight and extremely low-birth-weight in-
fants especially can benefit from the immune and neurodevelopmental
Contents viii
effects of human milk. However, human milk alone is nutritionally inade-
quate for the rapid growth of the very-low-birth-weight infant during a crit-
ical window for brain development and requires fortification to meet
current recommendations. There are a variety of products, devices, and
strategies that can be used to fine tune nutritional support of these very
vulnerable infants.
Human Breast Milk and the Gastrointestinal Innate Immune System 423
Brett M. Jakaitis and Patricia W. Denning
The gastrointestinal (GI) tract is a large potential portal for multiple infec-
tious agents to enter the human body. The GI system performs multiple
functions as part of the neonates innate immune system, providing critical
defense during a vulnerable period. Multiple mechanisms and actions are
enhanced by the presence of human breast milk. Bioactive factors found in
human milk work together to create and maintain an optimal and healthy
environment, allowing the intestines to deliver ideal nutrition to the host
and afford protection by a variety of mechanisms.
Donor Human Milk for Preterm Infants: What It Is, What It Can Do, and
What Still Needs to Be Learned 437
Tarah T. Colaizy
Donor human milk is a dietary intervention rapidly increasing in usage in
the very low birth weight (VLBW) preterm population. Donor milk may de-
crease risk of necrotizing enterocolitis and improve neurodevelopmental
outcomes in VLBWinfants compared with formula diets. The exclusive hu-
man milk diet shows promise as an intervention to decrease risk of necro-
tizing enterocolitis compared with formula. Further research is needed to
assess the impact of donor human milk on infectious, growth, and neuro-
developmental outcomes of VLBW infants, as well as the effect of milk for-
tifier choice (human vs bovine) on these outcomes.
LCPUFAs as Conditionally Essential Nutrients for Very Low Birth Weight and Low
Birth Weight Infants: Metabolic, Functional, and Clinical OutcomesHow Much is
Enough? 451
Maria Makrides and Ricardo Uauy
Preterm infants are denied the rapid accumulation of docosahexaenoic
acid (DHA) occurring during the third trimester in utero. The potential ben-
efit of long-chain polyunsaturated fatty acids (LCPUFAs) has generated in-
terest over the last 3 decades. Early intervention trials assessed the effects
of supplementing infant formulas lacking DHA with concentrations equiv-
alent to LCPUFA in milk of women from Westernized societies, leading to
the inclusion of LCPUFA by the year 2000. Recently attention has been on
determining the optimal dose of DHA and on whether there is in advantage
in matching the higher doses of late pregnancy.
Post-discharge Nutrition and the VLBW Infant: To Supplement or Not Supplement?:
A Review of the Current Evidence 463
Nneka I. Nzegwu and Richard A. Ehrenkranz
Due to advancements in neonatology, the survival of very-low-birth-weight
infants, especially extremely low-birth-weight infants continues to rise. The
Contents ix
goal of nutrition in these preterm infants is to match the intrauterine growth
curves of the normally growing fetus. Despite this recommendation from
the American Academy of Pediatrics Committee on Nutrition, neonatolo-
gists struggle daily to meet this goal, and as a result, postnatal growth
failure and restriction are common. This article reviews post-discharge nu-
trition in the VLBWpopulation, examining different types of post-discharge
nutrition, current evidence, and future and remaining questions. In addi-
tion, recommendations are provided for post-discharge nutrition in this
population.
Index 475
Contents x
Contributors
CONSULTI NG EDI TOR
LUCKY JAIN, MD, MBA
Richard W. Blumberg Professor and Executive Vice Chairman, Department of Pediatrics,
Emory University School of Medicine; Executive Medical Director, Childrens Physician
Group, Emory Childrens Center, Childrens Healthcare of Atlanta, Atlanta, Georgia
EDI TORS
BRENDA POINDEXTER, MD
Associate Professor of Clinical Pediatrics, Department of Pediatrics, Riley Hospital for
Children at Indiana University Health, Indianapolis, Indiana
HEIDI KARPEN, MD
Assistant Professor, Department of Pediatrics, Emory University School of Medicine,
Childrens Healthcare of Atlanta, Atlanta, Georgia
AUTHORS
STEVEN A. ABRAMS, MD
US Department of Agriculture/Agriculture Research Service, Department of Pediatrics,
Childrens Nutrition Research Center, Texas Childrens Hospital, Baylor College of
Medicine, Houston, Texas
DAVID H. ADAMKIN, MD
Director, Division of Neonatal Medicine; Professor of Pediatrics; University of Louisville
School of Medicine, Louisville, Kentucky
LAURA D. BROWN, MD
Section of Neonatology, Department of Pediatrics, Anschutz Medical Campus, University
of Colorado School of Medicine, Aurora, Colorado
KARA L. CALKINS, MD
Division of Neonatology and Developmental Biology, Department of Pediatrics, Mattel
Childrens Hospital, Assistant Clinical Professor, University of California, Los Angeles,
Los Angeles, California
REESE H. CLARK, MD
The Center for Research, Education, and Quality, MEDNAX Services/Pediatrix Medical
Group/American Anesthesiology, Sunrise, Florida
TARAH T. COLAIZY, MD, MPH
Associate Professor of Pediatrics; Carver College of Medicine, University of Iowa, Iowa
City, Iowa
PATRICIA W. DENNING, MD
Associate Professor, Division of Neonatology, Department of Pediatrics, Emory University
School of Medicine, Atlanta, Georgia
SHERIN U. DEVASKAR, MD
Division of Neonatology and Developmental Biology, Department of Pediatrics, Mattel
Childrens Hospital, Distinguished Professor, University of California, Los Angeles,
Los Angeles, California
KIMBERLY L. DINH, PharmD
Clinical Pharmacy Specialist, Neonatal Intensive Care, Texas Childrens Hospital,
Houston, Texas
RICHARD A. EHRENKRANZ, MD
Professor of Pediatrics & Interim Chief; Section of Neonatal-Perinatal Medicine,
Department of Neonatal-Perinatal Medicine, Yale University School of Medicine,
New Haven, Connecticut
KELI M. HAWTHORNE, MS, RD
Senior Registered Dietitian, US Department of Agriculture/Agriculture Research Service,
Department of Pediatrics, Childrens Nutrition Research Center, Texas Childrens
Hospital, Baylor College of Medicine, Houston, Texas
WILLIAM W. HAY Jr, MD
Section of Neonatology, Department of Pediatrics, Anschutz Medical Campus, University
of Colorado School of Medicine, Aurora, Colorado
KENDRA HENDRICKSON, MS, RD, CNSC, CSP
Department of Food & Nutrition, Anschutz Medical Campus, University of Colorado
Hospital, Aurora, Colorado
BRETT M. JAKAITIS, MD
Fellow, Division of Neonatology, Department of Pediatrics, Emory University School of
Medicine, Atlanta, Georgia
MARIA MAKRIDES, RD, PhD
Healthy Mothers, Babies and Children, South Australian Health and Medical Research
Institute, Adelaide; Womens and Childrens Health Research Institute, University of
Adelaide, North Adelaide, South Australia, Australia
CAMILIA R. MARTIN, MD, MS
Associate Director, NICU, Department of Neonatology; Director for Cross-Disciplinary
Research Partnerships; Assistant Professor of Pediatrics; Division of Translational
Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston,
Massachusetts
MARC L. MASOR, PhD
Science Educator; Former Director, Clinical Nutrition Research, Abbott Nutrition,
Durango, Colorado
NNEKA I. NZEGWU, DO
Fellow, Neonatal-Perinatal Medicine, Department of Pediatrics, Section of
Neonatal-Perinatal Medicine, Yale University School of Medicine, New Haven,
Connecticut
IRENE E. OLSEN, PhD, RD, LDN
School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
Contributors iv
KATIE M. PFISTER, MD
Division of Neonatology, Department of Pediatrics, University of Minnesota, Minneapolis,
Minnesota
JENNIFER L. PLACENCIA, PharmD
Clinical Pharmacy Specialist, Neonatal Intensive Care, Texas Childrens Hospital,
Houston, Texas
PAULA G. RADMACHER, MSPH, PhD
Research Manager; Assistant Professor, Neonatal Nutrition Research Laboratory,
University of Louisville School of Medicine, Louisville, Kentucky
SARA E. RAMEL, MD
Division of Neonatology, Department of Pediatrics, University of Minnesota, Minneapolis,
Minnesota
ALAN R. SPITZER, MD
Senior Vice President for Research, Education, and Quality; MEDNAX Services/Pediatrix
Medical Group/American Anesthesiology, Sunrise, Florida
BONNIE E. STEPHENS, MD
Adjunct Assistant Professor of Pediatrics; Warren Alpert Medical School, Brown
University, Providence, Rhode Island; Medical Director, NICU, Community Medical
Center, Missoula, Montana
RICARDO UAUY, MD, PhD
Division of Neonatology, Department of Pediatrics, Catholic University Medical School
and Institute of Nutrition, INTA University of Chile, Santiago, Chile
ROBERT S. VENICK, MD
Division of Gastroenterology, Department of Pediatrics, Mattel Childrens Hospital,
Associate Clinical Professor, University of California, Los Angeles, Los Angeles, California
BETTY R. VOHR, MD
Director, Neonatal Follow-up Program, Women and Infants Hospital; Professor of
Pediatrics, Warren Alpert Medical School, Brown University, Providence, Rhode Island
Contributors v
Foreword
Our Babi es Are What We Feed Them
Lucky Jain, MD, MBA
Consulting Editor
Tell me what you eat and I will tell you what you are, so wrote Anthelme Brillat-Savarin
nearly 300 years ago.
1
This age-old saying can be extrapolated to our NICUs to mean,
Tell me how you feed your babies and I will tell you how well you care for them.
Indeed, generations can be impacted by small changes in feeding practices early in
life. If we are what we eat, then our babies are what we feed them!
Managing nutritional needs of sick neonates has never been easy. When choices lie
between optimizing heart and lung function of a sick neonate versus advancing nutri-
tion, nutrition often takes the back seat. The result is a nutritional deficit that accrues
in the first weeks of life and is often hard to overcome in subsequent weeks (Fig. 1).
The goal for nutrition of the preterm infant should be to get to the same growth rate
a normal fetus would have achieved at the same gestational age in utero. Mothers
milk would be optimal but is often not available. Poor gut motility, reflux, and inade-
quate digestive function further complicate the picture. The cause of postnatal growth
restriction in preterm infants is arguably multifactorial, but it has been estimated that
about 50% of the variance can be attributed to inadequate nutrition.
2
There is also a
delicate balance between optimizing caloric intake and running the risk of complica-
tions such as fluid overload, liver damage, and necrotizing enterocolitis (NEC). The
result: an unacceptable level of variability in practices and outcomes when it comes
to growth and nutrition.
Yet there are solutions.
3
Breast milk has been shown to have innumerable benefits
but is still grossly underutilized. It is not always clear why that is the case; socioeco-
nomic status and lack of maternal commitment have often been blamed but many
inner-city NICUs claim near universal breast-feeding rates. Numerous studies have
shown that breast milk is better tolerated and reduces the risk of NEC. There are
also immunologic benefits that translate to lower risk of infections and immune disor-
ders later on in life.
Then there is the issue of early and aggressive versus delayed and slow feeding
advances. Evidence shows that early initiation and targeted rapid advances result in
Clin Perinatol 41 (2014) xvxvii
http://dx.doi.org/10.1016/j.clp.2014.04.001 perinatology.theclinics.com
0095-5108/14/$ see front matter 2014 Elsevier Inc. All rights reserved.
better feeding tolerance and enhanced growth
4
; yet, few neonatologists take advan-
tage of the fact that the fetus actively swallows amniotic fluid in large quantities
throughout gestation and is, as such, adept at enteral feeds. Lack of early enteral
feeds has its consequences with total parenteral nutritioninduced complications
and slower acceptance of feeds later on. Introducing progressive enteral feeds before
4 days after birth in very low-birth-weight infants and advancing the rate of feed
volumes at more than 24 mL/kg/d do not increase the risk of NEC.
5
There are clearly many more issues that could benefit from open discussion and
consensus-driven practices, particularly where evidence-based guidance is lacking.
As Drs Poindexter and Karpen point out in their preface, this is an exciting time in
neonatal nutrition with a shift in focus from just survival and growth to optimizing the
effect of each micro/macronutrient on long-termdevelopment anddisease prevention.
I am delighted that Drs Poindexter and Karpen have put together a comprehensive
review of advances in neonatal nutrition in this edition of the Clinics in Perinatology. In
addition to the authors, I would like to thank Kerry Holland and her team at Elsevier for
their support of this important topic. As Adelle Davis
2
pointed out in a Time article
several years ago, the consequences of our feeding choices are stark: every day
you do one of two things: build health or produce disease. Nowhere is this statement
truer than in our NICUs.
Lucky Jain, MD, MBA
Emory University School of Medicine
Childrens Healthcare of Atlanta
2015 Uppergate Drive
Atlanta, GA 30322, USA
E-mail address:
[email protected]
Fig. 1. Mean growth curves of weight by postmenstrual age and week of gestation,
superimposed on the British 1990 birth weight reference. (Adapted from Cole TJ,
Statnikov Y, Santhakumaran S, et al. Birth weight and longitudinal growth in infants
born below 32 weeks gestation: a UK population study. Arch Dis Child Fetal Neonatal Ed
2014;99:F38; with permission.)
Foreword xvi
REFERENCES
1. Swanson PD. We are what we eat. Gastronomica J Crit Food Stud 2012. April 13,
Web Exclusives.
2. Corpeleijin WE, Kouwenhoven SM, van Goudoever JB. Optimal growth of preterm
infants. World Rev Nutr Diet 2013;106:14955.
3. Hay WW. Strategies for feeding the preterm infant. Neonatology 2008;94:24554.
4. Morgan J, Young L, McGuire W. Slow advancement of enteral feed volumes
to prevent necrotizing enterocolitis in very low birth weight infants. Cochrane
Database Syst Rev 2013;(3):CD001241.
5. The SIFT Investigators Group. Early enteral feeding strategies for very preterm
infants: current evidence from Cochrane reviews. Arch Dis Child Fetal Neonatal
Ed 2013;98:F4702.
Foreword xvii
Preface
Neonatal Nutri ti on
Brenda Poindexter, MD Heidi Karpen, MD
Editors
Over the past several decades, advances in neonatal nutrition have focused on the
provision of early parenteral nutrition and the development of formulas and supple-
ments that most closely approximate maternal breast milk. The overall outcomes for
infants, including premature infants, have greatly benefited from these advances,
but there are still many nutritional unknowns that impact the lives of neonates. This
is an exciting time in neonatal nutrition as the focus has shifted from survival and
growth, which are still important goals, to effects of each micro/macronutrient on
development, prevention of disease states such as ROP, the effects of neonatal
nutrition on future health as an adult, and opportunities to improve long-term neurode-
velopmental outcomes by optimal early nutrition.
This issue focuses on aspects of enteral and parenteral nutrition that are at the fore-
front of neonatal care: assessing growth, parenteral nutrition components (including
alternate lipid formulations), optimal storage and use of human milk (including donor
milk), post-discharge nutrition, and the effects of various micro/macronutrients on
long-term developmental outcomes. It is anticipated that the study and implementation
of many of these novel concepts into the care of neonates, many of whom are severely
premature, will be of value to practitioners, researchers, and, most of all, our patients.
Brenda Poindexter, MD
Riley Hospital for Children
at Indiana University Health
Department of Pediatrics
Indiana University School of Medicine
699 Riley Hospital Drive RR208
Room 5900
Indianapolis, IN 46202, USA
E-mail address:
[email protected] (B. Poindexter)
Heidi Karpen, MD
Emory University School of Medicine
Childrens Healthcare of Atlanta
Department of Pediatrics
2105 Uppergate Drive NE, Room 324
Atlanta, GA 30033, USA
E-mail address:
[email protected] (H. Karpen)
Clin Perinatol 41 (2014) xix
0095-5108/14/$ see front matter 2014 Published by Elsevier Inc.
Assessment of Neonatal
Growth i n Prematurel y
Born I nfants
Reese H. Clark, MD
a,
*, Irene E. Olsen, PhD, RD, LDN
b
,
Alan R. Spitzer, MD
a
INTRODUCTION
The assessment and surveillance of growth in infants and children is recognized as an
important part of health assessment.
1,2
Many disturbances in health and nutrition, in-
dependent of their etiology, alter growth. The goals of monitoring growth are to
improve nutritional status, reduce the risk of inadequate nutritional intake, educate
caregivers, and produce early detection and evaluation of conditions manifested by
growth disorders. Understanding inadequate growth and excess growth are both
important. The focus of this review, therefore, is the examination and evaluation of
optimal growth in prematurely born infants.
a
The Center for Research, Education, and Quality, MEDNAX Services/Pediatrix Medical
Group/American Anesthesiology, 1301 Concord Terrace, Sunrise, FL 33323-2825, USA;
b
School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
* Corresponding author.
E-mail address: [email protected]
KEYWORDS
Growth assessment

Neonatal growth

Premature infants

Body proportionality
Growth curves

Small for gestational age

Growth status
KEY POINTS
Growth assessment should start at birth and continue on weekly intervals at a minimum
thereafter; birth and weekly assessments should include weight, length, and head
circumference.
Assigning an infant a set of percentiles for weight, length, and head circumference at birth
provides an estimate of morbidity risk and target goals for growth.
Where an infants growth measurements plot on growth charts and the assignment of
specific growth measurement percentiles differs between each set of charts. Assessment
of change in size over time, however, is comparable between growth charts.
Monitoring growth on growth curves allows for intervention when it decreases from birth
percentiles; in this setting, precise percentile measurements are less important than the
pattern of growth over time.
Because body composition is not routinely measured in the neonatal intensive care unit, a
proxy, such as body mass index, may be a useful clinical tool for preterm infants.
Clin Perinatol 41 (2014) 295307
The evidence that poor intrauterine growth manifests as small for gestational age
(SGA), excessive growth manifests as large for gestational age (LGA), and both influ-
ence health outcomes is not new
35
and remains a valuable consideration today.
6
Compared with premature infants born with normal weights for gestational age,
SGA preterm infants have a higher mortality and are more likely to have postnatal
growth failure, prolonged mechanical ventilation, and require treatment with postnatal
steroids.
6
Being born SGA is associated with an increased risk of death or neurode-
velopmental impairment. Similarly, infants born LGA are at increased risk for poor out-
comes, including hypoglycemia, respiratory distress, obesity, and longer hospital
stays.
710
Although intrauterine growth restriction (IUGR) and SGA are commonly considered
synonymous terms, the definitions and standards used to identify IUGR are different
from those used to define SGA. A fetus with a diagnosis of IUGR may not meet the
criteria for a diagnosis of SGA (usually defined as <10th percentile for age); however,
both IUGR and SGA are associated with increased risk for poor health.
1113
How an infant grows after being born prematurely also is important. Numerous ar-
ticles demonstrate that infants born prematurely are at high risk for poor extrauterine
growth (weight, length, and head circumference) when compared with estimates of
growth that would have occurred had the infants remained in utero.
1417
Risk factors
associated with poor extrauterine growth in prematurely born infants include immatu-
rity (lowgestational age), SGA status, male gender, need for assisted ventilation on the
day of birth, a history of necrotizing enterocolitis, need for respiratory support at
28 days of age, and exposure to steroids during the hospital course.
15
Risk factors
that influence growth also impact other outcomes and make it difficult to assess the
independent impact of early growth on long-term outcomes. Ehrenkranz and col-
leagues,
18
however, showed that the pattern of growth of prematurely born infants ex-
erts a significant, and possibly independent, effect on neurodevelopmental status and
growth outcome at 18 to 22 months corrected age. Data on how well individual sites
promote normal growth show that some neonatal intensive care units (NICUs) perform
better than other units.
1921
Site performance can be improved, and one method for
improving the growth of preterm infants admitted for intensive care is simply to
monitor their growth and thereby diagnose and treat growth failure at an early stage.
21
The concept that adequate nutritional status and normal growth are important is
well accepted. How to assess the adequacy of nutrition and howto define appropriate
growth remains an area of active debate. Our goal is to reviewhowgrowth is assessed
at birth and during the hospital stay of prematurely born infants, and to offer a stan-
dardized approach.
ASSESSMENT OF GROWTH STATUS AT BIRTH
In the NICU and the healthy newborn nursery, assessment of growth begins at birth.
The assessments of weight, length, and head circumference are all equally important
and must be a part of every admission examination. Meaningful assignment of SGA
and LGA classification therefore requires the following: accurate knowledge of gesta-
tional age; accurate measurement at birth of weight, length, and head circumference;
and cutoff values based on reference data from a relevant population,
22
all of which
are a challenge to achieve. For example, estimated gestational age is often not precise
and most experts would argue that gestational age precision is, at best, plus or minus
2 weeks. Although weights that use an electronic balance are quite accurate, individ-
ual head and length measurements may be less reliable in the clinical setting. Further-
more, the assessment tools (eg, growth curves) used to evaluate growth differ based
Clark et al 296
on numerous factors, such as sample selection (eg, population sample of infants
compared with healthy infants by excluding for infant/maternal factors that may
affect infant growth/size), how gestational age is defined (eg, completed or mid-
weeks),
22
combined or gender-specific curves,
23,24
and combined or race/ethnicity-
specific curves.
25
In the creation of growth curves, decisions related to these factors may change the
cutoffs used to define high risk in the NICU. Both gender and race/ethnicity also
confound the assignment of SGA and LGA.
2427
The impact of assigning SGA and
LGA independent of gender and race/ethnicity leads to errors in assignment.
2426
Gender/ethnicity-specific birth-weight distributions are significantly better at identi-
fying the infants at higher risk of neonatal morbidity.
25
Thus, understanding how an
assessment tool was created can help clinicians decide which tool best suits their pur-
pose and clinical setting. Assigning the precise percentile rank of any given growth
measurement for an individual newborn at a particular postnatal age in a specific pop-
ulation requires data that are specific for race/ethnicity, gender, environment,
maternal health, and population. For monitoring the pattern of growth, these factors
are less important, because trends over time are more important than precise assess-
ment of population-specific percentiles.
Normal gestation is longer than 37 weeks, and infants born preterm are, by defi-
nition, not normal. One reason infants are delivered prematurely is because they are
not growing well (ie, IUGR).
28,29
The distributions of birth-growth parameters by esti-
mated gestational age are not parametric (not normally distributed in a bell-shaped
curve). Instead they are slightly skewed toward lower values (Fig. 1). Moreover, vari-
ables that alter growth are difficult to collect and may be missing from administrative
data sets (eg, birth certificate data). Known influences on intrauterine growth are
Fig. 1. A histogram plot of birth weight for inborn infants without anomalies that were
reported to the Pediatrix Clinical Data Warehouse who had a gestational age of 27 weeks.
The solid line is the observed distribution of birth weights and the dashed line is a normal/
parametric distribution. Compared to a normal distribution, the observed distribution is
shifted to the left demonstrating that pretermbirth is associated with selection bias favoring
lower weights thanwouldbe predicted. This findingis consistent withthe clinical observation
that one of the reasons preterminfants are deliveredearly is due topoor intrauterine growth.
Growth Assessment in Premature Infants 297
maternal factors, such as smoking, hypertension, preeclampsia, diabetes, and
repeated courses of antenatal steroids.
30
Without a prospective study, it is difficult
to exclude infants who are exposed to perinatal risk factors for abnormal intrauterine
growth, and the percentiles on any set of growth charts will be partly affected by how
well patients with abnormal growth due to maternal illness/practices are
excluded.
28,29
All of these confounding variables make it difficult to define precise
growth assessment standards that are specific to the population being assessed.
To enhance accuracy, we need more precise measurements based on normal pop-
ulation samples.
One potential approach would be to assign a percentile or z score to each growth
parameter, rather than assigning a more general SGA or LGA classification. The tools
for making these assignments based on recent growth curves are readily available and
easily adaptable to electronic health records.
23,24,31
Birth weight, length, and head
circumference are continuous values; the derivatives (percentile or z score) assigned
to the measurement are also continuous values and can be considered as such. When
a patient is assigned a designation of SGA or LGA, however, a continuous value is
changed to a categorical value (for example <10th percentile for SGA and >90th
percentile for LGA). Just as each 100-g increase in birth weight is associated with
an increased likelihood that a prematurely born infant will survive,
32
infants with birth
weights at the 60th percentile are more likely to survive than infants with birth weights
at the 30th percentile.
32
Rather than making a categorical assignment, it is more help-
ful to assign a percentile or z score that provides a measure of how the newborns
growth measurements compare with a reference population by using a standardized
growth curve. None of the available standardized growth curves are perfect, and
continued research is needed to make them more clinically useful.
23
Clinicians should
pick a single standard and validate that standard against the patient population they
are assessing, similar that reported by Olsen and colleagues.
24
Equally important is that infants potential for future growth is influenced by where
they start at birth. An infant born LGA tends to stay large for gestation as she or he
grows in the NICU, and infants born SGA tend to stay SGA. The growth velocities
may be similar if they are following their birth percentile. Crossing percentiles for
any measurement (losing or gaining) suggest abnormal growth. For example, an infant
with a head circumference at birth that is at the 50th percentile who leaves the NICU
with a head circumference below the 10th percentile (poor head growth) is at serious
risk for neurodevelopmental problems.
18
If the same infant has a head circumference
above the 90th percentile at discharge, growth was not normal and hydrocephalus or
other causes for abnormalities should be considered.
Assigning an infant a set of percentiles for weight, length, and head circumference at
birth gives the clinician an estimate of risk for morbidity. It also allows the clinician to
estimate the goals for growth based on weight, length, and head circumference tar-
gets for achieving the same percentile at discharge from the hospital. Failure to
achieve normal growth targets is important in assessing health and future risk.
6,18
MONITORING GROWTH IN THE NICU
The second reason for using growth charts is to monitor postnatal growth of prema-
turely born infants.
The Problem with Growth Velocity As a Singular Measure of Growth in the NICU
The use of growth velocity alone without the plotting of growth measurements on stan-
dardized growth charts is not an ideal way to assess adequate nutrition and adequate
Clark et al 298
growth. Fetal growth is dynamic and not easily defined by a single slope (Fig. 2). Using
size at birth as an estimate of fetal growth, fetal growth velocity can be calculated over
each consecutive week and these calculations show that fetal growth changes with
gestational age (Tables 1 and 2).
24
From estimates of fetal growth and observed
growth of premature infants, targets for growth can be suggested: weight gain of 18
to 20 g/kg per day, length growth of 1.1 to 1.4 cm per week, and head circumference
growth from 0.9 to 1.1 cm per week.
18,24
The problem with this approach is that it pro-
vides no frame of reference with respect to normal. Plotting growth on standardized
growth charts gives a measure of both growth velocity and the deviation from fetal
growth.
1618
After delivery, infants lose weight.
33
Healthy newborn infants regain their birth
weight within the first 2 weeks. A similar pattern is seen in preterm infants. During
the first 2 to 3 weeks following birth, growth is poor (Fig. 3). The most concerning
observation is that this poor growth is not limited to weight gain alone but is also
seen with length and head growth.
3437
When assessing growth velocity, some inves-
tigators do not include this period of poor growth. Growth velocity is calculated for the
period between the time that the infant regained birth weight and when that infant was
discharged.
18
For the clinician providing daily care, the targets need to be based on
data points that are closer together and based on what is safely achievable.
The Case for Using Standardized Growth Charts to Assess Adequacy of Growth
During well-child visits, children are plotted on growth charts that are based on
cross-sectional studies; this assessment is an important measurement in health and
well-being. Just as there are debates about which sets of charts are the best tools
Fig. 2. Intrauterine growth pattern based on Olsen and colleagues
24
female growth charts.
Similar to Table 1, this chart shows how growth velocity changes with increasing gestational
age. Growth velocity increases with increasing postnatal gestational age. Growth velocity
changes with increasing postnatal gestational age. Growth velocity increases with increasing
gestational age until term gestation, when it decelerates. Growth velocity changes: 23 to 27
weeks (purple); 27 to 31 weeks (red); 31 to 35 weeks (deep blue); 35 to 38 weeks (green).
for monitoring growth from birth to adolescence, there are debates about how to best
monitor postnatal growth in prematurely born infants.
23,31
Development of fetal growth
charts based on observation of a healthy cohort of women who deliver a healthy infant
at term would be ideal; this work is ongoing (http://intergrowth21.org.uk/). Unfortu-
nately, although intrauterine growth charts based on ultrasound-estimated fetal size
might be more representative of normal fetal growth,
28
and reflect the growth of
the infants delivered at term, determination of an estimated weight of a fetus during
pregnancy is limited by the ability to accurately obtain the measurements.
38
This
approach becomes even more difficult when developing charts for head circumfer-
ence and length.
Poor growth, termed extrauterine growth restriction, is common in the NICU.
Growth charts allow the clinician to monitor how far a given infant is falling behind
and to adjust the nutritional approach accordingly (Fig. 4). The health benefits of hu-
man milk are well recognized; however, the precise nutritional content of fresh human
milk is variable and often not measured. Monitoring growth allows clinicians to inter-
vene in preterm infants who are falling behind or whose growth status is decreasing
from birth percentiles. In this setting, the precise percentile measurement is less
important than the pattern of growth over time. Weight is measured daily and can
be easily plotted in electronic medical records. The assessment of head circumfer-
ence and length are more commonly done once a week. These assessments are as
important as any laboratory value or procedural evaluation. Without visualizing
the pattern of growth, diagnosis and treatment of growth failure is delayed and
long-term outcome may be altered.
17,18
Although poor weight gain appears to be
Table 1
Estimated intrauterine weight gain velocity by EGA based on Olsen charts
Female Male
Median
Weight (g) Change (g/d)
Change
(g/kg/d)
Median
Weight (g) Change (g/d)
Change
(g/kg/d)
23 584 622
24 651 9.6 16 689 9.6 15
25 737 12.3 19 777 12.6 18
26 827 12.9 18 888 15.9 20
27 936 15.6 19 1001 16.1 18
28 1061 17.9 19 1138 19.6 20
29 1204 20.4 19 1277 19.9 17
30 1373 24.1 20 1435 22.6 18
31 1546 24.7 18 1633 28.3 20
32 1731 26.4 17 1823 27.1 17
33 1956 32.1 19 2058 33.6 18
34 2187 33 17 2288 32.9 16
35 2413 32.3 15 2529 34.4 15
36 2664 35.9 15 2798 38.4 15
37 2937 39 15 3058 37.1 13
38 3173 33.7 11 3319 37.3 12
39 3338 23.6 7 3476 22.4 7
40 3454 16.6 5 3582 15.1 4
Abbreviation: EGA, estimated gestational age.
Clark et al 300
Table 2
Estimated intrauterine weekly length and head circumferences growth velocity by EGA based
on Olsen charts
Female Male
Median
Length
(cm)
Change
(cm/wk)
Median Head
Circumference
(cm)
Change
(cm/wk)
Median
Length
(cm)
Change
(cm/wk)
Median Head
Circumference
(cm)
Change
(cm/wk)
23 29.9 20.9 30.3 21.3
24 31.1 1.2 21.8 0.9 31.5 1.2 22.2 0.9
25 32.3 1.2 22.7 0.9 32.9 1.4 23.2 1
26 33.6 1.3 23.6 0.9 34.3 1.4 24.2 1
27 35 1.4 24.5 0.9 35.7 1.4 25.2 1
28 36.5 1.5 25.5 1 37.2 1.5 26.1 0.9
29 38 1.5 26.5 1 38.7 1.5 27.1 1
30 39.5 1.5 27.5 1 40.1 1.4 28 0.9
31 41 1.5 28.4 0.9 41.6 1.5 28.9 0.9
32 42.3 1.3 29.3 0.9 43 1.4 29.9 1
33 43.7 1.4 30.2 0.9 44.4 1.4 30.8 0.9
34 45 1.3 31.1 0.9 45.7 1.3 31.6 0.8
35 46.2 1.2 31.9 0.8 46.9 1.2 32.4 0.8
36 47.4 1.2 32.7 0.8 48.1 1.2 33.2 0.8
37 48.5 1.1 33.3 0.6 49.3 1.2 33.9 0.7
38 49.5 1 33.7 0.4 50.2 0.9 34.4 0.5
39 50.2 0.7 34 0.3 51 0.8 34.6 0.2
40 50.8 0.6 34.3 0.3 51.6 0.6 34.8 0.2
Abbreviation: EGA, estimated gestational age.
Fig. 3. Postnatal growth pattern of an infant born at 26 weeks estimated gestational age
based on observation made in 1000 inborn infants who survived to be discharged. Note
that growth velocity continues to accelerate through term gestation. Growth velocity
changes following birth for an infant born at 26 weeks estimated gestational age: 0 to 5
days (black); 5 to 10 days (light blue); 10 to 28 days (light grey); 28 to 42 days (deep
blue); 42 to 56 days (brown). (Data from the Pediatrix Clinical Data Warehouse 20092010.)
301
the most predictive of poor outcome, all 3 measurements of growth (weight, length,
and head circumference) are valuable and essential to understanding proportional
growth.
Which Intrauterine Growth Charts Should Be Used As a Reference
Two sets of charts are commonly used in the NICU.
23,24
Between 23 and 37 weeks,
both the gender-specific Fenton and Olsen charts are similar.
23
There are 2 important
distinctions between these 2 sets of charts. First, the reformatted Olsen charts that
include the World Health Organization (WHO) charts, interface the Olsen and WHO
charts at 39 weeks postmenstrual age (instead of 40 weeks), because 39 weeks is
the median age for the WHO definition of full-term (range 3741 weeks) and 39 weeks
is the median age of US births (http://wonder.cdc.gov/controller/datarequest/D66).
Second, the Olsen charts and WHO charts are each based on independent sets of
data and for that reason are not connected. The smoothing process that joins the 2
distinctive charts distorts the estimates of percentile lines for both charts.
Although the median hospital stay of prematurely born infants is 36 to 37 weeks
postmenstrual age and most infants do not need charts that go beyond 37 weeks, crit-
ically ill preterm infants often require longer hospitalizations and therefore need to be
Fig. 4. Postnatal growth pattern (median body weight vs postmenstrual age in weeks) for in-
fants born at 24, 26, and 28 weeks estimated gestational age based on observations made in
inborninfants whosurvivedtobe discharged. The referenceis basedonthe population-based
10th and 50th percentiles and the data are from the Pediatrix Clinical Data Warehouse. For
each group of infants, the median weights fall away from the intrauterine growth charts,
so that by 36 weeks, the median postnatal weight for each group of preterm infants is
approaching the 10th percentile for the estimated fetal weight of a similar group of infants
who did not deliver prematurely. Similar to Ehrenkranz and colleagues,
16
the birth weights of
each group of infants are similar to the birth weights of the infants shown on the reference
intrauterine growthchart (they start at the 50thpercentile). As they growinthe NICU, most of
the infants born between 24 and 28 weeks gestation do not achieve the median birth weight
of the reference fetus of the same postmenstrual age, and many are discharged witha weight
less than the 10th percentile.
Clark et al 302
transitioned from a fetal reference chart to an infant chart. The WHO charts are
considered the standards for monitoring growth of children from birth into childhood
(024 months).
2,39
To monitor growth in preterminfants as they growbeyond 37 weeks
requires the addition of the WHO charts to intrauterine growth charts. The pattern of
preterm infant growth is consistent with intrauterine growth between 23 and 37 weeks
and the deceleration in growth velocity seen in growth as the fetus approaches
40 weeks gestational age (see Tables 1 and 2) is not seen in the healthy preterminfant
growing well in the NICU.
31
The reformatted Olsen charts are available at (http://www.
pediatrix.com/workfiles/NICUGrowthCurves7.30.pdf). The Fenton charts are available
at http://www.ucalgary.ca/fenton/2013chart.
We believe it is less important which set of charts is used than it is to routinely plot
growth over time to look for accelerations and decelerations. There is general agree-
ment that gender-specific charts should be used when assessing percentiles. What is
less certain is whether we need population-specific charts based on country or race/
ethnicity. Again, assessing the precise percentile of any given growth measurement at
any specific postnatal age, population-specific data are important, but for monitoring
the pattern of growth the data are less important.
MONITORING THE PROPORTIONALITY OF WEIGHT GROWTH RELATIVE TO STATURE
Body mass index (BMI) is an anthropometric index of weight relative to stature,
defined as body weight in kilograms divided by length in meters squared. BMI is
considered a reliable indicator of body fatness for most children and teens.
40
There
is no routinely used measure of body proportionality, like BMI, to assess body size
and associated risk in preterm infants in the NICU setting. An elevated BMI in children
and adults is correlated with higher body fat composition
41,42
and risk of later related
diseases.
4346
Thus, BMI is an important part of the clinical assessment for these age
groups. In preterm infants, rapid postnatal growth, fat accumulation, and the associ-
ation of these factors with adverse outcomes
4755
has increased interest in the
composition of postnatal growth of preterm infants.
56,57
Because body composition
is not routinely measured in the NICU, a proxy such as BMI may be a useful clinical
tool for preterm infants.
Historically, the growth assessment of preterm infants has focused on rates of
growth velocity and growth status based on size-for-age. This method evaluates
how an infant is growing compared with fetuses of the same age, as recommended,
yet it does not identify growth that is disproportionate or weight gain that might be too
low or too high for an infants length. A rough estimate of appropriate weight gain rela-
tive to length gain (or body proportionality) can be made by comparing weight-for-age
and length-for-age percentiles, determined by plotting these on intrauterine growth
charts. However, a measure of body proportionality provides a simple and possibly
more accurate method of identifying, quantifying, and tracking disproportionate
growth by comparing weight relative to length in one parameter.
A study of young preterm infants evaluated the utility of Lubchenco and colleagues
weight-for-length (defined as ponderal index or weight/length
3
-for-age
5
) curve in the
NICUand found that it categorized infants as small, appropriate, and large in a manner
different fromthe weight-for-age curve.
14
Most of the infants who were categorized as
small weight-for-age (or SGA) were categorized as appropriate weight-for-length at
birth and discharge (77% and 81%); 19% of the infants were categorized as appro-
priate weight-for-age (AGA) at discharge but were large weight-for-length. The mea-
sure of body proportionality provided different information about weight growth
status in preterm infants than weight-for-age alone.
14
Others also have described
variation in growth status when assessed by weight-for-age versus body fat or its
proxies (ie, measures of body proportionality).
54,58
Similar to other periods of the life
cycle, a combination of these measures should help clinicians to make more informed
and individualized nutrition-care decisions that have the potential to improve
outcomes.
The ideal measure of body proportionality for preterm infants of all gestational ages,
however, lacks agreement.
54
Weight-for-length ratios are good candidates, as these
measurements are routinely performed in the clinical setting. The current utility of
the Lubchenco ponderal index curve is limited because of its lack of generalizability
to contemporary US NICUs and it may not accurately capture the weight-for-length
relationship of preterm infants for all gestational ages.
59
Using the methods of
Benn,
60
who defined the ideal weight-for-length ratio as that most highly correlated
with weight and least correlated with length/height, Cole and colleagues
59
found that
the ideal ratio for infants born between 33 and 39 weeks gestation was the ponderal
index, BMI for infants born after 39 weeks. Infants born before 33 weeks gestation
were not studied.
Despite the benefits of including a measure of body proportionality in the growth
assessment of preterm infants, it has several important limitations. First, BMI is
designed to identify and quantify disproportionality between weight and length (ie,
asymmetrical growth). As a result, symmetric growth restriction or excess that results
in stunted weight and length or excessive weight and length, respectively, will not be
identified by a BMI or other measures of body proportionality. The second limitation of
BMI is that it does not distinguish between body fat mass and fat-free mass; thus, a
high BMI (indicating overweight-for-length) could be due to an excess of body fat
mass or a deficiency of fat-free mass. When the body composition of former preterm
infants at corrected full-term age is compared with that of full-term infants, fat mass is
equivalent or greater and fat-free mass is less in former preterm infants, resulting in
higher percentage of body fat estimates.
34,56,57,61
As more body composition data
for preterm infants become available, the relationships between measures of body
proportionality and body composition and outcomes will need to be thoroughly
explored.
54
SUMMARY
The assessment of intrauterine and extrauterine growth in preterm infants is an essen-
tial component of high-quality neonatal care. New and better tools for assessing
growth are available and represent important steps forward in the provision of
maternal/fetal and neonatal intensive care. How a fetus and how a prematurely born
infant grow influence outcome, and failure to diagnose and treat growth problems
can lead to poor outcomes. What represents healthy growth and decreasing the vari-
ability between growth outcomes among NICUs are essential areas for future
research.
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Li near Growth and
Neurodevel opmental
Outcomes
Katie M. Pfister, MD, Sara E. Ramel, MD*
INTRODUCTION
Despite recent improvements in nutritional support, premature infants continue to
exhibit disproportionate growth (characterized by reduced length/height and fat-free
mass [FFM], and increased relative adiposity), as well as neurodevelopmental delay.
Recent literature suggests that some of the same factors (eg, nutritional and inflamma-
tory) are responsible for both outcomes, by directly and negatively affecting both
developing neurons and white matter, and suppressing the growth hormone (GH)/
insulin-like growth factor 1 (IGF-1) axes. Reduced FFM accretion and linear growth
are associated with a risk to the developing brain. To date, neonatal nutritional strate-
gies have been ineffective in preventing failure of linear growth and its attendant risk to
cognitive development, in part because of a lack of thorough understanding of what
The authors have no disclosures.
Division of Neonatology, Department of Pediatrics, University of Minnesota, 2450 Riverside
Avenue East Building MB 630, Minneapolis, MN 55454, USA
KEYWORDS
Linear growth

