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Protein supplementation of human milk for promoting growth in preterm infants

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Authors

Kuschel CA, Harding JE

Background - Methods - Results - Characteristics of Included Studies - References - Data Tables & Graphs


Dates

Date edited: 23/02/2000
Date of last substantive update: 13/12/1999
Date of last minor update: / /
Date next stage expected / /
Protocol first published: Issue 3, 1997
Review first published: Issue 3, 1999

Contact reviewer

Dr Carl Kuschel

Staff Neonatologist
Newborn Services
National Women's Hospital
Private Bag 92 189
Auckland
NEW ZEALAND
Telephone 1: +64 9 638 9919 extension: 3200
Facsimile: +64 9 630 9753

E-mail: CarlK@ahsl.co.nz

Contribution of reviewers

Intramural sources of support

National Women's Hospital, Auckland, NEW ZEALAND
University of Auckland, Auckland, NEW ZEALAND

Extramural sources of support

  • None noted.

What's new

  • None noted.

Dates

Date review re-formatted: 16/09/1999
Date new studies sought but none found: / /
Date new studies found but not yet included/excluded: / /
Date new studies found and included/excluded: / /
Date reviewers' conclusions section amended: / /
Date comment/criticism added: / /
Date response to comment/criticisms added: / /

Synopsis

  • Synopsis pending

Abstract

Background

For term infants, human milk provides adequate nutrition to facilitate growth, as well as potential beneficial effects on immunity and the maternal-infant emotional state. However, the role of human milk in preterm infants is less well defined as it contains insufficient quantities of some nutrients to meet the estimated needs of the infant. Preterm infants require higher protein intakes than term infants to attain adequate growth rates, and have relatively higher protein turnover rates. Inadequate protein intakes may be partly responsible for low serum albumin and blood urea concentrations in preterm infants.

Objectives

The main objective was to determine if addition of protein to human milk leads to improved growth and neurodevelopmental outcomes without significant adverse effects in preterm infants.

Search strategy

The standard search strategy of the Cochrane Neonatal Review Group was used. This includes searches of the Oxford Database of Perinatal Trials, MEDLINE, previous reviews including cross references, abstracts, conferences and symposia proceedings, expert informants, and journal handsearching mainly in the English language.

Selection criteria

All trials utilizing random or quasi-random allocation to supplementation of human milk with protein or no supplementation in preterm infants who remained in hospital were eligible.

Data collection & analysis

Data were extracting using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by each author and synthesis of data using relative risk and weighted mean difference.

Main results

Protein supplementation of human milk results in increases in short term weight gain (WMD 3.6 g/kg/day, 95% CI 2.4 to 4.8 g/kg/day), linear growth (WMD 0.28 cm/week, 95% CI 0.18 to 0.38 cm/week) and head growth (WMD 0.15 cm/week, 95% CI 0.06 to 0.23 cm/week). There are insufficient data to evaluate long term neurodevelopmental and growth outcomes.

There are too few infants studied to be certain that adverse effects of protein supplementation are not increased. Blood urea levels are increased (WMD 1.0 mmol/l, 95% CI 0.8 to 1.2 mmol/l).

Reviewers' conclusions

Protein supplementation of human milk in relatively well preterm infants results in increases in short term weight gain, linear and head growth. Urea levels are increased, which may reflect adequate rather than excessive dietary protein intake. Further research should be directed towards the evaluation of specific levels of protein intake in preterm infants and the clinical effects of supplementation with protein, including long term growth and neurodevelopmental outcomes. This may best be done in the context of refinement of available multicomponent fortifier preparations.

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Background

Human milk is the recommended nutritional source for full-term infants for at least the first six months of postnatal life. It is known that in this group of infants, breast milk supplies adequate substrate to meet the infant's nutritional demands, as well as supplying the infant with other substances that may afford some physiological advantage (for example, immunoglobulins and gastrointestinal hormones). Breast feeding may also contribute to maternal-infant bonding.

However, the role of human milk in preterm infants is less well defined. The nutrient content of preterm human milk provides insufficient quantities of protein, sodium, phosphate and calcium to meet the estimated needs of the infant. In addition, large fluid volumes may be required to provide sufficient calories to maintain adequate growth.

