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Committee on Nutrition
The goal of feeding regimens for low-birth- In practice, caloric intakes of 110 to 150
weight infants is to obtain a prompt postnatal kcal/kg/day enable most low-birth-weight in-
resumption of growth to a rate approximating fants to achieve satisfactory rates of growth. If
intrauterine growth because this is believed to infants fail to gain satisfactorily, a higher caloric
provide the best possible conditions for subse- intake may be offered.
quent normal development. This statement
reviews current opinion and practices as well as Caloric Density of the Formula-Water
earlier reviews1-5 of the feeding of the low-birth- Requirement
weight infant. Although human milk or formulas that provide
67 kcal/dl (20 kcal/oz) are recommended for
Caloric Requirement term infants, more concentrated formulas are
The basal metabolic rate of low-birth-weight often used for low-birth-weight infants to facili-
infants is lower than that of full-term infants tate increased caloric intakes in infants with
during the first week of life, but it reaches and limited gastric capacity. Several studies have
exceeds that of the full-term infant by the second shown that feeding low-birth-weight infants
week. Daily caloric requirements reach 50 to 100 formulas with higher caloric densities results in
kcal/kg by the end of the first week of life and faster rates of growth.8-13 Some nurseries now feed
usually increase to 110 to 150 kcal/kg in subse- formulas of 81 kcal/dl (24 kcal/oz) and in some
quent active growth. instances 91 kcal/dl (27 kcal/oz). The 81-kcal/dl
A partition of the daily minimum energy re- concentration supplies most of the water required
quirements is shown in Table 1.6 by the infant (150 ml/kg)14 and provides 120
There are considerable variations from these kcal/kg.
average values, depending on both biological and The increased protein and mineral levels in
environmental factors. Infants who are small for these more concentrated formulas increase the
gestational age tend to have a higher basal renal solute load. With the limited capability of
metabolic.rate than do premature infants of the the immature kidney for concentrating urine,
same weight.7 The degree of physical activity sufficient water may not be supplied if the
appears to be a characteristic of the individual formula is too concentrated. Infants consuming
infant. Environmental factors may have a greater less than a normal volume of formula are particu-
influence than biological variation in determining larly vulnerable because, under constant condi-
the total caloric requirements. The maximal tions of extrarenal water loss, the lower the
response to cold stress can increase the resting formula intake the greater the proportion of
rate of heat production up to 21/2 times.6 Calories water required for renal excretion.'5 Infants
expended for specific dynamic action and for whose water balance is threatened (e.g., infants
fecal losses are dependent on the composition of exposed to heat, phototherapy, or cold stress, and
the milk or formula fed, as well as on individual those with infection or diarrhea) should have
variations in absorption of nutrients, particularly formulas of low renal solute load and should not
fat. be fed formulas of caloric density greater than 81
PEDIATRICS
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TABLE I IV fluid is discontinued or hyperglycemia and
ESTIMATED REQUIREMENTS FOR CALORIES IN A TYPICAL, hyperosmolality, which may be difficult to
GROWING PREMATURE INFANT' control.4 Serum glucose levels should be regularly
monitored and glucose infusion rates lowered to
Item kcal/kg/Day 0.4 g/kg/hr, or less if the serum glucose level
Resting caloric expenditure 50 exceeds 125 mg/dl.4 The first feeding should be
Intermittent activity 15 distilled water to avoid excessive damage to the
Occasional cold stress 10 lungs if vomiting occurs.
Specific dynamic action 8
Fecal loss of calories 12 Protein Requirement
Growth allowance 25
Total 120 The optimal protein intake for the low-birth-
weight infant has not been precisely defined;
'Data from Sinclair et al.6 however, it is between 2.25 and 5 g/kg/day for
cow's milk formulas. Human milk contains about
1.1 g of protein or less per deciliter, or 1.65 g/100
kcal.31 When fed at intakes of 120 kcal/kg/day,
keal/dl (24 kcal/oz).15 Preterm infants excrete human milk supplies almost 2 g of protein per
sodium well,16 17 and late metabolic acidosis seen kilogram per day. The feeding of human milk to
in low-birth-weight infants may be related to low premature infants was the preferred practice
mineral intake.16-19 Lactic acid-containing formu- until 25 years ago when Gordon et al.32 demon-
las should not be fed because they may produce strated that premature infants gained more
acidosis.20 weight and retained more nitrogen when fed
cow's milk formulas of higher protein content.