Fat-free mass

Inflammation

Outcomes

Neurodevelopment
Premature infants

Very low birth weight
KEY POINTS
Premature infants exhibit disproportionate growth characterized by reduced length/height
and fat-free mass (FFM), as well as neurodevelopmental delay.
Growth should no longer be defined as weight gain alone, as increases or stunting in other
metrics are associated with lasting effects on neurodevelopment.
Brain maturation is characterized by critical periods of growth, each with specific nutrient
needs.
Protein status plays an important role in FFM accretion, neurogenesis, and neuronal
differentiation.
Early inflammation and illness have a long-term negative influence on linear growth and in
FFM gains, as well as on later neurodevelopment.
causes suppression of linear growth and in part because of an inappropriate emphasis
on defining growth as weight gain. A potential change in care to improve develop-
mental outcomes might include more careful monitoring of linear growth and body
composition (including FFM), accompanied by strategic nutritional and nonnutritional
interventions aimed at supporting FFM growth. The latter could include strategies to
reduce the duration of illness and the number of inflammatory events.
INCIDENCE OF GROWTH FAILURE IN PREMATURE INFANTS
In 2011, the rate of preterm birth in the United States remained greater than 11%.
1
Ac-
cording to a reviewfromthe National Institute of Child Health and Human Development,
the rate of growth failure among VLBWpreterminfants remains unacceptably high, with
79% weighing less than the 10th percentile at 36 weeks.
2
Hack and colleagues
3
re-
ported that many of these infants remain underweight and short for age (<2 standard
deviations [SD]) at 20 months corrected age for prematurity, and that very low birth
weight (VLBW) males remain small and short into adulthood.
The prevalence and importance of poor weight gain in preterm infants has been
widely cited for decades. Although first described in 1981,
4
the incidence, persistence,
andsignificanceof linear-growthfailurehas onlyrecently reemergedas atopicof impor-
tance. This renewedemphasis is particularly important because linear growth andgains
in FFMclosely index organ growth, and specifically the brain, in other populations. Mul-
tiple recently published studies have described prolonged suppression of linear growth
in preterm infants beyond 18 to 24 months corrected age for prematurity (Fig. 1).
57
In each of these studies, length z-scores were more severely depressed and
remained lower longer than z-scores of weight and head circumference
6,7
and body
mass index (kg/m
2
).
5,6
This finding is unlike the classic undernutrition anthropometric
pattern of growth failure whereby weight is compromised but length and head circum-
ference are spared. The body habitus of excessively suppressed linear growth (ie, the
Fig. 1. Growth of very low birth weight preterm infants from birth to 24 months corrected
age illustrating persistent linear stunting. P values refer to statistical significance of the dif-
ference between the mean growth z-score at each time point compared with the mean
z-score at birth. HCZ, head circumference z-score; LZ, length z-score; WZ, weight z-score.
(From Ramel SE, Demerath EW, Gray HL, et al. The relationship of poor linear growth veloc-
ity with neonatal illness and 2 year neurodevelopment in preterm infants. Neonatology
2012;102:21; with permission.)
Pfister & Ramel 310
short, fat baby) suggests that nonnutritional factors may also play a role in this
suppression.
Linear growth reflects FFM accretion. However, accurate linear growth measure-
ments can be difficult to obtain. With the recent addition of infant air-displacement
plethysmography, repeat noninvasive body composition measurements in infants,
including those born prematurely, has become more feasible, and a plethora of
research data monitoring body composition has become available. Not unexpectedly,
it has been recently noted that preterm infants also have less FFM than term born in-
fants when measured at term corrected age.
8,9
Two small studies have documented
that this difference has subsided by 3 to 4 months corrected age
9,10
; however, further
long-term studies on body composition are needed.
DEFINITIONS OF GROWTH
Growth of the preterm infant has historically been defined as weight gain over time. As
weight gain and nutrition have been more extensively studied and their relationships
with neurodevelopmental outcomes have been established, other growth parameters
relationships to outcome have also been assessed. Weight gain, head circumference,
and linear growth all correlate with long-term outcomes in preterm infants. More
recent studies have looked at body composition, quality of weight gain, and relation-
ship to neurodevelopment as a more comprehensive evaluation of neonatal growth
than any single anthropometric measurement alone. The American Academy of Pedi-
atrics (AAP) recommends that the preterm infant achieve a growth rate similar to that
of the intrauterine fetus of the same gestational age.
11
Although this recommendation
continues to be interpreted as weight-gain velocity, growth in other metrics index
important physiologic processes, including neurodevelopment.
Weight
Weight gain is the traditional metric of growth in the neonate. Weight represents the
balance between energy intake and expenditure. The current recommendation for
weight-gain velocity in the preterm infant is 15 to 18 g/kg/d, which approximates
the weight gain of the fetus during the second through third trimester. However, higher
velocities (2030 g/kg/d) may be needed for extremely low birth weight infants to
regain birth z-scores by term,
12
likely because of the need for catch-up growth after
nutritional deficits in the first weeks of life. Although weight gain is associated with
neurodevelopmental outcomes
13,14
and there are distinct recommendations for rates
of weight gain in preterm neonates, this metric alone does not give a complete picture
of the overall nutritional state of the infant, and can be confounded by nonnutritional
weight gain (eg, edema).
Head Circumference
During the third trimester, the brain is undergoing tremendous changes characterized
by increasing dendritic complexity and synaptic connectivity, which are reflected by
increases in brain volume and surface area. In the absence of hydrocephalus, head
circumference indexes the brains growth and correlates with brain volume both
post mortem and on magnetic resonance imaging (MRI).
15,16
The growth velocity of
head circumference that mimics the fetus during the third trimester, and thus goal
for growth of the preterm infant, is approximately 1 cm/week.
17
MRI findings in pre-
term infants who develop microcephaly by term corrected age show significant losses
in deep nuclear gray matter (indicating neuronal loss, architecture, or both) compared
with infants with normal z-scores.
16
Slow head growth has also been independently
associated with delayed cortical gray matter maturation in preterm infants.
18
Stunting
of head growth in both the neonatal
6,13,16,19
and postdischarge
19
periods is associ-
ated with poorer neurodevelopmental outcomes. However, microcephaly reflects
severe malnutrition, owing to the head-sparing phenomenon, and thus loses its pre-
dictive value for neurodevelopment in most preterm infants who remain normoce-
phalic during their hospital stay.
Length
Linear growth represents lean body mass and protein accretion
20,21
and also indexes
organ growth and development, including the brain.
22
The AAP recommends that pre-
term infants grow similarly to the fetus,
11
but this guideline has been mostly applied to
weight gain. As already described, the ideal weight gain to optimize neurodevelop-
mental outcomes has been studied extensively. However, ideal linear growth has
yet to be defined. Intrauterine linear-growth velocity is approximately 1 cm/wk,
23
and therefore is the goal that most neonatologists currently follow. Given the
increasing evidence that linear-growth suppression is associated with poorer cogni-
tive outcomes,
5,7
length may be an important anthropometric biomarker for later neu-
rodevelopment. Research is needed to determine optimal goals of linear growth for
preterm infants so as to optimize later growth and neurodevelopmental outcomes.
Lower calorie and protein intakes during hospitalization are associated with pro-
longed suppression of linear growth.
7,24
In addition, inflammation, which increases
protein breakdown, is associated with reduced length z-scores out to 24 months cor-
rected age in preterm infants.
7
Strategies aimed at optimizing protein delivery with
adequate energy support and reducing inflammation to decrease protein breakdown
are 2 strategies that could potentially improve neurodevelopmental outcomes in this
vulnerable population.
Body Composition
Body composition, the assessment of fat mass and FFM, has recently begun to be more
thoroughly assessed in the preterm neonate. Like linear growth, FFM indexes organ
growth and protein status. Improved FFM accretion has also recently been associated
with improved speed of processing in preterm infants.
25
Fat also makes up a significant
portion of the brains structure. Fetal fat deposition begins during the third trimester, and
in the fetus the percentage of body fat rapidly increases to roughly 15% of body weight
by term.
26
Preterm infants, who are growing in the neonatal intensive care unit (NICU)
during the corresponding postconceptional time period, have increased adiposity
and less FFM at term corrected age when compared with their term gestation counter-
parts.
9,27,28
Moreover, fat stores in preterm infants are abnormally distributed, with
decreased subcutaneous and increased intra-abdominal adipose tissue at term
corrected age.
29
These alterations likely result from both nutritional abnormalities and
maladaptive metabolism,
27,30,31
and the ideal body composition and how to achieve
it in this population has not yet been defined. Given the concerns of increased adiposity
and long-termmetabolic risk in preterminfants, further research is needed to determine
the ideal nutritional regimen for this population, and likely will require individualization to
optimize growth, metabolic, and neurodevelopmental outcomes.
NUTRIENTS THAT AFFECT LINEAR GROWTH, FFM ACCRETION, AND
NEURODEVELOPMENT
Although all nutrients are important for growth and brain development, certain nu-
trients are of particular significance in the developing preterm brain during critical
Pfister & Ramel 312
periods of development. Nutrient deficiencies will have different effects based
on when the deficit occurs and how the brain is using it at that time.
32
Deficits
affect both the microstructure and the function of the brain. While a great deal is
known about the effect of deficit or oversupplementation of certain nutrients in
term infants and toddlers, many nutrients remain understudied, particularly in pre-
term infants. This population develops nutritional deficits during a period of tremen-
dous neurologic change including increases in neuronal differentiation, dendritic
complexity, synaptogenesis, and myelination. This article will focus specifically on
those nutrients that are known to directly influence linear growth, FFM accretion,
and neurodevelopment.
During the first few days to weeks of life, VLBW preterm infants accrue nutritional
deficits that have been shown to influence long-term growth and neurodevelopment.
This accrual is largely due to these infants dependence on parenteral nutrition, and
hesitancy to begin early enteral nutrition for fear of intolerance and development of
necrotizing enterocolitis. Protein, in particular, has been limited owing to concerns
over protein toxicity, stemming from previous trials that revealed metabolic acidosis,
uremia, poor growth, and poorer neurodevelopmental outcomes in protein-
supplemented infants.
33
However, current nutritional strategies use higher-quality
protein at lower levels than previously reported, and have documented not only safety
and tolerance of supplementation but also improved outcomes.
24,3436
Several recent studies, including a few clinical trials of protein supplementation
(range of 4.24.8 g/kg/d), have shown improved linear growth and FFM accretion dur-
ing hospitalization.
9,24,37,38
These findings are lasting in that infants receiving more
aggressive protein supplementation while in the NICU continue to have higher
amounts of FFM and improved length after discharge.
9,24,37
Protein plays an important role in the developing brain, and is necessary for
normal neurogenesis, dendritic arborization, synaptogenesis, and myelin produc-
tion, as well as for cell signaling in the form of growth factors and neurotransmit-
ters.
39
Between 26 weeks gestation and term, the fetal brain transforms from a
smooth, bilobed, 105-g organ to a complexly sulcated organ of 3.5 times this
weight by term. The third trimester is a period of tremendous microscopic changes
(see earlier discussion). Axonal and dendritic growth accounts for the large volume
increase in the brain during the last trimester. This rapid pace of development
leaves the preterm brain particularly vulnerable to the lack of critical nutrients
that support this process, especially protein. Recent studies have consistently
shown improved neurodevelopment in infants receiving more aggressive protein
supplementation during hospitalization,
24,25,36,37
and these findings are lasting.
Isaacs and colleagues
36
have documented improved brain volume and cognitive
scores during adolescence in those infants receiving improved early protein
intake.
Preterm infants have specific reductions in brain volume representing regional
vulnerabilities (most significantly in the sensorimotor cortex but also including sur-
rounding areas, corpus callosum, basal ganglia, amygdala, and hippocampus), which
correspond with poorer cognitive outcome.
40
Even among healthy preterm infants
and early term infants, shorter gestation is associated with decreases in gray-matter
density at school age.
41
Reduction in gray matter is largely a function of reduced
neuronal number and less neuronal complexity, both of which are induced by subop-
timal protein intake. This process is likely controlled by cell-signaling pathways such
as the mammalian target of rapamycin, which depends highly on branch-chain amino
acids, IGF-1, and protein sufficiency, and is involved in neurogenesis, neuronal differ-
entiation, and apoptosis.
42
Protein also plays a role in stimulating neural growth factors such as IGF-1 and
brain-derived neurotropic factor (BDNF). Animal studies have shown that protein
restriction decreases serum and brain-tissue levels of IGF-1.
43,44
As associations be-
tween improved IGF-1 levels and lower risk of abnormal cognition in preterm infants
45
have recently been reported, the GH/IGF-1 axis may contribute to the association
between improved protein status/linear growth and improved cognition.
Given the existing evidence, protein should be provided urgently to preterm infants.
This administration should begin immediately after birth at approximately 3 g/kg/d via
parenteral nutrition and be increased quickly to 4 to 4.5 g/kg/d. Protein supplementa-
tion should continue via human milk fortification and additional supplementation, as
needed, to maintain these levels until at least hospital discharge. Infants receiving
increased protein amounts (>3 g/kg/d) after discharge continue to have improved
FFM accretion.
27
As associations with linear growth/FFM accretion and neurodeve-
lopmental outcomes extend beyond hospital discharge, postdischarge fortification/
protein supplementation should also be considered.
Although protein is a main driver of linear growth and organ development, other nu-
trients such as carbohydrates, fats, and zinc are also important, and their deficiencies
can cause failure of linear growth despite optimal protein intake. Energy intake in the
form of carbohydrates and fat is essential for adequate weight gain. Improved caloric
intake has been shown to improve neurodevelopmental outcomes.
24
Recently, the
contribution of nonprotein calories to linear growth and lean body mass has also
been noted. Improved energy intake during hospitalization is associated with
increased FFM accretion at 4 months corrected age, and improved linear growth
out to 24 months corrected age for prematurity.
7,9
In addition, findings of improved
FFM accretion with increased caloric goals (150160 kcal/kg/d) have not been
coupled with increases in fat mass during the hospitalization or in short-term follow-
up.
9,38
Specific fats are also important for protein accretion. Similar to branch-chain
amino acids, long-chain polyunsaturated fatty acids are potent signaling molecules
that affect the expression of genes and, thus, proteins that control cell growth and dif-
ferentiation.
46
Therefore, current evidence does not support limiting energy intake as a
prudent method of normalizing body composition by reducing fat accretion. Such a
strategy may in fact reduce linear growth and lean body mass.
Zinc, second only to iron in trace-metal abundance in the brain, plays a key role in a
variety of functions that regulate linear and brain growth. These functions include gene
expression, enzyme and growth factor (IGF-1) activity, neurogenesis, cell signaling,
and modulation of neurotransmitter activity in the developing brain.
47
Most research
related to zinc and brain development has been done in rodent models. Mild zinc defi-
ciency during gestation leads to learning and memory deficits in pups.
48
Several
studies have shown that zinc supplementation, in the setting of malnutrition, leads
to improvement in biochemical alterations, in addition to improved growth and behav-
ioral tests.
49,50
Given that zinc is involved in cell replication and is essential for nucleic
acid and protein synthesis, it is an extremely important nutrient during periods of rapid
brain growth, such as during the third trimester in humans. Clinical studies of zinc sup-
plementation in VLBW infants and other growth-restricted populations show a signif-
icant impact on linear growth
5153
and motor scores during infancy.
52
ROLE OF INFLAMMATION/ILLNESS IN LINEAR GROWTH AND BRAIN DEVELOPMENT
The complete set of mechanisms responsible for linear-growth suppression, reduced
FFM, increased fat mass, and abnormal fat distribution in VLBW preterm infants are
not understood, and represent a significant gap in knowledge that prevents optimal
Pfister & Ramel 314
clinical management. In previous studies, growth failure has been proposed to be pri-
marily, if not exclusively, due to a lack of nutritional intake.
54
However, several studies
have suggested that weight gain during hospitalization is also negatively influenced by
acute and chronic illnesses affecting preterm infants, including sepsis, necrotizing
enterocolitis, and bronchopulmonary dysplasia. In the past these findings were inter-
preted to mean that these medical conditions limit the practitioners ability to provide
adequate nutritional intake.
5557
More recently, the relationship of nonnutritional factors, including inflammation, to
linear growth/FFM accretion in preterm infants has been considered. Degree of illness
and inflammation have been shown to be negatively associated with the degree of
catch-up growth in weight, length, and FFM domains after discharge in preterm in-
fants.
7,9
In particular, associations of these nonnutritional factors in the NICUwith sub-
sequent linear growth persist until at least 24 months corrected age.
7
These
associations with illness implicate inflammatory cytokine activation in the etiology of
reduced linear and FFM growth rate. In addition, the long-term nature of altered
growth and body composition suggests that longer-term disturbances in regulation
of the GH/IGF-1 axis have occurred and cannot be attributed solely to inadequate pro-
tein and energy intake, which have largely resolved by the time of hospital discharge.
Critically ill children and adults become relatively GHresistant, with elevated GH levels
and inappropriately low IGF-1 levels.
58,59
In turn, the GH axis is suppressed by inflam-
mation. In studies of children with chronic inflammation, levels of interleukin (IL)-6 and
tumor necrosis factor (TNF)-a have been associated with diminished IGF-1 levels and
poor linear growth.
60
Immune activation, as measured by C-reactive protein, has been
shown to correlate with decreased linear growth in a population of stunted children,
61
but associations have not yet been examined in the preterm population.
Inflammatory markers have been implicated in neuroinflammation, and have been
shown to have negative effects on cognition and, specifically, memory.
62
Increased
IL-8 and TNF-a levels have been associated with neurodevelopmental impairment, ce-
rebral palsy, and Mental Developmental Index and Psychomotor Developmental Index
of less than 70 in preterm infants.
63
Adipose tissue produces and releases several
proinflammatory and anti-inflammatory factors, including leptin, TNF-a, IL-6, and adi-
ponectin.
64
Altered levels of these molecules have been observed in a variety of in-
flammatory conditions, and have been shown to cross the blood-brain barrier and
potentially affect cognition.
6567
The relationship between increased adiposity and
levels of these adipokines has not yet been explored in preterm infants; however,
knowledge of this relationship may allow a better understanding of the mechanisms
linking altered adiposity, FFM accretion/linear growth, and cognition.
LINEAR GROWTH/FFM GAINS AND NEURODEVELOPMENTAL OUTCOMES
Diminished linear growth, irrespective of weight gain, is common in VLBW preterm in-
fants until 24 months corrected age, and has a significant relationship with reduced
cognition.
7
Even when controlling for weight and head circumference z-scores, cogni-
tive scores at 24 months corrected age are positively related to linear growth in the first
year after discharge, with an increase of approximately 4 points for each 1 SDincrease
in length z-score. Similarly, language scores on the Bayley Scales of Infant Develop-
ment (BSID)-III at 24 months corrected age are positively related to linear growth from
birth to hospital discharge, with an improvement of approximately 8 points for each
1 SD increase in z-score. Recently, a large study of preterm low birth weight infants
demonstrated that more rapid linear growth from term to 4 months corrected age is
associated with lower odds of IQ being less than 85 at ages 8 and 18 years.
5
In
addition, improved linear growth after hospital discharge in a group of infants born at
less than 33 weeks gestation is associated with improved motor scores at 18 months
corrected age on the BSID-II.
6
Improved postnatal catch-up linear growth in VLBW in-
fants in Switzerland is associated with improved cognitive and motor scores and lower
rates of cerebral palsy at 2 years corrected age.
68
Similar correlations have also been
noted in institutionalized children in Romania and children in Thailand, who demon-
strate a pattern of growth failure that is also characterized by greater length rather
than weight suppression.
69,70
Improved FFM accretion has also recently been linked to improved cognitive devel-
opment.
25
In a small group of preterm infants, increased FFM at term and 4 months
corrected age was associated with faster neuronal processing measured using visual
evoked potentials at 4 months corrected age (Fig. 2).
Fig. 2. Grand mean visually evoked potential waveforms of an infant with a relatively low
fat-free mass (FFM) at both visits (2.3 g at visit 1 and 4.39 g at visit 2) (dashed line) versus an
infant with a relatively high FFM at both visits (3.03 g at visit 1 and 5.56 g at visit 2) (solid
line). (From Pfister KM, Gray HL, Miller NC, et al. An exploratory study of the relationship of
fat-free mass to speed of brain processing in preterm infants. Pediatr Res 2013;74(5):57683;
with permission.)
Fig. 3. The complex interactions between nutrition, inflammation, linear growth, and
development. FFM, fat-free mass; IGF-1, insulin-like growth factor 1.
Pfister & Ramel 316
These associations of linear growth/FFM gains and later cognition may be
explained by the known positive effects of protein status on neuronal growth and
differentiation, as evidenced by studies assessing the consequences of protein re-
striction. However, the primary neuropathology likely results from a lack of protein
accretion, which may be due to lack of protein intake or increased protein break-
down. Premature infants are at risk for both low protein intake and inflammatory
states that promote protein breakdown. Thus, medical conditions such as inflamma-
tory states that increase somatic protein breakdown are likely to result in protein
deficits similar to those noted with dietary restriction (Fig. 3). Understanding
the role of this axis warrants further study, as IGF-1 and GH have been found to
be neuroprotective and neurostimulatory in animal models as well as in healthy
children, and support a link between gains in lean body mass and cognitive
development.
45,71,72
SUMMARY
Evidence suggests that diminished linear growth and FFM gains are potentially impor-
tant markers of future cognitive deficit in VLBW preterm infants. Possibly this is due to
associations with reduced GH-axis activation (lower IGF-1), which may reduce myeli-
nation and synaptic density, and may be influenced by both nutritional and nonnutri-
tional factors. Optimization of nutrition, including protein intake, in addition to
decreasing the duration or frequency of inflammatory episodes, will likely improve
long-term outcomes. Additional strategies of possible GH or IGF-1 supplementation
should be considered, and need further investigation.
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Protei n I ntake and
Neurodevel opmental
Outcomes
Bonnie E. Stephens, MD
a,b,
*, Betty R. Vohr, MD
c
There is a continuously accumulating body of evidence that suggests that malnutrition
during critical periods of brain growth and development alters the growth trajectory
of the developing brain and can have permanent negative developmental con-
sequences.
13
Although a great deal of indirect evidence points to the importance
of protein intake for the developing brain, there still exists very little direct evidence
of the effects of protein intake on neurodevelopment.
In humans, the most critical developmental period of brain growth and function oc-
curs during the third trimester of pregnancy and the first 2 years of postnatal life.
1,4
During this period, brain growth and development are occurring more rapidly than
at any other time in life. At 20 weeks gestation, the brain weighs only 10% of what
it weighs at term and is completely smooth, with only the Sylvian fissure having
The authors have no conflicts of interest to disclose.
a
Department of Pediatrics, Warren Alpert Medical School, Brown University, 222 Richmond
Street, Providence, RI, USA;
b
NICU, Community Medical Center, 2827 Fort Missoula Road, Mis-
soula, MT 59804, USA;
c
Neonatal Follow-up Program, Women and Infants Hospital, Depart-
ment of Pediatrics, Warren Alpert Medical School, Brown University, 222 Richmond Street,
Providence, RI, USA
* Corresponding author. NICU, Community Medical Center, 2827 Fort Missoula Road, Missoula,
MT 59804.
KEYWORDS
Protein

Neonatal

Prematurity

Outcomes

Neurodevelopment
KEY POINTS
Biologic factors associated with prematurity impede the ability to achieve current recom-
mended protein intake for preterm infants in the first week of life.
Recognition of potential deleterious effects of nutritional deprivation among extremely
preterm infants has resulted in recommendations for increased parenteral amino acid
intake.
There is evidence of benefit of early protein intake on head circumference growth among
preterm infants.
Further studies are needed to clarify the relationships among early protein intake, early
head growth and neurodevelopmental outcomes, and the differential effects of gender.
formed. The brain increases in weight in a linear fashion from 20 to 40 weeks, and in
the process, develops all remaining gyri and sulci.
5
The volume of the cortical gray
matter increases 4-fold from 29 to 40 weeks gestation, and a 5-fold increase in white
matter volume occurs from 35 to 40 weeks.
6
In addition to neuron formation, migra-
tion, maturation, synapse formation, and pruning via apoptosis are all occurring
rapidly during this period and continue to occur throughout and beyond the neonatal
period. The rapid changes associated with these developmental processes make the
developing brain extremely vulnerable to environmental perturbations.
1,4
One such environmental perturbation with the potential to have lasting effects on the
developing brain is an alteration in nutritional intake. In studies of malnutrition in rat
pups, even mild malnutrition during this critical period in brain development, result-
ing from a larger than normal litter size, led to deficits in neuron formation in the cere-
bellar granular layer and deeper layers of the cerebral cortex.
1
In preterm human
infants with birth weights less than 1750 g, caloric deprivation (defined as intakes of
<85 kcal/kg/d) has been directly related to poor head growth, and prolonged periods
of caloric deprivation (greater than 4 weeks in duration) has been associated with
lower scores on the Bayley Psychomotor Developmental Index (PDI) at 12 months
of age.
7
Thus, the provision of adequate nutrition to infants during the neonatal period seems
to be critical. Despite this, nutritional practices vary greatly among neonatal intensive
care units (NICUs), and energy-containing macronutrients (protein, carbohydrate, and
lipid) have historically been introduced slowly and increased cautiously because of
concerns for intolerance. This intolerance results in a period of nutritional deficiency
that is common and accepted as inevitable for newborns hospitalized in the
NICU.
8,9
Although all hospitalized newborns are vulnerable, those born preterm are
the most vulnerable and the most studied in the published literature.
The precise nutritional needs of the preterminfant are still unknown, as are the dura-
tion and degree of undernutrition that places the infant at neurodevelopmental risk.
The American Academy of Pediatrics Committee on Nutrition recognizes the impor-
tance of adequate nutrition for these vulnerable infants and recommends providing
sufficient energy and nutrients to meet the requirements of the growing fetus with
the goal of approximating the rate of growth and composition of weight gain for a
normal fetus at the same postmenstrual age.
10,11
Nevertheless, there are several
challenges encountered when attempting to achieve nutrient intake in preterm infants
commensurate with the intrauterine environment. Gastrointestinal constraints result in
delays in achieving full enteral feeds. Small stomach capacity, slow gastric emptying,
decreased intestinal motility, decreased enzyme production, immature sucking, and
diminished suck-swallow coordination contribute to potential nutritional deficits asso-
ciated with enteral feeds. Ehrenkranz and colleagues
12
showed that age of first enteral
feed was inversely related to birth weight. Parenteral alimentation, therefore, is the
initial primary method for providing early nutrition, including protein to very preterm in-
fants, and even with the provision of parenteral nutrition, there remains a difference
between the nutrient supply that the normally growing fetus typically receives and
that received by the postnatal, preterm counterpart.
The composition of the nutrients delivered by the placenta reflects the unique needs
of the growing fetus. Glucose is delivered at a rate that reflects energy use; amino acid
uptake is high and far exceeds that needed for accretion (oxidation of the excess is
used as a significant energy source), and lipid uptake is minimal. The typical neonate
in the intensive care unit receives high rates of glucose and lipid infusion in an attempt
to provide adequate calories for growth, yet lower of rates amino acid/protein infu-
sion.
13,14
This practice of limiting protein intake is especially commonplace in the
Stephens & Vohr 324
treatment of the sick or extremely low-birth-weight neonates during the early neonatal
period, in an attempt to avoid potential side effects, such as azotemia or acidosis,
seen with the infusion of some amino acid solutions. Thus, nutritional deficits inevitably
occur.
8
These deficits are greatest in the first week of life but continue to accumulate
through the first month.
In the typical fetus at less than 32 weeks, rates of protein accretion are approxi-
mately 2 g per day.
15
In contrast, when infants receive an intravenous infusion
of dextrose alone, rates of protein loss in the stable, 32-week preterm infant are
w1 g/kg/d and in the extremely preterm infant (26 weeks) approach 1.5 g/kg/d.
16
Thus, cumulatively, the extremely preterm infant receiving glucose alone loses 1%
to 2% of their protein stores daily.
16
When placed on an amino acid infusion rate of
1.1 g/kg/d, protein balance is zero, with no losses, but also no protein accretion to
support growth and development.
17
At infusion rates of at least 1.5 g/kg/d, protein bal-
ance becomes positive, and some protein accretion begins to occur. However, even
at infusion rates of 3 g/kg/d, protein accretion remains less than that of the reference
fetus. Adequate accretion rates require infusion rates of 3.85 g/kg/d if the goal remains
to approximate the rate of growth and composition of weight gain for a normal fetus
at the same postmenstrual age.
16
Provision of less results in cumulative losses that
are difficult to make up. For example, the infant who receives only 2 g/kg/d of amino
acid infusion develops a net loss of 14 g/kg over the course of a week.
8
Infusion of only
3 g/kg/d still results in a net loss of almost 6 g/kg at the end of the first week of life.
Why has the fear of side effects kept us from providing adequate protein to our
vulnerable preterm infants? Historically, the amino acid solutions available to us
were casein hydrolysates, which often led to acidosis and hyperammonemia. How-
ever, since the 1980s, newer crystalline formulations have been available that reduce
the incidence and severity of negative consequences.
There is clinical evidence that parenteral protein can be provided safely, without
adverse clinical sequelae, in the early neonatal period.
1823
Rates of acidosis and
elevated blood urea nitrogen (BUN) levels are similar regardless of early protein
administration.
1823
In fact, there is no correlation between amino acid intake in the
early neonatal period and serum BUN levels.
24
Amino acid levels also remain safely
at or below levels of the reference fetus during amino acid infusions.
22
Even parenteral
amino acid intake of 3 to 3.5 in the first days of life has been shown to be both safe and
effective in improving protein accretion.
19,22
Higher protein (and calorie) intakes, even in the first days of life, result in better
growth at NICU discharge in very-low-birth-weight (<1500 g) infants. Three studies
have demonstrated lower rates of growth restriction (parameters <10%) at discharge
in those infants fed more protein and calories in the first weeks of life.
20,23,25
A 2013
Cochrane Review of trials examining early (<24 hours) versus late (24 hours) paren-
teral amino acid administration in premature infants on outcome at 28 days identified
improved nitrogen balance but no effect on length and head circumference.
26
The tri-
als in this review were limited by small sample size. Neurodevelopmental outcomes
were not reported in any of these studies.
An association between poor growth and neurodevelopmental outcome has been
demonstrated in other studies. Connors and colleagues
27
demonstrated an associa-
tion between lower developmental scores and weight less than the 10th percentile at
2 years of age, in a cohort of 70 high-risk, extremely low-birth-weight infants. Ehrenk-
ranz and colleagues
28
demonstrated a significant relationship between in-hospital
growth velocity and neurodevelopmental outcome in 490 extremely low-birth-weight
infants. Lower rate of weight gain and lower rate of head growth were both significantly
associated with cerebral palsy, Bayley Mental Developmental Index (MDI) less than
70, and neurodevelopmental impairment at 18-months corrected age, when control-
ling for confounding variables. However, neither of these studies examined nutrient
intake.
Poor in utero and extrauterine head growth in very-low-birth-weight infants has also
been shown to predict lower scores on the MDI at 15 to 20 months of age,
29,30
and
lower verbal and performance intelligence quotients (IQ), receptive and expressive
language, and academic abilities at school age.
31
In infants born small for gestational
age, head circumference catch-up growth has been correlated with higher energy
intake during the first 10 days of life and higher IQ later in life,
32
thus implying an indi-
rect association between intake and neurodevelopmental outcome.
Interpretation of results of protein administration trials may be confounded by the
degree to which centers achieve successful implementation of the nutrition protocol.
The Glutamine trial
33
randomized infants weighing 401 to 1000 g, receiving parenteral
nutrition within 72 hours of birth, to receive either TrophAmine (control) or an isonitrog-
enous study amino acid solution with 20% glutamine for up to 120 days of age, death,
or discharge fromthe hospital. No group differences were found in rates of death, late-
onset sepsis, or growth at 36 weeks. However, examination of the data indicated that
only 18% of infants received the parenteral protein ordered.
Poindexter and colleagues
34
reanalyzed the growth data from the Glutamine Trial in
a secondary analysis and demonstrated better head growth at 18-months corrected
age in a cohort of extremely low-birth-weight infants (<1000 g) who actually received
at least 3 g/kg/d of amino acids in the first 5 days of life, compared with those who re-
ceived less. Significantly more infants in the group who received less than 3 g/kg/d
in the first 5 days had a head circumference less than the 10% and/or less than the
5%. In addition, boys who did not receive 3 g/kg/d of amino acids in the first 5 days
of life had smaller head circumferences. There was no effect for girls. No differences
in rates of neurodevelopmental impairment (MDI <70, PDI <70, cerebral palsy, blind,
deaf) at 18-months corrected age were identified between infants receiving higher
or lower protein intakes. Thus, better head growth did not translate to better neurode-
velopmental outcomes.
To date, only one published study examines the direct association between protein
intake in the first week of life and neurodevelopmental outcomes.
35
This study
analyzed the total daily enteral and parenteral calorie and protein intake in all
extremely low-birth-weight survivors in a single NICUduring a 2-year period and found
a significant association between intake and 18-month neurodevelopmental outcome.
Every gram per kilogram per day of protein received in the first week of life was asso-
ciated with an 8.2-point increase in MDI score at 18 months. However, this was a
retrospective analysis and rates of amino acid infusion were low, with an average of
only 1 g/kg/d on the first day of life and a gradual increase to 2.9 g/kg/d by the end
of the first week.
A prospective longitudinal study is needed to examine the effects of early, higher
parenteral protein intake fully in conjunction with known confounders on the outcomes
of preterm infants. At least one such trial is currently underway.
A clear association between early enteral intake and neurodevelopmental outcome
has been demonstrated in larger preterm infants. Lucas and colleagues
36,37
demon-
strated higher cognitive and motor scores at 18-month corrected age, as well as
higher verbal IQs and lower rates of cerebral palsy at 7.5 to 8 years of age in preterm
infants (<1850 g) fed preterm formula containing 2 g protein and 80 kcal per deciliter
versus term formula containing 1.45 g protein and 68 kcal per deciliter for the first
4 weeks of life. This association was most pronounced in infants born small for gesta-
tional age. The association with verbal IQ persisted at 16-year follow-up.
38
Stephens & Vohr 326
The association between breast milk intake and neurodevelopmental outcome is
less clear, especially in smaller preterm infants. Furman and colleagues
39
demon-
strated no effect of maternal milk intake in the first 4 weeks of life on 20-month cogni-
tive or motor outcomes in a cohort of 98 very-low-birth-weight infants (<1500 g).
Conversely, in a cohort of 1035 extremely low-birth-weight infants, Vohr and col-
leagues
40
found that those infants fed more breast milk during hospitalization in the
NICU had higher 18-month MDI scores.
Studies of enteral nutrition and its effects on developmental outcome fail to account
for nutrition in the first days and weeks of life, because most extremely low-birth-
weight infants do not begin to feed enterally for several days and do not reach full
enteral feedings for weeks. In addition, although preterm human milk has a higher
protein level than term human milk,
41
protein and energy levels are still inadequate
for growth, and supplementation with human milk fortifiers is needed.
42,43
In summary, there remains limited evidence in regard to the neurodevelopmental
effects of protein intake in the neonatal period. However, the evidence for higher levels
of enteral protein intake, combined with the indirect and retrospective data on paren-
teral protein intake, supports the concept that adequate protein intake in the hospital-
ized preterm infant may be associated with better neurodevelopmental outcomes.
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milk produced by mothers of preterm infants. Clin Nutr 2011;30:21520.
42. Kashyap S, Schulze KF, Forsyth M, et al. Growth, nutrient retention, and metabolic
response of low-birth-weight infants fed supplemented and unsupplemented
preterm human milk. Am J Clin Nutr 1990;52:25462.
43. Premji SS, Fenton TR, Sauve RS. Higher versus lower protein intake in formula-fed
low birth weight infants. Cochrane Database Syst Rev 2006;(1):CD003959.
Compl i cati ons Associ ated
wi th Parenteral Nutri ti on
i n the Neonate
Kara L. Calkins, MD
a,
*, Robert S. Venick, MD
b
,
Sherin U. Devaskar, MD
a
INTRODUCTION
Parental nutrition (PN) is an essential part of the medical management of critically ill
neonates. The primary goals of PN are to maintain hydration and electrolyte balance,
and to promote growth and neurodevelopment without adverse complications. For a
myriad of reasons, up to 70%of neonates in the neonatal intensive care unit (NICU) are
prescribed PN at some point, and approximately 16,000 children receive PN in the
home setting in the United States (Box 1).
1,2
Without PN, children who are unable
to consume sufficient enteral nutrition would succumb to malnutrition, dehydration,
and electrolyte derangements.
a
Division of Neonatology and Developmental Biology, Department of Pediatrics, Mattel Chil-
drens Hospital, University of California, Los Angeles, Los Angeles, CA, USA;
b
Division of
Gastroenterology, Department of Pediatrics, Mattel Childrens Hospital, University of California,
10833 Le Conte Avenue, MDCC, Los Angeles, Los Angeles, CA 90095-1752, USA
KEYWORDS
Parenteral nutrition

Neonates

Lipids
Parenteral nutritionassociated liver disease

Infections
KEY POINTS
Although parenteral nutrition (PN) is life-saving, it is associated with myriad of complica-
tions, some of which are transient and others life-threatening, including parenteral
nutritionassociated liver disease (PNALD) and central lineassociated bloodstreaminfec-
tions (CLABSIs).
Although fish oilbased lipid emulsions can biochemically reverse PNALD, clinicians
should bear in mind that the development and progression of PNALD is multifactorial.
It remains to be determined whether dose reduction of lipid emulsions can prevent PNALD
without sacrificing growth and neurodevelopment.
The phytosterol, long-chain polyunsaturated fatty acid, and antioxidant content of intrave-
nous lipid products seems to play an important role in the pathogenesis of PNALD.
Research is needed with regard to optimizing the PN content for the neonatal population
so as to safely promote growth and neurodevelopment.
Although outcomes in poorly resourced countries do not mirror what has been wit-
nessed in well-resourced countries, PN has undoubtedly contributed to the improved
survival of infants with gastrointestinal disorders and premature neonates world-
wide.
36
The survival rate of neonates born in the United States with gastroschisis is
approximately 90% to 97%.
7,8
By comparison, mortality rates in poorly resourced
countries vary between 40%and 100%depending on surgical and medical treatments
including the availability of PN.
3,5
Despite benefits, PN does not come without compli-
cations. Whereas some of these complications are transient with recovery, others are
associated with an increased risk of morbidity and mortality, specifically parenteral
nutritionassociated liver disease (PNALD) and central lineassociated bloodstreamin-
fections (CLABSIs) (Fig. 1).
2
The purpose of this review is to summarize some of the
commonly encountered complications associated with PN in the neonatal population.
METABOLIC COMPLICATIONS
Lipid Intolerance
Lipid emulsions provide long-chain polyunsaturated fatty acids (LC-PUFAs), which are
important for a multitude of reasons; they maintain the integrity of the cell membrane
and serve as precursors to eicosanoids and prostanoids (Fig. 2).
9,10
The United States
Food and Drug Administration (FDA)-approved and most frequently prescribed intra-
venous lipid product in the United States, Intralipid
20% (Frensenius Kabi, Uppsala,

Sweden), is derived entirely from soybean oil (SO), which mainly contains omega-6
fatty acids. SO contains the essential LC-PUFAs, linoleic and a-linolenic acid, but
lacks the downstream products, arachidonic acid (ARA), eicosapentaenoic acid
(EPA), and docosahexaenoic acid (DHA), which are important for cerebral and retinal
Box 1
Neonatal populations at high risk for complications secondary to parenteral nutrition (PN)
Premature neonates
Feeding intolerance
Necrotizing enterocolitis
Abdominal wall defects
Gastroschisis and omphalocele
Motility disorders
Hirschsprung disease and total aganglionosis
Intestinal obstructions
Atresia
Pseudo-obstruction
Malabsorption
Surgical short bowel syndrome (ie, necrotizing enterocolitis)
Enterocyte disorders (ie, tufting disorders and microvillus inclusion disease)
Neonates with poor intestinal perfusion
Cyanotic congenital heart disease
Other congenital disorders
Congenital diaphragmatic hernia
Calkins et al 332
Fig. 1. Common complications and benefits associated with parenteral nutrition (PN).
CLABSIs, central lineassociated bloodstream infections; PNALD, parenteral nutritionassoci-
ated liver disease.
Fig. 2. Omega-3 and omega-6 fatty acids and their functions. CNS, central nervous system.
Complications of Parenteral Nutrition in Neonates 333
development as well as the immune system (see Fig. 2, Table 1). Owing to increased
demand, immature metabolic machinery, and limited stores, it is not surprising that pre-
mature neonates and children dependent on parenteral nutrition for a prolonged period
are prone to developing omega-6 and omega-3 PUFA deficiencies, which are linked to
morbidities such as chronic lung disease and neurodevelopmental impairment.
9,11
While parenteral lipids serve as an important source of calories, improve metabolic
efficiency, and prevent essential fatty acid deficiencies, they can exacerbate or cause
hypertriglyceridemia and/or hyperglycemia. Particularly in the face of sepsis, lipids
may impair insulin sensitivity and increase gluconeogenesis, and result in lipid and
glucose intolerance.
12
The long-term risks of serum hypertriglyceridemia, unlike those
for hyperglycemia or hypoglycemia, are unknown.
1315
The temporary withholding or
long-term restriction of lipids also remains controversial.
9,16,17
At the same time, the
benefit of providing early and high-dose parenteral lipids shortly after birth is unclear.
In 2 meta-analyses, this strategy alone did not appear to decrease common neonatal
morbidities.
18,19
However, the prescription of 2 to 3 g/kg/d of parenteral lipids in com-
bination with approximately 2.5 to 3.5 g/kg/d of amino acids at birth may facilitate
growth by improving nitrogen balance and anabolism.
20
Glucose Intolerance
Parenteral glucose infusions, particularly when prescribed at high glucose infusion
rates, can result in abnormal serum glucose concentrations. After birth, the incidence
of hyperglycemia in the very low birth weight (VLBW) population is inversely propor-
tional to gestational age and birth weight, and can approach an incidence rate of
75%.
1315
Hyperglycemia and hypoglycemia are associated with increased neonatal
morbidity and mortality.
1315
In the NIRTURE (Neonatal Insulin Replacement Therapy
in Europe) study, a multisite, double-blind randomized controlled trial, insulin therapy
in the first week of life in VLBW neonates was reported to improve glycemic control
and decrease weight loss.
21
However, subjects who received insulin were more likely
to become hypoglycemic, die at 28 days of life, and develop ventricular hemorrhage or
periventricular lesions in comparison with controls.
21
Interestingly, in a study of neo-
nates with a mean gestational age of 24 weeks, a 60% reduction in the parenteral
glucose infusion rate fromapproximately 8.4 to 3.4 mg/kg/min reduced serumglucose
Table 1
Composition of three different intravenous lipid emulsions
Intralipid
Omegaven
SMOF
Vitamin E (mg/L) 38 250 47.6

Phytosterols (mg/L) 343 0 48
Oil Source
Soybean oil (%) 100 0 30
Fish oil (%) 0 100 15
Coconut oil (%) 0 0 30
Olive oil (%) 0 0 25
Fat Composition
Linoleic acid (g/100 mL) 5 0.10.7 2.85
Arachidonic acid (g/100 mL) 0 0.10.4 0.05
a-Linolenic acid (g/100 mL) 0.9 <0.2 0.275
Eicosapentaenoic acid (g/100 mL) 0 1.282.82 0.25
Docosahexaenoic acid (g/100 mL) 0 1.443.09 0.05
Calkins et al 334
concentrations by 30% without an increased incidence of serum hypoglycemia or
change in hepatic gluconeogenesis.
22
In order to combat hyperglycemia, the early
introduction of parenteral amino acids has been shown to decrease the risk for hyper-
glycemia by stimulating endogenous insulin production.
2327
Amino AcidRelated Complications
In a double-blind, randomized controlled study by Blanco and colleagues,
25
extremely low birth weight (ELBW, birth weight <1 kg) neonates were assigned to
1 of 2 interventions: early and high-dose amino acids in the form of Aminosyn PF
(Abbott Laboratories, Chicago, IL) or a control dose. The early and high-dose group
was prescribed a target goal of approximately 4 g/kg/d by day of life 3, whereas
the control groups amino acids were advanced to approximately 3 g/kg/d in the first
couple of days of life. In comparison with the control group, the early and high-dose
group exhibited decreased growth during follow-up. Whereas neurodevelopmental
scores at 18 months postmenstrual age were decreased in the interventional group
when compared with controls, at 24 months the cognitive scores were similar
between the 2 arms. Of notable concern was the negative correlation discovered be-
tween various plasma amino acid concentrations and growth and Mental Develop-
mental Index (MDI).
28,29
It remains unclear as to whether this finding is secondary
to the target dose of 4 g/kg/d, with 3 g/kg/d or less in the first few days of life being
more appropriate, specific outliers, and/or the specific amino acid formulation. Never-
theless, other studies have not replicated these results and have actually demon-
strated the converse. Once a protein and energy deficit occurs, it is difficult to
make up. Appropriate provisions of protein and energy promote lean body mass
and linear growthwhich may be just as important (if not more) as body weight.
24,30,31
As expected, concentrations of serum blood urea nitrogen (BUN) and, in some sub-
jects, serum ammonia, increased in the early and high-dose amino acid group in com-
parison with the control group in the aforementioned study by Blanco and
colleagues.
20,25,28,29,31
As with hypertriglyceridemia, it remains debatable as to what
constitutes a clinically significant state of uremia. What is an appropriate aminogram
for VLBW infants, and when parenteral protein should be decreased considering the
implications of a protein deficit, also remain questionable.
20,25,27
Higher BUN concen-
trations are to be expected when clinicians prescribe amino acids at a higher dose
immediately after birth, and in most cases reflect amino acid oxidation and protein
turnover, not toxicity.
Summary
Although the early introduction of parenteral amino acids and lipids after birth may be
associated with transient metabolic complications, numerous studies have demon-
strated that PN and continued refinements in PN care have resulted in improved
growth and long-term neurodevelopment that have far-researching benefits beyond
the NICU.
4,6,24,26,32
Although significant gains have been made, one should remember
that neonates, both pretermand term, who depend on PNin the NICU, still have a high
rate of growth failure that persists even after hospital discharge.
33,34
PARENTERAL NUTRITIONASSOCIATED LIVER DISEASE
Although PN is life-sustaining, it is associated with PNALD, which carries high
morbidity and mortality in the pediatric population.
2
PNALD, a heterogeneous liver
injury consisting of cholestasis, steatosis, fibrosis, and even cirrhosis, is characteris-
tically defined as the development of persistent, direct hyperbilirubinemia when other
causes of liver disease are excluded in patients who have received prolonged courses
of PN. As serum direct bilirubin rises, mortality and the need for a small bowel or com-
bined small bowelliver transplant increases.
1,35
While liver biopsy is considered the
gold standard for PNALD diagnosis, this type of invasive surveillance carries risks
related to bleeding and anesthesia. As a result, clinicians routinely rely upon laboratory
evaluations, specifically serum direct bilirubin concentrations and liver function tests,
to monitor PNALD. However, it is well recognized that histological injury begins soon
after PN initiation and does not correlate with bilirubin concentrations. In fact, biliiru-
bins can be normal in the presence of severe histological damage.
36
PNALD risk factors can broadly be characterized as either patient-related or
PN-related (Box 2). PNALD patient-related risk factors mainly center around the
percentage of calories a patient tolerates enterally versus parenterally, which in
turn depends on the patients gastrointestinal function and anatomy, such as
length of small-bowel remnant, gastrocolonic continuity, and presence of an ileo-
cecal value. By contemporary analyses, approximately 25% of neonates with
gastrointestinal disorders will develop PNALD.
37
The incidence and likelihood of
Box 2
Common risk factors for parenteral nutritionassociated liver disease (PNALD)
Patient-Related
Prematurity
SGA/IUGR
Gastrointestinal disorder
Lack of enteral feeds
Gastrointestinal surgeries, function, and anatomy
Bowel length
Presence of ileum, ileocecal valve, and colon
Intestinal continuity
Infections
PN-Related
Prolonged PN duration
CLABSIs
Phytosterols
Type of polyunsaturated fatty acid
Presence of antioxidants
Excess or deficiency of macronutrients or micronutrients
Carbohydrates
Amino acids
Fat
Copper
Abbreviations: CLABSIs, central lineassociated bloodstream infections; IUGR, intrauterine
growth restriction; SGA, small for gestational age.
Calkins et al 336
developing PNALD vary by specific gastrointestinal diagnosis and report.
1,37,38
Moreover, PNALD incidence increases significantly when a congenital gastrointes-
tinal diagnosis is complicated by any stage of necrotizing enterocolitis.
1,3741
For
children who develop short bowel syndrome (SBS), 67% will develop PNALD
and 17% will progress to end-stage liver failure.
42
In addition, prematurity, birth
weight, infections, and perhaps an individuals genetic makeup appear to be
important drivers for PNALD.
1,41
The odds ratio for developing cholestasis among
neonates with a birth weight of less than 750 g is 13.1, whereas for a neonate with
a birth weight between 1 and 1.5 kg this decreases to 2.8.
1
In one study, despite
receiving fewer PN days, small for gestational age neonates, in a comparison with
appropriate for gestational age controls, had an odds ratio of 3.3 for developing
cholestasis.
41
Intravenous Fatty Acid Emulsions and IFALD
Recent studies have demonstrated that the dose and composition of intravenous fatty
acid emulsions may play an important role in the development and progression of
PNALD.
16,17,39,40,43,44
SO has been traditionally prescribed at an approximate dose
of 0.5 to 4 g/kg/d. The American Academy of Pediatrics recommends a maximum
dose of 3 g/kg/d of intravenous lipids. An intravenous lipid emulsion composed
entirely of fish oil (FO), commercially available as Omegaven
10% (Fresenius Kabi,