There is evidence that preterm infants require higher protein intakes than term infants to attain adequate growth rates, and have relatively higher protein turnover rates (Hay 1994). Preterm infants fed human milk alone show slower growth than those fed a preterm infant formula containing supplemental protein (Bishop 1996; Lucas 1984; Lucas 1986; Lucas 1989; Lucas 1990a; Lucas 1990b; Lucas 1990c; Lucas 1994; Lucas 1994b). Declining serum albumin and blood urea concentrations in these infants suggest that inadequate protein intakes may be at least partly responsible for these changes. It is not clear to what extent the better neurodevelopmental outcomes reported in babies receiving preterm formula may be attributable to their higher protein intakes.

In contrast, excessive protein intakes have been reported to result in adverse neurodevelopmental outcomes, and to be associated with evidence of metabolic stress such as acidosis and elevated blood urea concentrations (Goldman 1969).

For a detailed discussion of the suitability of human milk for low-birthweight infants, see Schanler 1995.

This review updates the existing review of Protein supplementation of human milk for promoting growth in preterm infants which was published in The Cochrane Library, Issue 3, 1999 (Kuschel 1999). This update adds additional data from one previously included trial (Polberger 1989).

Objectives

To determine if addition of protein to human milk leads to improved growth and neurodevelopmental outcomes without significant adverse effects in preterm (less than 37 weeks gestation) infants.

Criteria for considering studies for this review

Types of studies

Controlled trials utilizing either random or quasi-random patient allocation.

Types of participants

Preterm infants receiving care within a hospital.

Types of interventions

All randomized and quasi-randomized controlled trials evaluating the supplementation of human milk with protein, in which supplemented was compared with unsupplemented human milk, are included.

A subgroup analysis was planned to evaluate differences in outcomes between supplementation with bovine milk protein and human milk protein.

Types of outcome measures

  1. Primary outcomes
    1. Short term growth parameters
      1. Weight gain
      2. Linear growth
      3. Head growth
    2. Long term growth parameters
      1. Weight
      2. Length
      3. Head circumference
    3. Neurodevelopmental outcomes
      1. Neurodevelopmental outcome at 12 to 18 months
  2. Secondary outcomes
    1. Nitrogen retention
    2. Serum albumin concentrations
    3. Adverse effects
      1. Gastrointestinal disturbance
      2. Feeding intolerance
      3. Diarrhea
      4. Necrotizing enterocolitis (NEC)
      5. Metabolic acidosis
      6. Blood urea

Search strategy for identification of studies

Searches of the Oxford Database of Perinatal Trials, MEDLINE, previous reviews including cross references, abstracts, conferences and symposia proceedings, expert informants, and journal handsearching mainly in the English language.

Search keywords included 'Infant, -Newborn', 'Dietary Protein', and 'Milk, -Human', including all subheadings for each term.

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Methods of the review

The criteria and standard methods of the Cochrane Neonatal Review Group were used to assess the methodological quality of the included trials.

Additional information was requested from the authors of each trial to clarify methodology and results as necessary.

Each author extracted the data separately, compared data, and resolved differences.

The standard method of the Neonatal Review Group was used to synthesize the data. Results were expressed as relative risk and weighted mean difference.

Description of studies

Four studies met the inclusion criteria (Rönnholm 1982, Putet 1987, Boehm 1988, Polberger 1989). Details of the included studies are included in the Table 'Characteristics of Included Studies'. All studies examined very low birthweight infants. Boehm 1988 also studied larger low birthweight infants but the results for this group have not been included in this overview. Putet 1987 studied only male infants.

Human milk protein supplements were used by three studies (Rönnholm 1982, Boehm 1988, Polberger 1989) and bovine casein hydrolysate by one (Putet 1987). Protein intakes approximated 1.5g/kg/day across all studies. Fluid intakes between studies ranged from approximately 164 to 200 ml/kg/day. The duration of intervention and the study period is not clear for three studies (Boehm 1988, Putet 1987, and Rönnholm 1982). Polberger 1989 ceased supplementation when infants were breast fed or reached a weight of 2200g.

Rönnholm 1982 provided supplemental calcium to the control group because of concerns that ultrafiltration of human milk inadvertently provided more calcium to the protein-supplemented group. Polberger 1989 supplemented all infants with calcium and phosphorus. Calcium and phosphorus supplementation in the other two studies is unknown. Rönnholm 1982 and Polberger 1989 provided supplemental vitamins.

Studies that were excluded from the review are listed in the Table 'Characteristics of Excluded Studies'. Beaufrere 1990 conducted a non-randomized study of protein supplementation. Moro 1991, Moro 1995, and Boehm 1990 did not use an unsupplemented control group. There was insufficient information in the report of the study by Minoli 1988 to include the results in this analysis and no further information could be obtained.

