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Meta-Analysis
. 2014 Apr 21;2014(4):CD003959.
doi: 10.1002/14651858.CD003959.pub3.

Higher versus lower protein intake in formula-fed low birth weight infants

Tanis R Fenton  1 , Shahirose S Premji, Heidi Al-Wassia, Reg S Sauve
Affiliations
Meta-Analysis

Higher versus lower protein intake in formula-fed low birth weight infants

Tanis R Fenton et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: The ideal quantity of dietary protein for formula-fed low birth weight infants is still a matter of debate. Protein intake must be sufficient to achieve normal growth without negative effects such as acidosis, uremia, and elevated levels of circulating amino acids.

Objectives: To determine whether higher (≥ 3.0 g/kg/d) versus lower (< 3.0 g/kg/d) protein intake during the initial hospital stay of formula-fed preterm infants or low birth weight infants (< 2.5 kilograms) results in improved growth and neurodevelopmental outcomes without evidence of short- and long-term morbidity.To examine the following distinctions in protein intake. 1. Low protein intake if the amount was less than 3.0 g/kg/d. 2. High protein intake if the amount was equal to or greater than 3.0 g/kg/d but less than 4.0 g/kg/d. 3. Very high protein intake if the amount was equal to or greater than 4.0 g/kg/d.If the reviewed studies combined alterations of protein and energy, subgroup analyses were to be carried out for the planned categories of protein intake according to the following predefined energy intake categories. 1. Low energy intake: less than 105 kcal/kg/d. 2. Medium energy intake: greater than or equal to 105 kcal/kg/d and less than or equal to 135 kcal/kg/d. 3. High energy intake: greater than 135 kcal/kg/d.As the Ziegler-Fomon reference fetus estimates different protein requirements for infants based on birth weight, subgroup analyses were to be undertaken for the following birth weight categories. 1. < 800 grams. 2. 800 to 1199 grams. 3. 1200 to 1799 grams. 4. 1800 to 2499 grams.

Search methods: The standard search methods of the Cochrane Neonatal Review Group were used. MEDLINE, CINAHL, PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library) were searched.

Selection criteria: Randomized controlled trials contrasting levels of formula protein intake as low (< 3.0 g/kg/d), high (≥ 3.0 g/kg/d but < 4.0 g/kg/d), or very high (≥ 4.0 g/kg/d) in formula-fed hospitalized neonates weighing less than 2.5 kilograms were included. Studies were excluded if infants received partial parenteral nutrition during the study period or were fed formula as a supplement to human milk. Studies in which nutrients other than protein also varied were added in a post-facto analysis.

Data collection and analysis: The standard methods of the Cochrane Neonatal Review Group were used.

Main results: Five studies compared low versus high protein intake. Improved weight gain and higher nitrogen accretion were demonstrated in infants receiving formula with higher protein content while other nutrients were kept constant. No significant differences were seen in rates of necrotizing enterocolitis, sepsis, or diarrhea.One study compared high versus very high protein intake during and after an initial hospital stay. Very high protein intake promoted improved gain in length at term, but differences did not remain significant at 12 weeks corrected age. Three of the 24 infants receiving very high protein intake developed uremia.A post-facto analysis revealed further improvement in all growth parameters in infants receiving formula with higher protein content. No significant difference in the concentration of plasma phenylalanine was noted between high and low protein intake groups. However, one study (Goldman 1969) documented a significantly increased incidence of low intelligence quotient (IQ) scores among infants of birth weight less than 1300 grams who received a very high protein intake (6 to 7.2 g/kg).

Authors' conclusions: Higher protein intake (≥ 3.0 g/kg/d but < 4.0 g/kg/d) from formula accelerates weight gain. However, limited information is available regarding the impact of higher formula protein intake on long-term outcomes such as neurodevelopmental abnormalities. Available evidence is not adequate to permit specific recommendations regarding the provision of very high protein intake (> 4.0 g/kg/d) from formula during the initial hospital stay or after discharge.

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Conflict of interest statement

None.