Hamburg, Germany), is composed mainly of the omega-3 fatty acids EPA and DHA
(see Table 1). FO is not currently FDA-approved but is available outside the United
States, and is prescribed at 1 g/kg/d. Studies have provided evidence that when
1 g/kg/d of exclusive FO is substituted for SO, direct hyperbilirubinemia is more likely
to resolve, and the incidences of death and transplant may be reduced.
4446
European
studies have also demonstrated that mixed fatty acid emulsions, such as SMOF
(Fresenius Kabi, Hamburg, Germany), which contain soybean, fish, olive, and coconut
oils, are associated with improved liver function, decreased markers of inflammation
and oxidative injury, and increased antioxidant activity (see Table 1).
4750
Whereas
FO and products containing FO appear to biochemically reverse PNALD, their effect
on histology, which is equally (if not more) important, remains unknown.
36
There is also evidence that the incidence and progression of PNALD can be modified
by decreasing the SO dose alone.
16,40,51
When compared with a historical cohort who
received the standard SOdose, surgical neonates with cholestasis who received 1 g/kg
of SOtwice a week had an increased incidence of cholestasis resolution (42%vs 10%).
However, 8 of 13 neonates developed a triene:tetraene ratio of greater than 0.05 but
less than 0.2, and without physical manifestations of an essential fatty acid defi-
ciency.
16
Traditionally an essential fatty acid deficiency has been defined as a triene:
tetraene ratio of greater than 0.2.
In a retrospective study of 214 neonates by Sanchez and colleagues
51
and a ran-
domized controlled pilot study of 28 subjects by Rollins and colleagues,
40
lipid sparing
appeared to prevent and slow down the onset of cholestasis. By contrast, in a much
smaller retrospective review by Nehra and colleagues,
52
neonates with gastrointestinal
disorders who received 1 g/kg/d of SO had a similar incidence of cholestasis when
compared with neonates who received 2 to 3 g/kg/d of SO. Of note, there was a trend
toward an increased rate of change in direct bilirubin in the 2 to 3 g/kg/d group
compared with the 1 g/kg/d group, which did not reach statistical significance (P 5.05).
All published studies investigating the efficacy and safety of SO sparing (1 vs
23 g/kg/d) for cholestasis prevention or treatment, with the exception of one small,
randomized controlled pilot trial by Rollins and colleagues,
40
are single-center retro-
spective or uncontrolled prospective investigations.
16,5153
As a result, methodological
issues in study design and confounding variables, specifically advances in neonatal
and nutritional care, have led to conflicting results.
16,5153
Likewise, all FOstudies have been performed at one institution and most have relied
upon historical controls.
4446
In a small randomized, controlled study of 19 neonates of
less than 3 months of age, there was no difference in the incidence of cholestasis and
maximum serum direct bilirubin concentrations between the FO and SO groups. Inter-
estingly one subject in each group crossed over to the other study arm because of a
serum direct hyperbilirubinemia. The study was stopped early because of the unex-
pected low incidence of PNALD and concerns for futility.
39
One concern with lipid minimization is the decreased energy intake from fat and the
risk for a deficiency of essential fatty acids. Postnatal growth restriction and necro-
tizing enterocolitis in the premature population are inversely related to gestational
age and directly linked to poor neurodevelopment.
34
Neonates with congenital gastro-
intestinal disorders are also at risk for long-term suboptimal growth and neurodevel-
opment.
54
To compensate for decreased calories many clinicians increase glucose
infusion rates, which may promote cholestasis and steatosis. Although most lipid-
sparing studies with either FO or SO have not demonstrated an increase in growth
failure, these studies are not designed to examine such an outcome. Studies on
long-term growth and development are clearly lacking.
16,39,40,45,46,51
Advantages to
mixed lipid emulsions such as SMOF
are that they contain omega-3 fatty acids,

can be dosed at 2 to 3 g/kg/d, and may better facilitate growth (see Table 1).
With regard to a deficiency of essential fatty acids, it does not seem likely that ne-
onates receiving 1 g/kg/d and upward of FO or SO will develop a biochemical defi-
ciency of essential fatty acids as measured by a serum triene:tetraene
ratio.
10,16,45,46
However, deficiencies of specific fatty acids with lipid sparing and
even toxicities with FO and SO may be possible, and may have unknown short-
term and long-term consequences.
11
Neonates, such as VLBWs and neonates with congenital gastrointestinal disorders
who develop SBS, may possibly reap the most benefit from the potential hepatopro-
tective properties of lipid sparing or alternative lipid emulsions. However, one must
also remember that these same infants are also at very high risk for nutritional defi-
ciencies and cognitive delays.
16,34,41
As a result, it remains unclear if the possible
benefit of lipid sparing (PNALD prevention and treatment) outweighs the possible risks
(poor growth and neurodevelopment) in these high-risk groups. While some risk fac-
tors that predict clear and definitive intestinal failure and advanced PNALD are present
at birth, many risk factors do not unfold until later in the patients hospital course, mak-
ing it difficult for clinicians to determine when to initiate FO or SO dose reduction (see
Box 2).
1,2,37,41,55
Complicating this dilemma even further, the required duration for
these therapies is unknown.
45
In summary, direct comparisons of FOversus SOand 1 g/kg/d versus 3 g/kg/d of SO
are complicated by the following: (1) published lipid-sparing studies have targeted
different populations; (2) primary outcomes aredifferent (cholestasis preventionvs treat-
ment); (3) investigations have used different doses and durations; and (4) issues with
trial design and sample size.
16,39,40,4446,5153,56
Considering the mounting evidence
that FO may prevent or delay the need for transplant, it may be unethical to conduct a
randomized controlled trial comparing FOwith SOat 1 g/kg/d in children with advanced
PNALDwho are at high risk for liver failure or who have liver failure.
1,35,4446
Considering
the importance of PNALD prevention, it would behoove the research community to
initiate well-powered, randomized, multisite, long-term studies, with or without a
factorial design, to determine whether lipid sparing (FO vs SO, each dosed at 1 g/kg/d,
and/or 1 g/kg/d vs 3 g/kg/d of SO) safely prevents cholestasis.
Calkins et al 338
Lipids, Phytosterols, and PNALD
Understanding the reasons why FO, SO dose reduction, and mixed lipid emulsions
may modify the incidence and progression of PNALD could provide important clues
to the etiology of this disease. Such clues may uncover targets for future preventive
strategies and therapeutics for PNALD. All 3 lipid strategies reduce the livers expo-
sure to phytosterols, which are known to interfere with bile acid transport, resulting
in biliary sludge: the hallmark of pediatric PNALD (Fig. 3).
43,5760
Phytosterols are
found in vegetable foods and include campesterol, stigmasterol, and sitosterol. SO
is made up of 43% cholesterol and 57% phytosterols. FO, by comparison, is made
up of cholesterol only.
61
There is linear correlation between PN duration and
increasing concentrations of serum phytosterols.
61
SO dose reduction and FO have
been associated with decreased serum phytosterols.
62
Approximately 5%to 10%of orally ingested phytosterols are absorbed by the intes-
tine while 90% to 95% are excreted in the feces by the enterocyte apical ABCG5/G8
transporter. However, intravenous fatty acids bypass this transporter and rely on the
canicular ABCG5/G8 transporter in the hepatocyte to secrete phytosterols into the
bile. Sitosterol inhibits cholesterol 7a-hydroxylase, the rate-limiting step that converts
cholesterol into bile acids, which plays an important role in lipid metabolism.
63
More-
over, stigmasterol antagonizes bile acid nuclear receptors, liver X receptor (LXR) and
farnesoid X receptor (FXR). FXR protects the liver from hepatotoxic bile acids by
reducing bile acid import via (1) suppression of the bile acid cotransporter (NTCP,
SLC10A1), (2) reduction of bile acid synthesis by suppressing CYP7A1, and (3)
enhancing bile acid efflux resulting from upregulation of the bile salt export pump
(BSEP) ABC11 and organic solute transporter (see Fig. 3). In animal models, FXR
knockouts develop liver injury, whereas treatment with FXR agonists protect against
the development of cholestasis.
64
In cell lines, stigmasterol antagonizes BSEP.
65
Moreover, mice infused with PN and FO exhibited less liver injury in comparison
with those infused with PN and SO. When stigmasterol was added to FO, these ani-
mals developed cholestasis.
43
Lastly, BSEP is developmentally regulated and is not
Fig. 3. Proposed etiology of parenteral nutritionassociated liver disease.
expressed or completely functional in the neonatal period, placing preterm neonates
at high risk for PNALD.
66
Lipids, Inflammation, Oxidant Injury, and PNALD
Bile acid transport is regulated not only by phytosterols but also inflammation (see
Fig. 3). Critically ill neonates are at high risk for systemic inflammation, specifically
bloodstream infections. The high mortality associated with long-term PN stems not
only from liver failure but also CLABSIs, which can result in multiorgan failure and
death.
2
Ninety percent of patients with intestinal resections develop cholestasis after
sepsis, and serum direct bilirubins increase considerably after sepsis.
55
Lipopolysac-
charides and cytokines alter the expression of specific bile acid transporters (BSEP
and NTCP), decreasing bile flow.
67,68
When liver macrophages were stimulated with
either stigmasterol, lipopolysaccharide, or placebo, cells subjected to stigmasterol
or lipopolysaccharide showed increased transcription of interleukin-6 (IL-6) and tumor
necrosis factor a (TNF-a).
43
In a large meta-analysis, lipid products that contained FO or higher concentrations
of omega-3 fatty acids were associated with a 25%reduction in infections (relative risk
0.75, 95% confidence interval 0.561.00). This finding may be the result of the immu-
nomodulatory properties of omega-3 fatty acids and antioxidants in these prepara-
tions or chance.
19
SO is composed mainly of omega-6 fatty acids, which produce a
cascade of proinflammatory bioactive compounds, and contains a small concentra-
tion of the antioxidant vitamin E. FO contains mainly anti-inflammatory omega-3 fatty
acids and a higher concentration of vitamin E (see Table 1). Lipid emulsions that pro-
vide a more appropriate omega-6:omega-3 fatty acid ratio and contain EPA and DHA
have been shown to decrease inflammatory mediators such as TNF-a, nuclear factor
kb, and IL-6, and increase proresolving lipid mediators, such as resolvins and protec-
tins.
57,58
In neonates and animals, FO and mixed emulsions increase the concentra-
tions of vitamins E and A and reduce lipid peroxidation, as measured by
F2-isoprostane and total antioxidant potential.
47,49,50,57,58,69
High omega-6:omega-3 fatty acid ratios also affect lipid metabolism by regulating
peroxisome proliferator-activated receptor (PPAR) and sterol regulatory element bind-
ing proteins (SREBPs).
57,70,71
PPAR regulates fatty acid storage, whereas SREBPs are
involved in cholesterol synthesis and fatty acid uptake. As fat accumulates in hepatic
cells, phagocytic dysfunction and impaired endotoxin clearance occurs, resulting in
hepatic injury. In fact, when rodents were provided with a high-carbohydrate, high-
fat diet, supplementation with EPA resulted in improved insulin sensitivity, increased
lipolysis, and decreased TNF-a and PPAR compared with animals who received a
similar diet without EPA.
72
LXR, which is regulated by phytosterols and inflammatory products, reduces pro-
duction of apolipoprotein E, resulting in impaired clearance of chylomicrons and
low-density lipoproteins.
73
In animal models, FXR agonists have been shown to be
hepatoprotective by decreasing apolipoprotein CIII, which inhibits hepatic uptake of
lipid-rich particles.
74
As a result, a lipid emulsion with a high omega-6:omega-3 fatty
acid ratio may alter lipid trafficking, thereby promoting steatosis, yet another histologic
feature of PNALD (see Fig. 3).
COST OF PN COMPLICATIONS
Considering that evidence-based and cost-effective medicine is essential to neonatal
practice, clinicians must remember that PN can come with a significant price. For
example, it is unknown whether the potential nutritional benefit of a short course of
Calkins et al 340
PN for a low birth weight neonate (birth weight <2 kg) outweighs the daily cost of PN,
which is approximately US $500. In one study, a NICU feeding protocol decreased PN
duration by approximately 5 days, in turn leading to a significant reduction in cost:
approximately $385,000 in hospital savings in 1 year.
75
PNis life-saving, but complications such as PNALDand CLABSIs cannot be ignored.
Once end-stage liver disease develops, the only remaining life-saving measure is com-
bined liver-intestinal transplant.
2
Indications for transplant, either intestine or combined
liver-intestine, include not only advanced PNALD, but also a history of repeated
CLABSIs, which can result in catheter removals and replacements and eventual loss
of vascular access. Five-year post-transplant survival is 50% to 70%, and the cost of
transplant is approximately $900,000 in the first year post-transplant and $375,000
each year thereafter.
2,45
After transplant, patients are still not free of complications
which include graft rejection and deadly infections and malignancies secondary to
immunosuppresion. With respect to CLABSIs, it is estimated that more than 2 million
nosocomial infections occur each year in the United States. Almost half of all deaths
in the NICU after 2 weeks of life are attributed to nosocomial infections, many related
to catheters, and increase the average NICU stay by a mean of 24 days.
76,77
SUMMARY
PN has revolutionized neonatology. However, potential long-term complications such
as PNALDand CLABSIs are life-threatening, pose an economic burden to society, and
profoundly affect the quality of lives of patients and their families. Research and
collaboration is warranted to: (1) optimize PNdelivery and composition to more closely
mimic placental nutrient supply and that of a healthy, breastfed term infant, (2) identify
biomarkers that reflect PN intolerance that are clinically relevant and predict the early
onset of adverse complications such as PNALD and CLABSIs, and (3) reduce the inci-
dence of PNALD and CLABSIs by improving current practices and developing new
preventive strategies and therapeutic modalities. Together, basic scientists and trans-
lational and clinical researchers, along with clinicians and families, can improve PN
care to enhance the health of all children.
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day of life, at high-risk of developing parenteral nutrition-associated liver dis-
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Mi cronutri ent
Requi rements of Hi gh- Ri sk
I nfants
Steven A. Abrams, MD
a,
*, Keli M. Hawthorne, MS, RD
a
,
Jennifer L. Placencia, PharmD
b
, Kimberly L. Dinh, PharmD
b
INTRODUCTION: NATURE OF THE PROBLEM
What Are the Critical Micronutrients to Be Considered and Why?
The termmicronutrient, as used in the context of infant nutrition, refers generally to any
vitamin or mineral that is required for tissue growth and development as well as cellular
or tissue function. This reviewfocuses on the primary bone minerals, along with iron and
zinc (Zn). The discussion of iron is limited to consideration of intravenous (IV) protocols
for use, and the discussion of Zn is primarily limited to the problem of Zn shortages.
Sources of Financial Support: This work is a publication of the US Department of Agriculture
(USDA)/Agricultural Research Service (ARS) Childrens Nutrition Research Center, Department of
Pediatrics, Baylor College of Medicine, and Texas Childrens Hospital, Houston, Texas. Contents
of this publication do not necessarily reflect the views or policies of the USDA, nor does mention
of trade names, commercial products, or organizations imply endorsement by the US government.
Conflicts of Interest: None.
a
US Department of Agriculture/Agriculture ResearchService, Department of Pediatrics, Childrens
NutritionResearchCenter, Texas Childrens Hospital, Baylor Collegeof Medicine, 1100Bates Street,
#7074, Houston, TX 77030, USA;
b
US Department of Agriculture/Agriculture Research Service,
Department of Pediatrics, Childrens Nutrition Research Center, Texas Childrens Hospital, Baylor
College of Medicine, 6621 Fannin Street WB1120, Houston, TX 77030, USA
KEYWORDS
Micronutrients

Premature infants

Nutrient shortages

Intravenous nutrition
Calcium
KEY POINTS
Preterm infants have unique and high requirements for bone minerals, including calcium,
phosphorus, and magnesium.
Guidelines for intravenous administration of these minerals emphasize preventing serum
abnormalities such as a low or high ionized calcium or total phosphorus.
A substantial issue, not yet fully resolved, is the ongoing shortage of minerals for intrave-
nous use, requiring complex decision making to achieve the best and safest use of these
minerals in high-risk infants.
Populations to Be Evaluated
Although the need for these minerals encompasses many groups of high-risk infants,
the focus in this article is on 2 groups in particular: infants with intestinal failure, espe-
cially those with problems related to anatomic or functional short gut syndrome, and
those who are very low birth weight (VLBW), less than 1500 g at birth. Both oral and IV
requirements and provision of these micronutrients are considered, but much of the
focus is on IV requirements and dosing.
Organization
The bone minerals, calcium(Ca), magnesium(Mg), and phosphorus (P) are considered
together, followed by aspects of parenteral requirements for Zn and iron. Included also
is a discussion related to nutrient shortages, especially for IV mineral components.
BONE MINERALS: CA, MG, AND P
Ca
One of the most important reasons for providing IV nutrition to high-risk neonates is to
provide the bone minerals consisting primarily of Ca, Mg, and P. These nutrients also
serve important physiologic functions, which can be critical in the neonatal period. The
tools for assessing bone mineral status in the first week of life are minimal and do not
fully reflect physiologic functioning.
The most difficult mineral to assess is Ca. For decades, total serumCa was measured,
and some attempted to adjust values for serum albumin. This approach was limited in
usefulness at best and led to overly aggressive therapy at times in small infants. More
recently, direct measurement of ionized Ca (iCa) has become widely available and
used to assess status, but this does not change the fundamental problem that there
are few clear data regarding either optimal or safe ranges for iCa in high-risk newborns.
Clinically, it is apparent that very preterm infants tolerate a lower iCa than full-term
infants. It is common for a VLBWinfant to have an iCa of 0.8 mmol/L without symptoms,
whereas a larger infant would likely have neurologic compromise fromthis level of iCa.
We initiate IV Ca in the first hours of life in high-risk neonates whenever they are be-
ing provided with total parenteral nutrition (TPN). At our institution, this group includes
VLBW infants, those with abdominal wall or similar abdominal defects, those with
major congenital heart disease, and those with congenital diaphragmatic hernia. We
provide 1 mmol/100 mL of Ca as part of TPN in a premixed starter TPN solution, which
is usually provided at 80 to 100 mL/kg/d. This solution is available throughout the eve-
ning at our neonatal intensive care unit (NICU). P (see later discussion) is begun by
24 hours of age, usually at a 1:1 M ratio with Ca. Stability for standard starter TPN
is 30 days when stored at 2
C to 8
C. However, sterility is the limiting factor to remain

compliant with US Pharmacopeia (USP)-797 standards. USP-797 recommends a
9-day beyond-use date for medium-risk level sterile products.
Advancing to an intake level of 1 mmol/100 mL of Ca is dependent on maintaining
an appropriate iCa. Our target range is 0.8 to 1.45 mEq/L in VLBW infants and 1.0 to
1.45 mEq/L in larger infants. Our goal is to reach 1.75 mmol/L administered at a vol-
ume of 130 mL/kg/d. At times, we advance to 2.0 mmol/L as well.
We consider the algorithm shown in Table 1 for management of hypercalcemia in
the first week of life in high-risk infants, especially those less than 1000 g birth weight.
P
Serum P is a reasonably accurate marker in early life of P status. However, there are
rapid changes that occur even in healthy infants in the first week of life. Initial levels are
Abrams et al 348
often increased and then decline over time. It can be difficult related to IV nutrition to
provide appropriate levels of P via TPN and monitor it in the first weeks of life.
Nonetheless, it has increasingly become common to provide P earlier than was
practiced in the past to VLBW and other high-risk infants. We now routinely add P
to TPN by 24 hours of life and often before that. This strategy is because of our expe-
rience that this is safe and the possibility that a high Ca/P ratio leads to hypercalcemia,
which is difficult to manage, especially in infants less than 1000 g birth weight.
Our practice is to add 1 mmol/L of P in TPNby 24 hours of age to keep the Ca/P ratio
at 1:1 on a molar basis or about 1.3:1 on an mg/mg basis. In the first days of life, it is
more common to have a low serum P of less than 3 to 4 mmol/L than a high one of
more than 8 to 9 mmol/L. In general, it is difficult or impossible to directly attribute
physical findings or other outcomes directly to the level of serum P in infants receiving
TPN. We discourage frequent manipulations of the Ca/P ratio in attempts to correct
minor changes in the level, unless it is persistently low or high, with general guidelines
as provided earlier related to Ca. We recommend monitoring serumP at 24 to 48 hours
of life and then every 2 to 3 days until feeding is primarily enteral.
Mg
In the first week of life, neonatologists are challenged to manage IV Mg therapy in
VLBW infants because of the prenatal use of IV Mg in many women in preterm labor.
Commonly, only a short maternal prenatal course of Mg is given, with little effect on the
infants Mg status, even when delivery occurs shortly after the maternal therapy. Our
routine is to provide 0.5 mEq/L of Mg in TPN provided to infants after the first hours of
life. There is no evidence to support routinely assessing serum Mg in high-risk new-
borns, although it is common to do so when the mother has received more than 24
to 48 hours of IV Mg within a short time of delivery.
Serum Mg levels can be low (<1.6 mEq/mL) or high (>3.0 mEq/L) in high-risk neo-
nates receiving TPN. In general, low Mg levels are associated with fluid restriction
and limited Mg intake. A renal wasting disorder is uncommon. Increasing the Mg con-
centration over a fewdays usually resolves hypomagnesemia. Aggressive intervention
including Mg boluses over 1 to 2 hours are mostly reserved for infants with serum Mg
levels less than 1.2 mEq/L, although there are no evidence-based guidelines for this.
Table 1
Management of hypercalcemia according to iCa level in high-risk infants
iCa Level Strategy for Action
1.301.45 Recheck in 24 h
Ensure that P is being provided at a (molar) ratio of 1:11.3:1
No change in IV infusion of Ca
Decrease Ca infusion by 20%
Maintain P infusion if serum P is 48 mg/dL
Increase P infusion if serum P is <4 mg/dL
May decrease P infusion if serum P is >8 mg/dL
Decrease Ca infusion by 50%80%
Same guidelines for P as for iCa of 1.461.6
>1.8 Recheck in 812 h
Stop Ca infusion
Same guidelines for P as for iCa of 1.461.6
Concerns about hypermagnesemia are more common than hypomagnesemia. We
are cautious about removing Mg from TPN unless the serum Mg level is greater than
3.9 mEq/L. This caution is because symptoms are generally uncommon at serum
values of 3 to 4 mEq/L, and the risk of having it omitted from TPN for an extended
period and hypomagnesemia are of concern. Others hold the Mg from the TPN when-
ever the level is greater than 2.9 mEq/L. Usually, if Mg is omitted from TPN, serum
levels should be drawn at least every other day and it should be readded when the
level is less than 3.0 to 3.5 mEq/L.
ENTERAL REQUIREMENTS: OVERVIEW
The need for bone minerals to achieve adequate bone mineralization is a critical issue
in high-risk neonates. This category includes VLBW infants but also other high-risk
groups such as infants with intestinal failure. The role of bone minerals in the neonatal
period is largely after the transition to oral feeds to prevent bone loss, especially clin-
ical rickets. This topic has been covered in a recent statement by the American Acad-
emy of Pediatrics (AAP).
1
Highlights of this statement with some additional comments
are provided in this review.
Box 1 lists factors that put preterm infants at risk for rickets. Key points are the crit-
ical role of nutrient intake restriction, which can occur as a result of conditions such as
bronchopulmonary dysplasia. Medication use can also be important, with steroid use
over a long period being a critical factor.
It is generally accepted that the primary problemleading to rickets in preterminfants
is inadequate Ca and P intake. Achieving the in utero accretion rate of Ca of about
120 mg/kg/d is challenging, as shown in Table 2. In the United States, use of high min-
eralcontaining human milk fortifiers or specialized formulas is a key aspect of man-
agement (Table 3). Transitional formulas are generally used at or near the time of
discharge.
The role of vitamin D in this process is a complex issue, which is beyond the scope
of this review. However, as shown in Tables 3 and 4, vitamin D should be provided
to these infants. There is no evidence to support routine assessment of serum
25-hydroxyvitamin D levels in otherwise healthy preterm infants or for routine high-
dose vitamin D supplementation.
RECOMMENDATIONS FOR DIETARY INTAKE
There are differences amongst groups in recommendations for the enteral intake
of the bone minerals (see Table 4). The AAP report
1
provides recommendations
Box 1
High-risk criteria for rickets in preterm infants
Born at less than 27 weeks gestation
Birth weight less than 1000 g
Long-term parenteral nutrition (eg, >45 weeks)
Severe bronchopulmonary dysplasia with use of loop diuretics (eg, furosemide) and fluid
restriction
Long-term steroid use
History of necrotizing enterocolitis
Failure to tolerate formulas or human milk fortifiers with high mineral content
Abrams et al 350
consistent with current usual practice in the United States. Recommendations from
Europe generally endorse lower amounts of Ca and P and higher vitamin D intakes.
The safety and role of high-dose vitamin D intake, especially in infants less than
1500 g is undetermined.
Iron
The use of IV iron is uncommon in otherwise healthy preterm infants. It is more
commonly considered for infants who are expected to have minimal enteral nutrition
for more than 6 weeks. Previous concerns about the risk of anaphylactic reaction to
the carrier have been decreased because of newer forms of these products (Table 5).
Multiple formulations of parenteral iron exist. If an alternative product must be used
because of a back order, close attention must be paid to the specific product when
ordering and administering. The incorrect selection or substitution of 1 formulation
for another may result in overdosing or underdosing or serious adverse reactions if
the dose or administration process is not adjusted.
Protocols for administration of IV iron are not widely available. Box 2, shows our
clinical protocol. Before administering IV iron, we always check serum ferritin levels.
Although there are no fixed standards for an increased ferritin level, we do not usually
administer IV iron if the ferritin level is markedly increased.
Parenteral iron can be administered IV or intramuscularly. Intramuscular iron dextran
use in neonates may be associated with an increased incidence of gram-negative
sepsis.
Table 2
Approximate Ca balance in a typical infant receiving 120 kcal/kg/per day intake
Ca Concentration
(mg/dL)
Intake
(mg/kg/d) Absorption (%)
Total
Absorption
(mg/kg/d)
Approximate
Retention
(mg/kg/d)
Human
milk
a
25 38 60 25 1520
Preterm formula
or fortified
human milk
145 220 5060 120130 100120
a
Human milk assumed to be 67 kcal/dL, and pretermformula and fortified human milk assumed to
be 81 kcal/dL.
Table 3
Intakes of Ca, P, and vitamin D from various enteral nutrition feedings at 160 mL/kg/d used in
the United States
Unfortified
Human Milk
a
(67 kcal/dL)
Fortified
Human Milk
a
(81 kcal/dL)
Preterm Formula
(81 kcal/dL)
Transitional
Formula (74 kcal/dL)
Ca (mg/kg) 37 184218 210234 125144
P (mg/kg) 21 102125 107130 7480
Vitamin D (IU/d)
b
2.4 283379 290468 125127
a
Human milk data based on mature human milk.
b
Based on an infant weighing 1500 g.
DRUG SHORTAGES IN THE UNITED STATES
According to data provided by the Drug Information Services at the University of Utah
in 2010, an average of 117 new shortages had been identified annually since 2001 in
the United States; however, the number of shortages has met a sharp increase in the
past 3 years, with 211 new shortages in 2010 and a record 267 newshortages in 2011.
Between January 1, 2012 and December 31, 2012, a total of 204 new drug shortages
were identified, down from267 in 2011. Although 2012 was the first time in 5 years that
a decrease in new drug shortages was seen, the number of active and ongoing short-
ages was still at an all-time high with 299 active drug shortages as of December 31,
2012.
5
Tables 6 and 7 describe the reasons that drug back orders have become a public
health and patient care issue.
There are several factors that contribute to a national drug shortage. These factors
can occur at any point along the supply chain, including sources of raw material, man-
ufacturers, regulators, wholesalers or distributers, prime vendors, group purchasing
organizations, and end-user health care systems. It is important to understand why
each drug shortage occurs to effectively manage the shortage.
On July 9, 2012, in an attempt to remedy some of these causes, President Obama
signed into law legislation that gave the US Food and Drug Administration (FDA) new
authority to combat drug shortages as well as impose new requirements on manufac-
turers. The FDA Safety and Innovation Act established an early notification require-
ment for manufacturers of drugs that are life supporting, life sustaining, or treat a
debilitating disease when it discontinues a product or experiences a production
interruption.
7
Table 4
Recommendations for enteral nutrition for VLBW infants
Ca (mg/kg/d) P (mg/kg/d) Vitamin D (IU/d)
Tsang et al,
2
2005 100220 60140 150400
a
Klein,
3
2002 150200 100130 135338
b
Agostoni,
4
2010
c
120140 6590 8001000
AAP Clinical Report
1
150220 75140 200400
a
Text says aim to deliver 400 IU/daily.
b
90125 IU/kg (total amount shown is for 1.5-kg infant).
c
Reflects European recommendations.
Table 5
Injectable iron formulations
Components
Test Dose
Needed Concerns
High-molecular-weight
(HMW) iron dextran
(Dexferrum, Lutipold
Pharmaceuticals, Shirley, NY)
Yes Black box warning: fatal anaphylactic reactions
may occur
Adverse event risk is reported to be higher with
the HMW iron dextran formulation
Low-molecular-weight iron
dextran (INFeD, Actavis, Inc.,
Parsippany, NJ)
Yes Black box warning: fatal anaphylactic reactions
may occur (risk lower than with HMW
formulation)
Iron sucrose (Venofer, American
Regent, Inc., Shirley, NY)
No
Abrams et al 352
National Shortage of Ca
Ca gluconate and Ca chloride are the only Ca salts available in the United States for IV
administration. Ca gluconate is the Ca salt of choice in most NICUs. It is compatible
with TPN and has a lower potential for extravasations compared with Ca chloride. In
early 2011, the FDA issued a drug shortage for Ca chloride as a result of suspended
distribution and manufacturing delays fromseveral manufacturers. A national shortage
of Ca gluconate soon followed as a result of the increaseddemandfor the only available
IV Ca alternative. Selected parenteral Ca preparations are listed in Table 8. Using
different manufacturers and vial sizes may temporarily alleviate the shortage until an
increased drug supply is made available.
Box 2
Sample protocol for iron dextran administration to TPN-dependent infants
Order anaphylaxis medications (diphenhydramine, hydrocortisone, and epinephrine) to
bedside to be administered only per physicians orders; physician must be present during test
dose administration
Day 1: test dose: 0.2 mg IV once over 5 minutes
Day 2 of test dose: give iron dextran 0.5 mg IV once over 5 minutes
Day 3 of test dose: give iron dextran 0.8 mg IV once over 5 minutes
Monitor blood pressure during and after administration
Then start: iron dextran 1 mg IV every Monday, Wednesday, and Friday
Table 6
Impact of drug shortages
Higher drug
acquisition cost
Need to purchase more expensive therapeutic substitutions
Purchasing back-ordered products from alternative suppliers who
charge 101000 times the original price
6
Increased personal
costs
Additional labor is required to manage back orders: keeping close
inventory counts and comparing with usage patterns, researching
alternatives, collaborating with physicians about alternatives/
guidelines for use, making operational changes for alternative
products (changes in database, labeling, and dilutions), and educating
pharmacy employees, prescribers, and nursing about changes
Safety issues Worsened clinical outcomes: there may be no alternative agent
available, causing delays in medication procedures/therapies, or the
alternative agent may not be so effective or may have a worse side
effect profile
Medication errors: substitution of different concentrations, resulting in
an overdose/underdose, use of alternative drug products with
different dosing, dilutions, and administration practices increases the
error potential (especially in emergent situations)
Lack of adherence
to clinical trial
protocols
A back order of a drug used in a clinical trial may result in delay in
patient enrollment
Deviation from a trial protocol may occur when alternative products are
used; this may cause the results of the trial to be questioned when
analyzed
Loss of trust
between health
care professionals
Shortages can occur with no warning, requiring pharmacies to make
abrupt changes; this may give the impression that pharmacy is not
keeping good track of their stock and cause loss of trust
Shortages are frustrating for everyone involved
Table 7
Factors contributing to national drug shortages
Limited raw or
bulk material
80% of raw materials used in pharmaceuticals originate from outside the
United States.
6
Factors that can decrease the supply of the raw materials
involve: political problems that disrupt trade, animal diseases
contaminating the source of the raw product, environmental conditions
limiting availability of drug product supplies, or raw materials being
contaminated during the acquisition process
Regulatory
issues
Manufacturing plants are monitored by the FDA to assess compliance with
current good manufacturing practices. If a company is found to be
noncompliant, correcting these issues is usually a lengthy and costly
process, leading some companies to close a specific manufacturing facility,
resulting in drug product shortages, especially if they are the sole producer
Voluntary
recalls
Voluntary recalls are usually related to an isolated manufacturing problem,
such as lack of assurance of safety of specific lots, and are usually temporary
situations. These problems can be safety related (eg, inability to assure ster-
ility, possible glass particulates) or technical issues (eg, labeling, packaging)
Change in
product
formulation
When products have to be reformulated because of regulations (eg,
changing propellants in inhalers) or change in the raw product (eg,
changing from pseudoephedrine to phenylephrine), a shortage usually
results because of the transition time
Change in
manufacturer
Sometimes companies take over production of products that were being
made by other companies. A shortage may result because of the lag in
start of production by the new company compared with the halting of
production by the old company
Business
decisions
Drug manufacturers are businesses and make decisions based on financial
return. If the financial return of producing a medication decreases, a
company may decide to stop production of that medication, causing an
acute shortage
Moving
production
locations
Many manufacturers have numerous production plants across the country.
Sometimes, the decision is made to move production of one product to
another plant, which causes a delay in production and therefore, a
temporary shortage
Inventory
management
strategies
Companies at various points of the supply chain use a just-in-time inventory
management strategy. This strategy improves a businesss return on
investment by decreasing inventory on hand and the carrying costs
associated with that inventory. One problem at any point along the supply
chain can result in a short-term shortage. Rural hospitals that cannot
borrow medications or that are far from their wholesaler are even more
affected by these types of problems
Acute changes
in usage
patterns
Production of medications is usually based on sales fromprevious quarters or
years. If there is an unexpected increase in demand for a product, the
manufacturer depletes their stock sooner than anticipated. This situation
can occur when usage spikes because of a new indication being approved
or when new medication recommendations are made by governing
organizations
Alternative
sources of
medications
The national back orders have caused an increase in the amount of
alternative distributors. These are companies that obtain medications for
the purpose of reselling them at a higher price to hospitals in need of the
medication. Obtaining medications from these companies is also
worrisome, because you cannot confirm that proper storage conditions
were followed during the chain of custody
Compounding pharmacies often try to produce the medications that are in
short supply. However, medications from these companies may not meet
standards for aseptic techniques or labeling requirements
Natural
disasters
Hurricanes, floods, fires, and tornadoes can result in loss of raw ingredients
used in medications or cause damage to manufacturing facilities, resulting
in shortages. The effect of these shortages may be worsened because there
is usually an increased need for medications after such events
354
If there is critically low or no supply, it may be necessary to convert from one Ca salt
form to another form, even after using different manufacturers. Ca salts have a varying
amount of elemental Ca per gram (Table 9). Close attention should be paid when
ordering and dispensing different salt forms of Ca. Substitution of Ca chloride for
Ca gluconate without proper dosage adjustment could result in a 3-fold overdose.
In addition, special attention is required to safely administer Ca (Table 10).
iCa reacts with freely available phosphate ions in solution to form an insoluble
dibasic Ca phosphate precipitate. Ca gluconate dissociates into free Ca ions at a
lower degree than Ca chloride, minimizing the potential for forming precipitates with
phosphate in TPN. This property favors the addition of Ca gluconate to TPNcontaining
phosphate. In addition, numerous studies have reported Ca and phosphate limits
along with established Ca and phosphate compatibility curves, validating Ca gluco-
nate as the Ca salt form of choice in neonatal TPN.
9
However, a recent study by Migaki and colleagues
10
provided compatibility infor-
mation for Ca chloride and sodium phosphate in neonatal TPN containing the amino
acid, TrophAmine (B. Braun Medical Inc., Bethlehem, PA). Solutions were visually
tested for the presence of precipitation and the investigators determined that amino
acid concentrations of 3% or greater were compatible with a maximum sodium phos-
phate concentration of 15 mmol/L and Ca chloride concentration of 12.5 mmol/L.
Although these data are valuable, additional studies under different study conditions
are warranted before Ca chloride is used in neonatal TPN containing phosphate,
because microprecipitates, capable of intravascular embolism, may exist even if in-
line filters are used and visual observations are conducted.
11
The precipitation of Ca and phosphate in TPN has resulted in at least 2 patient
deaths and 2 cases of respiratory distress.
12
Insoluble Ca phosphate is a life-
threatening hazard and a substantial patient safety concern. Although substituting
Ca chloride for Ca gluconate in phosphate-containing TPN is a strategy to manage
a critical shortage, this practice should be strongly discouraged. Ca chloride may
be considered an addition to TPNonly if phosphate is not present in the same solution.
If Ca gluconate is not available, Ca chloride could be used in TPN without phosphate,
administering infusions of phosphate separately. This is a potential strategy to
Table 8
Selected parenteral Ca preparations
Product Manufacturer Concentration (mg/mL) Vial Sizes (mL)
Ca chloride Hospira 100 10
American Regent/Luitpold 100 10
Amphastar Pharmaceuticals 100 10
Ca gluconate American Regent/Luitpold 100 50
100
APP 100 10
50
100
Table 9
Parenteral Ca salts
Salt (g) Elemental (mg) Elemental (mmol) Elemental (mEq)
Ca chloride 1 273 6.8 13.6
Ca gluconate 1 93 2.325 4.65
minimize the risk of extravasation from infusing a continuous Ca infusion separate
from the TPN, because this risk is significantly less with phosphate.
In addition to phosphate, there are several common neonatal medications that are
incompatible with Ca when infused via Y-site administration (Table 11). Determining
Table 10
Infusion guidelines for Ca chloride and Ca gluconate
Concentration For IV infusion, dilute Ca gluconate in normal saline or dextrose 5% in
water (D5W) to a usual maximum concentration of 20 mg/mL for Ca
chloride and 50 mg/mL for Ca gluconate. Undiluted drug (100 mg/mL)
should be reserved only for bolus doses during emergent situations
Site of
administration
IV administration via a central or deep vein is preferred. The following
routes of administration are not recommended because of a high risk
of severe necrosis and sloughing: intramuscular, subcutaneous, and IV
administration via scalp, small hand, or foot veins
Avoid rapid
administration
Rapid administration may cause a decrease in blood pressure, cardiac
syncope, or extravasation. For Ca chloride, do not exceed 100 mg/min,
except in emergent situations. For Ca gluconate, do not exceed
50100 mg/min, except in emergent situations, in which infusion
should not exceed 200 mg/min
Avoid intermittent
infusions for
maintenance
Intermittent infusions, even over 1 h, are nonphysiologic, potentially
harmful, and should not be the standard way to administer
maintenance Ca to a neonate
8
Data from Lexi-Comp Online, Pediatric and Neonatal Lexi-Drugs Online. Hudson (OH): Lexi-Comp;
2011.
Table 11
Y-site incompatibility of Ca gluconate and chloride with common neonatal medications (not
all inclusive)
Ca Gluconate Ca Chloride
Amphotericin B Amphotericin B
Ampicillin
a
Ampicillin
a
Ceftriaxone Cefazolin
Dexamethasone Ceftazidime
Diazepam Dexamethasone
Fluconazole
a
Diazepam
Hydralazine
a
Hydralazine
a
Hydrocortisone
a
Hydrocortisone
Indomethacin Indomethacin
Methylprednisolone Mg sulfate
Meropenem Methylprednisolone
Pantoprazole
a
Pantoprazole
Phenytoin Phenytoin
Potassium phosphate
a
Potassium phosphate
a
Sodium bicarbonate Sodium bicarbonate
Sodium phosphate
a
Sodium phosphate
a
a
Variable compatibility information.
Data from Trissel LA. Handbook on injectable drugs. Bethesda (MD): American Society of Health-
Systems Pharmacists; 2013.
Abrams et al 356
compatibility is highly complex and requires thoughtful consideration for safe admin-
istration. It is important to refer to the appropriate references (eg, Handbook on Inject-
able Drugs
13
) to thoroughly evaluate specific drug properties such as concentration
and manufacturer, before concomitantly infusing medications with Ca.
Potential incompatibility issues are often addressed when patients have limited line
access, which is a relatively common occurrence in the neonatal population. For
example, if Ca gluconate is not available, the patient requires 1 line access for TPN
and lipids, 1 line access for a continuous infusion of Ca chloride, and possibly another
line access for intermittent medications that are potentially incompatible with TPN,
lipids, or Ca chloride. Education on drug compatibility should be reinforced with the
bedside nurses who are unfamiliar with infusing the alternative Ca salt.
Implementing institutional-specific guidelines is a practical strategy to conserve
supply. Several federal and professional organizations such as the American Society
of Parenteral and Enteral Nutrition (ASPEN) have provided considerations in
approaching the national shortage of Ca, providing a good starting point for the clini-
cian.
14
A thoughtful and reasoned evaluation is necessary to apply the information in
an appropriate manner, recognizing what is clinically acceptable based on institutional
practice and patient population (Table 12).
If a limited supply of Ca gluconate is available, it may be prudent to reserve it for
neonatal patients. Neonates require maintenance Ca for their developing bones,
and providing Ca in TPN is ideal for critically ill patients who are dependent on TPN
for their nutrition. Also, neonates often have limited line access, which makes infusing
Ca chloride outside the TPN challenging. Decreasing the amount of Ca provided in the
TPN may further extend the supply and minimize the number of vials required to com-
pound TPN daily (Table 13). This strategy may be applicable in large neonatal units or
Table 12
Applying considerations for neonates to ASPEN recommendations for Ca during a national
shortage
ASPEN Recommendations Additional Considerations for Neonates
Monitor serum Ca concentrations
(iCa preferred or total Ca levels
with albumin) if Ca gluconate
is removed from TPN
There is a relatively greater iCa concentration for any
total Ca concentration in very premature infants
because of lower total protein concentrations. If iCa
is unavailable, the corrected free Ca should be
estimated with serum Ca adjustment formulas using
serum albumin level
Infuse Ca chloride as a separate
infusion from TPN
Adding Ca chloride to TPN containing phosphate is
discouraged because of a high risk of precipitation.
As a result of possible extravasation, it may be
desirable to add Ca chloride to the TPN. In this case,
remove phosphate and administer as a separate
infusion from TPN
Consider multielectrolyte solutions
containing Ca to prepare TPN
Multielectrolyte additives (eg, Nutrilyte, American
Regent, Inc., Shirley, NY) are indicated as a source of
replacement electrolytes for the depleted adult
patient and not intended for neonatal use
Consider premixed manufacturer-
prepared TPN containing Ca
Commercially available premixed TPN (eg, Clinimix,
Baxter International, Inc., Deerfield, IL) is not
formulated to contain the appropriate types and
concentrations of macronutrients and micronutrients
required for neonates
institutions that are able to compound customized TPN solutions. Institutions that out-
source the compounding of TPN solutions should collaborate with the company to
determine the severity of the shortage and identify strategies to reserve the supply
for critical neonates or explore other compounding companies with potentially more
access to the drugs in short supply. A minimum amount of Ca required for growth
should be provided, and close monitoring of serum Ca is required.
IV Ca chloride as a continuous or short intermittent infusion is needed for nonneo-
natal patients. If Ca chloride is also in low supply, it may also be necessary to deter-
mine an acceptable lower limit of serum Ca before IV Ca is provided. If patients can
tolerate oral feeds, oral Ca should be provided (Table 14).
National Shortage of P
Potassium phosphate and sodium phosphate are the only 2 IV P products commer-
cially available in the United States. If there is a national shortage, using different man-
ufacturers or vial sizes may be required to extend the supply (Table 15).
When procuring product is not possible to maintain the current usage, a shortage
plan should be used to conserve supply (Table 16).
Total sodiumandpotassiumcontent shouldbe evaluatedwhen switching to different
phosphate products (Table 17). For example, when sodium phosphate is being used
Table 13
Example guidelines to conserve Ca and phosphorus in neonatal TPN
Ca and
Phosphate Limits Considerations or Exclusions
Infants <1500 g 1.5 mmol/100 mL Exclude patients with rickets, severe fluid
restriction, or evidence of increased
alkaline phosphatase, and then may
increase to 1.752 mmol/100 mL
Infants 1500 g 0.6 mmol/100 mL Exclude patients with rickets, severe fluid
restriction, or requiring dialysis
Infants receiving
<60 mL/kg/d of TPN
and at least 60 mL/kg/d
of enteral feeds
Remove Ca and
phosphate
from TPN
Ca and phosphate can be removed in
patients who are TPN dependent for
extended periods at these low volumes of
TPN and on feeds (eg, short gut syndrome).
Remove Ca and phosphate if alkaline
phosphatase level is <500600 IU/L
Table 14
Selected oral Ca products
Ca Salt
Elemental Ca
(mg/1 g of Salt)
Elemental Ca
(mEq/1 g of Salt)
Commercially Available
Formulations
Acetate 250 12.7 Capsule, solution, tablet
Carbonate 400 20 Capsule, suspension, tablet,
chewable tablet, powder
Citrate 211 10.6 Capsule, granules, tablet
Lactate 130 6.5 Capsule, tablet
Phosphate (tribasic) 390 19.3 Caplet
Data from Lexi-Comp Online, Pediatric and Neonatal Lexi-Drugs Online. Hudson (OH): Lexi-Comp;
2011.
Abrams et al 358
Table 15
Selected parenteral phosphate preparations
Product Manufacturer
Concentration
(mmol/mL) Vial Sizes (mL)
Potassium phosphate Hospira 3 15
15
50
Sodium phosphate Hospira 3 15
15
50
Table 16
Applying considerations for neonates to ASPEN recommendations for P during a national
shortage
ASPEN Recommendations Additional Considerations for Neonates
Use an alternate salt Use sodium phosphate when potassium phosphate is on
shortage and vice versa. Consider the total mEq of sodium or
potassium contribution from the phosphate salt
Consider oral phosphate Enteral phosphate replacement products should be used when
possible. If a commercially available phosphate solution is
not available, it may be appropriate to compound a solution
from sodium/potassium-phosphate powder for oral solution
Consider premixed
manufacturer-prepared
TPN containing phosphate
Commercially available premixed TPN (eg, Clinimix, Baxter
International, Inc., Deerfield, IL) is not formulated to contain
the appropriate types and concentrations of macronutrients
and micronutrients required for neonates
Decrease the daily amount
of phosphate added to TPN
Refer to the example Ca/phosphate guideline limitations in
Table 13
Reserve phosphate for
pediatric and neonatal
patients
Depending on an institutions usage, IV phosphate may have
to be restricted only for neonates who are dependent on
TPN and cannot tolerate oral therapy. Nonneonatal patients
could receive replacement therapy if serum P levels decline
below a predetermined level (eg, 1.5 mg/dL)
Reserve phosphate for
patients with a
therapeutic medical need
Phosphate may also have to be reserved for patients requiring
continuous renal replacement therapy or who have diabetic
ketoacidosis
Data fromASPENparenteral nutrition electrolyte shortage. Available at: http://www.nutritioncare.
org/Professional_Resources/PN_Electrolyte_Shortage. Accessed November 19, 2013.
Table 17
Mineral content of potassium phosphate and sodium phosphate
P (mmol/mL) P (mg/mL) Potassium (mEq/mL) Sodium (mEq/mL)
Potassium phosphate 3 93 4.4 0
Sodium phosphate 3 93 0 4
instead of potassium phosphate, consider increasing potassium chloride in TPN to
provide maintenance potassium if the patient has normal renal function. Caution
should be exercised with orders for IV phosphate. The units (millimoles or milligrams)
and salt form(sodiumor potassium) should be used to express the phosphate product
and total requirement.
National Shortage of Zn
Zn sulfate and Zn chloride are the only Zn formulations available in the United
States for IV administration and are each produced by only 1 manufacturer. In
mid-2011, the FDA issued a drug shortage for both Zn sulfate and Zn chloride as
a result of suspended distribution and manufacturing delays from their manufac-
turers. Premature neonates require high amounts of Zn (400 mg/kg/d) because of
negligible body stores of Zn, increased catabolic state, low albumin binding, and
increased losses in the urine.
15
In late 2013, the FDA temporarily allowed for impor-
tation of Zn from non-US sources; however, the amount and distribution of this sup-
ply is uncertain.
Typically, trace element products that are available in the United States do not
contain enough Zn to provide maintenance requirements to this high-risk population.
Therefore, pharmacies must add extra Zn in these patients TPNs. Additional Zn
supplementation is also provided to patients with severe gastrointestinal (GI) abnor-
malities or losses. If injectable Zn goes on back order and needs to be limited, the
first strategy of rationing can be to stop providing the extra Zn in TPN to meet goal
maintenance requirements to reserve it for patients with severe GI losses. If it needs
to be restricted more, patients Zn levels can be monitored and supplemented only
if low (Table 18).
If even further restriction is required because of an extremely limited supply, Zn can
be administered only to patients who show signs and symptoms of Zn deficiency,
such as impaired wound healing, alopecia, growth failure, immunologic impairment,
and dermatitis. AquADEKS (Yasoo Health, Inc., Raleigh, NC) is a multivitamin and min-
eral supplement that is designed to help increase absorption of fat-soluble vitamins A,
D, E, and K and other micronutrients. It contains 5 mg elemental Zn/mL so it can be
used as an alternative to injectable Zn when patients are able to take enteral medica-
tions. Oral Zn formulations can also be compounded from tablets or capsules.
SUMMARY
Mineral nutrition in high-risk and preterm infants poses numerous challenges in
balancing these nutrients and providing a safe infusate. Limitations in the supply of
some of these minerals remain an additional challenge in providing these crucial
nutrients.
Table 18
Example guidelines for oral Zn administration with AquADEKS (Yasoo Health, Inc., Raleigh,
NC) (for infants on TPN who would be receiving supplemental Zn because of losses associated
with an ostomy or functional/anatomic short gut who are tolerating 30 mL/kg/d of feeds)
Infants >1500 g Start with 0.25 mL once daily and titrate up to see if patient can
tolerate the oral medication
Infants 15003000 g 0.5 mL once daily
Infants 3 kg to 1 y old 0.5 mL twice daily or 1 mL daily if tolerating well
Abrams et al 360
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in neonatal parenteral nutrition containing TrophAmine: precipitation studies and
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with calcium chloride in parenteral nutrition admixtures: response to Migaki et al.
JPEN J Parenter Enteral Nutr 2012;36:4978.
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ated with parenteral nutrition. Rockville (MD): Food and Drug Administration;
1994.
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Health-Systems Pharmacists; 2013.
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nutritioncare.org/Professional_Resources/PN_Electrolyte_Shortage. Accessed
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tal Wkly Rep 2013;62(7):1367.
Fatty Aci d Requi rements i n
Preterm I nfants and Thei r
Rol e i n Heal th and Di sease
Camilia R. Martin, MD, MS
a,b,
*
INTRODUCTION
Enhancing somatic growth through our knowledge of macronutrient requirements
(carbohydrates, proteins, and fats) is only one aspect of fully extracting the potential
of nutrition to optimize health in preterm infants. The composition and balance of
a
NICU, Department of Neonatology, Beth Israel Deaconess Medical Center, Harvard Medical
School, 330 Brookline Avenue, Rose-318, Boston, MA 02215, USA;
b
Division of Translational
Research, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline
Avenue, Boston, MA 02215, USA
* NICU, Department of Neonatology, Beth Israel Deaconess Medical Center, Harvard Medical
School, 330 Brookline Avenue, Rose-318, Boston, MA 02215.
KEYWORDS
Long-chain polyunsaturated fatty acids

