Ways to improve protein intake in preterm VLBWinfants

Trayce Gardner, MEd, RD, CSP, LD

Nutritional NeedsEnergy and protein are both important in the

prevention of postnatal growth restriction seen in premature LBW/ VLBW infants

Enteral protein intake needed for optimal growth in preterm infants 3.4-4 gm/kg/d

Ziegler, E. E.: Meeting the Nutritional Needs of the Low-Birth-Weight Infant. Ann Nutr Metab 2011;58 (suppl):8-19

Example standards for Use of added Protein in NICU settingAll VLBW infants receiving fortified human milk –

added DOL 17-21 (once tolerating full fortified feedings for 5-7 days)

VLBW infants switched to formula feedings with poor linear growth or BUN <15

LBW Infants receiving fortified human milk or formula feedings with poor linear growth or BUN < 15

Preterm infants requiring use of term formula feedings (i.e. Elecare)

Use of human milk fortifiers with increased protein content

Available Protein AdditivesLiquid Protein Fortifier (Abbott)

Extensively hydrolyzedCommercially sterileUsed with both human milk or formulaOnly protein modular that is labeled for use in

preterm and term infantsComplete Amino Acids (Nutricia North America)

Essential and nonessential amino acidsPowdered/ non-sterileUsed with human milk or elemental term formulas

AvailableProtein AdditivesBeneprotein (Nestle)

Whey ProteinPowdered/non-sterileCan be used with human milk or formulasUse in NICU/Pediatrics established despite the

usage statementCommercially available thus can be used for

discharge feeding plans

General usages *Step 1 for human milk

6 mL LPF for every 100 mL of MBM Additional 1 gm protein per 100 kcal

Step 2 for human milk8 mL LPF for every 100 mL of MBMAdditional 1.3 gm protein per 100 kcal

Using LPF with SSC 241-3mL LPF for every 100 mL SSC 24additional 0.2-0.6 gm protein per 100 kcal

* Note, volumes used at TriHealth Good Samaritian Hospital NICU Cincinnati, Ohio

Example Recipes using LPF *Step 1 for human milk

100 mL Expressed human milk + 4 pkts SHMF-CL + 6 mL LPF

Step 2 for human milk100 mL Expressed human milk + 4 pkts SHMF-

CL +8mL LPF Using LPF with SSC 24

100 mL SSC 24 + 1 mL LPF 100 mL SSC 24 + 3 mL LPF

* Note, volumes used at TriHealth Good Samaritian Hospital NICU Cincinnati, Ohio

Elecare Fortification / Formula feedings

Using Complete Amino Acid Powder for additional protein

Aiming for same protein content of feedings as when using LPF

Example Cases

Brief History

29 6/7 preterm twin. BW 1440 gm. Trophic feedings of MBM/DBM initiated DOL

2

Followed VLBW infant feeding protocol

Reached full fortified enteral feedings on DOL 14

Moving onContinued feedings of MBM 24, mother with

good milk supply (received small amounts of DBM within the first week of life only)

DOL 20rate of wt gain averaging 13.2 gm/kg/d, length up 0.5 cm, HC up 0.5 cm added LPF –step 1

DOL 25rate of wt gain averaging 20.3 gm/kg/d, no change in length, HC up 2 cm

DOL 29BUN had dropped from 21 to 15, nursing reported infant appeared “puffy”

increased LPF –step 2

Almost homeDOL 36Above 2 kg, gaining on average 23 gm/d, length up 2.5 cm, HC up 1

cm.Taking all feeding po, plan to make POAL with shift minimum (140

mL/kg)Changed Feedings to MBM 26 with Neosure powder

DOL 40Averaging 17 gm /d, length up 2 cm, HC up 1 cmAveraging 148-160 mL/kg 100 % poPlan to discharge home within next day

RecipesMBM 24 with LPF

step-1

MBM 24 with LPF step-2

MBM 26 with Neosure powder

125 mL MBM+5 pkts SHMF-CL+7 mL LPF

125 mL MBM+ 5 pkts SHMF-CL + 10 mL LPF

90 mL MBM + 4 gm Neosure powder

Nutrient composition of Feedings (160 mL/kg)

Nutrient Human Milk* 24 with LPF (step 1)

Human Milk* 24 with LPF (step 2)

Human milk* 26 with Neosure Powder

Kcal 126 126 141

Protein 4.37 4.72 2.61

Calcium 214 210 80

Phos. 120 118 44

Iron 0.58 0.57 0.68

* Per WebNova using term human milk nutrient profile

Brief History

27 4/7 preterm BW 1090 gm. Trophic feedings of MBM/DBM initiated DOL

2

Followed VLBW infant feeding protocol

Reached full fortified enteral feedings on DOL 14

Moving onRegained BW by first week of life

DOL 16averaging 26 gm/kg/d, length up 1 cm, HC up 1 cm

added LPF – step 1

DOL 20averaging 4.2 gm/kg/d. no change in length, HC up 2 cmurine sodium of 22sodium supplement started

DOL 28 began transition from DBM to SSC 24averaging 20.8 gm/kg/d, length up 2 cm, HC u 1.5 cm

DBM mixed 1:1 with SSC 24 ( two days)

Moving onDOL 30 transitioned to SSC 24DOL 34

averaging 19.5 gm/kg/d, length up 1 cm, HC up 1.5 cmdiscontinued sodium

DOL 42averaging 29 gm/d, length no change, HC up 1 cm

BUN 13 added LPF to SSC 24

DOL 49averaging 19.3 gm/d, length up 1, HC up 0.5 cm

made poal and gearing up for home, will keep the LPF until discharge and then send home on SSC 24

RecipesMBM 24 with LPF

step-1

SSC 24 HP + LPF

125 mL MBM+5 pkts SHMF-CL+7 mL LPF

100 mL SSC 24 HP + 1 mL LPF

Nutrient composition of Feedings(160 mL/kg)

Nutrient Human Milk* 24 with LPF (step 1)

SSC 24 SSC 24 with LPF

Kcal 126 129 130

Protein 4.37 4.26 4.5

Calcium 214 232 232

Phos. 120 129 129

Iron 0.58 2.32 2.32

* Per WebNova using term human milk nutrient profile

Available Fortifiers with increased Protein Content

Enfamil Human Milk Fortifier Acidified LiquidEstimated 4 gm pro/100 kcal when added 1 pkt : 25 mL

of perterm human milk4.8- 5.12 gm /kg when fed at 150-160 mL/kg respectively

http://www.meadjohnson.com/pediatrics/us-en/product-information/products/newborns/enfamil-human-milk-fortifier-acidified-liquid

SHMF HP CL (Available May 2014)Estimated 3.58 gm pro/100 kcal when added 1 pkt: 25

mL of perterm human milk4.3- 4.58 gm/kg when fed at 150-160 mL/kg respectively

http://static.abbottnutrition.com/cms-prod/abbottnutrition.com/img/shmfhpcl-gen2-mixing-tearsheet.pdf