Postdischarge nutrition for high risk neonates

Education of family members to support weaning to solids and nutrition in infants born preterm

BACKGROUND

Weaning refers to the period of introduction of solid food to complement breast milk or formula milk. Preterm infants are known to acquire extrauterine growth restriction by the time of discharge from neonatal units. Hence, the postdischarge and weaning period are crucial for optimal growth. Optimisation of nutrition during weaning may have long-term impacts on outcomes in preterm infants. Family members of preterm infants may require nutrition education to promote ideal nutrition practices surrounding weaning in preterm infants who are at high risk of nutritional deficit.

OBJECTIVES

To investigate the role of nutrition education of family members in supporting weaning in preterm infants with respect to their growth and neurodevelopment compared with conventional management.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 5), MEDLINE via PubMed (1966 to 26 June 2018), Embase (1980 to 26 June 2018), and CINAHL (1982 to 26 June 2018). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs.

SELECTION CRITERIA

RCTs and quasi-RCTs were eligible for inclusion if they examined the effects of nutrition education of family members as compared to conventional management for weaning of preterm infants up to one year of corrected gestational age. We defined prematurity as less than 37 completed weeks of gestation.

DATA COLLECTION AND ANALYSIS

At least two review authors independently screened potential studies for inclusion and planned to identify, extract data, and assess the quality of eligible studies. We resolved any differences in opinion through discussion with a third review author and consensus among all three review authors.

MAIN RESULTS

No eligible trials looking at the impact of nutrition education of family members in weaning of preterm infants fulfilled the inclusion criteria of this systematic review. Two studies investigating the ideal timing for weaning in premature infants reported conflicting results, AUTHORS' CONCLUSIONS: We were unable to assess the impact of nutrition education of family members in weaning of preterm infants as there were no eligible studies. This may be due to the lack of evidence to determine the ideal weaning strategies for preterm infants with regards to the time of initiating weaning and type of solids to introduce. Trials are needed to assess the many aspects of infant weaning in preterm infants. Long-term neurodevelopment and metabolic outcomes should also be assessed in addition to growth parameters.

Exploration of the Contribution of Biobehavioral Variables to the Energy Expenditure of Preterm Infants

Variation in energy expended by preterm infants may be due to infant maturity and history of resolved acute lung disease (respiratory distress syndrome [RDS]) as well as growth, caloric intake, and activity. Indirect calorimetry was used in this exploratory, short-term longitudinal study to estimate energy expenditure (EE) from measures of inspired and expired O2 and CO2 .The sample included 35 assessments for 10 preterm infants (5 with and 5 without RDS history). Lung disease history (resolved RDS, no RDS diagnosis), weight gain (g/d) from the day on which birth weight had been regained to the study day, mean activity level, the number of the assessment (1 6), and the interaction of lung disease history and time were included in a linear mixed model for repeated measures. Time was an index of postconceptional and postnatal age; all 3 were highly correlated. Because of high correlation with weight gain, caloric intake was not included in the analytic model. Lung disease history, mean activity level, and time were significant contributors to EE. A more precise measure of medical status than absence or presence of lung disease history, evenly spaced repetitions of EE assessment, and exploration of contexts in which the infants exhibit a higher activity level are needed in a replication study with a larger sample.

Post-discharge formula feeding in preterm infants: A systematic review mapping evidence about the role of macronutrient enrichment

BACKGROUND & AIMS

Preterm infants are a heterogeneous group and many accumulate growth deficits before and after initial hospital discharge. Although this is associated with worse cognitive outcome, recent meta-analyses suggest that nutrient fortification of breast milk, or the use of nutrient and energy rich formulae after discharge exert little effect on growth and neurodevelopment. However, the complexity of study design, inclusion criteria and outcome parameters, combined with differences in formula composition mean that meta-analysis may overlook important effects of differing interventions in sub-groups.

METHODS

We systematically identified evidence and mapped the information on Participants, Intervention, Comparator, and Outcome (PICO) from 31 published studies illustrating the marked heterogeneity in study design and interventions next to outcomes on (quality of) growth and neurodevelopment.