Alternate Feeding Procedures Subsequent reports have confirmed this, but in
When conventional feedings every few hours some reports the increased weight gains with the
do not result in the attainment of an adequate higher protein cow's milk formulas were
nutrient intake, alternate methods of feeding such attributed in part to increased electrolyte intake
as continuous nasogastric drip,21 nasojejunal feed- and subsequent water retention.33-37 However,
ing,22 23 intravenous (IV) administration of Babson and Bramhall38 found no increase in
nutrients supplemented by oral feeding,24 and weight gain when only minerals were added to
total IV alimentation25 27 may be tried. However, formula providing 1.8 g of protein per 100 kcal.
the hazards and complexities of IV administration In studies designed to determine the protein
preclude its use in routine practice.28 Parenteral requirement of low-birth-weight infants, protein
administration of (1) 20% glucose and 2.5% amino has been given at levels ranging from 1.7 to 9
acid solution; (2) 12% glucose with 2.5% amino g/kg/day. The feedings have consisted of human
acids and 10% soybean oil emulsion; and (3) 12% milk and cow's milk formulas, with the protein
glucose, 2.5% amino acids, and 1% alcohol in a content varied by dilution with carbohydrate or
volume of 125 to 150 ml/kg/day all provided by the addition of casein or deionized milk or
positive nitrogen balance.29 Glucagon levels were whey. Because of the many variables in the
lower and growth hormone levels higher in formulas, including types and levels of fat and
infants given the fat-free mixtures. Parenteral carbohydrate and levels of vitamins and minerals,
feedings appear to increase water retention.30 it is difficult to assess the nutritional adequacy of
In a controlled study of the feeding of low- the various formulas used in the studies or to
birth-weight infants by continuous nasogastric attribute the findings solely to dietary protein
drip,21 satisfactory growth and clinical progress level.
were reported with the feeding of human milk Infants fed 1.7 to 2.25 g of protein per kilogram
and a simulated human milk formula (67 kcal/dl). per day either from human milk or a cow's milk
Feeding was started at the fourth hour of life at formula did not increase in weight36-39 or
the rate of 60 ml/kg/day and increased to 300 length38-39 as rapidly as those fed higher intakes,
ml/kg/day (200 kcal/kg/day) by the ninth day. In and some developed low levels of serum
practice, the latter intake is difficult to achieve. proteins.
Although early administration of fluids is The feeding of relatively high levels of protein
generally considered beneficial to prevent dehy- (6 to 9 g/kg/day) was associated with hyperpy-
dration, excessive weight loss, hypoglycemia, and rexia and lethargy,40 high BUN levels,36 diar-
excessive jaundice,4 5 use of 10% glucose parenter- rhea,39 high urinary excretion of phenols,39 clin-
ally may cause reactive hypoglycemia when the ical edema,42 late metabolic acidosis, and
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increased mortality.39 The weight gains obtained breast milk had higher taurine levels than the
with the feeding of the high intakes of protein did other formulas. This suggestive study requires
not exceed those obtained by the feeding of confirmation.
moderate levels.36'39.40 Elevated plasma amino A review of the literature led Cox and Filer53 to
acid levels in low-birth-weight infants fed high- conclude that, with an adequate caloric intake,
protein formulas suggest that the high protein most low-birth-weight infants will grow satisfac-
intake may present an amino acid load that torily on cow's milk formulas supplying 2.25 to
exceeds the metabolizing capability of the imma- 5.0 g/kg/day of cow's milk protein. Fomon and
ture enzyme systems. Elevated levels of plasma co-workers estimated from hypothetical consider-
tyrosine and phenylalanine are not uncommon, a ations that the premature infant requires 3.0
finding related to late maturing of p-hydroxy- g/kg/day or 2.54 g of protein per 100 kcal,
phenylpyruvic oxidase.43 44 High plasma levels of assuming an intake of 120 kcal/kg/day.54
proline and methionine are also associated with If further studies confirm these findings,
high protein intake.45 consideration of protein quality along the lines
The amino acid composition of formulas for discussed here may be important in defining the
premature infants deserves special attention. optimal protein quantity for low-birth-weight
Low-birth-weight infants require some amino infants. With adequate intakes, human milk may
acids that are not essential for the term infant. In be the superior feeding for low-birth-weight
the balance studies of Snyderman,46 the removal infants.
