General properties of Protein and Carbohydrate requirements for premature (preterm) infants

Up to the 1940s, preterm infants were usually fed human milk. However, at that time Gordon and co-workers found that preterm infants would gain weight better when fed various artificial formulas than when fed the pooled, banked human milk then available. So how did this help?

Weight gain of the infants appeared to correlate more with the electrolyte or ash intake than with the protein intake. Intakes between 2.25 and 5.0 protein per kilogram per day were adequate but not toxic. The estimated requirements based on the fetal accretion rate of protein are 3.5 to 4g/kg per day.

The type of protein most suitable for preterm infants was studied by Gaull, Rama, and co-workers. They compared whey-predominant (60:40 ratio of whey casein proteins) to casein-predominant (18:82 ratio of whey:casein proteins) formulas. each at two concentrations- 1.5g/dL and 3g/dL. The metabolic effects and resultant growth following feeding of each of the four formulas were compared to the effects of feeding pooled milk from mothers of term infants. The BUN was higher in infants fed both of the 3g/dL formulas and the 1.5g/dL 18:82 formula than with the 1.5g/dL 60:40 formula. Metabolic acidosis and elevated plasma tyrosin and phenylalanine levels were found with the 3g.dL 18:82 formula, and plasma taurine levels were maintained longer with the 60:40 formulas. Gaull and co-workers concluded that there were no advantages, and some metabolic disadvantages. to the 3g/dL over the 1.5g/dL formulas, and that infants fed the whey-predominant (60:40) formulas, with whey:casein protein ratios similar to human milk, had metabolic indices and plasma amino acid levels closer to those of infants fed pooled, mature human milk.

Carbohydrates
The ability of the preterm infant to digest lactose may be poor in the first days of life because of a low intestinal mucousal lactase activity. In the absence of adequate lactase activity, undigested lactose may be present in high concentrations in the lower intestinal tract and serve as a substrate for proliferation of potentially pathogenic bacteria. Additionally, the lactose may cause intestinal distension by its osmotic effect. However, glycosidase enzymes for glucose polymers are active in small preterm infants, and these polymers are well tolerated clinically by preterm infants. Also, glucose polymers add fewer osmotic particles to the formula per unit weight than lactose. On the basis of these advantages. the carbohydrate portions of the various special formulas for preterm infants contain approximately 50% lactose and 50% glucose polymers.

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