RESULTS

Despite significant heterogeneity in study design, we found that nutrient enriched diets after discharge show no negative effects but frequently improve growth parameters at some point in the course of the study, in particular for boys. The data indicates that when energy requirements are adequate, increased protein results in increased growth and lean mass (LM) accretion; In particular, higher protein to energy ratios lead to increased lean mass accretion, and increased head circumference (HC) at one year. However, improvements in neurodevelopmental outcome were rarely seen.

CONCLUSION

This comprehensive evidence mapping approach to the field provides a broad but detailed overview of the currently available evidence. Furthermore, we identified key gaps in existing knowledge on the role of nutrient enrichment in the post-discharge period.

A.S.P.E.N. clinical guidelines: nutrition support of neonatal patients at risk for metabolic bone disease

BACKGROUND

Premature infants are at increased risk for metabolic bone disease, with resulting delayed bone growth, osteopenia, and rickets.

METHOD

A systematic review of the best available evidence to answer a series of questions regarding neonatal patients at risk of metabolic bone disease receiving parenteral or enteral nutrition was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation working group. A consensus process was used to develop the clinical guideline recommendations prior to external and internal review and approval by the American Society for Parenteral and Enteral Nutrition Board of Directors.

QUESTIONS

(1) What maternal risk factors predispose the neonate to metabolic bone disease? (2) What is the optimal type of feeding to promote neonatal bone health? (3) When and how should vitamin D supplements be administered? (4) Does parenteral nutrition (PN) predispose a neonate to metabolic bone disease, and if so, are there PN formulation recommendations to minimize this risk?

Multinutrient fortification of human breast milk for preterm infants following hospital discharge

BACKGROUND

Preterm infants are usually growth restricted at hospital discharge. Feeding preterm infants after hospital discharge with multinutrient fortified breast milk rather than unfortified breast milk may facilitate more rapid catch-up growth and improve neurodevelopmental outcomes.

OBJECTIVES

To determine the effect of feeding preterm infants following hospital discharge with multinutrient fortified human breast milk versus unfortified breast milk on growth and development.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included electronic searches of the Cochrane Central Register of Controlled Trials Register (CENTRAL, The Cochrane Library, 2012, Issue 3), MEDLINE, EMBASE and CINAHL (until August 2012), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared feeding preterm infants following hospital discharge with multinutrient fortified breast milk compared with unfortified human breast milk.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Neonatal Review Group with separate evaluation of trial quality and data extraction by two review authors and synthesis of data using risk ratio, risk difference and mean difference.

MAIN RESULTS

We identified two small trials involving a total of 246 infants. These did not provide evidence that multinutrient fortification of breast milk for three to four months after hospital discharge affected rates of growth during infancy. One trial assessed infants at 18 months corrected age and did not find any statistically significant effects on neurodevelopmental outcomes.

AUTHORS' CONCLUSIONS

The limited available data do not provide convincing evidence that feeding preterm infants with multinutrient fortified breast milk compared with unfortified breast milk following hospital discharge affects important outcomes including growth rates during infancy. There are no data on long-term growth. Since fortifying breast milk for infants fed directly from the breast is logistically difficult and has the potential to interfere with breast feeding, it is important to determine if mothers would support further trials of this intervention.

Multinutrient fortification of human breast milk for preterm infants following hospital discharge

BACKGROUND

Preterm infants are usually growth restricted at hospital discharge. Feeding preterm infants after hospital discharge with multinutrient fortified breast milk rather than unfortified breast milk may facilitate more rapid catch-up growth and improve neurodevelopmental outcomes.

OBJECTIVES

To determine the effect of feeding with multinutrient fortified human breast milk versus unfortified breast milk on growth and development in preterm or low birth weight infants following hospital discharge.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2010), MEDLINE (1966 to April 2010), EMBASE (1980 to April 2010), CINAHL (1982 to April 2010), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared feeding preterm infants following hospital discharge with multinutrient fortified breast milk compared with unfortified human breast milk.

DATA COLLECTION AND ANALYSIS

The standard methods of the Cochrane Neonatal Review Group were used, with separate evaluation of trial quality and data extraction by two review authors.