Additional information was provided by Professor NCR Räihä (co-author of Polberger 1989, Boehm 1988, and Minoli 1988), Dr S Polberger (Polberger 1989), and Professor G Putet (Putet 1987, Beaufrere 1990).

Methodological quality of included studies

Rönnholm 1982 used alternate allocation to assign infants. Polberger 1989 used sealed envelopes, and Boehm 1988 did not specify the randomization method. Putet 1987 did not specify the exact method and infants were randomized to either supplementation or no supplementation, with a "matched" infant assigned the other treatment. Polberger 1989 performed a double-blind study; masking of investigators is unclear in other studies.

Polberger 1989 withdrew two of nine infants randomized to the protein supplementation group (feed intolerance, need for parenteral nutrition) and one of eight infants randomized to the unsupplemented group (apnea). Rönnholm 1982 does not report results for ten infants randomized and then withdrawn, and group allocation is not able to be determined.

Polberger 1989 used a regression of growth parameters against time to calculate a measure of growth. The slope of the regression was converted to units of g/kg/day and cm/week for the study period.

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Results

These studies report results for a total of 90 infants. The a priori hypothesis evaluating differences between bovine and human milk protein supplementation was not undertaken because of insufficient numbers of infants receiving the former intervention.

Short Term Growth Parameters

All studies evaluated short term growth over the course of the intervention. Supplementation with protein resulted in an average increase in weight gain of 3.6 g/kg/day (95% CI 2.4 to 4.8 g/kg/day). Linear growth increased in infants receiving protein supplementation (WMD 0.28 cm/week, 95% CI 0.18 to 0.38 cm/week), as did head growth (WMD 0.15 cm/week, 95% CI 0.06 to 0.23 cm/week).

Long Term Growth Parameters

  • No study evaluated long term growth.

Neurodevelopmental Outcomes

  • No study evaluated long term neurodevelopmental outcomes.

Nitrogen Retention

  • No study evaluated this outcome.

Serum Albumin Concentrations

Only one study (Polberger 1989) evaluated serum albumin concentrations. There were no significant differences between the groups (29.5 vs. 27.0 g/l for protein-supplemented and unsupplemented infants, respectively - additional information provided by Dr S.Polberger). Putet 1987 found elevated total serum protein values (49.9 vs. 44.1 g/l, p < 0.05) in supplemented infants. Rönnholm 1982 demonstrated elevated total plasma amino acid levels in supplemented infants (2339 vs. 1447 umol/l at 8 weeks of age, p < 0.001).

Feeding Intolerance

Polberger 1989 withdrew one infant assigned supplemental protein.

Diarrhea

  • No study evaluated this outcome.

Necrotizing Enterocolitis

Polberger 1989, with results reported for only 7 infants in each group, stated that no infant developed NEC.

Metabolic Acidosis

Rönnholm 1982 found that blood pH was significantly lower in supplemented infants at 2 weeks of age (pH 7.32 vs. 7.37, p < 0.05, no standard deviation data provided) but there were no differences at subsequent intervals. Putet 1987 did not demonstrate any significant difference in bicarbonate levels between the groups (23.2 vs. 21.1 mmol/l).

Blood Urea

Three studies (Boehm 1988, Polberger 1989, Putet 1987) showed increased urea levels in supplemented infants (WMD 1.0 mmol/l, 95% CI 0.8 to 1.2). Rönnholm 1982 did not provide absolute values but similarly noted higher urea levels in supplemented infants. The clinical significance of this is unclear as the higher levels in the supplemented group were not outside a range considered normal.

Discussion

Protein supplementation of human milk in relatively well preterm infants at approximately 1.5 g/kg/day results in small but statistically significant increases in weight gain, linear, and head growth over the short term study periods evaluated. There is some heterogeneity in the results of the length measurements which may reflect difficulties in accurate measurements of this parameter or differences in study design.

Although the differences for these short term growth outcomes are small, the effect is cumulative. For prolonged hospital stays, a small advantage in weight gain or head or linear growth may have a significant impact on growth parameters at discharge or even age at discharge. These outcomes were not able to be evaluated in this review. Protein supplementation may also result in increased serum protein levels.

There is no information available evaluating the pre-specified long term growth and neurodevelopmental outcomes.