of either cystine or tyrosine from the diet resulted
in an impairment of growth and nitrogen reten- Fat
tion, and a depression of the level of that partic- The ability of low-birth-weight infants to
ular amino acid in the plasma. Infants requiring absorb fat, particularly saturated fat such as
cystine also failed to show an increase in plasma butterfat, is relatively poor.55-58 This limitation is
cystine level after a methionine load, a finding in associated with liver immaturity and decreased
accord with the lack of cystathionase in the livers bile salt synthesis,59 and it is found to a lesser
of fetuses and premature infants reported by extent in full-term infants during the first few
Sturman et al.47'48 The high levels of cystathionine weeks of life.606' When palmitic acid-a long-
in the plasma49 and urine50 of premature infants chain saturated fatty acid-is present in fat, its
fed high-protein formulas also suggest that absorption depends on its position in the triglyc-
conversion of methionine to cystine is not effi- eride molecule.6263 Early recommendations for
cient until some time after birth. the feeding of low-birth-weight infants included
Raiha et al.5152 fed low-birth-weight infants the feeding of low-fat formulas.64'65 However, the
five formulas, including pooled breast milk. The recognition that the vegetable oils were much
breast milk supplied approximately 1.7 g of better absorbed than butterfat and other satu-
protein per kilogram per day, two formulas rated fats55 led to use in formulas of vegetable oils,
supplied 2.25 g of protein per kilogram per day, or blends of vegetable oils and animal fats. These
and two formulas supplied 4.50 g/kg/day. One are absorbed well, as is human milk fat.66
formula at each protein level had a 60:40 ratio of Including medium chain triglycerides as part of
whey/casein proteins, and the other two had an the fat in the formula has been shown to improve
18:82 ratio of whey/casein proteins. All infants fat absorption in low-birth-weight infants.67'0
grew equally well when fed 117 kcal/kg/day; Medium-chain triglycerides have also been shown
statistically, the breast-fed group gained at a to increase weight gain70 and to enhance calcium
slightly lower rate. Significant differences in absorption69 and nitrogen retention.68
plasma amino acid and ammonia levels were Fat in human milk supplies a major proportion
noted. The lower ammonia, tyrosine, and phenyl- of the caloric content. Formulas with 40% to 50%
alanine levels were found in infants fed whey/ of calories from fat are recommended for the
casein of 60:40, and the highest levels were in feeding of low-birth-weight infants because
those fed the high-protein formula with casein formulas of a lower fat content may contain
predominant. Those fed the high-protein, casein- higher levels of protein which increase renal
predominant formula developed late metabolic solute load.
acidosis. Serum protein levels were lowest in To meet the normal infant's requirement for
infants fed breast milk. essential fatty acids, it is recommended71 that
A major difference between the formulas was infant feedings supply 3% of the total calories in
the higher content of cystine in the breast milk the form of linoleic acid or 300 mg of linoleic acid
and high-whey protein formula. In addition, the per 100 kcal. Proprietary infant formulas with
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TABLE II
NUTRIENT COMPOSITION OF HUMAN MILK AND PROPRIETARY INFANT FORMULAS AND RECOMMENDED LEVELS FOR FULL-TERM
AND LOW-BIRTH-WEIGHT INFANTS'
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mends that formula fed to premature infants ml/kg/day will support the desired weight gain
should provide 0.7 IU of vitamin E per 100 kcal in most infants.