MAIN RESULTS

One small trial (N = 39) was identified. Multinutrient fortification of breast milk for 12 weeks after hospital discharge resulted in higher rates of growth during infancy. At 12 months corrected age, weight (mean difference 1187g, 95% confidence interval (CI) 259, 2115 g), length (3.8 cm, 95%CI 1.2, 6.4 cm) and head circumference (1.0 cm, 95%CI 0.1, 1.9 cm) were statistically significantly greater in the intervention group. No evidence of an effect on neurodevelopmental assessments at 18 months corrected age was found.

AUTHORS' CONCLUSIONS

The limited available data suggest that feeding preterm infants following hospital discharge with multinutrient fortified breast milk compared with unfortified breast milk increases growth rates during infancy. The importance of these effects on long-term growth and development is unclear and deserves further assessment in randomised controlled trials. Since fortifying breast milk for infants fed directly from the breast is logistically difficult and has the potential to interfere with breast feeding, it is important to determine if mothers would support further trials of this intervention.

Improving the use of human milk during and after the NICU stay

The feeding of human milk (milk from the infant's own mother; excluding donor milk) during the newborn intensive care unit (NICU) stay reduces the risk of costly and handicapping morbidities in premature infants. The mechanisms by which human milk provides this protection are varied and synergistic, and appear to change over the course of the NICU stay. The fact that these mechanisms include specific human milk components that are not present in the milk of other mammals means that human milk from the infant's mother cannot be replaced by commercial infant or donor human milk, and the feeding of human milk should be a NICU priority. Recent evidence suggests that the impact of human milk on improving infant health outcomes and reducing the risk of prematurity-specific morbidities is linked to specific critical exposure periods in the post-birth period during which the exclusive use of human milk and the avoidance of commercial formula may be most important. Similarly, there are other periods when high doses, but not necessarily exclusive use of human milk, may be important. This article reviews the concept of "dose and exposure period" for human milk feeding in the NICU to precisely measure and benchmark the amount and timing of human milk use in the NICU. The critical exposure periods when exclusive or high doses of human milk appear to have the greatest impact on specific morbidities are reviewed. Finally, the current best practices for the use of human milk during and after the NICU stay for premature infants are summarized.

Growth and body composition of human milk-fed premature infants provided with extra energy and nutrients early after hospital discharge: 1-year follow-up

OBJECTIVES

Human milk (HM) is the optimal source of nutrition for premature infants; however, it is unclear whether HM alone is sufficient to meet their elevated nutritional requirements early after hospital discharge. We previously reported that premature infants (750-1800 g birth weight) fed HM containing extra nutrients for 12 weeks after discharge had dietary intakes closer to recommended levels and grew more rapidly than those fed HM alone. The objectives of the present article are to examine the impact of this intervention on bone mineralization, body composition, and HM use up to 1 year. Data are also presented on general developmental level at 18-month corrected age (CA).

PATIENTS AND METHODS

At discharge, predominantly HM-fed infants were randomized to receive for 12 weeks either approximately half of their feedings containing a multinutrient fortifier (intervention, n=19) or all of their feedings as HM alone (control, n=20).

RESULTS

Intervention infants remained longer (P<0.001) and had greater whole-body bone mineral content (P=0.02) until 12-month CA compared with controls. Intervention infants born less than or equal to 1250 g continued to have a larger mean head circumference throughout the first year of life (P<0.0001). Human milk feeding (mL.kg(-1).day(-1)) differed between groups at 6- (P=0.035), but not 12-month CA. No statistically significant differences were found between groups in the mental, motor, or behavior rating scale scores of the Bayley II at 18-month CA.

CONCLUSIONS

Adding a multinutrient fortifier to HM provided to predominantly HM-fed premature infants early after discharge results in sustained differences in weight, length, and whole-body bone mineral content, and in smaller babies, head circumference for the first year of life.