Docosahexaenoic acid

Arachidonic acid
Eicosapentaenoic acid

Linoleic acid

Lipid emulsions
KEY POINTS
There is selective uptake and transfer of free long-chain polyunsaturated fatty acids
(LCPUFAs) from the maternal circulation to the developing fetus.
LCPUFAs are critical for many biological processes, principally organogenesis (especially
of the brain and retina) and regulating inflammation.
Current nutritional practices are unable to meet the intrauterine fetal accretion rates of
LCPUFAs in the early postnatal period for preterm infants.
Inadequate postnatal delivery of LCPUFAs results in early, rapid deficits in critical fatty
acids, notably docosahexaenoic acid and arachidonic acid.
Altered postnatal LCPUFA levels and n-6/n-3 fatty acid ratios in the preterm infant are
associated with chronic lung disease and late-onset sepsis.
Current scientific literature, including both animal and human data, support the role of
LCPUFA supplementation in preventing disease and optimizing health in the preterm
infant.
The optimal strategy to delivery LCPUFAs to preterm infants to emulate recommended
fetal accretion rates, maintain birth levels of fatty acids and their relative ratios, prevent
early deficits in fatty acid levels, and achieve clinical benefit without potential harm re-
mains to be defined.
the individual building blocks within the macronutrients (sugars, amino acids, and fatty
acids) are equally essential to understand. These building blocks often serve as bioac-
tive molecules regulating many biological processes, such as organ development,
metabolic homeostasis, and immune responsiveness.
Provision of fats is part of a balanced nutritional diet that delivers high-energy con-
tent, enhances gluconeogenesis, and prevents essential fatty acid deficiency. A large
percentage of dietary fats are in the forms of triglycerides: 3 fatty acids on a glycerol
backbone. Enzymatic hydrolysis releases the fatty acids from the glycerol backbone,
allowing for trafficking and incorporation of the fatty acids into cell membranes, their
primary site of action.
There is an extensive and evolving scientific literature showing the pleiotropic effects
of fatty acids in health and disease. However, this literature is considerably more
expansive for the adult than for the neonate. Despite this situation, strong evidence
exists to support the beneficial role of fatty acids in neonatal health, especially in the
preterminfant, andthe needfor ongoingefforts to further understand their mechanisms
of action and to identify best nutritional or therapeutic strategies for delivery.
PLACENTAL TRANSFER AND FETAL ACQUISITION OF LONG-CHAIN POLYUNSATURATED
FATTY ACIDS
Placental Transfer of Long-Chain Polyunsaturated Fatty Acids
Long-chain polyunsaturated fatty acids (LCPUFAs) are critical for the development of
the fetal brain and retina. The importance of fetal acquisition of these critical fatty acids
is highlighted by the presence of specific mechanisms allowing for maternal and
placental transfer of fatty acids to the developing fetus. Although placental mecha-
nisms for transfer are necessary, the synthesis of LCPUFAs in the placenta is limited,
as it is in the developing fetus; thus, the maternal circulation is still considered the ma-
jor source of LCPUFAs.
13
Two major pathways have been proposed to facilitate the transfer of fatty acids from
the maternal circulation, across the placenta, to the developing fetus: passive diffusion
and protein-mediated transport (Fig. 1).
1,4,5
Maternal lipoproteins, triglycerides and
phospholipids, are converted by placental lipoprotein lipase and endothelial lipase
to form nonesterified or free fatty acids. Maternally derived free fatty acids are then
transported into the placenta by passive diffusion or via protein-mediated transport.
Transport proteins essential for the latter pathway include fatty acid transport proteins
(FATP) 1 6, of which FATP-4 seems to be of particular significance, because expres-
sion of this protein is directly correlated with docosahexaenoic acid (DHA) content in
cord blood phospholipids,
6
placental plasma membrane fatty acid binding protein,
and fatty acid translocase/CD36 (FAT/CD36). Once in the placenta, additional fatty
acid binding proteins carry the fatty acid to the fetal interface, where FATP and
FAT/CD36 deliver the free fatty acid to the fetal circulation.
Unique to this environment is the selective update and accumulation of LCPUFAs in
the placenta and the fetal circulation, a phenomenon termed biomagnification. Labeled
carbon studies tracking the transfer of fatty acids from the maternal to fetal circulation
have shown higher DHA(22:6 n-3) content in cord blood versus maternal plasma, again
emphasizing the unique role of the placenta in selectively transferring sufficient quan-
tities of LCPUFAs to support the needs of the developing fetus (Fig. 2).
2,7
Fetal Acquisition of LCPUFAs
The delivery of LCPUFAs substantially increases during the third trimester, coinciding
with continued organ development and rapid fetal growth. Fetal accretion is targeted
Martin 364
to the brain, retina, and other lean tissues and organs. However, another important
depot of fatty acids in the developing fetus is adipose tissue (Fig. 3). This reservoir
is important to sustaining fatty acid requirements in organ development after delivery
and throughout early infancy.
4
It is estimated that the delivery of long-chain fatty acids
Fig. 1. Model of placental fatty acidtransport. Acomplex interplay of different fatty acidtrans-
port proteins orchestrates fatty acid uptake by placental cells. Within the cell, NEFA are bound
by different fatty acidbindingproteins andhavemultiple functions likeenergy generation, TG,
and eicosanoid synthesis, and activation of nuclear transcription factors like PPAR/RXR. FAT,
fatty acid translocase; FATP, fatty acid transport protein; H-FABP, heart-fatty acid binding
protein; L-FABP, liver-fatty acid binding protein; LP, lipoprotein; LPL, lipoprotein lipase;
NEFA, nonesterified fatty acid; P-FABPpm, placental plasma membrane fatty acid binding pro-
tein; PPAR, peroxisome proliferator activated receptor; RXR, retinoid X receptor. (Reprinted
from Hanebutt FL, Demmelmair H, Schiessl B, et al. Long-chain polyunsaturated fatty acid
(LC-PUFA) transfer across the placenta. Clin Nutr 2008;27:688; with permission.)
Fatty Acid Requirements in Preterm Infants 365
to support optimal fetal accretion is 43 mg/kg/d of DHA and 212 mg/k/d of arachidonic
acid (20:4 n-6; AA) (Table 1).
8
In the preterm infant, this lack of accretion may have
both short-termand long-termimplications in predisposing to disease, as is discussed
in the next section.
The most well-understood roles of LCPUFAs in the developing fetus are to support
brain and retinal development. Approximately 55% of the brain comprises lipid, with
the gray matter being 35% lipid, white matter 50% lipid, and myelin nearly 80% lipid.
9
LCPUFAs are a critical component of many of these lipid-based structural compo-
nents, providing cell membrane structural integrity and fluidity within the phospholipid
bilayer along with mediation of cell signaling pathways important in modulating the
production of proteins that regulate neuronal differentiation and maturation, cell sur-
vival, and protection against oxidative stress.
2,10
Within the retina, DHA is concen-
trated in the outer segment of rod photoreceptors, playing an important role in
differentiation and survival as well as the incorporation and function of the visual
pigment rhodopsin.
10
Much is discussed regarding the accretion of DHA in the fetal brain and retina; how-
ever, AA is the predominant fatty acid in the developing brain and retina until
Fig. 2. Mean ratios between cord and maternal plasma area under the curve concentration
of
13
C-fatty acids, expressed as percentages (n 5 11).
13
C-PA, [
13
C]palmitic acid;
13
C-OA, [
13
C]
oleic acid;
13
C-LA, [
13
C]linoleic acid. (Reprinted from Gil-Sanchez A, Larque E, Demmelmair
H, et al. Maternal-fetal in vivo transfer of [
13
C]docosahexaenoic and other fatty acids across
the human placenta 12 h after maternal oral intake. Am J Clin Nutr 2010;92:120; with
permission.)
Fig. 3. Change in the rate of DHA use with stage of gestation. (Reprinted from Haggarty P.
Fatty acid supply to the human fetus. Annu Rev Nutr 2010;30:239; with permission.)
Martin 366
approximately 37 and 32 weeks of gestation, respectively (Fig. 4).
11
Thus, AA is likely
critical to the biological development and function of these organs. Similar to DHA, AA
plays important roles in cell division, differentiation, and cell signaling.
12
In addition,
adequate AA is important in infant growth.
13,14
Effect of Prematurity on Systemic Levels of LCPUFAs
Preterm delivery leads to an abrupt cessation in the maternal transfer of critical fatty
acids. The early termination of fatty acid delivery coupled with the lack of adipose tis-
sue stores make the preterm infant especially vulnerable to alterations in systemic
fatty acids and fully dependent on postnatal nutritional replacement strategies while
in the intensive care unit. The current parenteral and enteral nutritional management
strategies fail to meet the LCPUFA fetal accretion requirements and thus do not allow
preservation of levels that would have been otherwise seen if the infant had remained
in utero for the final trimester of pregnancy.
Whether evaluating whole blood or plasma fatty acid levels, preterm infants show a
decline in DHA and AA and a concomitant increase in linoleic acid (18:2 n-6; LA) levels
(expressed as mol%) within the first postnatal week (Fig. 5).
15,16
In addition, the ratios
Table 1
Estimates of the fatty acid accretion rate during the last trimester of pregnancy
Per Day (mg/d)
a
Per kg Body Weight Per Day (mg/kg/d)
b
LA (18:2n-6)
c
184 106
AA (20:4n-6) 368 212
LNA (18:3n-3) 7 4
DHA (22:6n-3) 75 43
a
Adapted from Giorgieff and Innis [35]; the intrauterine estimate assumes tissue AA to be two-
fold higher than LA [20,21]; the intrauterine estimate assumes that (1) DHArepresents 90%of total
n-3 fatty acids in all tissue except other 0 tissue [20,21], (2) the fatty acid composition of other
tissue (20) is equal to that of skeletal muscle and that skeletal muscle contains 4.5%n-3 fatty acids
[37], and (3) DHA represents 69% of total n-3 fatty acids in skeletal muscle [37].
8
b
Assumes weight between 25 and 41 weeks of gestation similar to Ref. [38].
8
c
Linoleic acid (LA), linolenic acid (LNA), arachidonic acid (AA), and docosahexaenoic acid (DHA).
Reprinted from Lapillonne A, Jensen CL. Reevaluation of the DHA requirement for the prema-
ture infant. Prostaglandins Leukot Essent Fatty Acids 2009;81:145; with permission.
Fig. 4. DHA (22:6n-3) and AA (20:4n-6) as a percent of total fatty acids in forebrain (A) and
retina (B). (Adapted from Martinez M. Tissue levels of polyunsaturated fatty acids during
early human development. J Pediatr 1992;120:S131; with permission.)
of these fatty acids relative to each other are driven in the opposite direction of what is
observed during the in utero period and at birth.
The rapid changes in fatty acid levels observed within the first postnatal week in pre-
term infants are principally driven by the current nutritional practices in the intensive
care unit. Specifically, reliance on a parenteral lipid emulsion that is not tailored for
the specific needs of the preterm infant and the delayed provision of enteral feedings
that do not have sufficient fatty acid content (or delivery strategy) necessary to main-
tain LCPUFA birth levels lead to the observed profound alterations in systemic fatty
acid levels.
Contribution of Parenteral Nutritional Practices to Altered Postnatal LCPUFA Levels
In the United States and much of North America, the principal lipid emulsion used for
early delivery of fats to preterm infants is IntraLipid (20%, Fresenius Kabi/Baxter, Bad
Homburg, Germany). Compared with the other available lipid emulsions (Table 2),
17
IntraLipid is 100% soybean oil, thus providing large amounts of LA but little to no
DHA and AA. This lipid emulsion, approved by the US Food and Drug Administration
(FDA) in 1972, was originally developed for use in the adult population. However, this
product was subsequently applied to the neonatal and pediatric population, especially
because no alternative has been approved for use in these specialized populations.
Although provision of IntraLipid and thus the essential fatty acids LA and a linolenic
acid (18:3 n-3) may be sufficient for adults dependent on parenteral nutrition, the pro-
vision alone of essential fatty acids is not adequate for the preterm population. The
rationale for providing essential fatty acids alone relies on the presumption that the
metabolic conversion of these fatty acids to downstream LCPUFAs is intact
(Fig. 6).
18
Although not fully elucidated, it remains controversial whether desaturase
and elongase activities are sufficient in the preterm infant to efficiently metabolize
the precursor essential fatty acids to downstream LCPUFAs at a rate that meets their
overall LCPUFA requirements.
1921
In addition, it is not known how the unique meta-
bolic state of the critically ill preterm infant affects overall fatty acid requirements.
Regardless, it is self-evident that the provision of IntraLipid in the preterm infant is
Fig. 5. (A) DHA levels in preterm infants decrease soon after birth and plateau by the first
postnatal week. (B) LA levels in preterm infants increase soon after birth, and AA levels
decrease soon after birth; both LA and AA plateau by the first postnatal week. (From
Martin CR, Dasilva DA, Cluette-Brown JE, et al. Decreased postnatal docosahexaenoic and
arachidonic acid blood levels in premature infants are associated with neonatal morbidities.
J Pediatr 2011;159:746; with permission.)
Martin 368
insufficient to maintain levels of LCPUFAs that emulate the patterns observed during
the third trimester of pregnancy and at birth.
Contribution of Enteral Nutritional Practices to Altered Postnatal LCPUFA Levels
Not uncommonly, the preterm infant is provided with enteral feedings in a slow step-
wise manner, such that the time to full enteral feedings to meet total energy require-
ments does not occur until, on average, the second postnatal week.
16
Thus, the
enteral approach to administering fatty acids is unlikely to prevent the changes in sys-
temic fatty acid levels that occur within the first postnatal week.
22
LCPUFAs are pre-
sent in breast milk, but there is tremendous interindividual and intraindividual variation
in mothers own milk and reduced levels in donor milk; thus, the levels that are present
in human milk are unlikely to meet the total requirements of the preterm infant.
23,24
In
the United States, preterm formulas have been supplemented with DHA and AA since
2002, but the current levels are not sufficient to prevent the early postnatal decline in
these fatty acid levels. Furthermore, the bioavailability of these supplemental fatty
acids is compromised by developmentally impaired lipolysis and absorption observed
in preterm infants.
8
HEALTH CONSEQUENCES OF ALTERED LCPUFA LEVELS IN PRETERM INFANTS
The changes in systemic fatty acid levels and n-6/n-3 ratios are directly linked to acute
neonatal morbidities.
16
In a cohort of preterm infants less than 30 weeks of gestation,
for every 1 mol% decline in whole blood DHA levels, there was a 2.5-fold increase in
the odds of developing chronic lung disease (CLD). For every 1 mol% decline in AA,
there was a 40% increase in the hazard ratio of developing late-onset sepsis. In addi-
tion, a positive change in the LA/DHA ratio was associated with an increase in the risk
of both CLDand late-onset sepsis. These results are consistent with the biological role
of LCPUFAs, especially DHA and AA, in regulating inflammation and immunity.
Although much has been described regarding the importance of DHA and AA in
brain and retinal development, a direct causal link of low levels of these fatty acids
to poor neurodevelopment has not been firmly established, especially given the
many other competing risks for impaired neurodevelopment in the ill preterm infant.
However, animal and human data on LCPUFA deprivation provide support for a critical
role of LCPUFAs in neurodevelopment.
In weaning rats, 15 weeks of an n-3 deprivation diet resulted in a decrease in brain-
derived neurotropin factor (BDNF) in the frontal cortex.
25
BDNF is an important
signaling protein, which promotes Akt activation and, in turn, upregulates the
CREB and mTOR pathways. Both CREB and mTOR are responsible for regulating
gene expression and synthesis of proteins that are involved in neuroprotection, syn-
aptic plasticity, actin organization, cell growth, and survival.
26,27
Nutritional modula-
tion of BDNF is of clinical significance in the preterm infant. At birth, plasma BDNF
levels in the preterm infant are lower than levels measured in term infants,
28
and
the disparity in these levels may be exacerbated by the inadequate provision of
n-3 fatty acids as a result of the current nutritional management strategies in the
postnatal period of a preterm infant. Thus, the combination of low birth levels of
BDNF and deprivation of critical LCPUFAs may place the preterm infant at risk for
abnormal brain development.
In nonhuman primate models, plasma levels of fatty acids parallel the levels of these
fatty acids in the brain.
29
As a result, the changes in whole blood and plasma levels of
DHA and AA in the preterm infant previously described
15,16
are likely to result in
changes in fatty acid composition in the developing preterm brain. Supportive of
Table 2
Commercially available intravenous fat emulsion products in the United States and outside the United States
Product Name Manufacturer/Distributor Lipid Source
Concentrations of Selected FA,
% by Weight
n-6/n-3
Ratio
a- Tocopherol
(mg/L)
Phytosterols
(mg/L) Linoleic a-Linolenic EPA DHA
IVFE available in United States
Intralipid Fresenius Kabi/Baxter 100% soybean oil 4462 411 0 0 7:1 38 348 33
Liposyn III Hospira 100% soybean oil 54.5 8.3 0 0 7:1 NA NA
IVFE available only outside the United States
Intralipid Fresenius Kabi 100% soybean oil 4462 411 0 0 7:1 38 348 33
Ivelip Baxter Teva 100% soybean oil 52 8.5 0 0 7:1 NA NA
Lipovenoes Fresenius Kabi 100% soybean oil 54 8 0 0 7:1 NA NA
Lipovenoes 10% PLR Fresenius Kabi 100% soybean oil 54 8 0 0 7:1 NA NA
Intralipos 10% Mitsubishi Pharma
Guangzhou/Tempo
Green Cross Otsuka
Pharmaceutical Group
100% soybean oil 53 5 0 0 7:1 NA NA
Lipofundin-N B. Braun 100% soybean oil 50 7 0 0 7:1 180 40 NA
M
a
r
t
i
n
3
7
0
Soyacal Grifols Alpha Therapeutics 100% soybean oil 46.4 8.8 0 0 7:1 NA NA
Intrafat Nihon 100% soybean oil NA NA 0 0 7:1 NA NA
Structolipid 20%
b
Fresenius Kabi 64% soybean oil 36% MCT 35 5 0 0 7:1 6.9 NA
Lipofundin MCT/LCT B. Braun 50% soybean oil 50%
MCT oil
27 4 0 0 7:1 85 20 NA
Lipovenoes MCT Fresenius Kabi 50% soybean oil 50%
MCT oil
25.9 3.9 0 0 7:1 NA NA
ClinOleic 20% Baxter 20% soybean oil 80%
olive oil
18.5 2 0 0 9:1 32 327 8
Lipoplus B. Braun 40% soybean oil, 50% MCT,
10% fish oil
25.7 3.4 3.7 2.5 2.7:1 190 30 NA
SMOFlipid Fresenius Kabi 30% soybean oil, 30% MCT,
25%olive oil, 15%fish oil
21.4 2.5 3.0 2.0 2.5:1 200 47.6
Omegaven Fresenius Kabi 100% fish oil 4.4 1.8 19.2 12.1 1:8 150296 0
Abbreviations: EPA, eicosapentaenoic acid; FA, fatty acid; IVFE, intravenous fat emulsion; MCT, medium-chain triglyceride; n-6/n-3 ratio, ratio of u-6 fatty acids to
u-3 fatty acids; NA, not available.
a
References 1, 10, 26, 37.
17
b
Fat source uses structured lipids.
Reprinted from Vanek VW, Seidner DL, Allen P, et al. ASPEN position paper: clinical role for alternative intravenous fat emulsions. Nutr Clin Pract 2012;27:156;
with permission.
F
a
t
t
y
A
c
i
d
R
e
q
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i
r
e
m
e
n
t
s
i
n
P
r
e
t
e
r
m
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n
f
a
n
t
s
3
7
1
this extrapolation are autopsy data that show abnormal DHA and AA content in the
brain of preterm infants maintained on prolonged parenteral nutrition or high n-6/n-3
diets.
11
EVIDENCE SUPPORTING THE ROLE OF LCPUFAS IN OPTIMIZING HEALTH IN PRETERM
INFANTS
LCPUFAs play a critical role in cellular structure and function, including the regulation
of membrane fluidity, cell signaling, and protein expression. It is through these intra-
cellular pathways that LCPUFAs modulate immune and inflammatory responses as
well as organogenesis (Fig. 7). Accruing animal studies and data from small human
clinical trials support the role of LCPUFA supplementation to optimize the health of
preterm infants. Examples are presented in the following sections for CLD, necrotizing
enterocolitis (NEC), retinopathy of prematurity (ROP), and neurodevelopment.
CLD
As discussed previously, in a cohort study of preterm infants of less than 30 weeks of
gestation, for every 1 mol% decline in DHA, there was a 2.5-fold increase in the odds
of developing CLD.
16
By the first postnatal week, infants who developed CLD had
Fig. 6. An overview of the n-3, n-6, and n-9 biosynthetic pathways. (Reprinted from
Freedman SD, Blanco PG, Zaman MM, et al. Association of cystic fibrosis with abnormalities
in fatty acid metabolism. N Engl J Med 2004;350:562; with permission.)
Martin 372
lower mean whole blood DHA levels compared with infants who did not develop CLD
(Fig. 8). The differences between these 2 groups persisted throughout the first post-
natal month. Supporting these observational data is the reduction of CLD in breast
milkfed infants less than 1250 g whose mothers were supplemented with a high-
DHA diet compared with infants whose mothers were not supplemented (34.5% vs
47%, respectively).
30
In addition, in a small clinical trial comparing delivery of IntraLi-
pid versus SMOFlipid (15% fish oil) in preterm infants, the subgroup of infants less
Fig. 7. Role of fatty acids in cellular mechanisms. (1) Formation of phospholipid bilayer of
the cell membrane, (2) cell signaling, (3) regulation of protein expression responsible for im-
mune and inflammatory responses and organogenesis.
Fig. 8. Mean DHA levels are higher throughout the first postnatal month in infants without
CLD compared with infants with CLD. *All P values <.02 comparing the mean DHA level in
each postnatal week in infants with and without CLD. Bars represent standard error of the
mean. (Reprinted from Martin CR, Dasilva DA, Cluette-Brown JE, et al. Decreased postnatal
docosahexaenoic and arachidonic acid blood levels in premature infants are associated with
neonatal morbidities. J Pediatr 2011;159:746; with permission.)
than 1500 g who received SMOFlipid were less likely to develop CLD.
31
Animal data
provide further biological plausibility for the role of LCPUFAs in ameliorating neonatal
lung injury. In a murine model of neonatal hyperoxia-induced lung injury, increased
exposure to DHA, either through increased maternal content in dam milk or directly
through oral administration to the mouse pups, ameliorated the expression of lung
injury with reduction of inflammatory biomarkers
32,33
and improved alveolarization.
32
NEC
In a rat model of NEC, the incidence of NEC was reduced with enteral supplementa-
tion of LCPUFAs, with the greatest reduction in the groups supplemented with DHA
(50% reduction) or both DHA and AA (30% reduction).
34
Mechanisms proposed
include a decrease in platelet-activating factor messenger RNA (mRNA) expression
in response to both DHA and AA supplementation and a decrease in toll-like receptor
4 (TLR4) mRNA expression with AA supplementation. Clinical trials of LCPUFA supple-
mentation in preterm infants have not shown a reduction in NEC. However, the few tri-
als of LCPUFA supplementation in preterm infants were not designed to study NEC as
a primary aim nor were they adequately powered to look at NEC even as a secondary
outcome. The best supporting evidence for the potential role of LCPUFAs in prevent-
ing NEC comes from the scientific literature in inflammatory bowel disease, an intes-
tinal disease process that may share similar mechanisms with NEC.
35,36
The current
scientific literature supports an immunomodulatory role of LCPUFAs at the level of
the enterocyte, including inhibition of TLR4 expression; downregulation of nuclear fac-
tor B (NF-B) signaling of inflammatory biomarkers through interaction with the nuclear
receptor, peroxisome proliferator activated receptor (PPAR), or through the produc-
tion of antiinflammatory terminal metabolites of DHA, such as the resolvin D series;
and, through modulation of other fatty acidderived proinflammatory cytokines
such as eicosanoids (Fig. 9).
35
ROP
In preterminfants of less than 32 weeks of gestation and less than 1250 g given either a
standard lipid emulsion without fish oil or a standard lipid emulsion blended with 100%
fish oil (Omegaven), the infants receiving fish oil had a trend toward a reduced inci-
dence of ROP requiring laser therapy.
37
Supporting this clinical finding are results
from a murine model of ROP. Pups born to mothers with an n-3dominant diet versus
an n-6dominant diet showed less retinal vaso-obliteration and neovascularization
secondary to hyperoxia exposure.
38
In addition, the same protective effect against
retinal injury with hyperoxia was found in pups in the n-6dominant diet group when
concurrently provided resolvin D1, resolvin E1 or neuroprotectin D1, all terminal anti-
inflammatory, bioactive metabolites of the n-3 fatty acids, DHA and eicosapentaenoic
acid (EPA). The protective effect of the n-3 fatty acid diet seems to be partially medi-
ated through a downregulation of tumor necrosis factor mRNA expression in the retina.
Neurodevelopment
Overall, the data for long-term neurodevelopmental benefits of LCPUFA supplemen-
tation in preterm infants are mixed.
39
Some of the potential reasons for this finding
are discussed in more detail later and include considerations such as dosing, timing
of delivery, and bioavailability with enteral consumption. However, intriguing data
are accumulating regarding the role of LCPUFAs in upregulating signaling pathways
important for brain development, reducing lipopolysaccharide (LPS)-induced neuronal
injury and attenuating the sequelae of traumatic brain injury. It was previously dis-
cussed that, compared with term newborns, preterm infants have lower levels of
Martin 374
BDNF,
28
which can be further compromised with n-3 fatty acid deprivation.
25
The in-
vestigators of the latter study also reported that BDNF protein levels can be restored
with DHA supplementation. Adequate levels of BDNF allow for downstream activation
of the Akt, CREB, and mTOR pathways, all critical pathways in the regulation of pro-
teins involved in brain organogenesis, homeostasis, and repair.
Neonatal sepsis is an independent risk factor for poor neurocognitive outcomes.
40
It
is hypothesized that systemic inflammation leads to microglial activation and subse-
quent oxidative injury and cell death. In vitro studies of cultured LPS-activated glial
cells show a DHA dose-dependent effect in reducing oxidative injury and attenuating
the production of proinflammatory biomarkers.
41
Furthermore, in a neonatal murine
model of cerebral hypoxic ischemic injury, provision of DHA after the brain insult
decreased the total infarction volume and thus brain injury.
42
Although, not specifically
evaluated, it was speculated that the protective effect of DHA was imparted by
reducing oxidative injury and subsequent cell death.
CHALLENGES IN DELIVERING LCPUFAS TO PRETERM INFANTS
Nutritional delivery to the preterm infant largely consists of 2 phases: the parenteral
phase, in which much of the nutritional content is delivered intravenously, and the
enteral phase, in which most of the nutritional intake is given through the gut. As
Fig. 9. Mechanisms of action of n-3 polyunsaturated fatty acids (PUFAs) in intestinal inflam-
mation. The n-3 PUFAs activate peroxisome proliferator activated receptor c (PPARc), which
inhibits the NF-kB signaling pathway. The effects of n-3 PUFAs may also inhibit TLR4. The n-3
PUFAs could also modulate fatty acid composition in cell membrane phospholipids, leading
to a decrease of inflammatory eicosanoids derived from AA and to an increased production
of antiinflammatory compounds such as resolvins. These regulatory pathways lead to
decreased generation of proinflammatory cytokines and decreased expression of adhesion
molecules, resulting in an inhibition of intestinal inflammation. (Reprinted from Marion-
Letellier R, Dechelotte P, Iacucci M, et al. Dietary modulation of peroxisome proliferator-
activated receptor gamma. Gut 2009;58:588; with permission.)
a result, delivering LCPUFAs to meet fetal accretion rates and to prevent the early al-
terations in postnatal changes in fatty acid levels must consider both phases.
Parenteral
As described earlier, the commonly used lipid emulsion in the United States, IntraLi-
pid, fails to meet the fatty acid requirements of the preterm infant. Other lipid emul-
sions are commercially available but have not received FDA approval. However, it is
not clear that even these emulsions fully meet the specific needs of the preterm infant.
Ideally, any lipid emulsion uniquely tailored for the preterm infant should meet intra-
uterine fetal accretion rates of critical LCPUFAs, which, in addition, would maintain
birth levels of these fatty acids (ie, prevent the early decline of DHA and AA and mini-
mize the increase in LA). Small trials comparing various lipid emulsions in the preterm
population indicate that currently available preparations are unable to preserve critical
LCPUFA levels and, furthermore, may lead to changes in other fatty acids, which may
pose different risks.
Forty-eight preterm infants with birth weights between 500 g and 1249 g were ran-
domized to receive a standard lipid emulsion (50:50 medium-chain triglyceride [MCT]/
soybean oil) or a study lipid emulsion containing 10%fish oil, 50%MCT, and 40%soy-
bean oil. Plasma phospholipid levels of AA, DHA, and EPA were determined at birth,
postnatal day 7, and postnatal day 14 (Fig. 10).
43
Compared with the standard lipid
Fig. 10. (A) AA; (B) DHA; (C) EPA content, as mol%; and (D) EPA/AA ratio in plasma phospho-
lipids (mean standard error of the mean) at day 0 (cord blood), day 7, and day 14. *P 5.02.
y
P<.01. (Reprinted from DAscenzo R, DEgidio S, Angelini L, et al. Parenteral nutrition of
preterm infants with a lipid emulsion containing 10% fish oil: effect on plasma lipids and
long-chain polyunsaturated fatty acids. J Pediatr 2011;159:36; with permission.)
Martin 376
emulsion group, receipt of the study lipid emulsion with 10%fish oil did not change the
overall postnatal decline in DHA and AA levels. DHA plasma phospholipid levels were
only slightly greater in the fish oil group compared with the standard lipid emulsion
group, and AA levels decreased in the fish oil group versus the standard lipid group.
There was a substantial, almost 5-fold increase in EPA (20:5 n-3) levels in the fish
oil group versus standard lipid group.
Although other small clinical trials of lipid emulsions containing fish oil have been
conducted, few have adequately described the changes in systemic fatty acid profiles
with parenteral administration of fish oil. Considering the data described earlier,
increasing the fish oil content of the lipid emulsion from 10% (Lipoplus) to 15% (SMO-
Flipid) to 100% (Omegaven) may lead to more exaggerated fatty acid profiles
compared with those described in the preceding paragraph. Thus, providing enriched
DHA and EPA substantially increases DHA and EPA levels, but because of lower de-
livery of LA and substrate competition between n-3 and n-6 fatty acids, systemic levels
of AA would decrease further. Supporting this premise are data from older, parenteral
nutritiondependent preterm infants who were switched from a predominantly soy-
bean lipid emulsion to one containing a high concentration of fish oil.
44
Over time,
plasma fatty acid patterns showed an 8-fold increase in DHA, a more than 20-fold
increase in EPA, and a substantial decrease in LA and AA levels.
Although increasing levels of DHA may be clinically desirable, a concomitant in-
crease in EPA may produce unknown but potential, adverse effects in the preterm
population. Prolific literature on the role of n-3 fatty acids in adult cardiovascular health
show biological effects of these fatty acids in inhibiting platelet-activating factor,
decreasing platelet aggregation, and increasing bleeding time.
45
In addition, n-3 fatty
acids reduce plasma triglyceride levels and the delivery of cholesterol to tissues.
Unique to EPA is the decrease in natural killer cell activity and in T-lymphocyte function
with increasing levels. All of these effects may be beneficial in an adult with cardiovas-
cular disease; however, these effects may be problematic in the preterm infant, in
whom there is a developmental bleeding diathesis and risk for intracranial hemor-
rhage, immune dysfunction, and a nutritional need for triglyceride and cholesterol pro-
duction for organ development. The decrease in AA levels seen in parallel with
enriched DHA/EPA delivery may be of concern given the critical functions that AA
serves in brain and eye development as well as overall growth. Different lipid emul-
sions need to be developed and studied to meet the unique LCPUFA needs of the pre-
term infant. It is imperative to carefully quantify the changes in systemic fatty acid
profiles with novel lipid emulsions and document potential side effects of the changing
fatty acid profiles in addition to its potential clinical benefits.
Enteral
Despite the presence of LCPUFAs in human milk as well as DHA and AA supplemen-
tation in formulas, dietary provision of breast milk or formula fails to meet the fatty acid
requirements in preterm infants
22
or fully attain the potential neurocognitive and visual
benefits of fatty acid supplementation.
39
Although some clinical trials of LCPUFA sup-
plementation have shown short-term benefits in neurocognitive outcomes and visual
motor function, these benefits are not sustained nor shown consistently in all studies.
The lack of a clear benefit of LCPUFA supplementation likely reflects inadequate
LCPUFA timing and delivery rather than a failure of clinical benefit from the fatty acid
itself. Many enteral supplementation studies have started the supplementation after
the infant has begun on enteral feedings or after the infant has achieved a substantial
daily intake by the enteral route, both of these time points well after the time when def-
icits in systemic DHA and AA levels have already occurred in the preterm infant.
Another factor complicating the enteral delivery of LCPUFAs is the ability of the pre-
terminfant to hydrolyze dietary triglycerides to allowabsorption of the resultant mono-
glycerides and free fatty acids. A measure of efficient fat hydrolysis and absorption is
the coefficient of fat absorption (CFA), which is expressed as the fraction (percent) of
the difference between total fat intake and total fecal fat losses over total fat intake. A
perfect rate of hydrolysis and absorption is 100%, with normal values being greater
than 90%. Thus, the higher the CFA value, the more efficient the hydrolysis and ab-
sorption. This value can be calculated for total fat as well as for individual fatty acids.
Total CFA and specific fatty acid CFAs for DHA and AA all show values in the 70% to
80%range in preterm infants fed formula or pasteurized human milk.
46
The lower DHA
and AA CFA values in infants fed formula and pasteurized human milk may be
accounted for by developmental pancreatic insufficiency and decreased production
of lipase as well as a reduction in bile acid pools. Preterm infants fed mothers own
milk (nonpasteurized) show higher CFA levels, likely because of the presence of bile
saltstimulated lipase in the milk, which is absent in formula and degraded in pasteur-
ized human milk.
Increasing the total content of DHA and AA in formulas to overcome the limitations in
lipid hydrolysis and intestinal absorption may be of limited value. In a lipase-deficient
murine model, enteral delivery of fats led to lipid-laden fat accumulation in the intes-
tinal enterocytes and intestinal injury.
47
Thus, the effects of surpassing the capacity
of the preterm infants ability to hydrolyze and absorb dietary fatty acids are unknown
but may be potentially harmful to the developing gut.
Enteral delivery of nutrients is preferred over parenteral administration. However,
adequate delivery of enteral fatty acids that translates to improved systemic fatty
acid profiles needs to consider and overcome the inadequacy of the current dosing
of DHA and AA in formula and breast milk to meet the fatty acid requirements of the
preterm infant. This necessity is especially important during the early postnatal period,
when the relative decrease in lipase production and bile acid pools to efficiently hydro-
lyze and absorb enterally administered fatty acids is at play.
Maternal
Another potential route to increase LCPUFA levels in the preterm infant is through
maternal strategies. An increase in the intake of maternal LCPUFAs can increase
the breast milk content of LCPUFAs, allowing for more efficient delivery to the preterm
infant. Although this strategy can lead to higher LCPUFA levels in the preterm infant
and is important in maintaining LCPUFA levels during the enteral phase of nutrition,
48
it is unlikely that this strategy alone ameliorates the deficits in LCPUFA levels that
become evident in the early postnatal period.
FUTURE DIRECTIONS
The premise that LCPUFAs are essential for neonatal health is validated given:
The presence of specialized mechanisms to enhance placental transfer from the
mother to the developing fetus
Their biological roles in fetal development, ongoing organogenesis, and regula-
tion of inflammation
Accruing promising data supporting their immunomodulatory capabilities in
ameliorating neonatal disease pathogenesis and optimizing normal development
However, before implementing new practices, either adopting new lipid emulsions
or administering new enteral formulations, careful research needs to be conducted
Martin 378
to understand the balance of what is required, for what therapeutic goal, and to mini-
mize potential harm.
Questions and concepts that need to be thoroughly considered include:
What is our therapeutic goal? Is it to fully emulate our current understanding of
fetal accretion rates? Is it to provide doses that support maintenance require-
ments to maintain birth levels of fatty acids and ongoing development? Or is it
to provide doses that target specific disease processes or inflammatory states?
What are the target levels (whole blood, plasma, tissue, or even cellular) and fatty
acid ratios that need to be attained to achieve the therapeutic goal? How are
these target levels modified, given the acuity and metabolic state of the infant?
What are the unique challenges with parenteral delivery of fatty acids versus
enteral delivery? What is the ideal formulation, including the biochemical struc-
ture, that supports fatty acid hydrolysis, absorption, and incorporation into the
target tissue?
What are biochemical assays and clinical parameters that need to collected and
evaluated to ensure the optimal balance between clinical benefit and potential
harm?
SUMMARY
The preterm infant presents a unique challenge but an exciting opportunity to define
the role of LCPUFAs in both maintenance of health and prevention of disease. Through
understanding of basic mechanisms and the pathophysiologic consequences of
altered fatty acid levels, the provision of critical fatty acids through parenteral or
enteral routes can mitigate the risk of diseases such as CLD, nosocomial sepsis,
NEC, ROP, and neurocognitive impairment. The challenge is to understand the chang-
ing nutritional and therapeutic goals along a developmental timeline with superim-
posed exposures to disease risks. The result is an effect on immunomodulatory
functions, organ development, and neuroprotection. Diligent research efforts to
further define fetal accretion requirements, mechanisms of intestinal fatty acid lipolysis
and absorption, and fatty acid metabolism and tissue incorporation will provide a
rational approach to novel therapeutic strategies.
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Martin 382
Hi gh- Protei n Formul as
Evidence for Use in Preterm Infants
Laura D. Brown, MD
a,
*, Kendra Hendrickson, MS, RD, CNSC, CSP
b
, Marc L. Masor, PhD
c
,
William W. Hay Jr, MD
a
NUTRITIONAL GOALS FOR PRETERM INFANTS AND THE NEED FOR NUTRIENT-
ENRICHED FORMULAS
The generally accepted goal for nutrition of the preterm infant is to achieve and main-
tain the growth rate and body composition of the normally growing, healthy human
fetus of the same gestational age.
1
Recent efforts to meet this goal include the admin-
istration of intravenous nutrition earlier after birth and at higher rates than previously
used and supplements to breast milk (mothers own milk and donor milk); these efforts
a
Section of Neonatology, Department of Pediatrics, Anschutz Medical Campus, University of
Colorado School of Medicine, Mail Stop F441, 13243 East 23rd Avenue, Aurora, CO 80045,
USA;
b
Department of Food & Nutrition, Anschutz Medical Campus, University of Colorado
Hospital, Mail Stop F763, 12605 East 16th Avenue, Aurora, CO 80045, USA;
c
Clinical Nutrition
Research, Abbott Nutrition, 10 Pine Ridge Loop, Durango, CO 81301, USA
KEYWORDS
Preterm

