Effects of Targeted Versus Adjustable Protein Fortification of Breast Milk on Early Growth in Very Low‐Birth‐Weight Preterm Infants: A Randomized Clinical Trial

Abstract

Background Breast milk is preferred for the feeding of very low‐birth‐weight (VLBW) infants, but it does not meet nutrition requirements unless it is fortified. Adequate protein intake to maintain the growth of preterm infants cannot be provided by standard fortification methods because of variation in the protein content of human milk. Individualization is necessary to achieve target protein intakes. The goal of this study was to compare the effects of 2 different methods of individualized protein fortification of breast milk on the early growth of VLBW preterm infants. Methods In a prospective observational study, VLBW preterm infants ≤32 weeks of gestational age were randomized into 2 groups according to the method of breast milk fortification. Anthropometric measurements were performed in both groups weekly for 4 weeks to compare their growth. Results During the trial period, the daily protein intake (targeted vs adjustable fortification groups) was (median [range]) 4.5 (4.4–4.6) vs 4.01 (3.5–4.4) g/kg/d (P = 0.001); the daily weight gains (g/d and g/kg/d; mean ± SD) were 25.7 ± 3.9 vs 22.2 ± 6.4 g/d (P = 0.048) and 23.1 ± 4.3 vs 18.7 ± 4.3 g/kg/d (P = 0.014); and the weekly increase in head circumference was 9.8 ± 1.5 vs 8.4 ± 2.1 mm/wk (P = 0.040). All parameters were significantly higher in the targeted than the adjustable fortification group. Conclusions Individualized protein fortification using the targeted method for VLBW preterm infants had more positive effects on short‐term growth compared with the adjustable fortification method.

Individualized target fortification of breast milk with protein, carbohydrates, and fat for preterm infants: A double-blind randomized controlled trial

“…groups or RCT design [12,25,26,29]. Three RCTs only adjusted protein, however, one of these studies found tremendous improvement of growth in the TFO compared to SF group (25.5 vs 12.0 g/kg/ d) [7,23,30]. The three remaining studies reported no difference or a reduced weight gain in the intervention group [24,27,28].…”

Review of Preterm Human‐Milk Nutrient Composition

“…Designing gestational age–specific fortifiers requires a complete understanding of their nutrition needs and composition of enteral intake. Human‐milk analyzers have been suggested as a means to address the nutrient disparity in human‐milk samples to promote better weight gain through targeted fortification 50‐52 . Human‐milk analyzers are expensive and may not be feasible outside of the research setting in which daily or weekly analysis of breast milk would be cumbersome and time consuming.…”

Protein Enrichment of Donor Breast Milk and Impact on Growth in Very Low Birth Weight Infants

“…Targeted protein fortification in human milk feedings has been examined in previous studies, but to our knowledge, none to date have described the use of baseline protein enrichment to improve early delivery with the initiation of enteral feedings and prior to multicomponent fortification [ 10 , 12 , 14 , 16 , 18 ]. Although multicomponent fortification is necessary to meet recommended nutrient intake, there is no consensus on the optimal timing of fortification in VLBW infants, which is often delayed due to the theoretical risk for NEC and feeding intolerance, despite lack of evidence of an association between early fortification and NEC [ 22 , 23 , 24 ].…”

“…One recent randomized controlled trial showed improved postnatal growth with targeted intake to meet recommendations from the European Society of Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN), including 4.5 g/kg/day protein [ 8 , 9 ]. Other smaller studies that targeted protein concentrations only or macronutrient concentrations that did not meet ESPGHAN intake or protein:energy ratio recommendations found more mixed results [ 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 ]. Although targeted fortification may be feasible, barriers to widespread use exist.…”