Urea levels are higher in infants receiving protein supplementation, but the clinical significance of this is not clear and elevated values may reflect adequate (rather than excessive) dietary protein intake. There are insufficient data to evaluate other potential adverse effects.

Reviewers' conclusions

Implications for practice

Protein supplementation of human milk in preterm infants leads to increases in short term weight gain (WMD 3.6 g/kg/day, 95% CI 2.4 to 4.8 g/kg/day), linear growth (WMD 0.28 cm/week, 95% CI 0.18 to 0.38 cm/week) and head growth (WMD 0.15 cm/week, 95% CI 0.06 to 0.23 cm/week). Urea levels are increased (WMD 1.0mmol/l, 95% CI 0.8 to 1.2) but remain within the normal range. Due to the small number of infants studied and the outcomes evaluated, there is an absence of data evaluating long-term effects and adverse effects of protein supplementation.

Implications for research

Further research should be directed towards the evaluation of specific levels of protein intake in preterm infants (particularly extremely low birth weight infants) and the clinical effects (both beneficial and adverse) of supplementation. As supplementation of human milk with multiple components (protein, carbohydrate, minerals, and vitamins) is common practice, further research should concentrate on the modification and refinement of available preparations. Long term outcomes of growth and neurodevelopmental status should also be evaluated, although the numbers of infants required to evaluate this would be extremely large.

Acknowledgements

  • None noted.

Potential conflict of interest

  • None noted.

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Characteristics of studies

Characteristics of Included Studies

Study Methods Participants Interventions Outcomes Notes Allocation concealment
Boehm 1988 Randomized study
Single center
Randomization method: Unknown
Blinding of randomization: Can't tell
Blinding of intervention: Can't tell
Complete follow-up: Yes
Blinding of outcome measure: Can't tell
9 treatment, 7 control infants entered trial. Preterm infants (VLBW < 1500g and LBW >1500g).
Feeding on day 1, full feeds by one week of life. Mean final feeding volume approximately 200ml/kg/day.
Exclusions: major clinical illness.
Lyophilized human milk protein (approximately 1.5g/kg/day) supplementation of maternal or donor preterm human milk (9 infants) vs. unsupplemented human milk (7 infants).
Not stated when intervention ceased.
Short term growth parameters
Blood urea levels
Only the VLBW arm of the study has been included in the overview, as this is consistent with the other studies in this review. B
Polberger 1989 Randomized study
Single center
Randomization method: Sealed envelopes
Blinding of intervention: Double blind
Complete follow-up: No
Blinding of outcome measure: Adequate
9 treatment, 8 control infants entered trial.
Preterm infants < 1500g, appropriate for gestational age
Enteral feeds tolerated at 170ml/kg/day
Exclusions: major illness or abnormality, oxygen dependency
1.0g human milk protein (lyophilized) per 100ml human (unpasteurized maternal or unpasteurized term banked donor) milk vs. unsupplemented milk.
Intervention ceased at approximately 2200g or when breast fed.
All infants were supplemented with additional vitamins, calcium lactate (30mg/kg/day) and sodium phosphate (20mg/kg/day). From 4 weeks, 2mg/kg/day elemental iron was given to all infants.
Short term growth parameters
Plasma amino acids and proteins
Urine amino acids
This study had four arms - unsupplemented vs. supplemented with protein vs. supplemented with fat vs. supplemented with fat and protein. The analyses of the fat and combined fat and protein arms are discussed in other reviews on fat and multicomponent fortification respectively.
34 infants were enrolled in all four study arms - 6 were withdrawn following randomization (1 control, 2 protein, 1 fat, 2 fat and protein) and 7 infants were left in each arm.
The infants in the treatment group were smaller than those of the control group at outset, and received more days of the intervention, and were heavier at study completion.
There were large fluctuations in the energy intake for all four groups across the study.
A
Putet 1987 Quasi-randomized study. First infant randomized, second infant "matched"
Single center
Randomization method: Unknown
Blinding of randomization: Can't tell
Complete follow-up: Yes
Blinding of outcome measure: Can't tell
8 treatment, 8 control infants entered trial. VLBW male infants.
Medically well, oral feeds started 24-48 hours after birth
Intakes 164(± 7) and 172(± 11) ml/kg/day for the treatment and control groups, respectively.
Casein hydrolysate (1g per 100ml) added to pooled human milk (8 infants) vs unsupplemented human milk (8 infants). Duration of intervention not clear. Short term growth parameters
Plasma amino acid levels.
Blood urea and protein levels.
Acid-base studies.
B
Rönnholm 1982 Quasi-randomized
Single center
Randomization method: Alternate allocation
Complete follow-up: No
Blinding of outcome measure: No
Uncertain number of treatment and control infants entered trial (see Notes). Preterm, < 1520g
Enrolled at 2 days if free of major illness and major malformation
0.8g human milk protein per 100ml human milk (pasteurized maternal or term donor milk) vs. unsupplemented human milk.
Target fluid volume 200ml/kg/day.
All infants reecived supplemental vitamins (although some infants in different doses, as part of another study). Control infants received calcium supplements (10mg/kg/day).
It is not clear when the intervention was ceased.
Short term growth parameters
Serum albumin and protein levels
Amino acid profiles
Hemoglobin levels (not analysed in this review)
54 infants were initially enrolled. 10 infants were excluded post-randomization for medical reasons or insufficient enteral feeding (group allocation unclear). Two infants who developed hydrocephalus were excluded from head circumference measurements.
Half the infants in each group received (randomly) supplementation with fat (MCT oil, 1.0g/100ml of milk). The authors state that fat supplementation did not affect outcomes and therefore grouped the infants according to protein supplementation. Data is not extractable for protein supplementation alone vs. unsupplemented milk alone. Despite addition of protein to dietary intakes, there was no difference in energy intakes between the protein supplemented and unsupplemented groups.
D

