1. Trayce Gardner, MEd, RD, CSP, LD

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. Elecare Fortification / Formula feedings Using Complete Amino Acid Powder for additional protein Aiming for same protein content of feedings as when using LPF

9. Example Cases

10. 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

11. 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

12. 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

13. Recipes MBM 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

14. Nutrient composition of Feedings (160 mL/kg) NutrientHuman Milk* 24 with LPF (step 1) Human Milk* 24 with LPF (step 2) Human milk* 26 with Neosure Powder Kcal126 141 Protein4.374.722.61 Calcium21421080 Phos.12011844 Iron0.580.570.68 * Per WebNova using term human milk nutrient profile

15. 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

16. 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)

17. 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

18. Recipes MBM 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

19. Nutrient composition of Feedings (160 mL/kg) NutrientHuman Milk* 24 with LPF (step 1) SSC 24SSC 24 with LPF Kcal126129130 Protein4.374.264.5 Calcium214232 Phos.120129 Iron0.582.32 * Per WebNova using term human milk nutrient profile

20. 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/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 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-mixing- tearsheet.pdf