Prematurity

Enteral feeding

Formulas

Preterm formulas
Premature infant formulas

High-protein formulas

Protein
KEY POINTS
Growth rates and body composition of very low birth weight preterm infants (<30 weeks
gestation, <1500 g birth weight) require 3.5 to 4.5 g/kg/d of protein in enteral formulas (or
milks, mothers own or donor) at usual feeding rates (150 mL/kg/d); but the requirement for
protein decreases as gestational age and birth weight advance towards term and growth
rates decrease.
Both energy and protein are required in formulas to promote growth and development,
though recent studies indicate that if the protein/energy ratio in formula is too low it can
promote excess fat deposition in adipose tissue that may lead to later-life obesity and
associated complications.
Deficiencies in brain, heart, lungs, liver, pancreas, kidney, and skeletal muscle have been
found following preterm birth and the usual undernutrition that preterm infants receive;
such deficiencies can last for the lifetime of the affected infant.
Tables included in this article document formulas that are enriched in protein for preterm
infants.
are discussed elsewhere in this edition of Clinics in Perinatology by Stephens and Vohr
in their article about protein intake and neurodevelopmental outcomes, as well as
Adamkin and Radmacher in their article about the fortification of human milk for
very low birth weight infants. Human milk supplemented with bovine milkderived or
human milkderived fortifiers is the preferred enteral feeding of choice for preterm in-
fants because of its protective effects against infection and necrotizing enteroco-
litis.
24
A mainstay of nutrition for preterm infants over the past 30 to 40 years,
however, has been the use of pretermformulas or formulas designed to meet the addi-
tional protein, energy, and micronutrient requirements of the preterm infant. Preterm
formulas contain more protein (2.4 g/100 mL or 3 g/100 kcal), energy (67.6
101.0 kcal/100 mL), calcium (133146 mg/100 mL or 165180 mg/100 kcal), and
phosphorus (6781 mg/100 mL or 83100 mg/100 kcal) than standard formulas for
term infants. New generations of high-protein preterm formulas are now available
that contain even higher protein contents (2.682.9 g/100 mL or 3.33.6 g/100 kcal).
Essentially all studies have documented that inadequate nutrient intakes in pretermin-
fants have resulted in widespread postnatal growth restriction.
5,6
As a result of inad-
equate postnatal nutrition, infants are at risk for long-term growth and
neurodevelopmental impairment.
711
Adequate protein intake, similar to what the
fetus would receive in utero, is essential for the preterm infant to maintain growth,
body composition, and nitrogen balance.
COMPLICATIONS OF INSUFFICIENT PROTEIN DELIVERY TO PRETERM INFANTS
The use of fortifiedhuman milk and/or pretermformula has resulted in greater success at
achieving increased growth in weight, length, and head circumference at hospital
discharge and close-to-term gestational age.
12
Such improved growth also has trans-
lated into improved, longer-term neurodevelopmental outcomes.
1315
Nevertheless,
preterm infants develop body compositions by term-corrected gestational age that
are characterized by lower lean mass (LM) and relatively increased adiposity (particularly
in intra-abdominal regions) in comparison with normally growing human fetuses.
16,17
Furthermore, very low birth weight (VLBW, defined as birth weight <1500 g) preterm in-
fants experience marked linear growth suppression (stunting) that continues at least
2 years beyond hospital discharge and contributes to shorter stature even into adoles-
cence and early adulthood.
18
A principal reason for such continued growth delays is that
nutrition remains inadequate, especially in the first 2 to 4 weeks of life when physiologic
instability precludes consistent protein and energy delivery.
19,20
Even when aggressive
nutritional approaches are used, deficits in protein and energy still accumulate during
the hospital stay of a preterm infant.
21
In addition, providing an optimal ratio of pro-
tein/energy (P/E) that fuels normal body composition is critical. If energy content of
the formula is in excess relative to protein, whole-body growth can favor fat deposition
over LM. On the other hand, if protein is in excess relative to energy, the excess protein
may be catabolized for energy rather than to support LM growth.
Weight, length, and occipitofrontal head circumference measurements are the
mainstays of monitoring growth in the neonatal intensive care unit (NICU). They are
used to represent the growth and development of essentially all of the body organs
in preterm infants, including the brain.
22
These measurements are positively associ-
ated with neurodevelopmental outcomes in preterm infants.
8,17,23
Conversely, poor
linear growth has been implicated in worse neurodevelopmental outcomes.
11
Indeed,
several studies have shown that improved nutrition with higher amounts of protein and
energy intake in the postnatal period in the preterm infant correlates with increased
length and head circumference at term-corrected gestational age
2426
and with
D. Brown et al 384
improved neurodevelopmental outcomes at 18 months corrected age.
27
For example,
when more specific analysis of brain growth was measured, VLBW infants who were
fed with preterm formula (increased in both energy and protein) versus regular-term
infant formulas had greater caudate growth and verbal IQ at adolescence.
28,29
In
another study, when preterm infants aged less than 32 weeks with evidence of white
matter disease were randomized to receive 100% versus 120% of recommended
average intake of protein and energy, the higher energy group had greater z scores
for weight, length, head circumference, and corticospinal axonal diameter at 6 and
12 months corrected age.
30
Thus, the sequential monitoring of weight, length, and
head circumference is a reasonable marker of adequate protein delivery and predictor
of neurodevelopmental outcome.
Simple measurements of weight, length, and head circumference, however, likely
underrepresent the specific growth deficits in lean body mass, organs, and tissues
that occur as a result of suboptimal protein intake. The brain is highly reliant on protein
for neuronal growth and differentiation.
31
Fetal undernutrition in animal models has
been shown to restrict the growth and development of nearly every organ system in
the body, including the lungs,
32
heart,
33
kidney,
34
liver,
35
pancreas,
36,37
and skeletal
muscle.
38
The growth of LM depends highly on sufficient protein availability. In addi-
tion to forming the building blocks of protein within tissues, amino acids have impor-
tant effects on the regulation of muscle protein synthesis and growth factor secretion.
Amino acids increase skeletal muscle protein synthesis in adults, both under normal
postprandial conditions as well as during catabolic states, such as after trauma or
sepsis.
39,40
Increasing amino acid delivery has been shown to positively affect the
net protein balance in infants born preterm or at term.
4143
These clinical data have
been corroborated by an extensive series of studies in the neonatal piglet, which
have shown that both a mixed complement of amino acids and/or leucine supplemen-
tation increases muscle protein synthesis independent of other growth factor influ-
ences.
4447
Although linear growth is a better marker for lean body mass and organ
growth than weight alone,
11,48
there is still considerable need for more precise mea-
surements of body composition, brain growth, organ size, and organ function, so that
more optimal protein requirements can be met in the preterm infant population.
HOW MUCH PROTEIN IS NEEDED TO ACHIEVE NORMAL IN UTERO GROWTH RATES?
Preterm infants require greater amounts of protein to produce gestational ageappro-
priate rates of protein accretion than what human milk and term formulas provide.
49
Studies in normally growing fetal sheep define fractional protein synthetic and growth
rates that, when scaled to human fetal growth rates, define a requirement for protein
intake of 3.6 to 4.4 g/kg/d at gestational ages that would be equivalent to 24 to
30 weeks gestational age in human fetuses.
50,51
This range encompasses the
mean value of 4.0 g/kg/d of protein that is necessary to support normal human fetal
growth rates at 24 to 30 weeks of gestation that was estimated by the factorial
method. The factorial method uses the chemical composition of human fetuses to
determine the protein and energy requirements needed to achieve fetal weight
gain.
52,53
For example, protein accretion rates in the normal human fetus 24 to
30 weeks gestation are estimated to be 1.7 g/kg/d, with lower rates as gestation pro-
gresses toward term.
54
Energy expenditure, the energy cost of growth, and the need
for conversion of dietary protein into body protein increase this protein requirement to
2.5 mg/kg/d. Obligatory protein losses through the urine and skin are estimated at 0.7
to 1.0 g/kg/d. Thus, the total required enteral protein intake of a VLBW preterm infant
of 24 to 30 weeks gestation needs to be at least 3.5 to 4.0 g/kg/d (Table 1).
55
High-Protein Formulas 385
Protein supply in preterm formulas must also compensate for any accumulated pro-
tein deficit, which has been observed in almost all VLBW preterm infants.
19,21,24
Some
excess of protein intake over the requirements has not been shown to cause detri-
mental effects in preterm infants (up to 4.5 mg/kg/d, see later section). Additionally,
there is consistent evidence that even a small deficit in protein will impair growth.
Thus, increased formula protein concentrations are necessary to achieve a minimal
overestimate of protein requirements.
Enteral protein requirements of 3.5 to 4.5 mg/kg/d for preterm infants less than
30 weeks gestation are supported by several clinical studies that varied the amount
of protein and energy and compared them with rates of neonatal growth. Ziegler
56
analyzed data from several studies published before 1986 and showed that daily
weight gain increased with increasing protein delivery up to 3.6 g/kg/d. A follow-up
analysis showed that protein intake ranging from 3.7 to 4.3 g/kg/d in preterm infants
weighing an average of 1200 g resulted in weight gain that matches growth rates of
a fetus of comparable weight (w20 g/kg/d).
57
Studies by Kashyap and colleagues
58,59
were among the first to explore the relationship between protein and energy delivery to
the VLBW preterm infant by measuring daily weight gain and nitrogen retention in
response to 3 different formulas with varying protein delivery (2.253.9 g/kg/d) and en-
ergy content (115147 kcal/kg/d). Increased protein intake positively impacted overall
body weight, length, and head circumference growth but not subcutaneous tissue
estimated by triceps skinfold thickness (Fig. 1). At higher protein intakes, however,
excess energy intake only contributed to the increased growth of body weight, largely
accounted for by increased fat deposition. This landmark study can be credited for
guiding the P/E ratio of standard preterm formulas (2.4 g/100 mL or 3 g/100 kcal).
At a typical energy intake of 120 kcal/kg/d, standard preterm formula will provide
3.6 g/kg/d of protein.
There is still a paucity of randomized controlled clinical trials that have studied
growth, nitrogen balance, body composition, and long-term neurodevelopmental out-
comes related to different protein intakes in preterm infants. A Cochrane review in
2006 compiled the randomized controlled trials available that contrasted levels of for-
mula protein intakes defined as low (<3.0 g/kg/d), high (between 3.0 and 4.0 g/kg/d),
and very high (>4.0 g/kg/d) in neonates with a birth weight less than 2500 g. This
review included 5 randomized controlled trials (including the studies of Kashyap
and colleagues
58,59
previously mentioned) and concluded that when protein intakes
are high while other nutrients are kept constant, weight gain and nitrogen accretion
are improved.
26
Because of the limited available evidence, however, specific recom-
mendations could not be made for the administration of very-high-protein intakes
Table 1
Enteral protein and energy requirements for preterm infants by the factorial approach
Body Weight (g) Protein (g/kg/d) Energy (kcal/kg/d) Protein: Energy (g/100 kcal)
500700 4.0 105 3.8
700900 4.0 109 3.7
9001200 4.0 119 3.4
12001500 3.9 127 3.1
15001800 3.6 128 2.8
18002200 3.4 131 2.6
Data from Ziegler EE. Meeting the nutritional needs of the low-birth-weight infant. Ann Nutr
Metab 2011;58(Suppl 1):818.
D. Brown et al 386
(>4.0 g/kg/d) and conclusions could not be made about the effects of protein delivery
on the long-term neurodevelopmental outcome. A representative study by Fairey and
colleagues,
60
who randomized preterm infants to receive preterm infant formula with
3.2 versus 2.6 g of protein/100 kcal, found no difference in net nitrogen retention or
partitioning of stored energy as protein and fat. Perhaps neither of these formulas pro-
vided sufficient protein for growth relative to energy, diminishing the impact of the so-
called greater protein intake used in these studies. Essentially all other studies have
shown improved growth with higher protein intake in the formulas used. For example,
Cooke and colleagues
61
randomized preterm infants with birth weights less than
1500 g to receive preterm infant formula with higher protein content (3.0 vs 3.6 g of
protein/100 kcal) in a balanced crossover design study. Increased protein accretion
and improved weight gain without evidence of metabolic stress were observed
when infants received a protein content of 3.6 g/100 kcal. These conclusions are
further supported by several studies that, either retrospectively or prospectively,
compared improved or aggressive nutritional practice changes to historical ap-
proaches. These studies included minimum rates of protein delivery of 3.5 g/kg/d.
Consistently, improved weight, length, and head circumference measurements were
observed with increased energy and protein delivery,
25,62,63
with specific improve-
ments in LM.
64
It is important to recognize that at more advanced gestational ages, normal fetal
fractional protein synthetic rates and growth rates decline, reducing the requirement
for protein intake. At approximately 36 weeks gestation, growth rates decline toward
those of the normal full-term infant, whose protein requirements are in the range of 1.5
to 2.0 g/kg/d seen in data fromfetal sheep (Fig. 2).
65
The potential benefit of increased
protein and energy intake from preterm formulas may become less significant at more
mature gestational ages, provided that the total intake of milk or 20-kcal term infant
formulas that contain approximately 2% protein reaches or exceeds 150 mL/kg/d and,
thus, provides sufficient protein intake.
66
For the late preterm infant born at 34 weeks
gestation or greater, standard term formula (if human milk is not available) ingested in
Fig. 1. Growth rates with varying protein and energy intakes. Weight, length, head circum-
ference, and triceps skinfold thickness were determined serially in preterm infants with a
birthweight of 900 to 1750 g fed one of 3 formulas which provided the following protein
and energy intakes: 2.24 g/kg/d and 115 kcal/kg/d (group 1, dotted bars), 3.6 g/kg/d and
115 kcal/kg/d (group 2, clear bars), and 3.5 g/kg/d and 149 kcal/kg/d (group 3, striped
bars). Weight gain and rate of increase in length and head circumference were less in group
1 than in groups 2 and 3. The rate of weight gain was not significantly greater in group 3
than in group 2, but the rate of increase in skinfold thickness was greater in group 3.
* Significantly different from other 2 groups (P<0.05). (Adapted from Kashyap S, Forsyth
M, Zucker C, et al. Effects of varying protein and energy intakes on growth and metabolic
response in low birth weight infants. J Pediatr 1986;108(6):958; with permission.)
adequate volumes might be sufficient. However, a significant amount of brain devel-
opment occurs between 34 and 40 weeks gestation, including a 50% increase in
cortical volume,
67
which could be compromised if suboptimal amounts of protein
are delivered. Furthermore, brain growth in the late preterm infant is particularly
vulnerable if growth is compromised by illness. Therefore, more than 2 g/kg/d of pro-
tein might be required to achieve appropriate gestational agespecific fractional pro-
tein synthesis and growth rates in the late preterm infant. For infants born between 24
and 30 weeks gestation, nutrient-enriched transitional formulas are recommended
after discharge through 6 to 9 months corrected age because most of these infants
have considerable protein and energy deficits even at term-corrected gestational
age.
68,69
Use of a transitional formula for 6 months after discharge versus standard
term formula in VLBW infants has been shown to increase LM without increasing
percent body fat at 1 year
70
and decrease body fat, truncal fat, and fasting insulin con-
centrations at 2 years.
71
NEED FOR ADDITIONAL ENERGY AS WELL AS PROTEIN IN HIGH-PROTEIN FORMULAS
Nearly all formulas with higher concentrations of protein also have increased caloric
density from additional carbohydrate and lipid. Both energy and protein intakes are
Fig. 2. Fractional rate of protein synthesis (K
S
) over the course of gestation in fetal sheep.
Fetal sheep at varying gestational ages (term 145 days) were infused with leucine (filled cir-
cle) and lysine (open circle) radioactive tracers to determine K
S
(grams of protein per kilo-
gram of body weight per day) and compared with the fractional rate of growth (K
G
)
(grams of body weight per kilograms per day). Equivalent time periods during human gesta-
tion are shown in italics. These data show that both the fractional rates of protein synthesis
and growth decrease between 30 and 36 weeks gestation, as does the protein requirement
for growth. (From Hay WW Jr, Regnault TR, Brown LD. Fetal requirements and placental
transfer of nitrogenous compounds. In: Polin RA, Fox WW, Abman SH, editors. Fetal and
neonatal physiology. 4th edition. Philadelphia: Saunders, an imprint of Elsevier, Inc; 2011.
p. 595; with permission.)
D. Brown et al 388
beneficial for growth of body weight, length, and head circumference. Energy intake is
required for the synthesis and deposition protein and fat or, in other words, the energy
cost of growth.
72
Preterm infants need a minimum of 110 kcal/kg/d to maintain the
growth of adipose tissue that is observed in the normally growing human fetus.
73
A
series of controlled enteral feeding studies in preterm infants further examined the ef-
fects of relative protein and energy intake on the rate and composition of weight
gain.
58,59
In general, relatively more protein was synthesized and deposited in
growing lean tissue at higher protein intakes and more fat was synthesized and
deposited in growth of adipose tissue at higher energy intakes. Slightly higher
amounts of energy, more than 100 kcal/kg/d, were needed to promote lean body
growth at the in utero rate. Thus, a caloric intake of 115 to 120 kcal/kg/d will appro-
priately support a protein intake of 3.5 to 4.0 g/kg/d; more energy produces more
body fat gain, but more protein than 4 g/kg/d does not independently increase LM
gain (Fig. 3),
74
supporting that excess protein relative to energy is catabolized rather
than used for LM growth.
Thus, there is no apparent benefit of an energy intake in excess of that necessary to
assure utilization of the concomitant protein intake. Excessive energy and carbohy-
drate intakes simply result in excessive fat deposition relative to protein deposition.
In fact, evidence indicates that changes in body composition in preterm infants during
their NICU days demonstrate a relatively greater gain in body fat than would have
occurred had these infants remained in utero.
16,53,75
The potential for such rapid gains
in adiposity may lead to later-life obesity and associated complications.
48,76
These ob-
servations account for recent efforts to enhance the P/E ratio of the diets of preterm
infants, particularly to add more protein supplements to maternal and especially
mature donor breast milk.
77
Fig. 3. Protein needs of the preterm infant. In a group of VLBW preterm infants, the effect
of increasing energy intake on protein gain at different protein intakes (2.0 [diamond], 2.5
[open circle], 3.0 [open square], 3.5 [filled square], and 4.0 [filled circle] g/kg/d) was deter-
mined. In the range of suboptimal energy intake (5090 kcal/kg/d) and lower protein intake
(2.5 g/kg/d), protein gain can be improved by increasing energy intakes. At 3.0 and 4.0 g of
protein per kilogram per day, energy increases beyond 70 kcal/kg/d added no more body
protein. With energy intakes more than 100 kcal/kg/d, there was minimal further positive
effect on protein gain regardless of protein intake. (From Micheli JL, Schutz Y. Protein. In:
Tsang RC, Lucas A, Uauy R, et al, editors. Nutritional needs of the preterm infant. 1st edition.
Pawling (NY): Caduceus Medical Publishers; 1993. p. 35.)
POTENTIAL COMPLICATIONS OF HIGH-PROTEIN DELIVERY
To meet the greater needs for protein and energy required for promoting growth and
development, preterm formulas, enriched relative to human milk and term infant
formulas, have been developed and have become a mainstay of nutrition of preterm
infants. Development and widespread use of such formulas began more than 40 years
ago. Even the first protein-enriched formulas were quite successful at promoting nitro-
gen balance and growth. However, there was significant concern for adverse out-
comes of high-protein administration to preterm infants.
7880
The classic studies in
this regard by Goldman and colleagues
8183
added bovine casein to produce 4%
versus standard 2% protein concentrations in the formulas, providing up to 6.0 to
7.2 g/kg/d of protein in the supplemented group versus 3.0 to 3.6 g/kg/d in the stan-
dard formulas. Most of the infants enrolled in these studies were born between 1500
and 2000 g, which is in a weight and corresponding gestational age range that would
not require such high rates of protein intake. Furthermore, a large proportion (w50%)
of the population was born small for gestational age (SGA, <10% of weight for gesta-
tional age). If these SGA infants were small because of intrauterine growth restriction
(IUGR), it is quite likely that higher protein intakes would not have been well tolerated
because of slower growth potential. Not surprisingly, therefore, several adverse out-
comes were associated with the higher protein intake of the supplemented group,
including metabolic acidosis, fever, poor growth, higher-than-normal plasma amino
acid concentrations, and later developmental delays. Such adverse outcomes primar-
ily occurred among those infants enrolled in the studies who had birth weights less than
1300 g. Not only was the 6- to 7-g/kg/d protein supply far greater than needed by the
healthy growing human fetus of earlier gestational age but also much in excess of the
protein requirements for older preterm infants more than 30 weeks gestation. Indeed,
Kashyap and colleagues
58
produced in utero growth in preterm infants of this same
gestational age and slightly younger with 3.5 g/kg/d of protein in the enteral diet.
More recent evidence of protein overload has been reported in preterm infants fed a
formula with a P/E ratio of 3.6 g/100 kcal that provided absolute protein intakes of
4.3 g/kg/d and energy intakes of 120 kcal/kg/d.
58
This study reported higher blood
urea nitrogen (BUN) concentrations (mean 10.5 mg/dL) as well as plasma threonine
and tyrosine concentrations of more than 2 SD more than the mean umbilical cord
plasma concentrations of infants born at similar gestational ages. However, in a
more recent study, VLBW preterm infants fed a formula with the same P/E ratio and
receiving absolute mean protein intakes of 4.6 g/kg/d for 1 week had no evidence
of metabolic stress.
61
The investigators of this study acknowledged that the duration
of the intervention was short, and it is unknown whether longer-term feeding of a high
P/E ratio might affect the metabolic status of these infants. Therefore, the upper limit of
protein intake and the ideal P/E ratio remain controversial. Current evidence supports
the beneficial and safe use of formulas providing a P/E ratio of 3.2 to 3.3 g/100 kcal. At
an energy intake of 120 kcal/kg/d, a preterm formula with a P/E ratio of 3.2 to 3.3 g/
100 kcal provides protein intake of 3.8 to 4.0 g/kg/d.
56,57,84
There is still a great
need, however, for longitudinal studies to assess the effects of these intakes on
long-term outcomes of growth, body composition, neurodevelopment, and clinical
susceptibility to adult-onset diseases.
Concerns for metabolic acidosis from high-protein delivery persist, though not from
studies or experience using preterm, higher-protein formulas but from supplementing
human milk with a new, higher-protein bovine liquid human milk fortifier that was acid-
ified to provide commercial sterility (successful aseptic processing in extremely small
volumes had not been achieved at the time this fortifier was introduced). One
D. Brown et al 390
randomized, third partymasked, multicentered published study demonstrated
improved growth and no differences for other potential complications among infants
fed the liquid protein supplement versus those fed a standard powdered human
milk supplement.
77
There were, however, indications of more acidity, including signif-
icantly lower pH at 6 days, lower bicarbonate at 6 and 14 days, lower carbon dioxide
(CO
2
) at 14 and 28 days, and higher chloride at 14 and 28 days. Although in the normal
range, all of these changes were in the direction of a more acidic physiology. Two
additional studies (one randomized and only documented in abstract form and the
other retrospective) showed slower rates of growth and lower serum CO
2
concentra-
tions and greater base deficits as evidence of increased metabolic acidosis among in-
fants fed the acidified liquid fortifier compared with other infants fed powdered human
milk fortifier.
85,86
The evidence, therefore, remains insufficient to determine whether an
extra acid load used for the purpose of sterility could be detrimental or not.
High concentrations of a single amino acid or a select few amino acids can interfere
with the uptake of amino acids by the brain and other organs and protein synthesis.
Despite the importance of achieving an appropriate balance of the serum amino
acid profile, only a few studies of infants receiving preterm formulas with protein deliv-
ery of 3.5 to 4.0 g/kg/d have measured plasma amino acid concentrations. Studies that
are available show that for most amino acids, their concentrations are similar to what
would be found in umbilical cord blood, with the exception of slightly higher threonine
and tyrosine concentrations.
59,87
It is more likely that the quality of protein influences
the balance of amino acid concentrations because the whey-to-casein ratio affects in-
dividual amino acid intakes. When preterm infants received study formulas that varied
the ratio of whey to casein, the plasma concentrations of several amino acid concen-
trations differed, though no difference was observed in acid-base status.
88
Notably,
plasma threonine concentrations were increased and phenylalanine and tyrosine con-
centrations were decreased in infants fed whey-predominant formula compared with
those fed casein-predominant formula.
58,88
This effect would be exacerbated in
100%-whey preterm formulas, which are partially hydrolyzed (such as Gerber Good
Start Premature 24, Nestle , Vevey, Switzerland (see Table 3)). Large neutral amino
acids (LNAA) such as tyrosine and phenylalanine are precursors for neurotransmitters
and compete for the LNAA transporter across the blood-brain barrier. Plasma amino
acid profiles also vary between preterm infants receiving fortified human milk versus
preterm formula, which contain different whey-to-casien ratios.
89
In contrast, attention
has shifted to studies of intravenous feeding whereby almost universally total amino
acid infusion rates of 3 to 4 g/kg/d have shown plasma amino acid concentrations
less than or equal to umbilical venous plasma amino acid concentrations in normally
growing human fetuses of the same gestational age.
43,9092
Such intravenous nutrition
studies have also shown modest and appropriate increases in BUN, no significant
increases in ammonia concentrations, and no significant metabolic acidosis.
93
PROTEIN AND ENERGY REQUIREMENTS FOR THE INFANT BORN WITH IUGR
Protein and energy requirements for the infant born with IUGR from insufficient
placental nutrient supply require special consideration. These infants are often born
both preterm and SGA. Placental insufficiency produces chronic fetal growth restric-
tion, as evidenced by abnormal Doppler flow studies with high resistive indices in the
umbilical vessels, shunting of blood flow to vital organs, and preserved head circum-
ference.
94,95
Selective redistribution of blood flow away from musculoskeletal struc-
tures results in decreased LM and fat mass at the time of birth.
96,97
Because of the
lack of published data about the nutritional requirements of this population,
recommendations for the nutritional management of the SGA infant are not distin-
guished from appropriate for gestational age (AGA) preterm infants.
98
However, IUGR neonates born preterm represent a true nutritional challenge. The
goal is still to provide sufficient nutrients to achieve postnatal growth similar to that
of a normal fetus of matched gestational age, especially because they are at higher
risk of poorer neurodevelopmental outcome than AGA preterm infants.
99
However,
rapid catch-up growth, especially by providing additional energy without parallel in-
creases in linear and LM growth, might increase the longer-term risk for metabolic
complications, including visceral obesity, insulin resistance, and type 2 diabetes.
100
Little is known about how an IUGR neonate handles higher protein supplementation.
A study in 1988 by Boehm and colleagues
101
showed that with protein intakes of more
than 2.5 g/kg/d, SGA infants had higher alpha-amino-nitrogen in the serum and urine
as well as total bile acid concentrations in the serumwhen compared with AGA infants.
The differences between SGA and AGA infants became more pronounced with an
increasing protein intake, suggesting that SGA infants are more sensitive to an exces-
sive protein intake than AGA infants. Another trial randomized term SGA neonates to a
nutrient-enriched versus standard formula and found a slightly lower psychomotor
developmental index at 9 months of age in those infants receiving the enriched for-
mula.
102
It is possible that postnatal hepatic clearance of amino acids might be
compromised because of chronic reductions in hepatic blood flow in utero from
reduced umbilical blood flow and dilation of the ductus venosus that would shunt um-
bilical blood flowpast the liver.
103
Future research is needed to determine optimal pro-
tein and energy requirements in this unique population of infants.
QUALITY OF PROTEIN IN PRETERM FORMULAS
The ratio of whey to casein protein in formulas affects protein absorption, metabolism,
and concentrations of circulating amino acids. Thus, it is an important consideration
when defining protein requirements for the preterm infant. Bovine milk protein is
casein predominant (whey-to-casein ratio of 18:82), whereas human milk protein is
whey predominant (whey-to-casein ratio of 70:30), although the actual whey-to-
casein ratio of human milk is quite variable.
104
Most formulas have been modified to
more closely match the protein composition of human milk and, therefore, have
whey-to-casein ratios of 60:40. Indeed, when optimization studies were done with
cow milk protein, a whey-to-casein ratio of 48:52 was found to produce plasma amino
acid concentrations in formula-fed term infants that most closely approximated those
of the term breast-fed infant.
105
However, the absolute concentrations of amino acids
in the more rapidly growing fetus are higher than slower-growing, breast-fed term in-
fants. For preterm formulas, a higher amount of protein as well as a greater whey-to-
casein ratio are needed to achieve both growth and appropriate plasma amino acid
concentrations.
Preterm infants fed formula with a whey-to-casein protein ratio of 60:40 have well-
balanced plasma amino acids and adequate protein utilization.
87
Higher proportions
of casein cannot be handled with the same efficiency, as shown by the development
of metabolic acidosis and higher plasma tyrosine and phenylalanine concentrations
reported with formulas derived from bovine milk with a 18:82 whey-to-casein ra-
tio.
106109
The complement of amino acids derived from protein digestion and absorp-
tion are important, not just for provision of sufficient amounts of essential amino acids
but also because the balance among individual amino acids seems to be important for
producing normal cellular development and function, particularly in the brain. As dis-
cussed earlier, the type of protein used in preterm formulas may change the levels of
D. Brown et al 392
specific amino acids.
88
The whey fraction provides lower concentrations of phenylal-
anine, tyrosine, and methionine and higher concentrations of taurine compared with
the casein fraction; these amino acid patterns are reflected in blood concentrations.
Taurine in cows milk is low, which is why both term and preterm formulas are supple-
mented with taurine.
110
Unfortunately, there still is a paucity of information about
optimal intakes of specific amino acids for the preterm infant.
Earlier casein-predominant formulas also produced complications of feeding intol-
erance and, in some cases, lactobezoars in LBW infants.
111
These complications
might have been because casein more easily coagulates when acidified in the stom-
ach. However, as a result of partial coagulation, casein digestion is slower than with
whey protein. Casein protein produces a slower increase in plasma amino acid con-
centrations over a longer period of time because of slower gastric emptying and diges-
tion.
112
Whey protein produces a more rapid increase in plasma amino acid
concentrations but for a shorter duration. Differences in absorption rates based on
the whey-to-casein ratio could have important effects on amino acid metabolism. In
adults, a more rapid increase in amino acids from the digestion of whey protein will
preferentially increase protein synthesis and amino acid oxidation, whereas slow
and sustained absorption of casein protein will have a greater effect on the reduction
of protein breakdown.
112
Such studies have not been conducted in preterm infants. However, animal studies
indicate that there may be similar responses to the duration of gastric emptying and
digestion in such infants, with greater protein synthesis produced by feedings that
produced rapid increases in plasma amino acid concentrations. For example, in
neonatal piglets, Davis and colleagues showed that intermittent bolus feedings
enhanced muscle protein synthesis greater than continuous feedings,
113,114
as did
leucine boluses during continuous feedings.
115
In the clinical setting, feeding tolerance
is generally increased by intermittent, bolus feedings versus continuous feedings in
preterm infants.
116
These studies lend support to the benefit of using more rapidly
digestible whey protein formulas to promote protein synthesis and lean body mass
growth in the preterm infant.
In this regard, preterm formulas are available with 100% whey partially hydrolyzed
protein and are marketed to improve enteral feeding tolerance by enhancing amino
acid absorption into the circulation. However, such potential benefits of improved
amino acid absorption are controversial, as there is evidence that hydrolyzed protein
is not used as efficiently as intact protein.
117,118
Instead, hydrolyzed protein in human
milk fortifiers and the use of relatively hydrolyzed protein in selected infant formulas
(the Gerber preterm formula line and nonpreterm formulas, such as Pregestimil
from Mead Johnson Nutrition [Evansville, IN] and Alimentum from Abbott Nutrition
[Abbott Park, IL]) have primarily been used when gut developmental defects
Table 2
Recommended enteral macronutrient intakes for VLBW preterm infants (<1500 g)
Protein (g/kg/d) Energy (kcal/kg/d)
Protein/Energy
(g/100 kcal)
ESPGHAN 3.54.5
a
110130 2.253.1
LSRO 3.44.3 110135 2.53.6
Canadian Pediatric Society 3.04.0
b
105135 2.53.0
AAP Committee on Nutrition 3.54.0 105130 2.93.3
a
Protein intake of 4.0 to 4.5 g/kg/d for infants weighing less than 1000 g.
b
Protein intake of 3.5 to 4.0 g/kg/d for infants weighing less than 1000 g.
Table 3
Composition of preterm formulas
Protein
(g/100 mL)
Calcium
(mg/100 mL)
Phosphorus
(mg/100 mL)
Zinc
(mg/100 mL)
Protein/Energy
(g/100 Kcal) Protein Source
Standard Preterm Formulas
Enfamil Premature 24 with Iron
(Mead Johnson Nutrition)
2.4 134 67 1.2 3.0 60% whey 40% casein
a
Gerber Good Start Premature 24 2.4 133 69 1.1 3.0 100% whey partially hydrolyzed
Similac Special Care 24 (Abbott
Nutrition)
2.4 146 81 1.2 3.0 60% whey 40% casein
a
High-Protein Formulas
Enfamil Premature 24 Cal High
Protein
2.8 134 67 1.2 3.5 60% whey 40% casein
a
Gerber Good Start Premature 24
High Protein
2.9 133 69 1.1 3.6 100% whey partially hydrolyzed
Similac Special Care 24 High
Protein
2.7 146 81 1.2 3.3 60% whey 40% casein
a
International Formulas
Milupa Aptamil Preterm
(Wiltshire, England)
2.6 94 62 1.1 3.3 60% whey 40% casein
a
Nestle Partially Hydrolyzed
Premature (Nestle )
2.9 116 77 1.2 3.6 100% whey partially hydrolyzed
Cow & Gate Nutriprem 1 Low
Birthweight (Cuijk, the
Netherlands)
2.6 94 62 1.1 3.3 61% whey 39% casein
a
a
From nonfat milk and whey protein concentrate.
D
.
B
r
o
w
n
e
t
a
l
3
9
4
(gastroschisis) or injuries (necrotizing enterocolitis, inflammation reactions to bovine
milk antigen) have limited digestive capacities.
HOW DO YOU CHOOSE THE RIGHT PROTEIN DELIVERY FOR YOUR PATIENT?
After an extensive review of the literature, several expert panels and committees have
made recommendations for protein, energy, and P/E balance that VLBW preterm
infants (<1500 g) should receive from enteral feeding. Recommendations from the Eu-
ropean Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)
Committee on Nutrition,
119
Canadian Pediatric Society,
120
American Academy of Pe-
diatrics Committee on Nutrition (AAP),
121
and the Expert Panel for the American Soci-
ety of Nutritional Sciences Life Sciences Research Office (LSRO)
122
are listed in
Table 2. The recommended range of protein intake from the ESPGHAN Committee
on Nutrition is 3.8 to 4.5 g/kg/d for infants up to 1000 g and 3.5 to 4.0 g for infants
from 1000 to 1800 g.
119
LSRO concluded that the minimum protein intake of prema-
ture infants is 3.4 g/kg/d and that a protein intake of 4.3 g/kg/d is without adverse con-
sequences. There is a gap in the recommendations for preterm infants with a birth
weight of more than 1800 g or more than 30 weeks gestational age, with little exper-
imental evidence to support goals for protein, energy, mineral, and micronutrient
needs for the intermediate to late preterm infant. Further research is very much
needed for this largest portion of the population of preterm infants to establish a
rational basis for their optimal nutrition.
Several formulas available in North America are marketed as either regular protein
content or high protein content (Table 3). International formulas contain relatively
higher protein content in their standard preterminfant formulas. They do not, however,
have a high-protein designation, perhaps related to the higher minimum protein in-
takes recommended by the 2010 guidelines from the ESPGHAN for preterm infants
weighing less than 1000 g used in Europe when compared with the 2002 guidelines
from the LSRO used in the United States. The source of protein is similar between
all products with the exception of the Gerber formula, which is 100% whey and
partially hydrolyzed. The micronutrients in the North American formulas vary by
more than 10% in many cases, whereas the international formulas shown are almost
identical in composition. When feeding a 120-kcal/kg/d diet, standard preterm
Box 1
Indications for using high-protein preterm formulas
Weight less than 1500 g
Fluid/volume-restricted infants
Promotion of wound healing
Cumulative deficit of protein intake
Prolonged peripheral parenteral nutrition (limited protein content)
Inadequate parenteral nutrition caused by fluid restriction
History of feeding intolerance resulting in interruption of enteral feeds
Multiple procedures/surgeries resulting in interruption of enteral feeds
Inadequate growth in length and/or head circumference
Partial unfortified human milk feeds (eg, direct breastfeeding)
Lower energy needs but higher protein needs
formulas provide 3.6 g/kg/d of protein, whereas high-protein formulas provide a range
of 3.9 to 4.35 g/kg/d of protein. There are several clinical circumstances that may war-
rant the use of high-protein formulas for preterminfants in the NICU, which are listed in
Box 1.
SUMMARY
High-protein, preterm formulas serve an important role in ensuring adequate nutrient
and protein delivery to the VLBW preterm infant, especially when human milk is un-
available. Nutritional goals in the NICU are to match protein requirements for fractional
rates of protein synthesis and growth of the fetus of equivalent weight and gestational
age. There is sufficient evidence to support high-protein delivery in the range of 3.0 to
4.5 g/kg/d to VLBW (<1500 g) and extremely low birthweight (<1000 g) infants. The
quantity of protein delivery depends on the gestational age, birthweight, and cumula-
tive deficits in protein delivery that a preterm infant experiences. There still are gaps in
knowledge regarding the quality of protein that should be fed to the preterm infant
(balance of whey and casein, need for hydrolyzed protein) as studies that measure
the plasma amino acid profiles in rapidly growing VLBW infants are limited. The con-
sequences of inadequate protein delivery are significant and are directly related to
long-termneurocognitive as well as metabolic outcomes. Therefore, meticulous atten-
tion to quantity and quality of protein delivery to the preterm infant has the potential to
improve lean mass growth, neurodevelopment, and metabolic health in this high-risk
population.
ACKNOWLEDGMENTS
The authors wish to thank Bonnie Savone for her tireless effort at article organiza-
tion. This work was supported by the NIH-K12-HD057022 Building Interdisciplinary
Research Careers in Womens Health (L.D. Brown), University of Colorado Center
for Womens Health Research (L.D. Brown), NIH-K12-HD068372 Child Health
Research Career Development Award (W.W. Hay Jr), NIH-UL1-RR025780 Colorado
Clinical and Translational Science Institute (W.W. Hay Jr), NIH-T32-HD007186-32
Training in Perinatal Medicine and Biology (W.W. Hay Jr), NIH-R01-DK088139
Research Project Award (W.W. Hay Jr), and The Bill and Melinda Gates Foundation
OPP1061082 Grand Challenges Explorations (W.W. Hay Jr).
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Forti fi cati on of Human
Mi l k i n Very Low Bi rth
Wei ght I nfants ( VLBW <1500 g
Bi rth Wei ght)
David H. Adamkin, MD
a
, Paula G. Radmacher, MSPH, PhD
b,
*
INTRODUCTION
The American Academy of Pediatrics supports the feeding of human milk for all in-
fants, term and preterm.
1
The benefits of human milk over formula feedings include
nutritional, immunologic, developmental, psychological, social, and economic advan-
tages. In the short term, feeding human milk to very-low-birth-weight (VLBW) infants
has been associated with reductions in morbidity and mortality specifically related
to sepsis and necrotizing enterocolitis (NEC).
27
Long-termbeneficial effects of human
milk for extremely low-birth-weight infants (<1000 g) in the neonatal intensive care unit
(NICU) have also been shown from data from the Eunice Kennedy Shriver National
a
Division of Neonatal Medicine, Department of Pediatrics, University of Louisville School of
Medicine, 571 South Floyd Street, Suite 342, Louisville, KY 40202-3830, USA;
b
Neonatal Nutrition
Research Laboratory, Department of Pediatrics, University of Louisville School of Medicine, 511
South Floyd Street, Room 107, Louisville, KY 40202, USA
KEYWORDS
Very low birth weight infants