Characteristics of excluded studies

Study Reason for exclusion
Beaufrere 1990 Not randomized.
Boehm 1990 Comparison of two forms of protein supplementation which did not include an unsupplemented control group.
Minoli 1988 Unable to obtain sufficient data from published abstract and communication with author.
Moro 1991 Comparison of human milk protein versus bovine milk protein. No unsupplemented control group.
Moro 1995 No control group receiving unsupplemented human milk.

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References to studies

Included studies

Boehm 1988

{published data only}

Boehm G, Müller DM, Beyreiss K, Räihä NCR. Evidence of functional immaturity of the ornithine-urea cycle in very-low-birthweight infants. Biol Neonate 1988;54:121-125.

Polberger 1989

{published and unpublished data}

* Polberger SKT, Axelsson IA, Räihä NCE. Growth of very low birth weight infants on varying amounts of human milk protein. Pediatr Res 1989;25:414-419.

Polberger SKT, Axelsson IE, Räihä NCR. Amino acid concentrations in plasma and urine in very low birth weight infants fed protein-unenriched or human milk protein-enriched human milk. Pediatrics 1990;86:909-915.

Polberger SKT, Fex GA, Axelsson IE, Räihä NCR. Eleven plasma proteins as indicators of protein nutritional status in very low birth weight infants. Pediatrics 1990;86:916-921.

Putet 1987

{published and unpublished data}

Putet G, Rigo J, Salle B, Senterre J. Supplementation of pooled human milk with casein hydolysate: energy and nitrogen balance and weight gain composition in very low birth weight infants. Pediatr Res 1987;21:458-461.

Rönnholm 1982

{published data only}

Rönnholm KAR, Sipila O, Siimes MA. Human milk protein supplementation for the prevention of hypoproteinemia without metabolic imbalance in breast milk-fed, very low-birth-weight infants. J Pediatr 1982;101:243-247.

Rönnholm KAR, Siimes MA. Haemoglobin concentration depends on protein intake in small preterm infants fed human milk. Arch Dis Child 1985;60:99-104.

Rönnholm KAR, Simell O, Siimes MA. Human milk protein and medium-chain triglyceride oil supplementation of human milk: plasma amino acids in very low-birth-weight infants. Pediatrics 1984;74:792-799.

* Rönnholm KAR, Perheentupa J, Siimes MA. Supplementation with human milk protein improves growth of small premature infants fed human milk. Pediatrics 1986;77:649-653.

Excluded studies

Beaufrere 1990

{published and unpublished data}

Beaufrere B, Putet G, Pachiaudi C, Salle B. Whole body protein turnover measured with 13C-leucine and energy expenditure in preterm infants. Pediatr Res 1990;8:147-152.

Boehm 1990

{published data only}

Boehm G, Melichar V, Senger H, Müller D, Räihä NCR. Effects of varying energy intakes on nitrogen retention and growth in very low birthweight infants fed fortified human milk. Acta Paediatr Scand 1990;79:228-229.

