H L Brumberg, L Kowalski^, A Troxell-Dorgan, et al. Randomized trial of enteral protein and energy supplementation in infants less than or equal to 1250 g at birth.  Journal of Perinatology (August 2010) 30, 517–521.  Abstract and Link to full text
 

Objective:  To determine if enteral protein and energy supplementation would significantly improve weight gain as compared with energy supplementation alone in <=1250 g infants.
 

Study Design:  Inclusion criteria were birth weight (BW)  <=1250 g, postnatal age <=14 days, diet of >75% enteral nutrition (fortified human milk or formula) and either failure to regain BW or weight gain<15 g kg⁻¹ per days. Infants were randomized to a multinutrient supplement that provided increased protein and energy (P/E) intake or energy alone (medium chain triglyceride oil, MCT). Growth rates were compared at the end of the 4-week study period.
 

Result:  Of 30 eligible infants, 23 were enrolled, 12 received MCT (BW=862±252 g, mean±s.d.) and 11 received P/E (BW=879±241 g). Significantly higher protein intake (P/E=3.5±0.3 g kg⁻¹ per day, MCT=3.0±0.5 g kg⁻¹ per day) and better growth (P/E=17.0±2.4 g kg⁻¹ per day, MCT=11.5±4.8 g kg⁻¹ per day) were observed in the P/E group.
 

Conclusion:  These data are consistent with the importance of providing additional daily protein intake to achieve increased postnatal growth in very low birth weight infants experiencing slow growth.

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Comments:  I selected this article for discussion because it looks at a different form of nutritional supplementation for premature infants who are not growing well on fortified breast milk or preemie formula.  At present, I believe the VON nutrition group is recommending adding extra enteral protein to the feedings of VLBW infants who are not growing well.  For infants who are feeding fortified human milk, this is usually done by adding Beneprotein powder to give an additional 1 Gm/Kg/day of protein.   In the present study, a protein + energy supplement in the form of Enfacare powder was added instead of Beneprotein.  The dose added was 1/4 tsp per 30 mL of fortified breast milk or preemie formula.  As expected, this supplement resulted in better growth than an energy supplement (MCT oil) alone.  The sample size was small (n=23) and there was no comparison group who received Beneprotein supplement.  The improvement in growth velocity was an additional 5.5 gm/Kg/d in the Enfacare fortified group as compared to the MCT fortified group.  A Cochrane review of protein-only supplementation of Fortified human milk showed an expected short-term growth velocity gain of only 3.6 Gm/kg/day. 

So here are the questions for discussion: 

1) Are you currently using an additional protein supplement for preemies who are not growing well?    What supplement?  How much?

2) Based on the results of this study, would you recommend using a Protein + Energy supplement (like Enfacare powder) rather than an energy-only supplement (like MCT oil), or a  pure-protein supplement (like Beneprotein)?

Please share your opinion. 

Andy Kairalla MD
Editor