Preterm human milk

Human milk fortification

Postnatal growth restriction

Neurodevelopment
KEY POINTS
Human milk is the preferred feeding for all infants.
Preterm human milk has immunologic and neurodevelopmental benefits for very-low-
birth-weight and extremely low-birth-weight infants that persist beyond the neonatal
intensive care unit hospitalization.
Preterm human milk is nutritionally inadequate, especially in protein, to fully support the
growth needs of the very-low-birth-weight and extremely low-birth-weight infant.
Several products and strategies are available to fortify preterm human milk.
Human milk analyzers can be used to gain information about nutrient content before add-
ing fortifiers.
Institute of Child Health and Development Neonatal Research Network.
8
Nutrition data
collected on 773 such infants showed positive effects related to human milk intake in
developmental outcomes at 18 months of age. At 30 months, increased receipt of
human milk during NICU hospitalization was associated with higher Bayley Mental
Developmental Index (MDI) scores, higher Bayley behavior score percentiles for
emotional regulation, and fewer hospitalizations between discharge and 30 months.
8
For each 10 mL/k/d increase in receipt of human milk, the MDI increased 0.59 points.
This persistence of effect far beyond the neonatal period, through 30 months of age, in
extremely premature infants provides evidence that providing mothers milk to VLBW
infants should be a priority in the NICU and after discharge.
In addition, infants receiving their mothers milk show
Improved gastrointestinal function, digestion, and absorption of nutrients
9
Improved cognitive
1012
and visual development
11,13
Improved host defense with reduced rates of infection (sepsis, NEC, and urinary
tract infection)
14,15
Less respiratory illness
11
Enhanced maternal psychological well-being and maternal-infant bonding
1
More rapid attainment of full enteral feeding and shorter duration of
hospitalization
9
However, there are nutritional limitations of human milk for these vulnerable infants
that must be addressed.
PRETERM AND DONOR HUMAN MILK
There are challenges in trying to provide exclusive human milk feedings for the VLBW
infant and to meet nutritional requirements: inadequate milk supply of the mother, the
high variability in nutrient content of the milk itself,
1619
clinically necessary volume re-
striction in some infants, and the nutrient limitations of the milk itself. Human milk
composition is known to vary with volume and method of milk expression, the time
of day, the type of milk obtained (foremilk or hindmilk), and the stage of lactation.
2023
There may be 2-fold to 3-fold differences in protein and fat (energy) regardless of the
stage of lactation simply because of these factors (Fig. 1).
16,24,25
In the latest recommendation from the American Academy of Pediatrics Committee
on Breastfeeding Medicine, donor human milk (DHM) should be used when mothers
milk is unavailable.
1
DHM is generally term in quality and has been pasteurized to
reduce the risk of infection. Pasteurization decreases the activity of many bioactive
factors that have roles in protecting the infant from infection and preparing the gastro-
intestinal systemfor extrauterine life.
2630
In addition, the processing of DHM(thawing,
pooling, pouring into new containers, and so on) most likely decreases fat and pro-
tein.
31
Thus, although DHM is preferable to bovine-based formula as a substitute for
preterm human milk (PHM), both are inadequate to meet the nutritional needs of the
VLBW infant without multicomponent fortification.
18
Until recently, those fortifier prod-
ucts have been derived from cow milkbased products, which may reduce the bene-
ficial effects of human milk administration.
When VLBW infants receive insufficient amounts of nutrients, poor growth is ulti-
mately observed and is a surrogate for inadequate nutrition. Slow growth because
of inadequate nutrition is associated with poor neurocognitive outcome.
32,33
Substan-
tial evidence suggests that it is mainly inadequate intake of protein that is responsible
for these outcomes.
32,3436
Although energy is important, it plays much less of a role
as a cause of slow growth. Although the exact requirements of vitamins, minerals, and
Adamkin & Radmacher 406
micronutrients for preterm infants are not exactly known, they are not normally prob-
lematic, although there are occasional reports of deficiencies.
37,38
Modest shortfalls or
excesses of these nutrients do not seem to cause problems.
39
MACRONUTRIENT REQUIREMENTS OF THE VLBW INFANT
Because the neonatal period represents a critical time in which the brain is especially
vulnerable to nutritional deficits, attention to the details of nutritional management is
critical. Neither insufficiency nor excess is desirable. The specific deficits (primarily
protein) of both PHM and DHM must be addressed with products that bring them in
line with recommended intakes for protein and energy. Table 1 shows protein and
protein/energy ratio recommendations based on epochs of postmenstrual age and
the need for catch-up growth.
40
Protein is limiting for growth and is essential for optimal neurodevelopment.
41
Appro-
priate protein fortification of human milk is therefore critical. Although there has been
concern that too much enteral protein is unhealthy, more recent data on requirements
Table 1
Advisable protein recommendation for growing preterm infants needing catch-up growth
Postmenstrual Age (wk) With Need for Catch-Up (g/k/d) Protein/Energy
2630 4.4 3.4
3036 3.84.2 3.3
3640 3.03.4 2.62.8
Data from Rigo J. Protein, amino acid and other nitrogen compounds. In: Tsang RC, Uauy R,
Koletzko B, et al, editors. Nutrition of the preterm infant: scientific basis and practical guidelines.
2nd edition. Cincinnati (OH): Digital Educational Publishing, Inc; 2005. p. 45.
Fig. 1. Preterm human milk protein content during 12 weeks of lactation and fortification.
(Data from Schanler RJ, Oh W. Composition of breast milk obtained from mothers of prema-
ture infants as compared to breast milk obtained from donors. J Pediatr 1980;96(4):67981.)
Fortification of Human Milk in VLBW Infants 407
have shown that VLBW infants require more protein than previously thought and that
there is a wide range of safety with current products and approaches.
39,4143
GOALS OF FORTIFICATION
The primary goal of any nutritional regimen for VLBW infants is to support a postnatal
growth rate that is similar to the intrauterine growth rate (15 g/k/d) with appropriate
body composition. To achieve that goal, there must be an adequate balance between
protein and energy (see Table 1). As the understanding of nutrient needs for VLBW in-
fants advances, products and processes have begun to adapt.
FORTIFICATION PRODUCTS
With the goal of providing preterm infants with enteral protein in the range of 3.5 to
4.5 g/k/d to support their rapid growth, current options for fortifying PHMare more var-
ied than ever before (Table 2). The Centers for Disease Control and Prevention no
longer recommend powder formulas and human milk fortifiers for preterm infants
because of the risk of bacterial contamination and subsequent bacteremia.
44,45
For women that have insufficient milk supply, 30 kcal/oz preterm formulas (PTF30)
have been used to increase the protein and to extend her limited supply. However, for
the woman that is producing adequate amounts of milk to meet her infants needs, us-
ing PTF30 as a fortifier displaces a substantial volume of PHM. The infant also receives
significant bovine antigen with each feeding, which may dilute the benefits that PHM
provides. Concentrated fortifiers increase the protein without the additional amount of
fat and carbohydrate that would be provided in PTF30.
The Enfamil Human Milk Fortifier Acidified Liquid (HMF-AL; Mead Johnson Nutrition,
Evansville, IN, USA) provides the highest amount of protein of the bovine fortifiers
(2.2 g in 4 vials added to 100 mL PHM). As a concentrated liquid, it displaces less
PHM than PTF30 and delivers less bovine antigen. However, it is possible that protein
concentrations in milk fortified with HMF-AL could exceed 5 g/k/d if the mother is pro-
ducing milk with higher than expected protein (>1.5 g/dL). If milk analysis is available,
the number of vials added to the mothers milk may be adjusted so that the final profile
meets the desired targets without exceeding them (Fig. 2).
Moya and colleagues
46
reported a study in which infants received PHMfortified with
either the HMF-AL (5 vials) or a powder fortifier (4 packets) per 100 mL. Infants
receiving the HMF-AL showed significantly better gains in weight and head circumfer-
ence at day 28 compared with infants receiving powder-fortified PHM. There were no
significant differences between groups in proportions of infants with abnormal labora-
tory values, including pH and PCO
2
.
Erickson and colleagues
47
created an in vitro simulation of acidified human milk us-
ing citric acid in place of the HMF-AL. Split samples of human milk were either acid-
ified to a pH w4.5 or left untreated. The investigators noted a significant decrease in
white cell content, total protein, and lipase activity in the treated samples compared
with the untreated samples. The clinical meaning of these changes is unknown but
the authors suggest that these effects may not be beneficial for the preterm infant.
Similac Human Milk Fortifier (Abbott Nutrition, Columbus, OH, USA), mixed as 4
vials plus 100 mL PHM, provides an additional 1.4 g protein. In its concentrated
form, it displaces less milk than PTF30 but provides less added protein than
HMF-AL. At the prescribed proportions, it is unlikely to meet recommendations (3.5
4.5 g/k/d of protein) with DHM or PHM with lower protein content.
Similac Liquid Protein additive is a sterile liquid that can boost protein content
(1 g/6 mL) in a PHM or PHM-fortifier mixture. When using PHM produced beyond
Table 2
Fortifier products
Product
Enfamil
a
Similac
b
Prolacta
c
Human Milk
Fortifier-
Acidified Liquid Premature 30 Special Care 30
Human Milk
Fortifier
Liquid
Protein D4 H
2
HMF
c
D6 H
2
HMF
c
D8 H
2
HMF
c
D10 H
2
HMF
c
Unit volume (mL) 5 As needed As needed 5 6 20 30 40 100
Mixing ratio 4 vials 1
100 mL PHM
75 mL 1
100 mL PHM
75 mL 1
100 mL PHM
4 vials 1
100 mL PHM
As
needed
20 mL 1
80 mL PHM
30 mL 1
70 mL PHM
60 mL 1
40 mL PHM
50 mL 1
50 mL PHM
Nutrients added to native human milk
Calories (kcal) 30 75 76 14 4 28 42 56 71
Protein (g) 2.2 2.27 2.28 1.0 1 1.2 1.8 2.4 3.0
Fat (g) 2.3 3.9 5.0 0.4 0 1.8 2.8 3.6 4.6
Carbohydrate (g) <1.2 per vial 8.3 5.9 1.8 0 1.8 2.7 3.6 4.5
Abbreviation: PHM, Preterm human milk.
a
Mead Johnson Nutrition, Evansville, IN.
b
Abbott Nutrition, Columbus, OH.
c
Prolacta Bioscience, Monrovia, CA. The nutrient values provided are for general reference only. They are based on target values and averages for Prolact 1H
2
HMF.
F
o
r
t
i
f
i
c
a
t
i
o
n
o
f
H
u
m
a
n
M
i
l
k
i
n
V
L
B
W
I
n
f
a
n
t
s
4
0
9
4 to 6 weeks or DHM, it is likely that protein will be more similar to term milk and be
inadequate for the growth needs of the VLBW infant. Liquid protein may be added
in conjunction with fortifier if the protein content of the native milk is especially low.
This product is designed to be an additive, not a sole nutrition source. It is supplied
in a 54-mL bottle that contains a total of 9 g of protein. Leftover product must be refrig-
erated after opening and used within 24 hours or discarded.
The ProlactPlus products (Prolacta Bioscience, Monrovia, CA, USA) are unique in
that they are concentrated human milk products. They are created in a variety
of additive concentrations (14, 16, 18, 110 kcal/oz) to provide the clinician with flex-
ibility in constructing an all-human milk feeding that can address specific issues, such
as fluid restriction, and still provide adequate protein and energy for growth (see
Table 2). The ProlactPlus products also supplement electrolytes and minerals. The
benefits of an exclusive HM diet in reducing NEC are discussed elsewhere.
APPROACHES TO FORTIFICATION
There are 3 approaches one can take to fortifying PHM:
Standard, fixed dosage enhancement of the preterm or DHM
Adjustable fortification using a surrogate for protein nutriture to modify the
dosage of fortification
Targeted (customized, individualized) fortification or fortification triggered by
poor growth and results from human milk analysis (HMA)
STANDARD FORTIFICATION
The most common strategy for fortification of human milk assumes an average
composition of human milk (native milk) at about 2 weeks of lactation (1.5 g/dL) and
Fig. 2. Pretermhumanmilk protein(g) achieved with4 different fortifiers when fed at 150 mL.
* MeadJohnsonNutrition. **Prolacta.
^
Abbott Nutrition. (DatafromRadmacher PG, Lewis SL,
Adamkin D. Individualizing fortification of human milk using real time human milk analysis. J
Neonatal Perinatal Med 2013;6:31923.)
then adds a fixed dosage of fortifier (standard, fixed dosage) (Fig. 1). This method
does not take into account that the caloric and nutrient content of the milk varies be-
tween mothers, duration of lactation, and even individual samples from the same
mother.
5,16,24,48
The resulting milk probably contains less protein and energy than
one would assume.
A recent Cochrane Review selected 13 trials that randomized (or quasi-randomized)
allocation to supplementation of PHM with multiple nutrients or no supplementation.
49
Multicomponent fortification was associated with short-term increases in weight gain,
linear growth, and head circumference. Nitrogen retention and blood urea levels
appeared to be increased. It was not clear if there was an effect on bone mineralization
itself. There were insufficient data to evaluate long-term neurodevelopmental and
growth outcomes in these studies, although there appeared to be no effect on growth
beyond 1 year.
Despite fortification, studies have shown that preterm infants fed fortified PHM
continue to grow more slowly than infants fed preterm formula.
34,43,50,51
Henriksen
and colleagues
52
conducted a study of 127 VLBW infants fed primarily fortified PHM,
evaluating nutrient intake andother relevant factors associated with extrauterine growth
restriction (body weight <10th percentile at discharge). Infants were fed their own
mothers milk or DHM that was fortified when enteral intake reached 120 mL/k/d.
They demonstrated that 58% of these infants were growth restricted at discharge.
The recommended energy and nutrient intakes for growing VLBW infants were not
achieved.
Recent studies have shown that the protein content of expressed human milk is
often lower than the assumed 1.5 g/dL
41,42
and with standard fortification would
deliver inadequate amounts of protein for the VLBW infant.
19
As mentioned above,
banked DHM, which is most often provided by mothers of term infants, is likely to
have an even lower protein content
18
and requires more than standard fortification
to compensate. Because of concerns about the consequences of high-protein in-
takes in these infants, commercial producers of HM fortifiers have chosen to design
their products for milk with a modest protein content (1.5 g/dL, representing milk pro-
duced at 23 weeks) (Fig. 1). Therefore, even when the milk protein content is at the
higher end of the possible range of protein content, the clinician is essentially guaran-
teed that protein intake would never be too high. Table 3 shows data that compare
Table 3
Macronutrient analysis results (mean SD)
Stage of Lactation
P 02 wk 24 wk 4 wk
Donor Human
Milk (term)
Protein (g/dL) 1.7 0.3 1.5 0.2 1.3 0.4 1.0 0.1 <.02 (DHM vs
PHM all stages) Range 1.32.8 1.22.0 0.91.9 0.81.1
Fat (g/dL) 3.0 0.9 3.6 1.1 3.8 0.9 2.5 0.3 .015 (DHM vs PHM
02 wk and 4 wk) Range 1.05.7 1.86.2 2.15.5 2.23.0
Lactose (g/dL) 6.5 0.5 6.6 0.3 6.5 0.2 6.1 0.4 <.005 (DHM vs
PHM all stages) Range 5.17.9 6.47.5 5.97.1 5.56.7
Energy (kcal/oz) 17.2 2.4 18.6 2.9 18.9 2.6 14.6 1.4 .021 (DHM vs PHM
02 wk and 4 wk) Range 12.424.5 13.625.7 14.223.6 13.116.6
Abbreviations: DHM, Donor human milk; PHM, Preterm human milk.
Data fromRadmacher PG, Lewis SL, Adamkin D. Individualizing fortification of human milk using
real time human milk analysis. J Neonatal Perinatal Med 2013;6:31923.
human milk macronutrient profiles over 3 separate 2-week periods of lactation to DHM
obtained from a milk bank.
53
The expected decline in protein is observed and protein
concentrations are statistically higher than that in DHM at every time point measured.
The difference in lactose is statistically significant but not clinically relevant.
53
Mean
energy is less than the assumed 20 kcal/oz and varies widely. Energy content in
DHM is the lowest of all.
ADJUSTABLE FORTIFICATION
Adjustable fortification is an approach centered on the VLBW infants metabolic
response to enteral protein intake. The amount of added fortifier (protein) is based
on changes in serial blood urea nitrogen (BUN) measurements and assumes that
BUN is the appropriate surrogate for adequate protein nutriture. In essence, this
method looks to the infant to indicate a need for more (or less) protein by an
increasing, decreasing, or static BUN response to enteral feedings. If this assumption
is correct, excessive protein intake should be avoided. It does not require the technol-
ogy and labor to conduct serial analyses of milk samples and it represents a potentially
practical method for managing the routine fortification of human milk.
This method was developed for a study comparing standard fortification (4
packets 1 100 mL PHM or DHM) with an adjustable regimen in which fortifier and/
or protein was added or subtracted from fortified PHM based on changes in serum
BUNusing a target of 9 to 14 mg/dL.
54
This study included 32 preterminfants between
600 and 1760 g birth weight. Infants were on their assigned regimens for 3 weeks,
receiving 60% of their volume of HM from their own mothers milk and 40% from
DHM. Nutrient intakes were calculated for these infants using assumed macronutrient
values and applied to the intake volume. For those in the adjustable arm, any changes
in the amount of fortifier and/or protein powder added to the native HM were included
in the final calculations. Groups were thought to be receiving comparable intakes of fat
and energy, with protein increased in the infants in the adjustable arm of the study.
Body weight and head circumference gains averaged 14 g/k/d and 0.7 cm/week (stan-
dard) compared with 18 g/k/d and 1.0 cm/week (adjustable) (P<0.01 for weight and
<0.05 for head circumference, respectively, between groups).
In a follow-up to this study, the investigators reported the actual nutrient content of
the milks used in the previous study compared with their calculated values.
41
The
assumed values for both groups were substantially lower than expected for protein.
Protein content of PHM decreases as lactation continues and is likely responsible
for the poor postnatal growth of infants with standard fortification.
The results of their study suggest that simply increasing the amount of fortifier can
be an approach for adding more protein. The assumed protein intake for infants fed
their own mothers milk or banked milk was greater than the actual intake because
of inaccurate estimates of protein content in the native milk. The result was that infants
received as much as 0.6 to 0.8 g/k/d less protein than expected. This is a significant
discrepancy that could affect growth. Another consideration is that fortifiers are multi-
nutrient products. For the purpose of protein enrichment of PHM, additional fortifier
increases not only the protein but also all of the other nutrients found in the products
(vitamins, minerals, fats, carbohydrate), which may not be desirable.
In a 2009 editorial about the adjustable fortification study, William Hay Jr. asks the
question, would an additional 1 g/k/d of protein be too much for those infants in
whom the mother has good milk protein content?
55
He concludes that it is not likely.
Many reports of human milk protein content consistently show levels in mothers milk
for preterm infants to be well under 2 g/dL.
5658
Adding 1 g/k/d of protein to such milk
would produce no more than 3 g/dL and an intake of less than 4.5 g/k/d at 150 mL/k/d.
Also, the total protein intake would decrease as the duration of lactation progresses
and protein content of the native milk naturally decreases.
TARGETED FORTIFICATION
Traditional milk analysis using reference chemical analysis, which is laborious, time-
consuming, andnot availableinreal-time, has givenway toinfraredspectroscopy.
57,59,60
These devices provide results quickly, are easy to use, and are becoming more common
for real-timenutrient analysisof humanmilk(seesectionontechnology). Informationfrom
these analyses enables the nutrition support teamto more specifically individualize forti-
fication for any preterm infant. These devices are not generally available for routine clin-
ical use.
The third strategy in human milk fortification for VLBWinfants is targeted fortification
in which the native milk is analyzed for macronutrient content and then fortified in such
a way as to reach the desired targets. This method was studied more than 10 years
ago using mid-infrared (MIR) spectroscopy to analyze macronutrients in human
milk.
58
Using the results as a guide to individualized fortification, the study aimed to
meet a protein target of 3.5 g/k/d. Ultimately, the protein intake was slightly less
than desired but infants grew at w15 g/k/d and had acceptable head circumference
growth.
Rochow and colleagues
57
reported their experience with establishing an infrastruc-
ture to perform target fortification of breast milk safely in the NICU by measuring and
adjusting for fat, protein, and carbohydrate content on a daily basis. Twelve-hour
pools of human milk for 10 prospectively enrolled infants were analyzed by near-
infrared spectroscopy (NIR; SpectraStar, Unity Scientific, Brookfield, CT, USA) and
fortified to meet macronutrient recommendations from ESPGHAN.
61
Growth patterns
were compared with similar historic controls. There were 650 pooled milk samples
analyzed; all of them required at least 1 macronutrient adjustment. Milk osmolalities
were checked for acceptability (400480 mOsm/kg) to preclude preparation errors.
Serumbiochemistries fromthe infants all fell within expected ranges. When compared
with historic controls, infants receiving targeted fortification grew at similar rates,
w20 g/k/d. There was a linear correlation between growth and milk intake among
the targeted cohort (R
2
5 0.68), which was not seen in the matched controls. Rochow
and colleagues suggest that the analytical approach allowed them to compensate for
the variable composition of the native milk.
Radmacher and colleagues analyzed 83 discrete samples of human milk using MIR
spectrophotometry (Calais Human Milk Analyzer; North American Instruments, Mur-
rieta, CA, USA).
53
Analyses confirmed that across lactation periods (02 weeks, 2
4 weeks, and >4 weeks) protein declined as expected with DHMhaving the lowest pro-
tein content (see Table 3). Fromthose samples, 3 PHMprofiles were chosen, as well as
a representative sample of DHM, to then calculate the nutrient content of those sam-
ples if they were fortified in the usual manner with a variety of products and fed at
150 mL/k/d. Milk profiles were chosen to represent expected protein and energy, ex-
pected protein but increased energy, high protein and marginal energy, and lowprotein
with lowenergy (DHM). Fig. 2 shows the calculated protein content for these samples.
As expected, all unfortified milk samples failed to meet recommendations for the VLBW
infant. Examining the various fortification strategies, one can see that the macronutrient
profile of the native milk has a substantial influence on the resulting fortified feeding. For
low protein milks (DHM or milk from women that are several weeks into lactation) or
milks that have more protein than expected, alternative fortification algorithms can
be implemented to adjust protein content (Fig. 3). Not all of these samples resulted in
milks that would deliver 120 kcal/k/d, but in the presence of sufficient protein, energy is
not growth limiting as long as it is in the range of 90 to 100 kcal/k.
41
Radmacher and colleagues also evaluated their own fortification strategies by
examining serum BUN before and during HM fortification.
56
In a study including 24
VLBW infants, pooled samples of PHM or DHM were analyzed (volume sufficient for
a 24-h period) before adding 30 kcal PTF (4 parts HM 1 3 parts PTF; Similac Special
Care 30; Abbott Nutrition) or concentrated fortifier (4 vials 1 100 mL HM; Enfamil Hu-
man Milk Fortifier Acidifed Liquid; Mead Johnson Nutrition). Milk was analyzed 1 to 2
times weekly and used to calculate the protein and energy content after fortifier was
added. Serum BUN and growth data were collected from the week before fortification
for an additional 4 weeks or until hospital discharge. Mean energy of the unfortified
milk was w17 kcal/oz and the protein content was w1.4 g/dL. Infants receiving
PHM fortified with HMF-AL received significantly more protein than infants receiving
milk fortified with PTF30, although weight and head circumference gains were not sta-
tistically significantly different at any time. By the fourth week of fortification mean
weight gain was w16 g/k/d and head circumference growth was 0.8 to 0.9 cm/
week. The mean BUN decreased significantly from approximately 17 mg/dL before
fortification, as total parenteral nutrition was weaning off, to approximately 6 mg/dL
after 1 week of fortification and even lower by the fourth week of fortification at
3.6 mg/dL.
It appears from this study that energy (90115 kcal/k/d) was not growth limiting, in
that the infants actually grew a bit more than fetal rate. BUN values were modest, even
low, in this group of infants who were experiencing acceptable growth. Thus with the
Fig. 3. Preterm human milk protein (g) achieved with alternate fortification strategies
when fed at 150 mL. * Mead Johnson Nutrition. ** Prolacta.
^
Abbott Nutrition. (Data from
Radmacher PG, Lewis SL, Adamkin D. Individualizing fortification of human milk using real
time human milk analysis. J Neonatal Perinatal Med 2013;6:31923.)
adjustable fortification strategy, more fortifier or other nutrients would have been
added to the milk when, indeed, it was probably not warranted.
Although routine HM analysis is not readily available in most nurseries, infants
showing slow growth (<15 g/k/d) or growth deceleration probably need more protein.
The addition of 1 g/k/d of protein is a reasonable approach.
55
TECHNOLOGY IN HM ANALYSIS
Currently available technology for HMA generally falls into 2 types: NIR and MIR spec-
troscopy (see Table 4). Each has been used in the dairy industry to monitor milk quality
from multiple mammalian species with appropriate calibrations for the matrix being
measured. These calibrations are based on results from well-accepted basic labora-
tory analyses, which are used to develop the computer models that convert the spec-
trometric data into quantitative results. Adaptation of these instruments for analysis of
human milk requires that calibrations be conducted with human milk in a similar
manner.
Laboratory analysis of human milk for calibration purposes relies on well-accepted
methods for protein, lactose, and fat.
62
Split samples of human milk are subjected to
laboratory and instrument analysis for each macronutrient. The computer model is
then adjusted based on these paired results to provide quantitative values for each
macronutrient.
MIR transmission spectroscopy is the Association of Analytic Communities (AOAC)
certified method used in the dairy industry for milk macronutrient analysis.
62
The
instrumentation includes a light source with filters that allow the transmission of spe-
cific wavelengths through a cuvette or flow cell, and a detector. Vibrations in the MIR
spectrumare associated with defined functional groups, which directly correlate to fat,
and lactose.
6366
The transmitted values are converted to concentrations by the spe-
cific calibration models for each macronutrient. Energy content is calculated based on
accepted values of 9 kcal/g for fat and 4 kcal/g each for protein and carbohydrate.
Casadio and colleagues
65
evaluated the accuracy and suitability of an MIR human
milk analyzer for routine macronutrient analysis (Miris AB, Uppsala, Sweden). Using
milk from term and preterm mothers at various stages of lactation, samples were
tested in the laboratory and by a human milk analyzer in their native state as well as
in dilution and altered states of skim and concentrated milk components. Although
they found some statistically significant differences between laboratory and HMA re-
sults, they concluded that the differences could be explained by chemical principles in
the laboratory methods and that they were small in relation to the variation in the
macronutrient concentrations reported for human milk and not clinically significant
Table 4
Currently available human milk analyzers
Vendors
Calais Human Milk Analyzer
a
Mid-infrared
North American Instruments, Murrieta, CA, USA
SpectraStar
Near-infrared
Unity Scientific, Columbia, MD, USA
Miris
b
Mid-infrared
Miris Holding AB, Uppsala, Sweden
a
Currently undergoing FDA review for approval as a medical device.
b
Not available in the United States.
in relation to the macronutrient intake for preterm infants. Their conclusion was that
HMA was efficient and practical for use in the nutritional management of preterm in-
fants being fed HM.
ONeill and colleagues
59
conducted a similar study in which they tested samples by
both laboratory and MIR analysis (Calais Human Milk Analyzer; North American Instru-
ments) as part of a comparison with creamatocrit. Although creamatocrit analysis
overestimated fat, and consequently energy, MIR and laboratory results for fat and en-
ergy were within 1%.
NIR devices have also been used to analyze macronutrients in human milk.
60,67
Although it is not the AOAC-approved method, NIR has been evaluated in a manner
similar to the MIR device. Sauer and Kim
60
and Corvaglia and colleagues
67
compared
NIR device results (SpectraStar; Unity Scientific and Fenir; Esetek Instruments, Rome,
Italy, respectively) with laboratory-based analyses. Both teams found acceptable
agreement between laboratory and analyzer results for protein, lactose, and fat.
Regardless of which device is used to analyze human milk samples, the inter-
woman and intra-woman variability of human milk has been reinforced in several
recent studies.
42,53,57,60
It is clear that the assumption of 20 kcal/oz and 1.5 g/dL pro-
tein is inaccurate for a large number of women who are expressing milk for their pre-
term infants. As nutritional adequacy in support of rapid growth and brain
development is extremely important during this critical period when VLBW infants
are in the NICU, data from periodic HM analysis can augment the overall nutritional
support plan. As more institutions acquire this technology and report their findings,
nurseries that do not have it may benefit from others experiences.
EXCLUSIVE HUMAN MILK FEEDING FOR PREVENTION OF NEC
NEC is the most significant gastrointestinal emergency occurring among VLBW in-
fants.
68,69
NEC remains a major cause of morbidity and mortality, with extremely
low-birth-weight infants having the highest rates of disease.
7072
When compared
with a diet of premature infant formula, preterm infants fed their mothers milk have
improved feeding tolerance and a lower incidence of late-onset sepsis and NEC.
5
The use of bovine milkbased fortifiers, while needed to improve nutritional adequacy
of PHM, may contribute to the onset of NEC.
A reduction in NEC, both medical and surgical, was reported more than 20 years ago
among infants who received only human milk when compared with infants less than
1850 g birth weight who received all bovine milkbased formula.
73
Those infants
who received a mixture of formula and human milk had an intermediate level of protec-
tion. This study preceded the use of powdered fortifiers for PHM. A contemporary
re-evaluationof this older study was donerecently, includingfortifiers as part of thenutri-
tional management of infants with birth weight of 500 to 1250 g.
7
Infants whose mothers
intended to provide their own milk were randomized to an all-human milk regimen (own
mothers milk, DHMsupplement, all human milk fortifier) or human milkbovine regimen
(human milk, bovine formula/fortifier supplement). Within the all-human milk group,
infants were fortified at 40 mL/k/d or 100 mL/k/d. The infants receiving an exclusively
human milk-based diet had significantly lower rates of NEC and surgical NEC when
compared with those that also received bovine milkbased products: 4.5% and 7% in
the all human milk groups, respectively, compared with 16% in the human milkbovine
group. Therateof surgical NECininfants receivingonly humanmilk was 1.5%compared
with 12% in those receiving the human milkbovine diet.
The background rates of NEC in the study centers were higher than that seen in
benchmark data from large networks and reports from many NICUs.
68,69
The study
was originally powered to evaluate days of total parenteral nutrition as a surrogate for
improved tolerance with exclusive human milk. However, statistical significance was
reached because of the magnitude of the NEC observed in those units. The data
from this study suggested that the number needed to treat (NNT) with an all-human
feeding protocol to prevent 1 case of NEC was 10, and the NNT to prevent 1 case
of surgical NEC or death was 8. The authors concluded that no other intervention
has had such a marked effect on the incidence of NEC.
7
It is impossible to determine whether the lower rate of NEC seen in the human milk
arm was due to the benefit of the human milk fortifier or to the benefit of giving human
milk as opposed to bovine formula milk. Another small randomized study feeding an
exclusively human milkbased diet with donor milk and the human fortifier compared
with preterm bovine milk formula showed a reduction in days of total parenteral nutri-
tion and a lower rate of surgical NEC in the exclusive human milk diet.
74
The groups
included 24 (bovine formula) and 29 (all human milk) infants with mean birth weights
of approximately 1000 g. Surgical NEC in the bovine formula group was statistically
significantly higher (17%) compared with none in the all human milk group. The au-
thors suggest that this study adds more evidence that all-human milk diets are impor-
tant for mitigating the morbidity and mortality of NEC.
In a recent letter to the editor in Breastfeeding Medicine, Embleton and colleagues
75
suggested that an unequivocal case for the use of the all human milk fortifier has not
been determined. They recommended that a definitive and appropriately powered trial
should be done to test these results further, using more common estimates of NEC
incidence.
The evidence that human milk provides VLBW infants with benefits related to immu-
nity, tolerance, and neurodevelopment is indisputable. Providing milk for her infant is
invaluable for the mother and her infant. Benefits persist through the NICU period and
beyond. However, human milk alone is nutritionally inadequate for the rapid growth of
the VLBW infant during a critical window for brain development. In 2013, there are
products and technological devices that can be used to assist the clinician in meeting
the needs of these vulnerable infants.
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Human Breast Mi l k and the
Gastroi ntesti nal I nnate
I mmune System
Brett M. Jakaitis, MD, Patricia W. Denning, MD*
INTRODUCTION
The epithelial layers and mucus secretions of the pulmonary, genitourinary, and
gastrointestinal (GI) systems all provide a complex mechanical barrier and an inherent
defense against pathogens that constantly threaten the human body. Evidence sug-
gests that these systems do not work independently, but form what is referred to as
the mucosal immunologic system, an integrated network of tissue, cells, and signaling
molecules.
1
Of the 3 systems, the lining of the GI tract provides the largest interface
with the external environment (200300 m
2
). Although it was long believed to exist
solely for food digestion and nutrient absorption, it is now known that the responsibil-
ities of the intestinal system are diverse and critical to host defense. This amazing
organ has evolved an elaborate defense system to protect the human body from
Division of Neonatology, Department of Pediatrics, Emory University School of Medicine, 2015
Uppergate Drive, 3rd Floor, Atlanta, GA 30322, USA
KEYWORDS
Mucosal innate immune system

Human breast milk

Bioactive factors
Lactoferrin

Antimicrobial peptides

Commensal bacteria

Intestinal microbiome
KEY POINTS
Newborns infants are in a susceptible immunologic state after birth, with an immature
adaptive immune system, making them reliant on their innate immune system for
protection.
The gastrointestinal innate immune system is comprised of many components. The acidic
environment in the stomach and the mucus layer of the small intestine provide an initial
barrier. The intestinal epithelial cells create a physical barrier and are involved in signaling
to the underlying tissue. The lamina propria is rich in immune cells and contributes greatly
to intestinal defense.
In addition to providing optimal nutrition to infants, human breast milk has an abundance
of bioactive factors that act as a part of the innate immune system of the gastrointestinal
tract. Some factors have intrinsic properties that act as part of the defense system,
whereas others enhance the ability of the gastrointestinal tract to defend the host.
continuous threats of numerous disease-causing agents and commensal bacteria
present at an impressive number (1 10
14
CFU).
2
At no time in life is this function
more important than shortly after birth. The infants abrupt introduction to life outside
the uterus and exposure to antigens forces the GI tract to adapt quickly and
commence its crucial duties. But the neonates adaptive immune system is naive,
and the developmental immunologic immaturity leaves the newborn in a state of
vulnerability and at increased risk for serious infection. Components of the intestinal
innate immune system do not rely on memory and can act with a preformed, nonspe-
cific response.
Feeding exclusively with human milk is recommended for the first 6 months of life
3
and provides unique components and nutrients, leading to optimal nutrition, growth,
and development of the newborn infant.
4
The benefits of human breast milk and its as-
sociation with healthier babies have been intermittently noted over the past few thou-
sand years.
5
In 1934, Grulee and colleagues
6
showed that formula-fed infants had
higher morbidity and mortality when compared with breastfed infants. More recently,
breast milk has been associated with a decreased incidence of necrotizing enteroco-
litis (NEC),
7
gastroenteritis,
8
severe respiratory illness,
9
otitis media,
1014
and urinary
tract infections.
15
The unique and dynamic composition of human milk not only sup-
plies optimal nutrients but also contributes an abundance of bioactive factors,
16
which
support and enhance the deficient immunologic system of the newborn.
In this article, selected factors in breast milk and howthey either act alone to provide
innate protection or augment GI innate immune function are reviewed. First, a broad
and brief overview of innate immunity within the intestinal system is provided. Then,
individual constituents present in human breast milk and the variety of mechanisms
by which they exert their effects and afford protection to the newborn infant are
discussed.
THE INNATE IMMUNE SYSTEM OF THE GI TRACT
The complex immune system of the intestine can be divided into 2 broad categories:
innate and adaptive immunity. Although the innate arm, as its name implies, is present
from birth and capable of immediate protection at the local level, the adaptive immune
system of the gut is initially naive and needs time to generate an appropriate response
and memory. Although much of our focus is on the components of innate immunity in
the gut, it is important to remember that this system does not work in isolation. The
information it gathers communicates with the adaptive immune system, allowing the
2 to work in concert to provide optimal protection for the host. The innate defense sys-
tem of the intestine can be broken down into 3 main components: the secreted mucus
layer within the gut lumen, a single intestinal epithelial cell (IEC) layer, and the under-
lying lamina propria.
Mucus Layer
Large, highly glycosylated proteins called mucins are secreted by specialized goblet
cells,
17,18
also known as mucin-secreting cells, and are the primary component of
mucus. The mucus layer, which is present throughout the GI tract, provides protec-
tion, lubrication, and compartmentalization, minimizing contact between the epithe-
lium and commensal bacteria. Mucins secreted by salivary glands coat food and
assist with esophageal transit.
19
The mucus layer in the stomach plays a role in pro-
tecting the epithelium from the harsh acidic environment.
19
The gel-forming mucin,
MUC2, is the most predominant mucin in both the small and large intestine.
20
There
is 1 unattached layer of mucin in the small intestine, which acts as a physical and
Jakaitis & Denning 424
chemical barrier, preventing pathogenic bacteria from contacting the intestinal
epithelia.
21
The colon has 2 distinct mucus layers, with the outer layer containing
many bacteria and the inner layer being resistant to bacterial penetration.
22
Attached
to the apical side of enterocytes in the small intestine is a separate, thin layer of mucus,
made up of transmembrane mucins. This layer is commonly referred to as the glyco-
calyx; it affords protection to the IECs by means of a physical barrier and plays a role in
cellular signaling.
23
An abnormal mucus layer may lead to both acute and chronic
intestinal diseases and has been shown to be associated with colitis in a murine
model.
24
Antimicrobial peptides (AMPs), a critical element in the chemical response of the
innate immune system, are released into the mucus layer of the intestine. These small
peptides (2040 amino acids long) are secreted by the Paneth cell, a pyramidal
columnar exocrine cell located at the base of the crypts of Lieberku hn, and can
respond to a threat within a matter of hours. The continual release of AMPs by Paneth
cells maintains the relatively sterile environment of the intestinal crypt, where the intes-
tinal epithelial stem cells reside. When stimulated by inflammatory mediators, AMPs
are also secreted into the lumen to help with mucosal defense.
23
They have microbici-
dal activity against a wide range of pathogens, including many gram-negative and
gram-positive bacteria, fungi, protozoa, and viruses.
18
Paneth cell dysfunction has
been shown to lead to decreased clearance of pathogenic Escherichia coli.
25
Several
AMPs are present in the neonates intestine. Some of the most important and abundant
are a-defensin, b-defensin, lysozyme, and LL-37 (a member of the cathelicidin family).
IECs
The intestinal epithelial layer is made up of 4 different types of cells: absorptive enter-
ocytes, hormone-secreting enteroendocrine cells, mucus-secreting goblet cells, and
antimicrobial-secreting Paneth cells. These cells mature from a common pluripotent
stem cell located in the base of the crypts. This single layer of highly polarized IECs
sits below the mucus layer, creating a physical barrier that is anchored by junctional
proteins. They are also responsible for sampling intraluminal contents, which insti-
gates transcellular signaling and transcription of genes, resulting in a defense
response via the release of cytokines and chemokines and subsequent attraction of
leukocytes. This function is mediated by multiple pattern recognition receptors
(PRRs), critical for the identification of foreign elements such as peptidoglycan, lipo-
proteins, viral DNA, and commensal microflora. The remarkable ability of these recep-
tors to distinguish between harmful and helpful bacteria with subsequent appropriate
signaling is critical to intestinal homeostasis.
26
Toll-like receptors (TLRs) are the pre-
dominant type of PRR found on the apical side of IECs. Another group of PRRs that
cooperate with TLRs are the intracellular NOD-like receptors (NLRs). NOD1 is
expressed by IECs, and NOD2 is found in monocytes, dendritic cells, and Paneth
cells.
23
Tight junctions (TJs) regulate paracellular permeability and maintain separation of
tissue compartments by sealing the intercellular space
27,28
and are an essential
component of the epithelial barrier. A breakdown in the functioning of TJs and, subse-
quently, the intestinal immune barrier has been implicated in the pathogenesis of idio-
pathic inflammatory bowel disease,
29,30
infectious enteritis, and NEC.
31
Three types of
proteins make up TJs: occludins, claudins, and junctional adhesion molecules.
Although not much is known about the occludin proteins, it is known that the family
of claudin proteins control the size, strength, and specificity of the ions that can
pass through the epithelium.
23
In addition to TJs, adherens junctions are present on
the lateral side of the epithelial cells and facilitate intercellular signaling.
Breast Milk and the GI Innate Immune System 425
Lamina Propria
A comprehensive reviewof the innate and adaptive immune functions occurring within
the lamina propria is beyond the scope of this article. Further, the gut-associated
lymphoid tissue include Peyer patches, isolated lymphoid follicles, and M cells, which
are not discussed in this review. Intraepithelial T-cell lymphocytes have also recently
been recognized as an important innate immune cell, which is critical for host-
microbial homeostasis and protects the gut from injury.
32
The lamina propria contains
many innate immune cells; the functions of these cells are being elucidated in ongoing
animal and human studies. Among these cells are macrophages and dendritic cells;
their roles include antigen uptake and transport, induction of T-cell differentiation,
stimulation of immunoglobulin production (IgA), and tissue repair.
33
Macrophages
and dendritic cells are also important for maintaining tolerance to the commensal
microbiota.
33
In addition to different populations of T-cell and B-cell lymphocytes pre-
sent in the lamina propria, innate lymphoid cell populations have recently been
described, including natural killer cells, which are purported to play important roles
in producing proinflammatory and regulatory cytokines.
34
There certainly are other components of the innate immune system, which are not
discussed here but are important. One simple example is the acidic and bacteriocidal
environment of the stomach, which not only aids in digestion but also decreases the
number of viable pathogens reaching the distal intestine. The disruption of this milieu
can lead to disease. Multiple studies have revealed an association between the use of
histamine 2 blockers, which inhibit gastric acid secretion, and both NEC and late-
onset sepsis.
3538
INNATE IMMUNITY AND HUMAN BREAST MILK
Human infants are born with certain developmental immune deficiencies.
39
Phagocyte
function and responses are immature and inadequate. Antibody production is limited
and delayed, and serum IgA levels are far lower than adult levels. Both the classic and
alternative pathways of the complement cascade have decreased performance. In
addition to nutritive components, the ingestion of human breast milk delivers
numerous antipathogenic and antiinflammatory bioactive factors
40
that provide pas-
sive protection to the neonate and stimulate maturation of host intestinal defenses.
This factor is particularly relevant for premature infants, whose immune defenses
are more immature than term neonates. The milk of mothers who give birth prema-
turely contains higher amounts of phagocytes and secretory immunoglobulin A
(sIgA).
4143
Breast milk is capable of directly modulating the development of the
immune system,
44
as breastfed infants have been shown to have a reduced incidence
of allergic disease
45
and autoimmune diseases such as Crohn disease
46
and insulin-
dependent diabetes mellitus.
47
These collective properties make breast milk the gold
standard for providing protective nutrients to the newborn.
48
The Intestinal Microbial Environment
Colonization of the infant gut with more than 400 species of commensal bacteria lays
the foundation for a healthy microbiome, which contributes to immune homeostasis,
setting up a symbiotic relationship between colonizing bacteria and the underlying
epithelial cells and lamina propria.
49,50
Barrier function, mucin and IgA secretion,
inflammation, and homeostatic processes such as proliferation and apoptosis are
influenced by these helpful bacteria.
5156
Their effects on the intestinal immune system
are believed to be largely mediated through TLRs present on IECs, which are able to
distinguish between commensal bacteria and harmful pathogens.
57
Normal
colonization begins at the time of birth with a vaginal delivery, when the infant is
exposed to maternal vaginal and colonic bacteria. This process is followed by an
exclusive diet of human milk, which contains factors that promote the growth of
commensal bacteria. Distinct differences have been shown in the intestinal flora of
breastfed and bottle-fed infants.
58
Oligosaccharides are nondigestable sugars found in breast milk and are believed to
be responsible for promoting the growth of protective bacteria in the colon. They make
up approximately 1% of the milk and 10% of the caloric content,
59
although the
amount present varies diurnally and with duration of lactation and the infants gesta-
tional age.
60
The presence of a nonnutritional substance at such high concentrations
led to the hypothesis that glycans, including oligosaccharides, play a role in protection
against disease. Because they are indigestible, oligosaccharides pass through the
small intestine and enter the colon. Here, they produce short-chain fatty acids through
fermentation, creating a favorable environment for the growth of probiotic bacterial
species such as bifidobacteria and lactobacilli. This factor leads to a stable ecosystem
in the intestine and augmentation of intestinal host defenses. The stimulation of sIgA-
producing plasma cells in the intestine by these commensal bacteria is 1 such
example of this symbiotic relationship.
61
Furthermore, glycans can inhibit binding of
pathogens to the intestinal cell wall by acting as ligands, attaching to various bacteria,
toxins, and viruses.
62
sIgA
In the human adult, large amounts of sIgA are produced daily by plasma cells in the gut
and transported into the intestinal lumen. This abundant antibody coats both harmful
and commensal microorganisms, preventing colonization and penetration of the
mucosal barrier, and it may even be able to inactivate certain viruses.
63
In the full-
term newborn gut, plasma cells responsible for producing sIgA are absent for about
10 days after birth, and it takes up to 30 days postpartum for the neonatal intestine
to produce levels of sIgA that are sufficient for protection.
64
To compensate for this
deficiency, maternal milk contains large amounts of sIgA, which accounts for 90%
of total immunoglobulins in milk. More than 50 years ago, it was discovered that there
was up to 12 g/L of sIgA in human colostrum and 1 g/L in mature milk.
65
When
secreted by the infants gut, sIgA can be considered a part of the innate immune sys-
tem, but when sIgA is ingested in mothers milk, it works through a unique system of
immunity whereby the infant acquires protection from enteric pathogens to which the
mother is exposed. First, within the mothers intestine, a novel enteric pathogen is pre-
sented to the dendritic cell. Next, activated T lymphocytes stimulate B lymphocytes,
inducing the production of IgA by plasma cells at the basolateral side of the mammary
epithelial cell. IgA is then transported across the epithelial cell attached to the polyim-
munoglobulin receptor. On the apical side, the complex is cleaved, and dimeric sIgA is
secreted into the milk, conferring immunity to the nursing infant.
66
Selected Bioactive Proteins in Breast Milk with Antipathogenic Activity
Lactoferrin
This multifunctional, iron-binding glycoprotein possesses many anti-infective proper-
ties that act as part of the innate immune system and is present in mature human
breast milk at concentrations of 1 to 3 g/L and in colostrum at 7 g/L.
67
It also occurs
naturally in most exocrine fluids such as tears, saliva, bile, and pancreatic secretions.
A recent study performed in very lowbirth weight infants showed that administration of
bovine lactoferrin (LF), which is nearly homologous with human LF, either alone or in
combination with LGG, can reduce the incidence of late-onset sepsis caused by
bacteria and invasive fungal infections.
68,69
Antiviral properties have also been shown
against a wide range of viruses, including human immunodeficiency virus, cytomega-
lovirus, herpes simplex virus, hepatitis B and C, adenovirus, and rotavirus.
70
Many modes of action have been discovered by which LF acts to provide protection
to the neonate, including its high affinity for iron, which may limit the amount of iron
available to bacteria and other microorganisms. When LF is exposed to pepsin in
the stomach, a potent antimicrobial agent is produced called lactoferricin, which is
capable of killing a wide range of pathogens and, in particular, disrupts the cell mem-
brane of gram-negative bacteria.
71
Another factor contained in breast milk, lysozyme,
acts together with LF in the stomach to kill gram-negative bacteria.
72
Intact LF is
passed into the small intestine and can bind to multiple receptors, including TLRs
and CD14, blocking the adherence of pathogens to the intestinal epithelium.
73
Other
beneficial actions of LF in the intestine include initiation of apoptosis in infected
IECs,
74
promotion of growth of commensal bacteria,
75
stimulation of proliferation
and differentiation of IECs,
76
and a reduction in inflammatory cytokine production
through inhibition of nuclear factor kB activation in monocytes.
48,77
LF continues to
be at the forefront in the fight against systemic infections and NEC in premature in-
fants. There are multiple ongoing clinical trials studies looking at the effects of either
bovine LF or human recombinant LF.
Lysozyme
This antibacterial enzyme is present in breast milk at relatively high concentrations. It
can act alone to degrade bacteria by cleaving b,1-4 glycoside linkages in their cells
walls.
78
As mentioned earlier, the activity of lysozyme can be increased through its
relationship with LF. This expansion of its capabilities is accomplished when LF dis-
rupts the outer membrane of gram-negative bacteria, such as Salmonella typhimurium
and E coli. Lysozyme can then enter the bacteria and destroy it.
72
Caseins
This family of highly glycosylated proteins makes up about 40% of the protein present
in human milk and has immunologic activity in the newborn. b-casein is the predom-
inant casein found in human milk. A synthetic peptide of b-casein has been shown to
stimulate the expression of MUC2 genes and increase the numbers of goblet cells and
Paneth cells in the small intestine of a rat pup model.
79
As discussed earlier, MUC2 is
the most prevalent mucin in the mucus layer of the small intestine and provides pro-
tection through multiple mechanisms. k-Casein is a minor casein subunit in breast
milk.
80
It can act as a receptor analogue, preventing the attachment of bacteria to
mucosal epithelium
81
and inhibit binding of Helicobacter pylori to human gastric mu-
cosa in vitro.
82
Cytokines and Chemokines Found in Human Milk
The gut of the newborn lacks the ability to respond appropriately to foreign pathogens
and, more specifically, the capacity to produce a contained inflammatory response.
There is a tendency toward excessive inflammatory signaling, as shown in immature
IECs when exposed to inflammatory stimuli such as interleukin 1b (IL-1b), tumor
necrosis factor a, and lipopolysaccharide, with an increased release of IL-8,
48,83
a
chemokine known to stimulate neutrophil recruitment.
84
Cytokines are responsible
for mediating, regulating, and modulating immune responses. Human breast milk
contains a significant amount of this diverse group of signaling molecules, which
help control the inflammatory response. For example, the antiinflammatory cytokine,
IL-10, is present in breast milk
85
and believed to be critical for intestinal homeostasis
and protection of the host. IL-10deficient mice develop chronic enterocolitis,
86
and
human infants with defects in the genes encoding IL-10 receptor subunit proteins
have severe early-onset colitis.
87
With regard to NEC, IL-10 knockout mice have
increased intestinal inflammation and increased apoptosis of IECs when exposed to
hypoxia and formula feeding,
88
and the feeding of maternal milk in a rat model led
to a reduction in the severity of NEC and increased intestinal IL-10.
89
Claud and col-
leagues
83
found that IL-10 and transforming growth factor b (TGF-b) both decreased
IL-8 secretion by fetal human enterocytes in vitro.
The TGF-b family of immunoregulatory cytokines have been shown to be involved in
wound healing, the inhibition of inflammation by decreasing the production of proin-
flammatory cytokines, and the regulation of lymphocytes, natural killer cells, dendritic
cells, macrophages, and granulocytes.
90
Neonates have decreased expression of
TGF-b,
91
but maternal milk supplies sufficient levels of the much-needed cytokine.
92
Exogenous supplementation can have a significant impact on the developing mucosal
immune system, through its effects on oral tolerance and regulatory T cells. Infants
breastfed by mothers with increased levels of TGF-b in breast milk have a decreased
risk of wheezing and atopic dermatitis in childhood.
93,94
In direct relation to the innate
immune system, TGF-b can also initiate local production of IgA in the gut, providing
additional protection.
95
Development and Repair of the GI Epithelium
With exposure to multiple factors in amniotic fluid and human breast milk, growth and
differentiation of the intestinal epithelium peak shortly after birth. Epidermal growth
factor (EGF) is a peptide that augments IEC proliferation and differentiation
96
and is
secreted by multiple cells throughout the GI system into the intestinal lumen. EGF is
supplied by amniotic fluid throughout pregnancy, whereas the infant in the postnatal
period relies on the significant concentrations of EGF found in human milk and colos-
trum. Milk from mothers who have delivered an extremely premature infant contains
50% to 80% more EGF when compared with milk from mothers with full-term in-
fants,
97
leading to speculation that EGF may be one of the reasons why human milk
is protective against NEC.
98
Enteral administration of EGF resulted in a 50% reduction
of NEC in a rat model.
99
More specifically, EGF has been associated with increased
goblet cell density and MUC2 production in the ileum, and normalization in the expres-
sion of the intestinal epithelial TJ proteins, occluding and claudin, resulting in improved
intestinal barrier function.
98,100
Another protein found in human milk that is capable of
contributing to the development of the epithelium is LF. In addition to its antibacterial
activity discussed earlier, experiments in human intestinal cell lines have shown that
LF, which peaks in colostrum, induces cell proliferation at high concentrations and
cell differentiation at low concentrations.
76
Other Active Components in Breast Milk
Leukocytes
During early lactation, human milk contains large amounts of macrophages (up to 80%
of total cells present), and an infant may consume up to 10
10
maternal leukocytes per
day.
16
Breast milk phagocytes, which are believed to be derived frommaternal periph-
eral blood monocytes, possess unique functional features. One study showed that
after phagocytosis of breast milk components, the phagocytes were capable of spon-
taneously producing granulocyte-macrophage colony-stimulating factor and differen-
tiating into dendritic cells.
101
There is speculation that these cells possess many more
functions that we do not yet know about.
Triglycerides
The fat or triglyceride found in human milk is a key constituent for infant nutrition and
growth. It also has an additional function. When the triglyceride enters the stomach, it
is digested by lingual and gastric lipases. This process releases free fatty acids and
monoglycerides. These products act as a part of the innate immune system in the
stomach and provide immediate protection to the newborn infant through their lytic
effect on various viruses and some antibacterial and even antiprotozoal activity, spe-
cifically against Giardia (Table 1).
39,66,102
SUMMARY
The neonatal intestine faces many changes, including adaptation from a sterile intra-
uterine environment to one in which a diverse microbial population outnumbers human
cells 10 to 1. To maintain homeostasis, it must protect the host from potential noxious
and infectious stimuli and tolerate the diverse commensal microbes that colonize the
entire gut. Furthermore, the gut must also perform important digestive and absorptive
functions. Human breast milk contains many components that aid neonatal gut func-
tion and development. Understanding both neonatal gut immunity and how breast
milk components influence its development and function are areas of active investiga-
tion. Future studies in this field are needed to develop targeted strategies to prevent
and treat neonatal gut injury and infection, particularly in extremely low birth weight
and premature infants.
Table 1
Selected components present in human breast milk that act as part of the GI innate immune
system
Component in
Breast Milk Action Reference
Oligosaccharides
(or prebiotics)
Promote growth of commensal bacteria
Directly bind pathogenic bacteria and viruses
62
Secretory IgA Coats harmful and commensal bacteria, preventing
penetration of the epithelial barrier
63
LF Binds iron within gut and limits its availability to
microorganisms
Produces lactoferricin when exposed to pepsin
Binds receptors, interfering with pathogen binding to the
epithelial barrier
Stimulation of proliferation and differentiation of IECs
Reduces inflammatory cytokine production
Induces IEC proliferation and differentiation
48,71,73,76,77
Lysozyme Degrades bacterial cell walls
78
Casein proteins Increase numbers of goblet cells, Paneth cells, and
expression of MUC2 genes
Can act as receptor analogues
79,81
IL-10 Attenuates inflammation in the gut
83
TGF-b Stimulates local production of sIgA in the gut
Regulation of multiple types of immune cells
95
EGF Increases goblet cell density and MUC2 production in ileum
Normalizes expression of TJ proteins
98,100
Free fatty acids and
monoglycerides
Antiviral, antibacterial, and antiprotozoal activity in
stomach
39,66,102
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Donor Human Mi l k for
Preterm I nfants
What It Is, What It Can Do, and What Still Needs to
Be Learned
Tarah T. Colaizy, MD, MPH
INTRODUCTION
Donor human milk is not a new idea, with wet-nursing being a common practice for all
of recorded history. The Code of Hammurabi, written in 1770 BC, outlines punishment
for wet-nurses whose charges die,
1
and Soranus laid out ideal attributes for wet
nurses in first century AD Rome.
2
Milk banking began in France in the 1800s, with
the first human milk bank formed in the United States in Boston, Massachusetts, in
1912. In 1934, the Dionne quintuplets were fed an estimated 237 L (8000 oz) of milk
donated by women from Toronto, which was shipped to their rural Ontario home by
train.
3
As evidence of differences in outcomes of very low birth weight (VLBW) infants fed
maternal human milk compared with those fed infant formula has mounted, donor hu-
man milk has become an increasingly used intervention when maternal milk is unavai-
lable. Use of maternal milk during the birth hospitalization in VLBW infants has been
Carver College of Medicine, Department of Pediatrics, University of Iowa, 200 Hawkins Drive,
8809 JPP, Iowa City, IA 52242, USA
KEYWORDS
Donor human milk

VLBW infant

Neurodevelopmental outcomes
KEY POINTS
Donor human milk is different from maternal milk, and although similar or equivalent ben-
efits might be postulated, high-quality evidence for benefits of donor milk use in very low
birth weight (VLBW) infants in the era of routine human milk fortification is sparse.
There is a significant body of evidence that maternal human milk use results in superior
outcomes in multiple domains (infection, neurodevelopment) compared with formula diets
in VLBW infants.
Donor milk is an appropriate choice for VLBW infants whose maternal milk is either insuf-
ficient in quantity or unavailable.
associated with lessened in-hospital morbidity including lower rates of necrotizing
enterocolitis (NEC),
48
late-onset sepsis,
4,5
bronchopulmonary dysplasia,
4,9
the com-
posite outcome of NEC or death,
10
and severe retinopathy of prematurity.
7
Maternal
milk diets have also been associated with shorter hospital stays
4
and lower incidence
of rehospitalization
9
than preterm formula diets. Most important for lifelong benefit,
maternal milk intake in preterm infants has also been associated with superior neuro-
developmental outcomes compared with formula diets, measured at 18 to 22 months,
9
30 months,
11
and 7 to 8 years,
12
with demonstration of a significant dose-response
relationship.
9,12
Donor human milk, dispensed as a pooled, pasteurized product from accredited
milk banks, is used as a replacement for infant formula when maternal milk is insuffi-
cient or unavailable to the VLBW infant. Most donor human milk dispensed in the
United States and Canada to preterm infants comes from the member banks of the
Human Milk Banking Association of North America (HMBANA). Growth in milk banking
in North America has been brisk over the past decade, with 6 banks dispensing in
2003 and 16 in 2013, with 3 more in the development phase. In 2011, the member
banks of the HMBANA dispensed more than 64,470 L (2.18 million ounces) of donor
milk, up from 32,530 L (1.1 million ounces) dispensed in 2007.
13
Donor milk is also
available commercially, from Prolacta Bioscience (Monrovia, CA).
Donor human milk is different from maternal milk, and although similar or equivalent
benefits might be postulated, high-quality evidence for benefits of donor milk use in
VLBW infants in the era of routine human milk fortification is sparse.
This article introduces donor human milk and describes the known biological differ-
ences between maternal milk and donor milk. Evidence for benefits of donor human
milk for VLBW infants compared with term or preterm infant formula is explored.
DONOR MILK: AN INTRODUCTION
Donor human milk dispensed by milk banks is obtained in North America from volun-
teer donors, most of whom have given birth to healthy term infants. Donors may
donate existing frozen stored milk, may express milk in an ongoing manner specifically
for donation to the bank, or may use a combination of these donation strategies. Milk
donors undergo a thorough screening process to assess for behavioral risk factors for
blood-borne infection, and undergo serologic screening for all strains of human immu-
nodeficiency virus (HIV), HTLV I and II (Human T-Lymphocytic Virus), hepatitis B and
C, and syphilis. They may not be users of nicotine products or use alcohol daily in
excess of 2 drinks. Few chronic medications are compatible with milk donation,
with only low-dose oral contraceptives, insulin, thyroid hormone replacement, and
selected selective serotonin reuptake inhibitors allowed. Medications taken for tem-
porary periods require abstaining from milk donation for 5 times the half-life of the
medication,
14
and donors are instructed to refrain from expressing milk for donation
within 12 hours following alcohol consumption.
14
Donor Milk Processing
Donors express milk at home, using personally owned equipment. They are given
instruction on clean technique for milk expression, including cleaning of pump parts,
hand washing, appropriate storage containers, and handling of milk. Milk is stored
frozen before delivery to the milk bank. At the bank, frozen milk from several donors
is thawed gradually in refrigerators. It is pooled to equilibrate the nutritional content
of the milk. Donor milk in North America is then pasteurized by one of 2 methods:
Holder pasteurization or high-temperature short-time (HTST) pasteurization. Member
Colaizy 438
banks of HMBANA use the Holder method, in which sealed bottles of pooled milk are
heated in a water bath to 62
C and maintained at that temperature for 30 minutes. The

