Trayce Gardner, MEd, RD, CSP, LD
Nutritional Needs
 Energy 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 setting
 All 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 Additives
 Liquid Protein Fortifier (Abbott)
 Extensively hydrolyzed
 Commercially sterile
 Used with both human milk or formula
 Only protein modular that is labeled for use in preterm
and term infants
 Complete Amino Acids (Nutricia North America)
 Essential and nonessential amino acids
 Powdered/ non-sterile
 Used with human milk or elemental term formulas
AvailableProtein Additives
 Beneprotein (Nestle)
 Whey Protein
 Powdered/non-sterile
 Can be used with human milk or formulas
 Use in NICU/Pediatrics established despite the usage
statement
 Commercially 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 milk
 8 mL LPF for every 100 mL of MBM
 Additional 1.3 gm protein per 100 kcal
 Using LPF with SSC 24
 1-3mL LPF for every 100 mL SSC 24
 additional 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 milk
 100 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 on
Continued feedings of MBM 24, mother with good milk
supply (received small amounts of DBM within the first week of life only)
DOL 20
rate of wt gain averaging 13.2 gm/kg/d, length up 0.5 cm, HC up 0.5 cm
added LPF –step 1
DOL 25
rate of wt gain averaging 20.3 gm/kg/d, no change in length, HC up 2 cm
DOL 29
BUN had dropped from 21 to 15, nursing reported infant appeared “puffy”
increased LPF –step 2
Almost home
DOL 36
Above 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 40
Averaging 17 gm /d, length up 2 cm, HC up 1 cm
Averaging 148-160 mL/kg 100 % po
Plan to discharge home within next day
Recipes
 MBM 24 with LPF step-1
 125 mL MBM+5 pkts
SHMF-CL+7 mL LPF
 MBM 24 with LPF step-2
 MBM 26 with Neosure
powder
 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 on
Regained BW by first week of life
DOL 16
averaging 26 gm/kg/d, length up 1 cm, HC up 1 cm
added LPF – step 1
DOL 20
averaging 4.2 gm/kg/d. no change in length, HC up 2 cm
urine sodium of 22
sodium supplement started
DOL 28 began transition from DBM to SSC 24
averaging 20.8 gm/kg/d, length up 2 cm, HC u 1.5 cm
DBM mixed 1:1 with SSC 24 ( two days)
Moving on
DOL 30 transitioned to SSC 24
DOL 34
averaging 19.5 gm/kg/d, length up 1 cm, HC up 1.5 cm
discontinued sodium
DOL 42
averaging 29 gm/d, length no change, HC up 1 cm
BUN 13
added LPF to SSC 24
DOL 49
averaging 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
Recipes
 MBM 24 with LPF step-1
 125 mL MBM+5 pkts
SHMF-CL+7 mL LPF
 SSC 24 HP + 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 Liquid
 Estimated 4 gm pro/100 kcal when added 1 pkt : 25 mL of
perterm human milk
 4.8- 5.12 gm /kg when fed at 150-160 mL/kg respectively
http://www.meadjohnson.com/pediatrics/us-en/productinformation/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 milk
 4.3- 4.58 gm/kg when fed at 150-160 mL/kg respectively
http://static.abbottnutrition.com/cms-prod/abbottnutrition.com/img/shmfhpcl-gen2-mixingtearsheet.pdf