Growth and nutrient intakes of human milk-fed preterm infants provided with extra energy and nutrients after hospital discharge

OBJECTIVES

The purpose of this pilot study was to determine whether mixing a multinutrient fortifier to approximately one half of the human milk fed each day for a finite period after discharge improves the nutrient intake and growth of predominantly human milk-fed low birth weight infants. We also assessed the impact of this intervention on the exclusivity of human milk feeding.

METHODS

Human milk-fed (> or = 80% feeding per day) low birth weight (750-1800 g) infants (n = 39) were randomly assigned at hospital discharge to either a control or an intervention group. Infants in the control group were discharged from the hospital on unfortified human milk. Nutrient enrichment of human milk in the intervention group was achieved by mixing approximately one half of the human milk provided each day with a powdered multinutrient human milk fortifier for 12 weeks after discharge. Milk with added nutrients was estimated to contain approximately 80 kcal (336 kJ) and 2.2 g protein/100 mL plus other nutrients. Intensive lactation support was provided to both groups.

RESULTS

Infants in the intervention group were longer during the study period, and those born < or = 1250 g had larger head circumferences than infants in the control group. There was a trend toward infants in the intervention group to be heavier at the end of the intervention compared with those in the control group. Mean protein, zinc, calcium, phosphorus, and vitamins A and D intakes were higher in the intervention group.

CONCLUSIONS

Results from this study suggest that adding a multinutrient fortifier to approximately one half of the milk provided to predominantly human milk-fed infants for 12 weeks after hospital discharge may be an effective strategy in addressing early discharge nutrient deficits and poor growth without unduly influencing human milk feeding when intensive lactation support is provided.

Weaning preterm infants: an open issue

Survival rates for very low birth weight (VLBW) and extremely low birth weight infants have substantially increased during the past few decades. Most of these infants pose new and difficult problems related in particular to neurodevelopmental outcome and growth impairment. In fact, a high percentage of very low birth weight infants fail to achieve their growth potential and experience postnatal growth restriction. Because of this in-hospital growth failure and nutrient deficits, correct nutritional intervention after hospital discharge must be instituted to avoid postnatal malnutrition and to correct the acquired deficit. Nutrient-enriched formulas for several months after discharge have shown some benefits, although their clinical value remains unclear. Weaning, which certainly represents a relevant source of nutrients for the preterm infant, has attracted little attention until now. There are no precise guidelines on this topic, and too often weaning practices are left totally to the parents, without considering the specific nutritional needs of the single infant.

Multicomponent fortification of human breast milk for preterm infants following hospital discharge

BACKGROUND

Preterm infants are usually growth restricted at hospital discharge. Feeding preterm infants after hospital discharge with nutrient-fortified breast milk (rather than unfortified breast milk) may facilitate more rapid catch-up growth and improve neurodevelopmental outcomes.

OBJECTIVES

To determine the effect of feeding with multicomponent fortified human breast milk versus unfortified breast milk on growth and development on preterm or low birth weight infants following hospital discharge.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), MEDLINE (1966 - May 2007), EMBASE (1980 - May 2007), CINAHL (1982 - May 2007), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared feeding preterm infants following hospital discharge with multicomponent fortified breast milk compared with unfortified human breast milk.

DATA COLLECTION AND ANALYSIS

The standard methods of the Cochrane Neonatal Review Group were used, with separate evaluation of trial quality and data extraction by two review authors.

MAIN RESULTS

No eligible trials were identified.

AUTHORS' CONCLUSIONS

There are no data from randomised controlled trials to determine whether feeding preterm infants following hospital discharge with multicomponent-fortified breast milk compared with unfortified breast milk affects growth and development. Given the potential for nutrient fortification to affect growth and development, this intervention may merit further assessment. Since fortifying breast milk for infants fed directly from the breast is logistically difficult (and has the potential to interfere with breast-feeding), it would be important to determine if mothers would support a trial of this intervention. It may be that a trial should first focus on infants who are not able to consume ad libitum quantities of breast milk directly from the breast, who have poor growth or nutritional status, or who have on-going additional metabolic requirements.

Nutrient-enriched formula versus standard term formula for preterm infants following hospital discharge

BACKGROUND

Preterm infants are often growth-restricted at hospital discharge. Feeding infants after hospital discharge with nutrient-enriched formula rather than standard term formula might facilitate "catch-up" growth and improve development.