HTST procedure used by Prolacta Bioscience uses a temperature of 72
C for 16 sec-
onds.
15
Milk is then quickly chilled in an ice bath and frozen at 20
C until dispensed.
A bottle from each batch is sent for bacteriologic testing and must contain less than
1 cfu/mL of bacteria to qualify for dispensing.
14
Pasteurization and Effects on Human Milk
The good: prevention of bacterial and viral disease transmission
In North America, donor milk is pasteurized to reduce or eliminate the risk of transmis-
sion of bacterial and viral disease to recipients. Bacterial colonization of milk donated
to milk banks is common. All raw milk donated to the Mothers Milk Bank of Texas in
2003 was subjected to bacterial culture, both as individual donor samples and as pool
samples. Milk from 78% of mothers grew at least one organism, and most pooled
samples grew at least 2 organisms. Eighty-seven percent of pooled samples grew
coagulase-negative Staphylococcus, and 61% grew at least one gram-negative
organism.
16
Holder pasteurization eradicated most bacteria, because 93% of pooled
samples were sterile on postpasteurization culture.
16
The HTST pasteurization proce-
dure has also been shown to eradicate colonization of donor milk contaminated by
Escherichia coli, Staphylococcus aureus, and Staphylococcus agalactiae under exper-
imental conditions.
15
In a more recent study comparing bacterial profiles of Internet-
sourced informally shared milk and donor bank samples, 20 donor samples from
the Ohio Mothers Milk Bank had a 35% colonization rate with gram-negative organ-
isms, 25% coliform organisms, 25% Staphylococcus spp, and 20% Streptococcus
spp; 25% had no bacterial colonization.
17
Viral colonization of donor milk also occurs.
A study of Norwegian milk donors reported that 62% of donors were cytomegalovirus
(CMV) immunoglobulin (Ig) G positive,
18
although milk was not tested for the presence
of CMV. In the previously discussed study of informally shared versus donor-banked
milk, 5% of milk bank samples similarly tested positive for CMV, and none positive for
HIV.
17
Both Holder and HTST procedures have been shown to eradicate CMV infec-
tivity in vitro.
19
The bad: impact on anti-infectious properties of donor human milk
Although pasteurization protects donor milk recipients, it also negatively affects some
of the unique anti-infectious properties of human milk. Human milk contains active
maternal T cells,
20
B cells, macrophages, and neutrophils,
21
all of which are inacti-
vated by pasteurization.
22
In addition, secretory IgA levels are reduced by 28% to
60%with Holder pasteurization,
2325
and lactoferrin and lysozyme activity are reduced
up to 80%and 60%, respectively.
25
Pasteurization does not affect the levels of human
milk oligosaccharides,
26
and although patterns and levels of these compounds may
differ between donor and maternal milk fed to VLBW infants in neonatal intensive
care units (NICUs),
27
the significance of this is unclear.
Nutritional Properties of Donor Human Milk Versus Maternal Milk
Donor milk differs nutritionally from maternal milk to some degree when fed to VLBW
infants, and neonatologists should be aware of these differences because they may
affect the need for nutrient fortification when donor milk is used. Some of these differ-
ences are consequences of pasteurization, but others are simply a result of handling of
donor milk and stage of lactation of donors compared with mothers of newborn VLBW
infants. Most studies report that pasteurization does not affect protein, fat, and carbo-
hydrate levels of human milk
23,28
but a recent study of Brazilian banked milk refuted
Donor Human Milk for Preterm Infants 439
this, showing modest decreases in protein (6%) and fat (8%) when milk was pasteur-
ized, frozen, and thawed.
29
Levels of most vitamins and minerals are not affected by
pasteurization,
30,31
although milk antioxidant capacity is significantly reduced, more
so with Holder compared with HTST methods,
32
which could be hypothesized to
affect infection preventative actions of human milk.
Protein content of donor human milk approaches the generally accepted standard
estimate of 1 g/dL for term human milk,
33
but typically does not reach the levels of
1.2 to 1.5 g/dL reported for milk expressed by mothers delivering preterm in the first
4 to 6 weeks after delivery.
34
This is a consequence not of pasteurization but of donors
donating later in lactation after having delivered term infants. In a study of a US nation-
wide sample of donor milk, mean protein content was 1.16 g/dL, but 30% of the
415 samples tested contained less than 1 g/dL,
33
and a study of 1 year of milk dona-
tions to the Mothers Milk Bank of Iowa reported mean protein content of donated milk
to be 0.85 g/dL.
35
A study of samples from the Mothers Milk Bank of Ohio similarly
reported a mean protein content of 0.9 g/dl
28
with only minor before-and-after
pasteurization differences in free amino acid concentrations. Fat content of donor
milk is reported to be 3.22 to 3.9 g/dL for pooled samples, similar to that for preterm
maternal milk, with similar wide variability,
3335
although there is a higher concentra-
tion of free fatty acids in pasteurized milk than in fresh milk.
36
Long-chain Polyunsaturated Fatty Acid Levels in Donor Human Milk
Levels of the long-chain polyunsaturated fatty acids (LC-PUFAs) docosahexaenoic
acid (DHA) and arachidonic acid (ARA) vary among milk samples from different milk
banks, and are often less than the reported US mean DHA concentration of
0.14%.
37,38
Holder pasteurization did not significantly change the concentration of
these molecules in human milk samples, but samples obtained from the Mothers
Milk Bank of Iowa contained a mean concentration of DHA of only 0.07%, much lower
than reported nationwide levels. Milk from several other geographically diverse
HMBANA banks contained levels similar to reported US means, including Texas,
North Carolina, and California.
37
The investigators hypothesized that donors in the
Midwest are less likely to consume dietary LC-PUFAs in the form of fatty fish than
are donors nearer coastal areas. This difference may need to be considered when
using donor human milk, particularly when DHA content is compared with the levels
with which infant formula is supplemented, which are higher (0.14%0.32%, depend-
ing on product).
Current State of the Evidence: Differences Between Maternal and Donor Milk
Pasteurization results in inactivation of white blood cells, bacteria, and viruses in
human milk.
Pasteurization also results in loss of some protective compounds present in milk,
whereas others are not affected.
Donor milk obtained from term donors contains less fat and protein than typical
preterm maternal milk, and may not contain adequate DHA and ARA.
Differences between maternal and donor milk should be recognized and
addressed when donor milk is fed to VLBW infants.
OUTCOMES OF VLBW INFANTS FED DONOR HUMAN MILK COMPARED WITH OTHER
DIETS
NEC
Maternal human milk compared with formula diets has been shown to be consistently
protective against NEC in VLBW infants in multiple studies conducted over the past
Colaizy 440
30 years,
47,10
when fed with or without multicomponent fortifiers.
48,10
It is reasonable
to think that donor human milk would perform similarly, and limited evidence suggests
that this is the case. Several trials of unfortified donor human milk compared with for-
mula diets were performed in the 1980s, and 2 high-quality meta-analyses including
these trials have been published.
39,40
Boyd and colleagues
39
conducted a meta-
analysis of 3 trials of preterm infants born in the 1970s and 1980s
41,42
that were
designed to compare growth between infants fed diets of contemporary preterm for-
mulas and infants fed unfortified donor human milk. Two of the studies were random-
ized,
6,42
and 1 was observational.
41
NEC was reported as a secondary outcome in all
studies, and was not statistically significantly associated with either diet in any of the
trials. When meta-analysis was performed, the donor human milk diet was associated
with significantly lower risk of NEC (combined relative risk [RR], 0.21; 95% confidence
interval [CI], 0.060.76; P 5.017). Stated another way, an unfortified donor human milk
diet reduced the risk of NEC by 79% (95% CI, 24%, 94%). The investigators calcu-
lated that, in populations in which the risk of NEC in formula-fed infants is 5% to
20%, 18.5 (95% CI, 9.7200) preterm infants would have to be fed donor milk to pre-
vent 1 case of NEC.
39
Quigley and colleagues
40
performed another high-quality meta-
analysis of trials comparing a variety of donor milk diets with preterm formula diets.
Two trials selected for the Boyd and colleagues
6
meta-analysis described earlier
were also included in the analysis of formula (all types) compared with unfortified
donor human milk as the sole diet,
6,42
as well as an additional small randomized trial
from the same time period.
43
Analysis of these 3 trials yielded an RR of 0.25 (95% CI,
0.06, 0.98; P 5 .047) for development of NEC with donor milk diets, which is a similar
effect size to that noted earlier.
40
Although these data are intriguing, they are difficult to interpret when choosing a diet
for contemporary VLBW infants whose mothers milk is not available or is available in
insufficient quantity. Rates of breastfeeding initiation have recently been high in
mothers of VLBW infants,
44
but mothers milk alone is often insufficient,
45
so a more
typical diet consists of partial maternal milk and partial formula or donor human
milk. In addition, all types of human milk fed to VLBW infants are routinely fortified
with multicomponent human milk fortifiers (HMFs), rather than being unmodified as
in the trials that comprise the meta-analyses described earlier. There is limited addi-
tional evidence regarding fortified donor human milk use in practice. Schanler and col-
leagues
5
published the first randomized trial of fortified donor human milk compared
with preterm formula as a supplement to maternal milk in 2005, in which NEC was re-
ported as a primary outcome. Bovine milkderived fortifier was used in this trial. VLBW
infants whose mothers intended to provide maternal milk were randomized to receive
donor human milk or preterm formula if maternal milk supply was insufficient. Infants
receiving only a fortified maternal milk diet and those receiving donor milk supple-
ments experienced the lowest incidence of NEC (6% in both groups), with a higher
incidence in the group supplemented with preterm formula (11%), although these dif-
ferences were not statistically significant (P 5 .27, donor milk vs formula; P 5 .39,
maternal milk vs both supplement groups combined).
Recent evidence suggests that combined use of both donor human milk and human
milkderived HMF (HHMF), both as supplements to maternal milk when insufficient,
46
and as a sole diet when mothers decline to initiate breastfeeding
47
results in lower
NEC incidence than using preterm formula in these circumstances. This dietary
approach, referred to as the exclusive human milk diet (EHM), is now possible
because of commercial availability of HHMF. Sullivan and colleagues
46
randomized
VLBW infants whose mothers were providing milk to receive either the EHM diet
(donor milk as a supplement if maternal milk insufficient plus HHMF for all human
milk), or a diet containing all available maternal milk, fortified with bovine milkderived
HMF (BHMF), and supplemented with preterm infant formula if maternal milk insuffi-
cient. Infants in EHM group experienced a lower rate of NEC, both medical and surgi-
cal. The odds ratio for NEC with the EHM diet was estimated as 0.23 (95% CI, 0.08,
0.66; P 5.007) relative to the diet containing BHMF and/or preterm formula. All infants
in this trial who developed surgical NEC received BHMF or formula, either by trial
design or by protocol violation. Cristofalo and colleagues
47
studied the EHM diet in
the setting of mothers who never provide milk to their infants, randomizing
53 VLBW infants to a sole EHM diet or a sole diet of preterm formula for the duration
of hospitalization. NECoccurred in only 1 infant in the EHMgroup (3%), but in 5 infants
in the formula group (21%; P 5 .08).
Current State of the Evidence: NEC and Donor Milk
The most common mode of donor milk use (ie, as a supplement to maternal milk
with BHMF) is poorly studied with regard to risk of NEC compared with formula
supplementation, but such use may be protective.
NEC risk of donor milk plus BHMF as a sole diet has not been compared with the
risk with preterm formula.
The EHM diet shows promise as an intervention that may be superior to formula
use; both sole formula diets and maternal milk diets supplemented with formula.
Growth in VLBW Infants Fed Donor Human Milk
VLBW infants fed unfortified
48
and fortified
4,49
maternal milk have been consistently
reported to grow more slowly in early life than those fed preterm or term formula,
which is concerning because poor growth in this period has been associated with
potentially lifelong neurodevelopmental impairment.
50
Several investigations of
growth in preterm infants fed donor human milk have been undertaken, both with un-
fortified and fortified donor human milk. Multiple trials of in-hospital growth of infants
fed unfortified donor milk and the only trial of fortified donor milk
5
compared with term
or preterm formulas were reviewed for the Cochrane Report in 2007, with growth out-
comes analyzed for studies of donor milk as both a sole diet and a supplement to
maternal milk.
40
In the sole diet category, only studies of unfortified donor milk were
available, and infants fed donor milk grew 2.7 g/kg/d (95% CI, 2.0, 3.4) slower than
those fed formula. Two studies of donor milk supplementation to maternal milk, 1 un-
fortified,
48
and 1 fortified,
5
were combined for analysis, and a similar growth deficit
was noted: infants fed donor milk grew 2.4 g/kg/d (95% CI, 1.3, 3.5) more slowly.
When all trials, sole diet and supplemental, were combined for analysis, the growth
deficit was similar (2.59 g/kg/d; 95% CI, 1.99, 3.2).
40
Again, most of the trials included
in these meta-analyses used unfortified donor milk, which is not a currently used diet in
VLBW infants. Therefore, the ability to generalize these results to current clinical prac-
tice is limited.
Two trials have reported in-hospital growth in infants fed bovine-fortified donor hu-
man milk both as a supplement to maternal milk and as a sole diet. One reported growth
as a secondary outcome.
5
Infants fed donor milk supplement gained weight more
slowly than those fed formula supplements, with a deficit of 3 g/kg/d (P 5 .001), but
length and head circumference growth was similar between groups. Infants fed donor
milk grew similarly to those fed solely maternal milk in this trial (difference, 1.7 g/kg/d in
favor of maternal milk; P 5 .08).
5
Colaizy and colleagues
51
studied growth by amount
and type of bovine-fortified human milk received by a cohort of VLBW infants born be-
tween 2003 and 2005. Most of the infants received more than 75% human milk
throughout hospitalization, with varying proportions of donor and maternal milk.
Colaizy 442
Although diets with more than 75%human milk compared with diets containing less hu-
man milk were associated with a larger negative change in weight z score from birth to
discharge (0.6 vs 0.3; P 5 .03), type of human milk was not significantly associated
with z-score change. Infants receiving more than 75% of the in-hospital diet as donor
milk experienced a weight z-score change of 0.84 versus 0.56 for infants receiving
more than 75%maternal milk (P 5.28). Infants in this trial also received levels of protein
fortification in excess of those produced with manufacturer-directed BHMF use,
through additional BHMF use or as single-component protein powders.
51
Three trials have reported growth outcomes for infants fed the EHM diet: the 2
multicenter interventional trials discussed earlier regarding NEC,
46,47
and an addi-
tional single-center observational trial.
52
In the trial comparing a diet of maternal
milk fortified with BHMF and supplemented with formula versus a diet of maternal
milk fortified with HHMF and supplemented with donor milk, infants gained weight
similarly in both groups (14.2 g/kg/d human group vs 15.1 g/kg/d bovine group;
P 5 .13).
46
Length and head circumference gain were also similar between diet
groups in this study. In the subsequent study comparing the EHM diet with a diet
of preterm formula in infants whose mothers did not provide milk, rate of weight
gain was similar between groups (17 g/kg/d for bovine group vs 15 g/kg/d for human
milk group; P>.05), but infants in the bovine group experienced faster length gain
(1.12 cm/wk vs 0.84 cm/wk in the human group; P 5 .006). Head circumference
gain was similar between groups (0.88 cm/wk in the bovine group vs 0.78 cm/wk
in the human group).
47
A single-center observational trial was conducted after
institution of EHM for infants less than 1250 g at birth, fed EHM through 34 weeks
postmenstrual age (PMA).
52
The investigators used an aggressive early fortification
scheme, with all infants receiving HHMF to fortify their maternal or donor milk to 36.4
KJ/dL (26 kcal/oz), similar to the bovine-based strategy reported by Colaizy and
colleagues.
51
With this feeding regimen, rates of growth were better than typically re-
ported for infants fed human milk, regardless of fortifier type. Weight gain was
24.8 g/kg/d frombirth to 34 weeks PMA, length gain was 0.99 cm/wk, and head circum-
ference growth was 0.72 cm/wk. The investigators compared these values with those
reported for the first trial of the EHM diet
46
and noted better weight gain (P<.0001), bet-
ter length gain (P 5 .008), and similar head circumference gain (P 5 .84).
Current State of the Evidence: Growth in VLBW Infants Fed Donor Human Milk
VLBW infants fed human milk are typically reported to grow more slowly during
birth hospitalization than those fed formula, when both maternal and donor milk
are studied.
Recent studies report improved rates of growth with dietary strategies that focus
on protein supplementation beyond standard fortifier use according to manufac-
turer recommendations.
These strategies should be used, or neonatologists should at least be aware that
additional protein supplementation may be needed in VBLW infants fed donor
human milk.
Length of Hospital Stay, Length of Parenteral Nutrition
Maternal human milk feeding in VLBW infants has been shown to decrease length of
initial hospital stay, as well as length of parenteral nutrition use. Schanler and col-
leagues
4
reported that hospital stay was shortened by 15 days, and total parenteral
nutrition (TPN) use decreased by 10 days when fortified maternal milk was fed
compared with preterm formula. Both of these outcomes result in substantial cost
savings to the medical system, and in 2001 Wight
53
estimated the cost savings of
using donor human milk using the effect size estimates from these data. She calcu-
lated that $10,600 2001 dollars could be saved per infant in hospital daily charges
and TPN cost by using donor milk. However, this figure assumes that use of donor hu-
man milk in lieu of formula results in the same outcomes as maternal milk use, which
has not been thoroughly investigated.
Hospital length of stay and TPNuse length have been studied for donor milk used as
a supplement to maternal milk, and in both studies of the EHM diet. Schanler and col-
leagues
5
study of donor milk as a supplement to maternal milk compared length of
stay in donor milk supplemented infants with those supplemented with preterm for-
mula and found no difference (87 days for donor milk vs 90 days for preterm formula;
P 5 .66). However, the control infants fed entirely with maternal milk experienced
shorter stays (75 days; P 5 .04 vs both supplements), suggesting that donor milk
may not be as effective as maternal milk in reducing length of stay. Although the inves-
tigators did not study length of TPN use specifically, they reported length of central
venous catheter use, which can be used as a surrogate for TPN use. Infants in all three
groups had similar length of central catheter use.
When the EHM diet was studied in VLBW infants receiving maternal milk, infants
who received formula supplements and bovine fortifier experienced similar length of
stay to those receiving the EHM diet (P 5 .9), and length of TPN use also did not
vary by type of supplement and fortifier (P 5 .71).
46
However, when the EHM diet
was studied as an alternative to formula for VLBW infants whose mothers never pro-
vided milk, infants receiving human milk received fewer days of TPN (28 days EHM vs
36 days formula; P 5 .04), and were hospitalized for 10 fewer days than those fed
formula, although the difference in length of stay was not significant.
47
Current State of the Evidence: Donor Human Milk and Hospital Stay, TPN Use
Donor human milk, fortified with bovine fortifier and used as a supplement to
maternal milk, has not been shown to affect TPN usage or length of hospital stay
Donor human milk, fortified with human HMF and used as a supplement to
maternal milk, has not been shown to affect length of stay or TPN use compared
with the use of bovine fortifier and formula supplements to maternal milk
An EHMdiet is associated with shorter length of TPNuse compared with preterm
formula in infants receiving no maternal milk
Neurodevelopmental Outcomes
The most significant benefits of maternal human milk feeding in VLBWinfants arguably
are neurodevelopmental advantages. Similar to evidence in term infants,
54
several in-
vestigators have reported that VLBW infants fed maternal milk during the birth hospi-
talization have higher neurodevelopmental testing scores at age 18 to 22 months,
9
30 months,
11
and 7 to 8 years.
12
In the cohort studied by Vohr and colleagues,
11
in
which neurodevelopmental benefits persisted to 30 months in extremely low birth
weight (ELBW) infants fed human milk, and in which a dose-response relationship
was identified between volume of milk fed and Bayley Scales of Infant Development
II scores, these benefits were similar for infants fed maternal milk only during hospital-
ization as well as in those who were subsequently breastfed at home. This finding is
compelling, because it suggests that a dietary intervention given for a few months
in infancy can result in lifelong functional benefit. However, it is not known whether
donor human milk results in similar developmental advantages.
Women who breastfeed in the United States tend to be older, better educated, and
have higher incomes than those who do not,
44
and these characteristics are also
associated with better neurodevelopmental outcomes for preterm infants. In a study
Colaizy 444
undertaken in the Netherlands of former VLBW infants, intelligence quotient (IQ) at
age 19 years was most strongly associated with parental education, with children
of highly educated parents scoring 14.2 points higher in IQ than children of parents
with low educational achievement. This difference in IQ by parental education was
more pronounced than the effect of any other variable studied, including gestational
age and in utero growth retardation status.
55
Thus, maternal breastfeeding may be a
surrogate measure for an enriched environment, and some of the effect seen with
improved neurodevelopmental outcomes with maternal milk feeding of ELBWs may
not be caused by the human milk, but rather by the mother. Donor human milk iso-
lates the effect of the milk from the effects of social factors associated with
breastfeeding.
There have been 2 studies of neurodevelopmental outcomes in preterm infants fed
donor human milk, both of which were performed with unfortified donor human milk.
Lucas and colleagues
56
published a randomized controlled trial of donor milk and
neurodevelopmental outcomes in preterm infants, undertaken in the United Kingdom
in the 1980s. Infants less than 1850 g at birth whose mothers did not provide milk were
randomized to unfortified donor milk or preterm formula diets during hospitalization,
and their neurodevelopmental outcomes were assessed using the Bayley Scales of
Infant Development II at 18 to 22 months of age. Developmental outcomes in the
two groups were similar but, when the outcomes in infants fed donor milk were
compared with outcomes in another cohort, studied by the same investigators,
who were fed term formula, donor milk was associated with neurodevelopmental
advantage. Infants fed donor milk scored 8.8 points higher on the Bayley Mental
Development Index, and 2.1 points higher on the Bayley Psychomotor Development
Index than did those fed term formula. A similar study was performed in the United
States.
43
VLBW infants were randomized at 10 days of age to unfortified donor milk
or term formula, and neurodevelopmental outcomes were assessed at 37 weeks
PMA using the Brazelton Neonatal Behavioral Assessment Scale. Infants fed donor
milk experienced significant growth failure compared with those fed formula, and per-
formed more poorly on a task that tested orientation to inanimate stimuli (P<.02).
43
However, neither of these studies informs current practice well because unfortified
milk is not routinely fed to VLBW infants. The infants who were fed unfortified donor
milk in the large randomized trial by Lucas and colleagues
56
performed similarly to
those fed preterm formula, despite experiencing higher rates of growth failure, sug-
gesting that there are positive neurodevelopmental effects of human milk that are
separate from maternal factors that can overcome the detrimental effects of poor
growth.
At the time of this publication, there are 3 randomized trials of fortified donor human
milk underway in VLBW infants, all of which were designed with neurodevelopmental
outcome as the primary outcome. Two single-center trials, one in Canada (the Donor
Milk for Improved Neurodevelopmental Outcomes [DoMINO] Trial, ISRCTN3531714)
and one in the United States (Donor Human Milk and Neurodevelopmental Outcomes
in VLBW Infants, clinicaltrials.gov NCT01232725), have randomized infants to receive
fortified donor milk or preterm formula as a supplement to maternal milk, and are
assessing outcomes at 18 to 22 months. A third trial, underway at the centers of the
National Institute of Child Health and Human Development Neonatal Research
Network (The MILK trial, NCT01534481), will randomize 670 infants whose mothers
provide no or minimal milk to fortified donor breast milk or preterm formula, and will
assess outcomes at 22 to 26 months. The results of these trials, which collectively
will test this intervention in 1000 ELBW infants, should be instrumental in determining
the developmental effects of donor milk.
Current State of the Evidence: Donor Human Milk and Neurodevelopmental
Outcomes
Neurodevelopmental effects of fortified donor human milk have not been studied,
but 3 studies are underway.
Unfortified donor milk has been shown to result in BSID II scores at 18 to
22 months that are superior to those of term formula in preterm infants.
PROFESSIONAL SOCIETY RECOMMENDATIONS
Two prominent professional bodies have recently published recommendations for the
use of donor human milk in preterm infants. The American Academy of Pediatrics,
Section on Breastfeeding, published an updated policy statement, Breastfeeding
and the Use of Human Milk, in 2012. The statement recommends that all preterm in-
fants receive maternal milk, or, if not available, that pasteurized donor milk should be
used.
57
This statement cites the Cochrane Review
40
and the study of the EHM diet as
a supplement to maternal milk,
46
both of which are extensively discussed earlier as
evidence for this recommendation. The European Society for Pediatric Gastroenter-
ology, Hepatology, and Nutrition Committee on Nutrition published a more extensive
review of the use of donor human milk in preterm infants, and also recommends uni-
versal maternal milk feeding, with donor human milk as the preferred second-line
diet.
58
SUMMARY: SHOULD ALL VLBW INFANTS RECEIVE DONOR MILK IF MATERNAL MILK IS
NOT AVAILABLE?
Donor human milk represents an intriguing option for the feeding of VLBW infants.
There is a significant body of evidence that maternal human milk use results in superior
outcomes in multiple domains (infection, neurodevelopment) compared with formula
diets in VLBW infants. Clinicians should make extensive efforts to promote maternal
provision of breast milk in NICUs, using lactation support, peer support, and environ-
mental support (private room NICUs, provision of breast pumps, and so forth), all of
which have been shown to improve the ability of mothers of VLBW infants to provide
milk.
However, the optimal nonmaternal-milk diet is yet to be determined. This article de-
scribes studies conducted during 2 eras of neonatal nutrition: before and after routine
fortification of human milk in the VLBWpopulation. In the unfortified era compared with
various formula diets, donor milk has been associated with decreased risk of infectious
complications of prematurity, poorer growth outcomes, and equivalent or improved
neurodevelopmental outcomes. In the fortification era, bovine-fortified donor milk as
a supplement to maternal milk has been associated with similar infectious complica-
tions and poorer growth outcomes to preterm formula. Human-fortified donor milk
as a supplement to maternal milk, the EHM diet, has been associated with improved
rates of NEC and poorer growth outcomes compared with bovine-fortified maternal
milk supplemented with formula. In addition, human-fortified donor milk has been
associated with lower rates of NEC and lower TPN usage compared with preterm for-
mula in infants receiving no maternal milk. There are no published data regarding neu-
rodevelopmental outcomes of infants receiving the EHM diet compared with a diet
containing bovine fortifier and/or formula.
Where does this leave clinicians? In the limited studies available in the fortification
era, donor milk has not been associated with adverse outcomes and there are hints
of benefit, and the evidence from the unfortified era is more convincing as to benefit.
Colaizy 446
Therefore, donor milk is an appropriate choice for the VLBW infant whose maternal
milk is either insufficient in quantity or unavailable. However, further research should
be undertaken for this intervention, particularly in the areas of:
1. Neurodevelopmental outcomes of infants fed fortified donor milk compared with
those fed formula
2. The impact of fortifier choice (bovine vs human) on growth, infectious outcomes,
and neurodevelopmental outcomes
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Colaizy 450
LCPUFAs as Condi ti onal l y
Essenti al Nutri ents for
Very Low Bi rth Wei ght and Low
Bi rth Wei ght I nfants
Metabolic, Functional, and Clinical OutcomesHow
Much is Enough?
Maria Makrides, RD, PhD
a,b,
*, Ricardo Uauy, MD, PhD
c
Disclosures: M. Makrides receives honoraria (payable to her institution) for scientific advisory
board contributions to Fonterra, Nestle Nutrition Institute, and Nutricia.
Associated honoraria for M. Makrides are used for professional development of students and
early career researchers.
a
Healthy Mothers, Babies and Children, South Australian Health and Medical Research Insti-
tute, North Terrace, Adelaide, South Australia, 5000, Australia;
b
Womens and Childrens
Health Research Institute, University of Adelaide, 72 King William Road, North Adelaide,
South Australia 5006, Australia;
c
Division of Neonatology, Department of Pediatrics, Catholic
University Medical School and Institute of Nutrition, INTA University of Chile, Santiago, Chile
* Corresponding author. Womens and Childrens Health Research Institute, 72 King William
Road, North Adelaide, South Australia 5006, Australia.
KEYWORDS
Preterm

Low birth weight infants

Very low birth weight infants

LCPUFA
Randomized controlled trials

Development
KEY POINTS
Preterm infants have a high requirement for preformed dietary docosahexaenoic acid
(DHA), approximately three times the concentration in mature human milk or infant for-
mula, if they are to meet the in utero rapid accumulation of DHA that normally occurs in
late pregnancy.
Long-chain polyunsaturated fatty acid (LCPUFA) intervention trials before 2000 mostly as-
sessed whether infant formulas that lacked LCPUFA should be supplemented to the
equivalent concentrations of DHA and other LCPUFAs typically found in human milk of
women from Westernized societies.
Trials of LCPUFA-supplemented formulas demonstrate that supplementation with at least
0.3% total fatty acids as n-3 LCPUFA improved visual development, especially in infants
born less than 30-weeks gestation or with birth weights less than 1500 g.
Continued
INTRODUCTION
In examining the effects of long-chain polyunsaturated fatty acids (LCPUFAs) on the
clinical and developmental outcomes of preterm children, it is considered it logical
to evaluate the early trials of formula feeding in relatively healthy low birth weight
(LBW) and very low birth weight (VLBW) infants separately from the more recent
controlled trials that assessed higher doses of LCPUFA. In particular, the roles of
long-chain n-3 fatty acids (ie, eicosapentaenoic acid 20:5 n-3 [EPA] and docosahex-
aenoic acid 22:6 n-3 [DHA]) in more immature, sicker preterm infants are considered.
The early randomized controlled trials of LCPUFA interventions were designed to
assess whether the infant formula for preterm infants required supplementation with
n-3 and n-6 LCPUFA. At that time, formulas were devoid of all LCPUFA and contained
only the precursor essential fatty acid (EFA), n-3 alpha-linolenic acid 18:3n-3 (ALA), in
small amounts and much larger quantities of the n-6 EFA, linoleic acid 18:2 n-6 (LA)
(Fig. 1).
These trials, limited to preterm infants who were exclusively fed formula from the
time enteral feeding began, compared formulas containing only precursor EFAs with
those supplemented with LCPUFA. Initial studies focused only on n-3 LCPUFA sup-
plementation through fish oils. Later studies included the n-6 LCPUFA arachidonic
Fig. 1. Schema showing the metabolism of n-6 and n-3 essential fatty acids to their long
chain polyunsaturated fatty acid derivatives.
Continued
Attention is nowfocused on determining whether there is added advantage to meeting the
in utero accumulation rate of DHA.
The largest intervention trial to date indicates that higher dose DHA may improve cognitive
scores, reduce the risk of developmental delay, and reduce the risk of bronchopulmonary
dysplasia in the smallest and most immature infants.
Makrides & Uauy 452
acid 20:4n-6 (AA) to try to mimic the concentrations of LCPUFA in the human milk of
women from Westernized societies. The infants studied were selected from those
healthy enough to receive enteral feeds; few of these infants had birth weights less
than 1000 g. Almost none of these intervention trials of formula feeding intervened
with DHA concentrations that exceeded approximately 0.3%of total fatty acids. How-
ever, the first set of studies used deodorized menhaden oil as a source of DHA. This oil
contained approximately 0.3% to 0.4% DHA but also provided approximately 0.6%
EPA; therefore, the total amount of C 20 n-3 LCPUFA was close to 1%. These early
studies, which focused on the effects on biochemical endpoints and sensory or
cortical neurodevelopment, were of small sample size and thus were not powered
to examine relevant clinical outcomes. Collectively, these studies led to the gradual
inclusion of both n-6 and n-3 LCPUFAs to premature and, later, to full term infant for-
mula. By the year 2000, infant formula for preterm infants in developed countries was
universally supplemented with LCPUFAs equivalent to the concentration found in
mature human milk of women from Westernized societies. Attention since then has
focused on determining the optimal dose of DHA required by preterm infants.
LCPUFA FETAL ACCRETION RATE AND METABOLISM IN PRETERM INFANTS
The measurement of fetal accretion and early ex utero accretion rates represent a rela-
tively common approach to estimate a minimum dietary requirement. The amount of
nutrient required to match accretion at the corresponding postconceptional age rep-
resents the absolute minimum for the specific nutrient required by preterm infants. In
addition, this amount needs to be corrected by relative absorption of the nutrient from
human milk or infant formulas and by the oxidative losses because not all that is
ingested is absorbed and some of what enters the body is used as fuel and cannot
be considered available for tissue deposition. Therefore, the recommendation can
be derived by considering the minimumamount that needs to be taken to compensate
the absorptive losses that will result in a net retention rate similar to the intrauterine ac-
cretion rate. Most attention has focused on DHA accumulation in the central nervous
system. Whether the brain is preferentially protected when availability of DHA is limited
is not known; however, the ease with which fetal-brain DHA is altered by maternal di-
etary n-3 fatty acid intake suggests that the membrane lipid composition of the fetal
brain is sensitive to changes in DHA supply.
1
Because most LCPUFAs accumulate
in white adipose tissue and, to a lesser extent, in lean mass and the liver,
2
it is impor-
tant to consider accumulation of DHA and other LCPUFAs in all relevant organs.
Analyses of fetal autopsy tissue yield estimates of intrauterine accretion of LCPU-
FAs during the last trimester. These include LA, 106 mg/kg/d; ALA, 4 mg/kg/d; AA,
212 mg/kg/d; and DHA, 43 mg/kg/d.
2
It is likely that the accumulation of LCPUFAs
is not linear during the last trimester. Using these numbers to calculate average daily
rates of fatty acid accumulation will overestimate or underestimate tissue require-
ments during specific periods of growth. A more precise estimate of the fetal accretion
rate cannot be determined until more data become available. However, these data
based on postmortem tissue analyses of stillbirths suggest that during the third
trimester in utero whole-body accumulation of DHA is of the order of 60 mg/kg/d.
2
Based on this information, it is estimated that preterminfants who are born early and
denied the rapid accumulation of DHA occurring predominantly during the last
trimester of pregnancy require DHA greater than or equal to 1% total fatty acids.
3
Cur-
rent research is focusing on supplementation strategies to increase the LCPUFA con-
centration in both human milk and infant formula from approximately 0.3% to 1% total
fatty acids as DHA to match ex utero intakes with in utero accretion during the third
LCPUFAs as Conditionally Essential Nutrients 453
trimester. This article examines the relevant trials in two sections: (1) trials related to
the effects of LCPUFA supplementation of infant formula (comparing no LCPUFA vs
LCPUFA equivalent with human milk levels) and (2) trials reporting the effects of
LCPUFA supplementation that assessed higher doses (comparing LCPUFA concen-
trations equivalent with human milk vs estimated in utero accretion levels).
EFFECT OF LCPUFA SUPPLEMENTATION OF INFANT FORMULA ON VISUAL
DEVELOPMENT OF PRETERM INFANTS
The role of LCPUFA, particularly that of DHA, has been a point of intense investigation
since the early 1990s when the first published clinical study showed that electroretino-
graphic function and cortical processing of visual stimuli, as measured by visual
evoked potentials of preterm human infants born weighing less than 1500 g, was
improved following supplementation of formula with marine oil rich in n-3 LCPUFA
(0.36% of total fatty acids) compared with a control formula high in LA (n-6 EFA pre-
sent in corn oil) without n-3 LCPUFA and with only trace amounts of ALA, the meta-
bolic precursor of DHA.
4,5
A third group in the intervention study included infants
who were fed formula containing soy oil as a source of ALA. The retinal and cortical
function of the infants in the soy-oil formula group were intermediate between the con-
trol and marine oil group, indicating that preformed n-3 LCPUFA was needed for
optimal function (matching the performance of human milk-fed neonates) (Fig. 2).
4,5
Importantly, the visual function of the n-3 LCPUFAsupplemented infants at 36-weeks
postconceptual age did not differ from a reference group of infants fed human milk,
which contains LCPUFA, or from a group of neonates born at the equivalent postcon-
ceptional age studied soon after birth.
4
The poignancy of these early observations
stems from the control formula used in this clinical study. It derived most of its
Fig. 2. Effect of early diet on retinal function of very low birth weight infants. Formula A
represents a corn oil based infant formula, Formula B contained soy oil while Formula C con-
tained a mixture of soy oil and marine oil. (Adapted from Uauy RD, Birch DG, Birch EE, et al.
Effect of dietary omega-3 fatty acids on retinal function of very-low-birth-weight neonates.
Pediatr Res 1990;28:48592; with permission.)
Makrides & Uauy 454
PUFA from corn oil
4
and had a fatty acid composition similar to the n-3 fatty aciddefi-
cient diet used by Neuringer and colleagues.
6,7
They showed that infant rhesus mon-
keys fed n-3 fatty aciddeficient formula experienced visual loss that was associated
with reductions in brain DHA concentration, compared with infant monkeys fed their
mothers milk or the n-3 fatty acidsufficient diet based on soy oil.
The follow-up assessments of this study showed similar effects on visual acuity at
4-months corrected age using electrophysiological assessments.
5
The 1990s and
early 2000s saw several randomized intervention trials of formula supplemented
with LCPUFA and many of these studies focused their efficacy assessment on visual
function during infancy. The relevant trials are summarized in the most recent
Cochrane systematic review and, although the review concludes that there is no
consistent benefit of LCPUFA supplementation of infant formulas for preterm infants
on visual development, it acknowledges that major differences in assessment
methods between studies does not allow for a meta-analysis to be performed.
8
It is,
therefore, interesting to consider the differences between the trials that did report
some improvement in visual maturity with LCPUFA supplementation compared with
the trials reporting no effects. It seems two factors may be influential: (1) the dose
of n-3 LCPUFA or DHA supplied and (2) the maturity of the infants included in the trials.
Trials of n-3 LCPUFA supplementation are more likely to report a beneficial effect on
visual development if most infants included were less than 30-weeks gestation or less
than 1500 g, and the dietary intervention contained at least 0.3% total fatty acids as
n-3 LCPUFA.
4,9,10
Further analysis to explain the heterogeneity in responses across
different studies has considered the preformed DHA consumed as well as the poten-
tial contribution to the DHA pool from the endogenous conversion of ALA to DHA.
Measurements of DHA formation from deuterium-labeled ALA have revealed low
levels of conversion for preterminfants (3%5%), this is further compromised by intra-
uterine growth retardation.
11
Thus, only a small fraction of the ALA fed to a group of
growth-retarded infants and/or LBW infants is converted to DHA. A meta-regression
dose-response analysis of the effect of DHA supply on visual-acuity measures in
term infants across multiple studies considered the preformed DHA consumed as
well as the total DHA equivalents formed fromALA desaturation and elongation. Allow-
ing for a potential 1%, 5%, and 10% conversion, they revealed a progressively stron-
ger correlation reaching 0.7 when a 10% endogenous formation was from ALA.
12
A
similar approach with trials involving preterm infants may be useful to better under-
stand the difference between individual trials.
EFFECTS OF LCPUFA SUPPLEMENTATION OF INFANT FORMULA ON GLOBAL INDICES OF
DEVELOPMENT
Beyond visual function,
7
different randomized trials of formula feeding with LCPUFA
have assessed global indices of neurodevelopment, generally using the Bayley Scales
of Infant and Toddler Development (BSITD).
10,1318
Although some developmental sci-
entists criticize the use of these global indices as being blunt measures of specific
developmental domains, they nevertheless provide standardized measures that are
useful to clinicians and families alike.
The outcomes of these
7
trials with Bayley developmental quotients (DQs) fromeither
the first or second version of the BSITD are summarized in two relatively recent sys-
tematic reviews.
8,19
The two reviews had somewhat different approaches to
combining the data in meta-analyses and, as a result, have differing outcomes.
Schulzke and colleagues
8
separately reported DQs of preterm children at 12- and
18-months corrected age despite that the BSITD is age standardized. They showed
no significant difference in cognitive DQ between groups at either age. Four trials
included 364 preterm infants at 12-months corrected age (weighted mean difference
[WMD], 0.96 points, 95% CI 1.42 to 3.34) and three trials included 494 preterm in-
fants (WMD 2.4 points, 95% CI 0.33 to 5.12) at 18-months corrected age.
8
On the
other hand, Smithers and colleagues
19
combined the 12- and 18-month data because
all of the DQ scores are age standardized. They conducted a subgroup analysis
according to the first BSITD version because the second version of the BSITD
included more language and problem-solving items for 12- to 18-month-old children
compared with the first version, as well as differences in scoring and administration.
Smithers and colleagues
19
found that in the meta-analysis of all seven trials, the cogni-
tive DQof LCPUFA-treated pretermformula-fed children did not differ fromthe control
in 976 preterm infants (WMD 2.13 points, 95% CI 0.87 to 5.14). However, the meta-
analysis of data from the BSITD version II demonstrated an advantage of LCPUFA
treatment in five trials with 879 infants (WMD, 3.4 points, 95% CI 0.566.31). These
five trials included the most infants and were less likely than other trials to be subject
to biases.
Beyond 18 months, only one published study has followed children into childhood
to determine cognitive effects of LCPUFA supplementation in infancy.
20
They found no
difference in intelligence quotient but did report that girls who received LCPUFA sup-
plemented formula performed significantly better at single-word reading accuracy and
spelling than girls who received unsupplemented formula.
20
However, the study was
limited by large losses to follow-up (55%) making interpretation and generalization
difficult. It, therefore, seems that the question of whether LCPUFA supplementation
of preterm infant formula results in long-term neurodevelopmental benefit remains
open and may be difficult to definitively answer because formulas for preterm infants
are now all supplemented with LCPUFA.
LCPUFA NEEDS FOR LBW AND VLBW INFANTS AFFECTED BY COMMON DISEASES OF
PREMATURITY
Thinking about the potential benefits of dietary LCPUFA on the diseases of prematurity
demands due consideration of the importance of n-3 and n-6 LCPUFA in modulating
the inflammatory immune response as well as the effects of these EFA on endothelial
function, coagulation, inflammation, and neural tissue recovery after ischemic or hyp-
oxic injury. These processes define the severity or potential recovery from hypoxic or
ischemic injury.
21
Many of the randomized controlled trials comparing the outcomes of preterminfants
receiving supplemented formulas with DHA or both DHA and AA with the outcomes of
infants receiving unsupplemented formula have reported a range of clinical outcomes,
including necrotizing enterocolitis, sepsis, retinopathy or prematurity, intraventricular
hemorrhage, and bronchopulmonary dysplasia (BPD). The relevant trials have been
summarized in a systematic review and meta-analysis.
19
Because the clinical signs
and symptoms used to diagnose these diseases may differ between neonatal units
and may change with improvements in clinical practice over time, two sensitivity
analyses were conducted. Apart from combining all data, sensitivity analyses only
included trials using internationally accepted definitions of the relevant diseases or tri-
als with a low risk of bias based on reporting adequate concealment of randomization
and analysis according to the intention-to-treat principle. In meta-analyses of data
from about 1500 preterm infants, the risk of necrotizing enterocolitis and sepsis did
not differ between infants fed LCPUFA supplemented or control formula when all avail-
able data were included, when necrotizing enterocolitis or sepsis were confirmed
Makrides & Uauy 456
according to international standards or in the trial quality sensitivity analysis.
19
In over-
all analyses, there were no clear differences in retinopathy of prematurity, intraventric-
ular hemorrhage, or BPD between preterm infants fed LCPUFA-supplemented or
control formula. There were also no differences when trials reported diseases accord-
ing to the prespecified definitions or in the quality of trial sensitivity analysis. However,
the data were limited by small sample sizes and potential biases associated with the
studies and the definitions of the diseases.
19
EFFECTS OF LCPUFA SUPPLEMENTATION DESIGNED TO MIMIC IN UTERO
ACCUMULATION
With the publication of two relevant intervention trials in the last 5 years,
22,23
attention
has turned to whether dietary DHA supplementation to match in utero supply results in
measurable benefits to the growth, development, or clinical outcomes of children born
preterm. One trial focused on human milkfed preterm infants,
22
whereas the other
was inclusive of all infants regardless of whether they were fed human milk, formula,
or a mixture.
23
Henriksen and colleagues
22
randomly allocated 141 VLBW infants
(<1500 g) who were human milk fed to 32 mg of DHA and 31 mg of AA per 100 mL
milk and demonstrated an improvement in problem-solving at 6-months corrected
age. In a follow-up at 20 months of age, they showed no difference in cognitive DQ
but there was a significant improvement in sustained attention in free-play activities.
24
No other differences in clinical outcomes were reported.
22,24
The relatively small
sample size and losses to follow-up make interpretation difficult.
The single largest trial, involving more than 650 infants born less than 33 weeks, was
designed to assess the delivery of approximately 1% total fatty acids with DHA
compared with approximately 0.3% DHA supplied either through human milk, infant
formula, or a combination to mimic typical feeding practices in neonatal units.
23
All
milks contained 0.4%to 0.5%total fatty acids as AA. The trial was powered for neuro-
developmental outcomes and reported on outcomes related to visual development,
growth, and the typical diseases of prematurity. Although there were no significant
differences between groups in overall cognitive DQ at 18-months corrected age
(WMD 1.9; 95% CI 1.0 to 4.7), severe cognitive delay (score <70) was reduced
from 10.5% in the control group to 5% in the higher DHA group (relative risk 0.50;
95% CI 0.260.93).
23
Furthermore, there were significant treatment interactions indi-
cating that higher DHA treatment had differential responses by infant sex and birth
weight category. Girls had a significant improvement in cognitive DQ with high-DHA
treatment, whereas boys did not differ between groups. For infants born weighing
less than 1250 g, the cognitive DQ in the high-DHA group was higher than with stan-
dard DHA and there were no group difference in infants born weighing at least 1250 g
(Fig. 3).
In secondary analyses relating to the clinical outcomes of infants, there were no
group differences relating to the incidence of sepsis, necrotizing enterocolitis, or intra-
ventricular hemorrhage; however, high-DHA treatment may result in lower rates of
BPD, particularly in infants born weighing less than 1250 g and male infants.
23,25
Other
secondary analyses indicated that the high-DHA group had better visual acuity at
4 months of age compared with the standard-DHA group
26
and that infants fed higher
DHA were 0.7 cm longer at 18-months corrected age (95% CI 0.11.4, P 5 .02).
27
There was an interaction effect between treatment and birth weight strata for weight
and length. Higher DHA resulted in increased length in infants born weighing less
than or equal to 1250 g, at 4-months corrected age, and in weight and length at
12- and 18-months corrected age.
27
Although complex, these data indicate that
DHA up to 1% total dietary fatty acids is safe, does not adversely affect growth, and
may have other clinical advantages in relation to BPD and early childhood neurodeve-
lopmental outcomes for important subgroups of infants. The relatively consistent
benefit of higher dietary DHA, designed to emulate in utero accretion, in the smallest
and most immature infants is consistent with the hypothesis that suboptimal DHA
availability during the critical neonatal period results in disturbed DHA accumulation
has consequences on development. Current large-scale trials, such as N3RO (N-3
LCPUFA for Respiratory Outcomes in Infants Born <29 weeks), should provide conclu-
sive and contemporary data for higher dose DHA supplementation to the most vulner-
able infants as well as offer some new insights into the mechanisms by which higher
dose dietary DHA may work to dampen inflammatory immune responses.
FUTURE DIRECTIONS OF RELEVANCE TO NEONATAL AND PERINATAL MEDICINE
Over the past three decades, knowledge of DHA effects on gene expression and on
the production of n-3derived eicosanoids has expanded significantly beyond the
areas covered in this short review. Animal studies using a genetic modification have
produced a rat that overexpresses delta-6 desaturase (fat-1 rat), allowing significant
experimentation in animals that have increased DHA content of all tissues. In addition,
studies can be done on unique models of stroke as a hypoxic injury that can be treated
with DHA-derived compounds capable of resolving the associated inflammatory
insult. Owing to their potential relevance to neonatal health and/or amelioration of
neonatal conditions affecting VLBW infants, the authors suggest some areas in which
further research may reveal significant benefits:
1. Prevention of excessive inflammation, especially in the gut and lung, and under-
standing of some of the mechanisms by which dietary n-3 LCPUFA may alter the
onset and progression of necrotizing enterocolitis and BPD.
Fig. 3. Effect of high DHA (w1% total fatty acids) on Bayley cognitive development
compared with standard DHA (w0.3% total fatty acids as DHA) by birth weight strata.
(Adapted from Makrides M, Gibson RA, McPhee AJ, et al. Neurodevelopmental outcomes
of preterm infants fed high-dose docosahexaenoic acid: a randomized controlled trial.
JAMA 2009;301:17582.)
Makrides & Uauy 458
2. Protection from hypoxic or ischemic organ damage as demonstrated by the use of
DHA derivatives in ischemic brain infarctions and may have relevance to the hyp-
oxic or ischemic brain injury experienced with intraventricular hemorrhage.
3. Some of the latest trials suggesting that higher dose DHA administered in preg-
nancy reduces the risk of early preterm birth may offer additional treatment modal-
ities with potential to administer DHA to mothers who potentially will deliver preterm
or growth-retarded infants to prevent or ameliorate the later consequences of these
conditions.
SUMMARY
The essentiality of LCPUFA, particularly DHA, for preterm infants has been a point of
discussion in the literature for some 25 years. Although most of the biochemical
studies clearly show the insufficiency of DHA in the diet of preterm infants, the picture
has not been so clear from the intervention trials with clinical and developmental out-
comes. The early intervention trials, and most of the controlled trials, were designed to
assess whether infant formulas that were devoid of LCPUFA should be supplemented
to the equivalent concentrations of DHA and other LCPUFA found in typical human
milk. Intervention studies involving exclusively formula-fed preterm infants have
demonstrated improved visual development using neurosensory and behavioral tech-
niques. The trials showing the most consistent benefit included those in which most
infants were born less than 30-weeks gestation or had birth weights less than
1500 g and the dietary intervention contained at least 0.3% total fatty acids as n-3
LCPUFA. With the universal supplementation of all preterm infant formula with
LCPUFA since the year 2000, attention has focused on determining the specific die-
tary requirement of DHA and whether there is added advantage to meeting the in utero
accumulation rate of DHA, which is approximately three times the concentration in
most human milk and infant formula.
To date, the largest intervention trial addressing this question indicates that higher
dose DHA may improve cognitive scores, reduce the risk of developmental delay, and
reduce the risk of bronchopulmonary dysplasia in the smallest and most immature
infants.
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26(Suppl A):S705.
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3. Lapillonne A, Groh-Wargo S, Gonzalez CH, et al. Lipid needs of preterm infants:
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4. Uauy RD, Birch DG, Birch EE, et al. Effect of dietary omega-3 fatty acids on retinal
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5. Birch EE, Birch DG, Hoffman DR, et al. Dietary essential fatty acid supply and
visual acuity development. Invest Ophthalmol Vis Sci 1992;33:324253.
6. Neuringer M, Connor WE, Lin DS, et al. Biochemical and functional effects of pre-
natal and postnatal omega 3 fatty acid deficiency on retina and brain in rhesus
monkeys. Proc Natl Acad Sci U S A 1986;83:40215.
7. Neuringer M, Connor WE, Van Petten C, et al. Dietary omega-3 fatty acid defi-
ciency and visual loss in infant rhesus monkeys. J Clin Invest 1984;73:2726.
8. Schulzke SM, Patole SK, Simmer K. Long-chain polyunsaturated fatty acid supple-
mentation in preterm infants. Cochrane Database Syst Rev 2011;(2):CD000375.
9. Carlson SE, Werkman SH, Rhodes PG, et al. Visual-acuity development in healthy
preterminfants: effect of marine-oil supplementation. AmJ Clin Nutr 1993;58:3542.
10. OConnor DL, Hall R, Adamkin D, et al. Growth and development in preterm in-
fants fed long-chain polyunsaturated fatty acids: a prospective, randomized
controlled trial. Pediatrics 2001;108:35971.
11. Llanos A, Lin Y, Mena P, et al. Infants with intrauterine growth restriction have
impaired formation of docosahexaenoic acid in early neonatal life: a stable
isotope study. Pediatr Res 2005;58:73540.
12. Uauy R, Hoffman DR, Mena P, et al. Term infant studies of DHA and ARA supple-
mentation on neurodevelopment: results of randomized controlled trials. J Pediatr
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13. van Wezel-Meijler G, van der Knaap MS, Huisman J, et al. Dietary supplementa-
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14. Fewtrell MS, Morley R, Abbott RA, et al. Double-blind, randomized trial of long-
chain polyunsaturated fatty acid supplementation in formula fed to preterm
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chain polyunsaturated fatty acid supplementation with fish oil and borage oil in
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term infants fed infant formulas containing docosahexaenoic acid and arachi-
donic acid. J Pediatr 2005;146:4618.
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aenoic acid and arachidonic acid on visual acuity and neurodevelopment in
larger preterm infants. Chang Gung Med J 2005;28:70815.
18. Carlson SE, Cooke RJ, Werkman SH, et al. First year growth of preterm infants fed
standard compared to marine oil n-3 supplemented formula. Lipids 1992;27:
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preterm infants on disease risk and neurodevelopment: a systematic review of
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20. Isaacs EB, Ross S, Kennedy K, et al. 10-year cognition in preterms after
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32151.
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among preterm infants attributable to early supplementation of human milk with
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Post- di scharge Nutri ti on
and the VLBW I nfant: To
Suppl ement or Not Suppl ement?
A Review of the Current Evidence
Nneka I. Nzegwu, DO*, Richard A. Ehrenkranz, MD
INTRODUCTION
Because of advancements in neonatology, the survival of very-low-birth-weight
(VLBW; birth weight [BW] <1500 g) and extremely low-birth-weight (ELBW; BW
<1000 g) infants has increased over the past several decades. Unfortunately, survival
of these infants has been associated with a persistent occurrence of neonatal morbid-
ities, such as growth failure, bronchopulmonary dysplasia (BPD), necrotizing entero-
colitis (NEC), retinopathy of prematurity, late-onset infections, cerebral palsy, and
neurodevelopmental impairment. Current consensus nutritional recommendations
are designed to provide nutrients to approximate the rate of growth and composition
of weight gain for a normal fetus of the same postmenstrual age (PMA).
1,2
Despite
these recommendations, endorsed by the American Academy of Pediatrics (AAP)
Committee on Nutrition, and other national and international organizations
Section of Neonatal-Perinatal Medicine, Department of Pediatrics, Yale University School of
Medicine, 333 Cedar Street, PO Box 208064, New Haven, CT 06520-8064, USA
KEYWORDS
Post-discharge nutrition