Minoli 1988

{published data only}

Minoli I, Moro G, Fulconis, Räihä N. Growth and protein metabolism in VLBW infants fed with human milk formula: a reference model. 11th European Congress of Perinatal Medicine. Abstract 4102. Rome, Italy, April 10-13, 1988.

Moro 1991

{published data only}

Moro GE, Minoli I, Fulconis F, Clementi M, Räihä NCR. Growth and metabolic responses in low-birth-weight infants fed human milk fortified with human milk protein or with a bovine milk protein preparation. J Pediatr Gastroenterol Nutr 1991;13:150-154.

Moro 1995

{published data only}

Moro GE, Minoli I, Ostrom M, Jacobs JR, Picone TA, Räihä NCR, Ziegler EE. Fortification of human milk: evaluation of a novel fortification scheme and of a new fortifier. J Pediatr Gastroenterol Nutr 1995;20:162-172.

* indicates the primary reference for the study

Other references

Additional references

Bishop 1996

Bishop NJ, Dahlenburg SL, Fewtrell MS, Morley R, Lucas A. Early diet of preterm infants and bone mineralization at age five years. Acta Paediatr 1996;85:230-236.

Goldman 1969

Goldman HI, Freudenthal R, Holland B, Karelitz S. Clinical effects of two different levels of protein intake on low-birth-weight infants. J Pediatr 1974;85:764-769.

Hay 1994

Hay WW Jr. Nutritional requirements of extremely low birthweight infants. Acta Paediatr Suppl 1994;402:94-99.

Lucas 1984

Lucas A, Gore SM, Cole TJ et al. Multicentre trial on feeding low birthweight infants: effects of diet on early growth. Arch Dis Child 1984;59:722-730.

Lucas 1986

Lucas A, Baker BA. Breast milk jaundice in premature infants. Arch Dis Child 1986;61:1063-1067.

Lucas 1989

Lucas A, Morley R, Cole TJ et al. Early diet in preterm infants and developmental status in infancy. Arch Dis Child 1989;64:1570-1578.

Lucas 1990a

Lucas A, Brooke OG, Morley R, Cole TJ, Bamford MF. Early diet of preterm infants and development of allergic or atopic disease: randomised prospective study. BMJ 1990;300:837-840.

Lucas 1990b

Lucas A, Cole TJ. Breast milk and neonatal necrotising enterocolitis. Lancet 1990;336:1519-1523.

Lucas 1990c

Lucas A, Morley R, Cole TJ, et al. Early diet in preterm babies and developmental status at 18 months. Lancet 1990;335:1477-1481.

Lucas 1994

Lucas A, Morley R, Cole TJ, Gore SM. A randomised multicentre study of human milk versus formula and later development in preterm infants. Arch Dis Child 1994;70:F141-F146.

Lucas 1994b

Lucas A, Morley R. Does early nutrition in infants born before term programme later blood pressure. BMJ 1994;309:304-308.

Schanler 1995

Schanler RJ. Suitability of human milk for the low-birthweight infant. Clin Perinatol 1995;22:207-222.

Other published versions of this review

Kuschel 1999

Kuschel CA, Harding JE. Protein supplementation of human milk for promoting growth in preterm infants. In: The Cochrane Library, Issue 3, 1999. Oxford: Update Software.

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Table of comparisons

01 Protein supplementation vs control

01 Weight gain(g/kg/day)
02 Linear growth (cm/week)
03 Head growth (cm/week)
04 Serum albumin (g/l)
05 Feeding intolerance
06 Blood urea (mmol/l)

Notes

Unpublished CRG notes

Short title (no longer in use): Protein supplementation of human milk

Additional tables

  • None noted.

Amended sections

  • None noted.

Contact details for co-reviewers

Prof Jane Harding

Professor of Neonatology
Department of Paediatrics
University of Auckland
Private Bag 92 019
Auckland
NEW ZEALAND
1001
Telephone 1: +64 9 373 7599 extension: 6439
Telephone 2: +64 9 638 9909
Facsimile: +64 9 373 7497

E-mail: j.harding@auckland.ac.nz

Secondary address:
National Women's Hospital
Claude Road, Epsom
Auckland
NEW ZEALAND


This review is published as a Cochrane review in The Cochrane Library, Issue 3, 1999 (see http://www.thecochranelibrary.com External Web Site Policy for information). Cochrane reviews are regularly updated as new evidence emerges and in response to feedback, and The Cochrane Library should be consulted for the most recent recent version of the review.