OBJECTIVES

To determine the effect of feeding nutrient-enriched formula compared with standard term formula on growth and development for preterm infants following hospital discharge.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Review Group were used. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), MEDLINE (1966 - May 2007), EMBASE (1980 - May 2007), CINAHL (1982 - May 2007), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared the effect of feeding preterm infants following hospital discharge with nutrient-enriched formula compared with standard term formula.

DATA COLLECTION AND ANALYSIS

Data was extracted using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two authors, and synthesis of data using weighted mean difference and a fixed effects model for meta-analysis.

MAIN RESULTS

Seven trials were found that were eligible for inclusion. These recruited a total of 631 infants and were generally of good methodological quality. The trials found little evidence that feeding with nutrient-enriched formula milk affected growth and development. Because of differences in the way individual trials measured and presented outcomes, data synthesis was limited. Growth data from two trials found that, at six months post-term, infants fed with nutrient-enriched formula had statistically significantly lower weights [weighted mean difference: -601 (95% confidence interval -1028, -174) grams], lengths [-18.8 (-30.0, -7.6) millimetres], and head circumferences [-10.2 ( -18.0, -2.4) millimetres], than infants fed standard term formula. At 12 to 18 months post-term, meta-analyses of data from three trials did not find any statistically significant differences in growth parameters. However, examination of these meta-analyses demonstrated statistical heterogeneity. Meta-analyses of data from two trials did not reveal a statistically significant difference in Bayley Mental Development or Psychomotor Development Indices. There are not yet any data on growth or development through later childhood.

AUTHORS' CONCLUSIONS

The available data do not provide strong evidence that feeding preterm infants following hospital discharge with nutrient-enriched formula compared with standard term formula affects growth rates or development up to 18 months post-term.

Nutrient-enriched formula milk versus human breast milk for preterm infants following hospital discharge

BACKGROUND

Preterm infants are often growth-restricted at hospital discharge. Feeding infants after hospital discharge with nutrient-enriched formula milk instead of human breast milk might facilitate "catch-up" growth and improve development.

OBJECTIVES

To determine the effect of feeding nutrient-enriched formula compared with human breast milk on growth and development of preterm infants following hospital discharge.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), MEDLINE (1966 - May 2007), EMBASE (1980 - May 2007), CINAHL (1982 - May 2007), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared feeding preterm infants following hospital discharge with nutrient-enriched formula compared with human breast milk.

DATA COLLECTION AND ANALYSIS

The standard methods of the Cochrane Neonatal Review Group were used, with separate evaluation of trial quality and data extraction by two review authors.

MAIN RESULTS

No eligible trials were identified.

AUTHORS' CONCLUSIONS

There are no data from randomised controlled trials to determine whether feeding preterm infants following hospital discharge with nutrient-enriched formula milk versus human breast milk affects growth and development. Mothers who wish to breast feed, and their health care advisors, would require very clear evidence that feeding with a nutrient-enriched formula milk had major advantages for their infants before electing not to feed (or to reduce feeding) with maternal breast milk. If evidence from trials that compared feeding preterm infants following hospital discharge with nutrient-enriched versus standard formula milk demonstrated an effect on growth or development, then this might strengthen the case for undertaking trials of nutrient-enriched formula milk versus human breast milk.

Feeding preterm infants after hospital discharge: a commentary by the ESPGHAN Committee on Nutrition

Survival of small premature infants has markedly improved during the last few decades. These infants are discharged from hospital care with body weight below the usual birth weight of healthy term infants. Early nutrition support of preterm infants influences long-term health outcomes. Therefore, the ESPGHAN Committee on Nutrition has reviewed available evidence on feeding preterm infants after hospital discharge. Close monitoring of growth during hospital stay and after discharge is recommended to enable the provision of adequate nutrition support. Measurements of length and head circumference, in addition to weight, must be used to identify those preterm infants with poor growth that may need additional nutrition support. Infants with an appropriate weight for postconceptional age at discharge should be breast-fed when possible. When formula-fed, such infants should be fed regular infant formula with provision of long-chain polyunsaturated fatty acids. Infants discharged with a subnormal weight for postconceptional age are at increased risk of long-term growth failure, and the human milk they consume should be supplemented, for example, with a human milk fortifier to provide an adequate nutrient supply. If formula-fed, such infants should receive special postdischarge formula with high contents of protein, minerals and trace elements as well as an long-chain polyunsaturated fatty acid supply, at least until a postconceptional age of 40 weeks, but possibly until about 52 weeks postconceptional age. Continued growth monitoring is required to adapt feeding choices to the needs of individual infants and to avoid underfeeding or overfeeding.