Post-discharge formula

Nutrient-enriched formula
Human milk

Multinutrient fortification

Postnatal growth failure
KEY POINTS
Suboptimal and varied nutritional practices regarding very-low-birth-weight infants
(VLBWs) in the neonatal intensive care unit contribute to continued growth failure and
restriction in the post-discharge period.
Human milk has many benefits; it is recommended solely for term infants and is the
preferred source of enteral nutrition for preterm infants.
Systematic reviews have shown limited benefits in growth and neurodevelopmental out-
comes with the use of post-discharge formulas or multinutrient fortification of human milk.
It is important to have an individualized approach to post-discharge nutrition as VLBW
infants have varying rates of postnatal growth failure and restriction.
(ESPGHAN, Life Sciences), neonatologists struggle daily to meet this goal, and post-
natal growth failure and restriction are common.
3,4
Suboptimal nutritional practices of VLBWs have been shown to contribute to a
period of inadequate nutrition and poor growth.
5
Data from the National Institute for
Child and Human Development Neonatal Research Network, collected from live births
between 1995 and 1996, demonstrated that 97% of the VLBW population experi-
enced growth failure with weights less than the 10th percentile at 36 weeks PMA,
and that 99% of ELBW infants were less than the 10th percentile at 36 weeks
PMA.
6
At 18 months corrected age (CA), Dusick and colleagues
7
reported that
40% of the infants in the 501 to 1000 g BW group still had weights, lengths, and
head circumferences less than the 10th percentile. Postnatal growth failure and inad-
equate nutrition have been associated with poor long-term neurodevelopmental out-
comes. Ehrenkranz and colleagues
8
reported that more rapid in-hospital growth
velocity was associated with better neurodevelopmental and growth outcomes at
18 to 22 months CA.
Significant focus has been placed on alleviating the protein and energy deficits in
the initial postnatal period, including early initiation of total parenteral nutrition (ie,
amino acid proteins), use of higher protein preterm formulas, and feeding guidelines
with a focus on early initiation of minimal enteral feedings.
9
Despite strides made to
match intrauterine growth rates in the immediate postnatal period and during neonatal
intensive care unit (NICU) hospitalization, many preterm infants continue to have
growth restriction at discharge.
7,10
Furthermore, preterm infants are frequently dis-
charged home before term equivalent age (40 weeks CA) and less than term equiva-
lent size. Previous studies
1113
have shown that there may be a window for catch-up
growth in the initial post-discharge period. This article reviews post-discharge nutri-
tion in the VLBW population, examines different types of post-discharge nutrition,
the current evidence, and future and remaining questions. Also provided are recom-
mendations for post-discharge nutrition in this vulnerable population.
NUTRIENT NEEDS OF VLBW INFANTS VERSUS TERM INFANTS
Preterm infants have increased macronutrient and micronutrient requirements
compared with term infants. Most of these macronutrients and micronutrients would
have been acquired during the third trimester of pregnancy.
1416
The main macronu-
trients (protein, fat, and carbohydrate) and micronutrients (vitamins, minerals, electro-
lytes, and trace elements) are needed in increased quantities to sustain rapid growth
of preterminfants.
16
It is widely thought that these infants will require protein intakes of
3.5 to 4.0 g/kg/d once the continuous supply of amino acids, glucose, and essential
fatty acids fromthe placenta ceases.
17,18
In order for bone mineralization to occur nor-
mally, VLBW infants must receive adequate intakes of protein and energy. Further-
more, during the post-discharge period, these infants continue to have greater
nutritional requirements for calcium, phosphorus, and other vitamins and trace min-
erals (Table 1).
1,2
The AAP recommends human milk as the sole nutrient for healthy, term infants for
the first 6 months of life, breast-feeding to 12 months of life, and human milk as the
preferred source of enteral nutrition for preterm infants.
1,19
Atkinson
20
and others
have reported on the differences between the composition of term human milk and
preterm human milk, especially during the early lactation period (colostrum, transi-
tional milk). Both preterm and term human milk are inadequate in meeting the nutri-
tional requirements of VLBW infants. Just as protein and energy are important for
linear growth, micronutrients such as calcium, phosphorus, and Vitamin D are equally
Nzegwu & Ehrenkranz 464
important in growth and bone mineralization. The AAP Committee on Nutrition recom-
mends 150 to 220 mg/kg/d of calcium, 75 to 140 mg/kg/d of phosphorus, and 200 to
400 IU/d of vitamin D for enterally fed VLBW infants.
21
During hospitalization, human
milk fortifiers added to human milk, or high protein preterm formulas, are used to meet
these increased demands.
Post-discharge nutrition is an area garnering more attention, because it has been
shown that pretermand extremely preterminfants are at a higher risk for growth failure
at discharge and that poor growth is associated with impaired neurodevelopmental
outcomes.
22,23
Currently, there are no widely accepted feeding recommendations
for the post-discharge nutrition of preterm infants and no studies have elucidated
any lasting effects on growth and neurodevelopmental outcomes. Post-discharge
nutritional practices vary widely by NICU, individual health care providers, and coun-
try.
24
The spectrum of post-discharge nutritional practices involves a range of breast-
feeding and nutrient enrichment of enteral feedings. Preterm and extremely preterm
infants may vary in the extent of their growth failure and thus have the potential to
be discharged home with different nutritional expectations.
Post-discharge nutrition should be thought of for 3 groups of infants: (1) the exclu-
sively breast-fed preterm infant, (2) the breast-fed preterm infant supplemented with
post-discharge formula, and (3) the preterm infant receiving post-discharge and/or
term formula.
TYPES OF POST-DISCHARGE NUTRITION
Table 2 compares the composition of mature human milk with the most commonly
used post-discharge and termformulas. In the hospital setting, commercially available
preterm infant formulas and human milk multinutrient fortifiers have been made to
address specifically the increased nutritional needs of preterm and extremely preterm
infants. Multinutrient fortifiers and preterm formulas are not generally commercially
available because of concerns for toxicity if the recommended intake of certain nutri-
ents is exceeded. Preterm formulas (24 kcal/oz) have higher amounts of protein,
energy, calcium, phosphorus, and other trace elements and vitamins when compared
with term formulas. Post-discharge formulas are an intermediate or transitional
formula between preterm and term formula with more energy (22 kcal/oz), protein
Table 1
Recommended macronutrient/micronutrient requirements (units/kg/d) for the stable preterm
infant
Term ELBW VLBW VLBW Postterm
Energy, kcal 90120 130150 110130 90100
Protein, g 1.52 3.84.4 3.44.2 2.0
Carbohydrate, g 1620
a
920 717 6.814.1
Fat, g 810.3
a
6.28.4 5.37.2 4.06.6
Vitamin A, IU 1333 7001500 7001500 5451273
Vitamin D, IU 200 150400 150400 400
Calcium, mg 70120 100220 100220 253377
Phosphorus, mg 3575 60140 60140 105273
Iron, mg 0.09
a
24 24 1.82.7
Zinc, mg 666
a
10003000 10003000 890
a
For an average term infant 06 months of age.
Data from Refs.
2,18,24,29,3840
Post-discharge Nutrition and the VLBW Infant 465
(2.8 g/100 kcal), calcium, phosphorus, and zinc.
25
These increased nutrient compo-
nents help to promote linear growth and improve neurodevelopmental outcomes.
Feeding human milk during the NICU hospitalization has some advantages for pre-
term infants, such as decreased risk of NEC and sepsis, better gastrointestinal toler-
ance,
26
and improved neurologic outcomes at 18 months CA and at 7 to 8 years of
age.
27,28
Use of human milk fortifiers during the NICU hospitalization addresses a
main disadvantage of human milk: that it does not meet the nutritional requirements
for VLBW infants for protein, energy, calcium, phosphorus, and important trace ele-
ments and vitamins.
2,29
This use of human milk fortifiers raises questions regarding
how to supplement human milk to provide additional nutrients if the infant is solely
breast-feeding post-discharge. Specifically, what would be the most appropriate caloric
density of the supplement or the amount of multinutrients that should be provided, how
long should the supplementation be provided, and if supplementation in the post-
discharge period leads to improved growth and neurodevelopmental outcomes.
MONITORING GROWTH IN THE POST-DISCHARGE PERIOD
Monitoring the nutritional status of preterm and extremely preterm infants is of the
utmost importance as an infant nears discharge. Nutritional needs and a feeding
plan should be discussed with families of preterminfants to ensure that parents under-
stand the nutritional goals before discharge. Infants should be transitioned to the feed-
ings they will be on at home several days to a week before discharge to ensure that the
feedings are well tolerated and that the infant is taking adequate volumes and demon-
strating growth. Furthermore, preterm infants should be seen by a pediatrician within
48 hours of discharge to complete an overall assessment of nutritional status. The
in-hospital health care team should discuss concerns about growth and the nutritional
plan as part of discharge planning to ensure a smooth transition to the outpatient care
setting.
25
Trained personnel should obtain serial measurements of weight, length, and head
circumference plotted on validated growth charts to monitor postnatal growth and
identify potential growth or developmental issues.
24
Two recently described growth
charts, Fenton and Olsen (Figs. 1 and 2), can be used to follow growth in the
Table 2
Composition of post-discharge formulas (per 100 mL) and mature human milk
Mature
Human
Milk
39
Similac
Neosure
22 kcal/oz
a
Enfamil
Enfacare
22 kcal/oz
b
Similac
Advance
20 kcal/oz
a
Enfamil Lipil
20 kcal/oz
b
Nestle
Good Start
20 kcal/oz
c
Energy, kcal 6570 74.4 74 67.6 68 67
Protein, g 1.03 2.1 2.1 1.4 1.4 1.5
Carbohydrate, g 6.77.0 7.5 7.9 7.2 7.4 7.5
Fat, g 3.5 4.1 3.9 3.8 3.6 3.4
Calcium, mg 2025 78.1 89 52.8 53 44.9
Phosphorus, mg 1214 46.1 49 28.4 29 25.5
Sodium, mg 1225 24.5 26 16.2 18.4 18.4
Iron, mg 0.30.9 1.34 1.3 1.2 1.2 1.0
a
Mead Johnson Nutritionals, Evansville, IN; http://www.meadjohnson.com/Brands/Pages/Products-
by Need.aspx.
b
Abbott Nutrition, Abbott Laboratories, Columbus, OH; http://abbottnutrition.com/.
c
Gerber (Nestle ) Infant Formulas, Glendale, CA; http://medical.gerber.com/products/Default.aspx.
NICU
30
and then in the outpatient setting until 50 weeks PMA. After 50 weeks PMA,
the Centers for Disease Control and Prevention (CDC), in conjunction with the AAP,
recommend the use of the World Health Organization (WHO) growth charts
19
until
24 months CA to monitor growth. The Fenton growth chart
31
is gender-specific and
based on a meta-analysis of 6 population-based reports. The Olsen intrauterine growth
curves
32
are derived from an administrative data set from the Pediatrix Medical Group
based on a large, diverse sample consisting of 257,855 US infants between 23 and
41 weeks gestation. Growth and nutritional assessments should be obtained every
2 to 4 weeks in the early post-discharge period until stable weight gain is established.
Preterm infants who are predominantly breast-fed, or who have significant morbid-
ities such as BPD, should be monitored very closely in the outpatient setting. Pediatri-
cians should advocate and provide support for the establishment and continuation of
successful breast-feeding in preterm infants and coordinate additional resources,
such as certified lactation consultants and nutritionists. When there is faltering growth
or a decrease in growth percentiles, further investigation is warranted to determine the
underlying cause. Beyond obtaining a thorough maternal and postnatal history and
following up on the state newborn screening results, there are several biomarkers of
nutritional status that may help in assessing for nutritional deficiencies. Hall
33
recom-
mended an initial assessment of prealbumin, ferritin, blood urea nitrogen, and alkaline
phosphatase. Because of the differing nutritional needs of preterm infants, it is impor-
tant to have an individualized approach to their nutrition.
CURRENT EVIDENCE ABOUT POST-DISCHARGE NUTRITION
Because of the increasing belief that post-discharge nutrition plays a role in optimizing
growth and improving long-term growth and neurodevelopmental outcomes, many
Fig. 1. (A, B) The Fenton preterm infant growth charts can be used to monitor postnatal
growthof preterminfants from22weeks gestational ageto10weeks postterm. (FromFenton
TR, Kim JH. A systematic review and meta-analysis to revise the Fenton growth chart for pre-
term infants. BMC Pediatr 2013;13:59. 2013 Fenton and Kim. Accessed November 6, 2013.)
studies over the last 2 decades have examined different types of post-discharge nutri-
tion for varying lengths of time in the preterm infant. Recent Cochrane Reviews have
included mainly randomized controlled trials comparing nutrient-enriched formula
(post-discharge formula or preterm formula) and standard term formula for preterm
infants following discharge
34
and multinutrient fortification of human breast milk for
preterm infants following hospital discharge.
35
Fig. 2. (A) The Olsen intrauterine growth curves (girls) combined with the WHO-CDC growth
charts can be used to monitor postnatal growth of preterm infants from 23 to 50 weeks
gestational age. (B) The Olsen intrauterine growth curves (boys) combined with the
WHO-CDC growth charts can be used to monitor postnatal growth of preterm infants
from 23 to 50 weeks gestational age. (From Pediatrix Medical Group. Available at: http://
www.pediatrix.com/workfiles/NICUGrowthCurves7.30.pdf; with permission. Accessed
November 6, 2013.)
The first review (Table 3) included 15 eligible trials with 1128 preterm infants. The
trials were subdivided into 2 groups: post-discharge formula versus term formula
and preterm formula versus term formula. This meta-analysis did not identify a signif-
icant growth benefit associated with the use of post-discharge formulas compared
with term formulas. Therefore, the results of this review do not support current expert
opinion or consensus guidelines that recommend that formula-fed preterm infants
should receive a post-discharge formula for up to 12 months post-discharge.
34
How-
ever, when an in-hospital preterm formula was compared with term formula post-
discharge, significant increases in anthropometric indices were identified up to 12
to 18 months CA. A limitation of these trials was that the preterm infants included
were fed ad libitum and more information is needed on infants with morbidities such
Fig. 2. (continued)
Table 3
Cochrane Review: nutrient-enriched formula versus standard term formula
Post-discharge Formula vs Standard Term Formula
Anthropometrics No. of Studies No. of Participants
Effect Size
MD 95% CI
Weight (g)
34 mo CA 5 408 3.76 [156.67, 149.15]
6 mo CA 6 461 56.23 [111.53, 223.98]
9 mo CA 4 347 244.09 [16.95, 471.23]
12 mo CA 2 120 71.53 [344.06, 487.12]
18 mo CA 1 192 100.0 [246.90, 446.90]
Crown heel length (mm)
34 mo CA 5 408 4.18 [0.77, 9.13]
6 mo CA 6 461 3.46 [1.21, 8.13]
9 mo CA 4 347 7.33 [1.80, 12.87]
12 mo CA 2 120 0.83 [9.00, 9.34]
18 mo CA 1 192 9.0 [0.32, 17.68]
Head circumference (cm)
34 mo CA 5 408 0.87 [3.73, 1.99]
6 mo CA 6 461 0.72 [2.12, 3.56]
9 mo CA 4 347 0.16 [3.21, 3.53]
12 mo CA 2 120 0.25 [5.50, 6.01]
18 mo CA 1 192 3.0 [8.24, 2.24]
Development at 18 mo CA
Bayley-II: MDI 1 184 0.90 [3.24, 5.04]
Bayley-II: PDI 1 184 2.70 [1.28, 6.68]
Preterm Formula vs Standard Term Formula
Effect Size
Anthropometrics No. of Studies No. of Participants MD 95% CI
Weight (g)
34 mo CA 3 130 74.41 [267.10, 415.93]
6 mo CA 4 273 74.60 [164.73, 313.92]
9 mo CA 1 59 112.0 [482.69, 706.69]
12 mo CA 4 265 539.48 [255.03, 823.92]
18 mo CA 2 162 490.81 [142.19, 839.44]
Crown heel length (mm)
34 mo CA 3 130 2.27 [13.09, 8.56]
6 mo CA 3 160 1.83 [6.25, 9.92]
9 mo CA 1 59 3.0 [17.03, 11.03]
12 mo CA 3 152 5.13 [4.23, 14.49]
18 mo CA 2 162 11.0 [1.89, 20.11]
(continued on next page)
as BPD and congenital heart disease because they do not feed ad libitum. None of the
studies included in this review assessed the long-term growth and neurodevelopmen-
tal outcomes beyond 12 to 18 months CA and some of the studies only have reported
growth outcomes up to 6 months CA.
In the second review,
35
2 trials including 246 infants were identified (Table 4). This
systematic review reported no statistically significant difference in growth rates
between preterminfants fed human milk fortified with multinutrients compared with in-
fants fed unfortified human milk post-discharge. Both studies showed that fortification
Table 3
(continued)
Preterm Formula vs Standard Term Formula
Effect Size
Anthropometrics No. of Studies No. of Participants MD 95% CI
Head circumference (mm)
34 mo CA 3 130 3.61 [2.09, 9.31]
6 mo CA 3 160 5.82 [1.32, 10.32]
9 mo CA 1 59 8.0 [0.85, 15.15]
12 mo CA 3 152 6.07 [1.07, 11.06]
18 mo CA 2 162 5.42 [0.69, 10.14]
Development at 18 mo CA
Bayley-II: MDI 2 143 1.44 [6.22, 3.35]
Bayley-II: PDI 2 143 1.13 [4.19, 1.93]
Statistical method: mean difference (IV, Fixed, 95% CI).
Abbreviations: Bayley-II: MDI, Bayley Scales of Infant Development-II: Mental Developmental
Index; Bayley-II: PDI, Bayley Scales of Infant Development-II: Psychomotor Developmental Index;
CI, confidence intervals; MD, mean difference.
Data from Young L, Morgan J, McCormick FM, et al. Nutrient-enriched formula versus standard
term formula for preterm infants following hospital discharge. Cochrane Database Syst Rev
2012;(3):CD004696.
Table 4
Cochrane Review: multinutrient fortification versus no fortification of human milk
Anthropometrics No. of Studies No. of Participants
Effect Size
MD 95% CI
Weight (g)
34 mo CA 2 236 138.26 [89.87, 366.40]
12 mo CA 2 211 255.25 [93.40, 603.90]
Length (cm)
34 mo CA 2 236 0.60 [0.14, 1.33]
12 mo CA 2 211 0.88 [0.01, 1.74]
Head circumference (cm)
34 mo CA 2 235 0.22 [0.15, 0.58]
12 mo CA 2 197 0.16 [0.27, 0.60]
Statistical method: mean difference (IV, fixed, 95% CI).
Abbreviations: CI, confidence intervals; MD, mean difference.
Data from Young L, Embleton ND, McCormick FM, et al. Multinutrient fortification of human
breast milk for preterm infants following hospital discharge. Cochrane Database Syst Rev
2013;(2):CD004866.
of human milk did not adversely affect the duration or exclusivity of breast-feeding. No
data on long-term growth or neurodevelopmental outcomes beyond 18 months CA
were reported. OConnor and colleagues
36
demonstrated no statistically significant
differences for preterm infants on the Bayley II Scales for Infant Development Mental
and Psychomotor Developmental Index scores at 18 months CA. However, in a later
report,
37
the investigators showed that, in the same cohort of preterm infants, those
infants fed mostly a human milk diet with the addition of a multinutrient fortifier had
higher grating acuity and contrast sensitivity (used a surrogate marker of neurodevel-
opment) than infants feed with human milk alone at 4 and 6 months CA.
These reports suggest that the provision of post-discharge formulas or multinutrient
fortification of human milk results in minimal improvements in growth and neurodeve-
lopmental outcomes. There is currently no consistent, convincing evidence that the
use of different types of post-discharge nutrition leads to significant improvements
in neurodevelopmental outcomes or is more effective in supporting post-discharge
growth. Further studies are needed examining long-term growth and neurodevelop-
mental outcomes in early childhood and adolescence and its effects (Box 1).
SUMMARY
There is good evidence in the literature to suggest that, despite intensive nutritional
practices to improve nutrition after birth,
14
preterm and extremely preterm infants
are still at a significant risk for growth failure in the immediate post-discharge period.
Past studies have suggested that there may be a window of catch-up growth in which
linear growth and neurodevelopmental outcomes can be affected. Optimization of in-
hospital nutrition with early parenteral nutrition and early initiation of minimal enteral
feedings will significantly impact the growth deficits that exist soon after birth.
9
In addition, developing a strategy to monitor the growth and development of these
preterm infants post-discharge is crucial to decreasing the risk of continued growth
failure. This strategy should be individualized to each VLBW infant as nutritional needs
may be wide ranging. In addition, as endorsed by the AAP and WHO, finding ways to
support breast-feeding and lactation practices will serve to increase the number of
preterm infants receiving breast milk or being breast-fed post-discharge, which has
previously been shown to be beneficial for growth and neurodevelopmental out-
comes. Further research is needed to determine if there are any growth or neurodeve-
lopmental outcome benefits for VLBW infants beyond 18 to 24 months CA if an
individualized approach is undertaken towards post-discharge nutrition.
Box 1
Recommendations for post-discharge nutrition of the VLBW infant
Post-discharge nutrition needs may be met by human milk, human milk supplemented with
post-discharge or term formula, or exclusively post-discharge or term formula because
systematic reviews have shown minimal benefit in growth and neurologic outcomes
An individualized approach is essential for the post-discharge nutrition of the VLBW infant
Human milk is preferred for preterm infants and breast-feeding should be advocated by
pediatricians and lactation resources should be made available
Before going home, a discharge nutrition plan should be discussed among the health care
team, parents, and, if possible, the outpatient care provider
Close monitoring of growth parameters using validated growth curves (weight-, length-,
head circumference-for-age) and nutritional intake should be assessed at discharge and
every 2 to 4 weeks thereafter, until stable weight gain is established
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15. Bhatia J, Griffin I, Anderson D, et al. Selected macro/micronutrient needs of the
routine preterm infant. J Pediatr 2013;162(Suppl 3):S4855.
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19(4):21722.
17. Embleton ND. Optimal protein and energy intakes in preterm infants. Early Hum
Dev 2007;83(12):8317.
18. Tudehope D, Fewtrell M, Kashyap S, et al. Nutritional needs of the micropreterm
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19. American Academy of Pediatrics, Section on Breastfeeding. Breastfeeding and
the use of human milk. Pediatrics 2012;129(3):e82741.
20. Atkinson S. Human milk feeding of the Micropremie. Clin Perinatol 2000;27(1):
23547.
21. Abrams SA. Committee on nutrition. Calcium and vitamin D requirements of enter-
ally fed preterm infants. Pediatrics 2013;131(5):e167683.
22. Franz AR, Pohlandt F, Bode H, et al. Intrauterine, early neonatal, and postdi-
scharge growth and neurodevelopmental outcome at 5.4 years in extremely pre-
term infants after intensive neonatal nutritional support. Pediatrics 2009;123(1):
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23. Shah MD, Shah SR. Nutrient deficiencies in the premature infant. Pediatr Clin
North Am 2009;56(5):106983.
24. Lapillonne A, OConnor DL, Wang D, et al. Nutritional recommendations for the
late-preterm infant and the preterm infant after hospital discharge. J Pediatr
2013;162(Suppl 3):S90100.
25. Poindexter BB, Schanler RJ. Enteral nutrition for the high-risk neonate. In:
Gleason CA, Devaskar S, editors. Averys Diseases of the Newborn. 9th edition.
Philadelphia, PA: Elsevier Saunders; 2012. p. 95262.
26. Cristofalo EA, Schanler RJ, Blanco CL, et al. Randomized trial of exclusive human
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163(6):15925.e1.
27. Fewtrell M, Lucas A. Enteral feeding of the preterm infant. Curr Paediatr 2002;
12(2):98103.
28. Schanler RJ. Outcomes of human milk-fed premature infants. Semin Perinatol
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29. Greer FR. Post-discharge nutrition: what does the evidence support? Semin Peri-
natol 2007;31(2):8995.
30. Bhatia J. Growth curves: how to best measure growth of the preterm infant.
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31. Fenton TR, Kim JH. A systematic review and meta-analysis to revise the Fenton
growth chart for preterm infants. BMC Pediatr 2013;13:59.
32. Olsen IE, Groveman SA, Lawson ML, et al. New intrauterine growth curves based
on United States data. Pediatrics 2010;125(2):e21424.
33. Hall RT. Nutritional follow-up of the breastfeeding premature infant after hospital
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34. Young L, Morgan J, McCormick FM, et al. Nutrient-enriched formula versus stan-
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Database Syst Rev 2012;(3):CD004696.
35. Young L, Embleton ND, McCormick FM, et al. Multinutrient fortification of human
breast milk for preterm infants following hospital discharge. Cochrane Database
Syst Rev 2013;(2):CD004866.
36. OConnor DL, Khan S, Weishuhn K, et al. Growth and nutrient intakes of human
milk-fed preterm infants provided with extra energy and nutrients after hospital
discharge. Pediatrics 2008;121(4):76676.
37. OConnor DL, Weishuhn K, Rovet J, et al. Visual development of human milk-fed
preterm infants provided with extra energy and nutrients after hospital discharge.
JPEN J Parenter Enteral Nutr 2012;36(3):34953.
38. Leaf A, Subramanian S, Cherian S. Vitamins for preterm infants. Curr Paediatr
2004;14(4):298305.
39. American Academy of Pediatrics Committee on Nutrition. Chapter 3: Breast-
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2742.
I ndex
Note: Page numbers of article titles are in boldface type.
A
Absorptive enterocytes, in immune system, 425
Adipose tissue, deposition of
energy requirements for, 389
LCPUFAs in, 365366
Adjustable fortification approach, 412413
Alimentum formula, 393
Alpha-linoleic acid
fetal accretion of, 453454
in visual development, 454455
American Academy of Pediatrics recommendations
donor human milk, 446
formulas, 395
human milk use, 405406, 464465
post-discharge nutrition, 463464
Amino acids, supplementation with, 325326
complications of, 335
in high-protein formulas, 391395
Ammonia accumulation, in parenteral nutrition, 335
Antimicrobial substances
in human milk, 427429
in immune system, 425
Appropriate for gestational age infants, protein requirements in, 392
Aptamil formula, 394
Arachidonic acid
fetal accretion of, 453454, 457458
for common diseases of prematurity, 456457
levels of
alterations in, health consequences of, 369, 372375
in donor human milk, 440
in enteral nutrition, 377378
in parenteral nutrition, 368371, 376377
placental transfer of, 366369
B
Bayley Scales of Infant and Toddler Development, LCPUFAs effects on, 455456
Bilirubin, accumulation of, in parenteral nutrition, 335340
Bioactive factors, in human milk, 427430
Biomagnification, in placental fatty acid transfer, 364
Birth, growth assessment at, 296298
http://dx.doi.org/10.1016/S0095-5108(14)00033-5 perinatology.theclinics.com
Blood urea nitrogen
in parenteral nutrition, 335
milk fortification and, 414
Body composition
in growth definition, 312
protein requirements and, 385
Body mass index, in growth assessment, 303304
Bovine proteins, in high-protein formulas, 390394
Brain, development of. See also Neurodevelopmental outcomes.
protein requirements for, 385, 388
Brain-derived neurotropin factor, levels of, in fatty acid deprivation, 369, 375
Breast milk. See Human milk.
Bronchopulmonary dysplasia
LCPUFAs effects on, 455456
neurodevelopmental outcome and, 315
C
Calais Human Milk Analyzer, 413416
Calcium supplementation
precautions with, 355358
protocol for, 348
supply shortage in, 353, 355358
Canadian Pediatric Society, formulas recommendations of, 395
Carbohydrates
in human milk, analysis of, 413416
requirements of
post-discharge, 464466
with high-protein formulas, 388389
Casein
antimicrobial activity of, 428
in high-protein formulas, 390394
Chemokines, in human milk, 428429
Cholestasis, in parenteral nutrition, 337338
Chronic lung disease, LCPUFA levels and, 369, 372374
Citric acid, in milk fortification, 408409
Claudins, in immune system, 425
ClinOleic fatty acid emulsion, 371
Coefficient of fat absorption, 378
Colostrum, bioactive factors in, 427
CREB pathway, in LCPUFA metabolism, 369, 375
Cytokines, in human milk, 428429
Cytomegalovirus, in donor human milk, 439
D
Defensins, in immune system, 425
Dendritic cells, in lamina propria, 426
Discharge, nutrition supplementation after, 463474
Docosahexaenoic acid
Index 476
levels of
in enteral nutrition, 377378
in parenteral nutrition, 376377
parenteral nutrition effects on, 368371
DoMINO (Donor Milk for Improved Neurodevelopmental Outcomes) trial, 445446
Donor human milk, 437450
composition of, 406407
donation process of, 446447
fortification of, 408415
growth results with, 442443
indications for, 446
LCPUFAs in, 440
length of hospital stay with, 443444
milk banks for, 437439
necrotizing enterocolitis and, 440442
neurodevelopmental outcomes with, 444446
nutritional properties of, 439440
outcomes of, 440446
parenteral nutrition use with, 443444
pasteurization of, 446447
processing of, 438439
recommendations for, 446
versus maternal milk, 440, 446447
Donor Human Milk and Neurodevelopmental Outcomes in VLBW Infants, 445446
Donor Milk for Improved Neurodevelopmental Outcomes (DoMINO) trial, 445446
Drug shortages, of dietary supplements, 352360
E
EHM diet, 441444
Endothelial lipase, in placental fatty acid transfer, 364
Energy requirements, with high-protein formulas, 388389
Enfamil Human Milk Fortifier Acidified Liquid, 408409, 414
Enfamil Premature 24 Cal High Protein formula, 394
Enteral nutrition
LCPUFA levels in, 377378
protein requirements for, 386388
Enterocytes, absorptive, in immune system, 425
Enteroendocrine cells, in immune system, 425
Epidermal growth factor, in human milk, 429
Eunice Kennedy Shriver National Institute of Child Health and Developmental Neonatal
Research Network, 405406, 464
European Society for Pediatric Gastroenterology, Hepatology, and Nutrition
recommendations
for donor human milk, 446
Index 477
European (continued)
for formulas, 395
for post-discharge nutrition, 463464
Expert Panel for the American Society of Nutritional Sciences Life Sciences Research
Office, formula recommendations of, 395
F
Fat(s)
dietary, neurodevelopmental outcome and, 314
in human milk, analysis of, 413416
post-discharge requirements of, 464466
Fat-free mass, neurodevelopmental outcomes and, 309317
Fatty acid(s)
emulsions of, complications of, 337340
long-chain polyunsaturated, requirements for, 363382
Fatty acid translocase, in placental fatty acid transfer, 364
Fatty acid transport proteins, in placental fatty acid transfer, 364
Fatty acids(s), in colon, 427
Fenton growth chart, 302303, 466467
Fish oil emulsions, complications of, 337340
Fortification, of human milk, 405421
adjustable approach to, 412413
analytical technology for, 415416
challenges in, 406407
goals of, 408
in post-discharge nutrition, 463474
necrotizing enterocolitis prevention and, 416417, 441443
preterm versus donor, 406407
products for, 408410
standard approach to, 410412
targeted approach to, 413415
G
Gastrointestinal immune system, 423435
Gerber Good Start Premature 24, 391, 394
Glucose
in parenteral nutrition, complications of, 334335
intake of, neurodevelopmental outcomes and, 324325
Glutamine Trial, 326
Glycans, in breast milk, 427
Goblet cells, in immune system, 425
Growth
definitions of, 311312
energy cost of, 388389
linear, neurodevelopmental outcomes and, 309321
with donor human milk diet, 442443
Index 478
Growth assessment, 295307
at birth, 296298
for future potential growth, 298
importance of, 295296
in NICU, charts for, 298303
proportionality of, 303304
standard growth charts for, 299303
velocity, 298299
Growth failure
incidence of, 310311
neurodevelopmental outcomes in, 406407
Growth hormone deficiency, neurodevelopmental outcome and, 315
H
Head circumference
assessment of
in protein deficiency, 384
in growth assessment, 295304
High-protein formulas, 383403
complications of, 390391, 393
energy needs with, 388389
for intrauterine growth restriction, 391392
nutritional goals for, 383384
protein levels in, 384
protein quality and, 385386
protein requirements and, 385388
selection of, 392395
High-temperature short-time pasteurization, of donor human milk, 446447
Holder pasteurization, of donor human milk, 446447
Human milk
benefits of, 405406, 424, 438
donor. See Donor human milk.
fortification of, 405421, 441443, 463474
gastrointestinal immune system and, 423435
LCPUFAs in, 369, 377378
neurodevelopmental outcomes and, 327
Human Milk Banking Association of North America, 438
Hypercalcemia, in calcium supplementation, 348
Hyperglycemia, in parenteral nutrition, 334335
Hypermagnesemia, in magnesium supplementation, 350
Hypertriglyceridemia, in parenteral nutrition, 332334
Hypoglycemia, in parenteral nutrition, 334335
I
Immune system, gastrointestinal, 423435
Immunoglobulin A, secretory, in gastrointestinal tract, 427
Index 479
Inflammation
in lipid supplementation, 340
Infrared spectroscopy, for milk analysis, 413416
Innate immune system, gastrointestinal, 423435
Interleukins, in human milk, 428429
Intestinal epithelial cells, in immune system, 425
Intrafat fatty acid emulsion, 371
Intralipid product, 368370, 373374, 376
Intralipos fatty acid emulsion, 370
Intrauterine growth, protein requirements for, 385388
Intrauterine growth restriction
definition of, 296
energy requirements in, 391392
growth assessment and, 295307
protein requirements in, 391392
Intraventricular hemorrhage, LCPUFAs effects on, 455456
Iron supplementation, 351
Ivelip fatty acid emulsion, 370
J
Junctional adhesion molecules, in immune system, 425
L
Lactoferrin, in human milk, 427429
Lamina propia, in immune system, 426
LCPUFAs. See Long-chain polyunsaturated fatty acids.
Lean body mass, protein deficiency and, 384385
Length
assessment of
in protein deficiency, 384
Length of hospital stay, donor human milk diet and, 443444
Leukocytes, in human milk, 429
Linear growth, neurodevelopmental outcomes and, 309321
gains in, 315317
inflammation and, 314315
nutrients and, 312314
Linoleic acid levels
in preterm infants, 367
Lipid supplementation
intolerance of, 332334
Lipoplus fatty acid emulsion, 371
Lipoprotein lipase, in placental fatty acid transfer, 364
Index 480
LipoSyn III fatty acid emulsion, 370
Lipovenoes fatty acid emulsions, 370371
Liver disorders, in parenteral nutrition, 335340
Liver X receptors, in parenteral nutrition, 340
LL-37, in immune system, 425
Long-chain polyunsaturated fatty acids, 363382, 451461
delivery of, 375378
fetal accretion of, 453454, 457458
global development outcomes in, 455456
in breast milk, 369
levels of
enteral nutrition effects on, 369
in maternal diet, 378
parenteral nutrition effects on, 368371
prematurity effects on, 367368
to replace in utero accumulation, 457458
visual development impact of, 454455
Lubchenco ponderal index, 304
Lymphoid follicles, in immune system, 426
Lysozyme
in human milk, 428
in immune system, 425
M
M cells, in immune system, 426
Macrophages
in human milk, 429
in lamina propia, 426
Magnesium supplementation, protocol for, 349350
Medications, in donor human milk, 446
Metabolic acidosis, from high-protein formulas, 390393
Metabolic complications, of parenteral nutrition, 332335
Microbiome, of gastrointestinal tract, 426427
Micronutrients, 347361
bone minerals, 348360
critical, 347
enteral requirements for, 350351
populations evaluated for, 348
supply shortages of, 352360
zinc, 360
Mid-infrared spectroscopy, for milk analysis, 413416
Milk banks, 437439
MILK trial, 445446
Mothers Milk Bank of Iowa, 440
Mothers Milk Bank of Ohio, 440
Index 481
Mothers Milk Bank of Texas, 439
mTOR pathway, in LCPUFA metabolism, 369
Mucosal innate immune system, gastrointestinal, 423435
Mucus layer, of immune system, 424425
N
N3RO (N-3 LCPUFA for Respiratory Outcomes in Infants Born less than 29 Weeks), 458
Natural killer cells, in lamina propia, 426
Near-infrared spectroscopy, for milk analysis, 413416
in donor human milk diet, 440442
LCPUFAs effects on, 455456
prevention of, 416417
Neonatal Insulin Replacement Therapy in Europe (NIRTURE) study, 334335
Neurodevelopmental outcomes
LCPUFAs role in, 365367, 374375, 457458
linear growth and, 309321
of donor human milk diet, 444446
of protein deficiency, 384385, 406407
protein intake and, 313314, 317, 323329
NIRTURE (Neonatal Insulin Replacement Therapy in Europe) study, 334335
Nutrition
fatty acid requirements in, 363382, 451461
high-protein formulas for, 383403
human milk for. See Human milk.
micronutrient requirements in, 347361
neurodevelopmental outcomes and. See Neurodevelopmental outcome.
parenteral. See Parenteral nutrition.
O
Occludins, in immune system, 425
Ohio Mothers Milk Bank, 439
Oligosaccharides, in breast milk, 427
Olsen growth chart, 302303, 466467
Omegaven fatty acid emulsion, 371
P
Paneth cells, antimicrobial peptides secreted from, 425
Parenteral nutrition, 331345
complications of
cost of, 340341
liver disease, 335340
metabolic, 332335
delivery of, 376377
donor human milk with, 443444
Index 482
indications for, 331332
LCPUFA levels in, 368369
Pasteurization, of donor human milk, 446447
Pattern recognition receptors, in immune system, 425
Peroxisome proliferator-activated receptor, in parenteral nutrition, 340
Peyer patches, in immune system, 426
Phosphorus supplementation
preparations for, 358360
protocol for, 348349
supply shortage in, 358360
Phytosterols, in parenteral nutrition, 339340
Placenta, fatty acid transfer in, 364369
Placental insufficiency, protein and energy requirements in, 391392
Placental plasma membrane fatty acid binding protein, 364
Ponderal index, for growth assessment, 303304
Pregestimil formula, 393
Preterm human milk
composition of, 406407
fortification of, 408415
Preterm infants
growth in
assessment of, 295307
LBW, LCPUFAs for, 451461
nutrition for
donor human milk, 406415, 437450
fatty acid requirements, 363382
gastrointestinal innate immune system and, 423435
high-protein formulas, 383403
human milk fortification, 405421
LCPUFAs for, 451461
micronutrient requirements, 347361
parenteral, 331345
protein intake, 323329
VLBW
donor human milk for, 437450
high-protein formulas for, 383403
human milk fortification for, 405421
LCPUFAs for, 451461
neurodevelopmental outcomes of, 309321
post-discharge nutrition for, 463474
Prolacta products
donor human milk, 438439
milk fortifiers, 409410
Proportionality, of weight to stature, 303304
Protein
deficiency of
neurodevelopmental outcomes in, 406407
fortification with, 383403, 407415
Index 483
Protein (continued)
neurodevelopmental outcomes and, 313314, 317, 323329
recommendations of, 406408
R
Retina, development of, LCPUFAs role in, 365367, 374
Retinopathy of prematurity, LCPUFA levels and, 374, 455456
Rickets, risk for, 350
S
Safety and Innovation Act, for drug shortages, 352
Secretory immunoglobulin A, in gastrointestinal tract, 427
Sepsis
LCPUFAs role in, 375, 455456
Short bowel syndrome, 337
Similac Human Milk Fortifier, 408409
Similac Liquid Protein additive, 408410
Similac Special Care 24 High Protein formula, 394
Similac Special Care 30, 414
Sitosterol, in parenteral nutrition, 339340
Small for gestational age infants
definition of, 296
energy requirements in, 391392
protein requirements in, 391392
SMOFlipid fatty acid emulsion, 371, 373
Soyacal fatty acid emulsion, 371
Soybean oil
in Intralipid, 368370, 373374, 376
SpectraStar device, for milk analysis, 415416
Standard fortification approach, 410412
Staphylococcus aureus, in donor human milk, 439
Stigmasterol, in parenteral nutrition, 339340
Streptococcus, in donor human milk, 439
Sugars, nondigestible, in breast milk, 427
T
Targeted approach, to human milk fortification, 413415
Taurine supplementation, 393
Tight junctions, in intestinal epithelial cells, 425
Toll-like receptors, in immune system, 425
Transforming growth factor-b, in human milk, 429
Triglycerides, immune function of, 430
Index 484
U
Uremia, in parenteral nutrition, 335
V
Visual development, LCPUFAs effects on, 454455
Vitamin D, supplementation of, 350
W
Weight
assessment of, in protein deficiency, 384
post-discharge assessment of, 466471
postnatal loss of, 299
proportionality of, to stature, 303304
Weight-for-length curve, for growth assessment, 303304
Wet nursing, history of, 437
Whey, in high-protein formulas, 390395
World Health Organization, growth charts of, 302303, 467
Z
Zinc
supplementation with, 360
Index 485

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EgyptianPediatrics

Parenteral nutritionassociated liver disease

20% (Frensenius Kabi, Uppsala,

Vitamin E (mg/L) 38 250 47.6

10% (Fresenius Kabi,

are that they contain omega-3 fatty acids,

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Long-chain polyunsaturated fatty acids

Premature infant formulas

Very low birth weight infants

Mucosal innate immune system

Donor human milk

C and maintained at that temperature for 30 minutes. The

Randomized controlled trials

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