Figures

1.1
1.1. Analysis
Comparison 1 High versus low protein intake (restricted to studies meeting all a priori inclusion criteria), Outcome 1 Growth parameters.
1.2
1.2. Analysis
Comparison 1 High versus low protein intake (restricted to studies meeting all a priori inclusion criteria), Outcome 2 Nitrogen utilization.
1.3
1.3. Analysis
Comparison 1 High versus low protein intake (restricted to studies meeting all a priori inclusion criteria), Outcome 3 Nitrogen balance.
1.4
1.4. Analysis
Comparison 1 High versus low protein intake (restricted to studies meeting all a priori inclusion criteria), Outcome 4 Phenylalanine levels.
1.5
1.5. Analysis
Comparison 1 High versus low protein intake (restricted to studies meeting all a priori inclusion criteria), Outcome 5 Necrotizing enterocolitis.
1.6
1.6. Analysis
Comparison 1 High versus low protein intake (restricted to studies meeting all a priori inclusion criteria), Outcome 6 Metabolic acidosis (pH, base excess).
1.7
1.7. Analysis
Comparison 1 High versus low protein intake (restricted to studies meeting all a priori inclusion criteria), Outcome 7 Serum albumin (g/L).
1.8
1.8. Analysis
Comparison 1 High versus low protein intake (restricted to studies meeting all a priori inclusion criteria), Outcome 8 Sepsis.
1.9
1.9. Analysis
Comparison 1 High versus low protein intake (restricted to studies meeting all a priori inclusion criteria), Outcome 9 Diarrhea.
3.1
3.1. Analysis
Comparison 3 Very high versus high protein intake (restricted to studies meeting all a priori inclusion criteria), Outcome 1 Growth parameters at discharge.
3.2
3.2. Analysis
Comparison 3 Very high versus high protein intake (restricted to studies meeting all a priori inclusion criteria), Outcome 2 Growth parameters at term.
3.3
3.3. Analysis
Comparison 3 Very high versus high protein intake (restricted to studies meeting all a priori inclusion criteria), Outcome 3 Growth parameters at 12 weeks corrected age.
4.1
4.1. Analysis
Comparison 4 High versus low protein intake (adding studies comparing formulas with differences in other nutrients), Outcome 1 Growth parameters.
4.2
4.2. Analysis
Comparison 4 High versus low protein intake (adding studies comparing formulas with differences in other nutrients), Outcome 2 Nitrogen utilization.
4.3
4.3. Analysis
Comparison 4 High versus low protein intake (adding studies comparing formulas with differences in other nutrients), Outcome 3 Nitrogen balance.
4.4
4.4. Analysis
Comparison 4 High versus low protein intake (adding studies comparing formulas with differences in other nutrients), Outcome 4 Phenylalanine levels.
5.1
5.1. Analysis
Comparison 5 Very high versus low protein intake (adding studies comparing formulas with differences in other nutrients), Outcome 1 Weight gain (g/wk).
5.2
5.2. Analysis
Comparison 5 Very high versus low protein intake (adding studies comparing formulas with differences in other nutrients), Outcome 2 Linear growth (cm/wk).
5.3
5.3. Analysis
Comparison 5 Very high versus low protein intake (adding studies comparing formulas with differences in other nutrients), Outcome 3 Phenylalanine levels.
6.1
6.1. Analysis
Comparison 6 Very high versus high protein intake (adding studies comparing formulas with differences in other nutrients), Outcome 1 Growth parameters.
6.2
6.2. Analysis
Comparison 6 Very high versus high protein intake (adding studies comparing formulas with differences in other nutrients), Outcome 2 Nitrogen utilization.
6.3
6.3. Analysis
Comparison 6 Very high versus high protein intake (adding studies comparing formulas with differences in other nutrients), Outcome 3 Nitrogen balance.
6.4
6.4. Analysis
Comparison 6 Very high versus high protein intake (adding studies comparing formulas with differences in other nutrients), Outcome 4 Low IQ or Bayley score at 18 months and/or later (all infants).
6.5
6.5. Analysis
Comparison 6 Very high versus high protein intake (adding studies comparing formulas with differences in other nutrients), Outcome 5 Low IQ or Bayley score at 18 months and/or later (in infants < 1300 g).
6.6
6.6. Analysis
Comparison 6 Very high versus high protein intake (adding studies comparing formulas with differences in other nutrients), Outcome 6 Phenylalanine levels.
6.7
6.7. Analysis
Comparison 6 Very high versus high protein intake (adding studies comparing formulas with differences in other nutrients), Outcome 7 Metabolic acidosis (base excess).
6.8
6.8. Analysis
Comparison 6 Very high versus high protein intake (adding studies comparing formulas with differences in other nutrients), Outcome 8 Serum albumin (g/L).
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Update of

References

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References to other published versions of this review

Premji 2006
    1. Premji S, Fenton T, Sauve RS. Higher versus lower protein intake in formula fed low birth weight infants. Cochrane Database of Systematic Reviews 2006, Issue 1 10.1002/14651858.CD003959.pub2. [DOI: 10.1002/14651858.CD003959.pub2] - DOI - PubMed

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