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Original Investigation
January 2017

Effect of Increased Enteral Protein Intake on Growth in Human Milk–Fed Preterm InfantsA Randomized Clinical Trial

Author Affiliations
  • 1Department of Neonatology, University Children’s Hospital, Eberhard-Karls University, Tuebingen, Germany
  • 2Division of Endocrinology, Diabetology, Vascular Medicine, Nephrology and Clinical Chemistry, and Pathobiochemistry, Department of Internal Medicine IV, University of Tuebingen, Tuebingen, Germany
  • 3Institute of Diabetes Research and Metabolic Diseases (IDM) of the Helmholtz Center Munich, University of Tuebingen, Tuebingen, Germany
  • 4German Center for Diabetes Research (DZD), Muenchen-Neuherberg, Germany
  • 5Center for Pediatric Clinical Studies, University Children’s Hospital, Eberhard-Karls University, Tuebingen, Germany
JAMA Pediatr. 2017;171(1):16-22. doi:10.1001/jamapediatrics.2016.2681
Key Points

Question  Does additional enteral protein intake enhance growth of predominantly human milk–fed preterm infants?

Findings  In this randomized clinical trial of 60 very premature infants, increasing enteral protein intake from 3.7 to 4.3 g/kg/d had no significant effect on weight gain to discharge (16.3 in lower vs 16.0 g/kg/d in higher protein group), but near-fetal growth rates were achieved in both groups during postnatal hospitalization.

Meaning  There may be a ceiling effect for enteral protein intake with respect to growth in preterm infants with a median birth weight of 1200 g.

Abstract

Importance  Protein, supplied in currently available commercial fortifiers, may be inadequate to meet the requirements of very preterm infants; in addition, intraindividual and interindividual variability of human milk protein and energy content potentially contribute to unsatisfactory early postnatal growth.

Objective  To determine effects on growth of different levels of enteral protein supplementation in predominantly human milk–fed preterm infants.

Design, Setting, and Participants  This randomized clinical and partially blinded single-center trial was conducted in a neonatal tertiary referral center in Germany. Sixty preterm infants (gestation <32 weeks and weight <1500 g at birth) were recruited from October 2012 to October 2014 and included 35% of 173 eligible infants. Median (interquartile range [IQR]) gestational age at birth was 29.9 (28.7-31.2) weeks. All analyses were conducted in an intention-to-treat population.

Interventions  Infants were randomly assigned to either a lower-protein (adding 1 g of bovine protein/100 mL of breast milk through a commercial human milk fortifier; n = 30) or a higher-protein group at a median (IQR) postnatal age of 7 (6-8) days. The higher-protein group (n = 30) received either standardized higher-protein supplementation (study fortifier adding 1.8 g of bovine protein/100 mL of breast milk [n = 15]) or individualized high-protein supplementation based on protein and fat content of administered breast milk (n = 15). Study interventions were continued for a median (IQR) of 41 (30-57) days and until definite discharge planning.

Main Outcomes and Measures  Primary outcome was weight gain (g/kg/d) from birth to the end of intervention.

Results  Sixty preterm infants (gestation <32 weeks and weight <1500 g at birth), 33 girls, were recruited from October 2012 to October 2014 and included 35% of 173 eligible infants. Median (IQR) gestational age at birth was 29.9 (28.7-31.2) weeks. Demographic characteristics and hospital courses were similar in both groups, and birth weights ranged from 580 to 1495 g in the lower-protein group and 490 to 1470 g in the higher-protein group. Weight gain was similar in the lower- and higher-protein groups: mean (95% CI), 16.3 g/kg/d (15.4-17.1 g/kg/d) in the lower-protein group vs 16.0 g/kg/d (15.1-16.9 g/kg/d) in the higher-protein group) (P = .70), despite an increase in actual protein intake by 0.6 g/kg/d (0.4-0.7 g/kg/d) (P < .001). Head circumference and lower leg longitudinal growth were also similar, as was the proportion of cumulative total enteral feeding volume provided as breast milk: median (IQR) proportion of breast milk, 92% (79%-98%) in the lower-protein group vs 94% (62%-99%) in the higher-protein group (P = .89).

Conclusions and Relevance  An increase in protein intake by 0.6 g/kg/d to a mean intake of 4.3 g/kg/d did not further enhance growth of very preterm infants with a median birth weight of 1200 g, who achieved near-fetal growth rates. This might point to a ceiling effect for enteral protein intake with respect to its influence on growth.

Trial Registration  clinicaltrials.gov Identifier: NCT01773902

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