Growth and breastfeeding among low birth weight infants fed with or without protein enrichment of human milk

The effect of protein enrichment of mother's milk on growth of low birthweight infants needs further exploration in order to optimize feeding strategies. The aim of this study was to describe feeding and growth of infants weighing <1,900 g at birth, up to a corrected age of 18 months, with or without protein-enriched breastmilk. A retrospective, descriptive, non-experimental design was used to describe the growth of 52 low birthweight infants. Data on their growth and feeding were collected from medical records at hospitals and child health care clinics. Despite more severe morbidity, the infants given protein-enriched milk showed similar growth as the other study infants. Standard deviation score for length at birth correlated positively with delta standard deviation score for length, from discharge to 12 and from discharge to 18 months corrected age. Duration of 'full' breastfeeding had a significant impact on subsequent improvement in SDS for weight. At discharge a smaller proportion of singletons fed with protein enriched milk were breastfed 'fully'. Infants who established breastfeeding at an early post-menstrual age were born with more optimal weight standard deviation score and had a better weight gain after discharge. We conclude that protein-enriched breast milk enables low birthweight infants requiring especially intensive care to attain growth at discharge comparable to that of healthier infants not given enriched milk. Low standard deviation score for length at birth may predict poor growth after discharge. However duration of 'full' breastfeeding had a significant impact on subsequent improvement in SDS for weight. Therefore it is important that mothers of LBW infants are given sufficient support of lactation and breastfeeding.

Calorie and protein-enriched formula versus standard term formula for improving growth and development in preterm or low birth weight infants following hospital discharge

BACKGROUND

Preterm and low birth weight infants are often growth-restricted at hospital discharge. Feeding infants post-hospital discharge with calorie and protein-enriched formula milk might facilitate "catch-up" growth and improve development.

OBJECTIVES

To review the evidence from randomised controlled trials that feeding following hospital discharge with calorie and protein-enriched formula compared with standard term formula improves growth and development for preterm or low birth weight infants.

SEARCH STRATEGY

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2004), MEDLINE (1966 - December 2004), EMBASE (1980 - December 2004), CINAHL (1982 - December 2004), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared the effect of feeding preterm or low birth weight infants post-hospital discharge with calorie and protein-enriched formula compared with standard term formula.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two authors, and synthesis of data using weighted mean difference and a fixed effects model for meta-analysis.

MAIN RESULTS

We found six trials that were eligible for inclusion. These recruited a total of 424 infants and were generally of good methodological quality. These trials found little evidence that feeding with calorie and protein-enriched formula milk affected growth and development. Because of differences in the way individual trials measured and presented outcomes, data synthesis was limited. Meta-analysis of data from two trials found a statistically significant effect on crown-heel length at 18 months post-term (weighted mean difference 9.7 millimetres (95% confidence interval 3.2 to 16.2)), but not on weight or head circumference. Meta-analysis of data from the two trials that assessed neurodevelopment at 18 months post-term did not reveal a statistically significant difference in either Bayley Mental Development Index (weighted mean difference 0.23 (95% confidence interval -2.99 to 3.45)) or Psychomotor Development Index (weighted mean difference 0.56 (95% confidence interval -1.95 to 3.07)). There are not yet any data on growth or development through later childhood.

AUTHORS' CONCLUSIONS

The limited available data do not provide strong evidence that feeding preterm or low birth weight infants following hospital discharge with calorie and protein-enriched formula compared with standard term formula affects growth rates or development up to 18 months post-term.