and at least 1.0 IU of vitamin E per gram of An appropriate requirement for protein equiv-
linoleic acid. In addition, the multivitamin alent to casein for the low-birth-weight infant
supplement given to low-birth-weight infants would appear to fall in the range of 2.5 to 5.0
should provide 5 IU of vitamin E, preferably in g/kg/day, or 2.25 to 4.5 g/100 kcal. A more
water-soluble form. precise statement of optimal protein quantity
awaits the definition of optimal protein quality
Formula Compositions for low-birth-weight infants. Evidence has been
Table II shows the composition of major accumulating that some amino acids considered
proprietary formulas available for feeding full- nonessential for the normal infant are indispens-
term and low-birth-weight infants, the average able to low-birth-weight infants. Thus, the
composition of human milk, and the recent apparent normal growth of infants fed breast milk
recommendations of the Committee on Nutri- supplying 1.7 g of protein per kilogram of body
tion71 for proposed standards for infant formula. weight may be caused in part by its distribution of
This information is presented in units per 100 amino acids. For the larger low-birth-weight
kcal-which relate specific nutrient needs to infant, recommendations similar to those for the
caloric requirements-and is particularly useful in term infant, including the desirability of breast
discussing formulas for low-birth-weight infants feeding, apply.71
because it allows easy comparison of formulas of Fat mixtures in formulas currently in use
differing caloric densities. include unsaturated vegetable oils and/or me-
In many instances, formulas for term infants are dium-chain triglycerides, which are well ab-
used for feeding low-birth-weight infants, and, in sorbed. Although good absorption of fat is impor-
other instances, special formulas are available for tant-not only for energy requirements but also to
premature and low-birth-weight infants. enhance the absorption of fat-soluble vitamins
Discussions in this statement suggest that levels and certain minerals-other aspects must be
of some nutrients in formulas for low-birth-weight considered in the selection of ideal formula fat
infants should be somewhat higher than the compositions for low-birth-weight infants. The
minimum levels proposed by the Committee for fatty acid composition of the diet influences the
full-term infants; however, all of these recom- composition of body lipids, especially in low-
mendations can be met within the proposed birth-weight infants who have meager stores of
standards for infant formulas.7 body fat. Fat mixtures should not be too saturated
or too unsaturated.
The occurrence of hemolytic anemia in low-
Conclusions birth-weight infants has been related to the
The optimal diet for the low-birth-weight polyunsaturated fat, vitamin E, and iron content
infant may be defined as one that supports a rate of the formula. The fortification of infant
of growth approximating that of the third formulas with vitamin E, related to the polyunsat-
trimester of intrauterine life, without imposing urated fatty acid content, is particularly impor-
stress on the developing metabolic or excretory tant for the low-birth-weight infant because poor
systems. Cell division and growth of all tissues in absorption of naturally occurring vitamin E by
the infant should proceed at a rapid rate; undue low-birth-weight infants makes them more
delay in the resumption of growth may have susceptible to a deficiency. This is especially
serious and lasting consequences. The attainment important if iron-supplemented formulas are used
of an adequate caloric intake is the primary in the early weeks of life.
requirement, and this may be facilitated by the Recent evidence indicates that some mineral
feeding of formulas of caloric density greater than requirements (e.g., calcium, sodium, copper) of
that of human milk. However, the feeding of this the low-birth-weight infant may be greater per
type of formula requires special attention to avoid 100 kcal than for full-term infants. This suggests
too high an osmolar load and to provide sufficient that slightly higher levels of these minerals be
water. The use of continuous intragastric or present in formulas for low-birth-weight infants
intrajejunal drip with formulas providing 67 or 81 than the minimum levels proposed by the
kcal/dl also may be a safe and practical means of Committee for full-term infants.
increasing caloric intake. Caloric intakes of about Low body stores of vitamins, possible defects in
120 kcal/kg/day in formula volumes of 150 to 200 absorption (particularly of fat-soluble vitamins),
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and low intakes of formula in the first weeks of 9. Snyderman SE, Holt LE Jr: The effect of high caloric
life necessitate the use of vitamin supplements, feeding on the growth of premature infants. J
even though a formula adequate for full-term Pediatr 58:237, 1961.
10. Combes MA, Pratt EL: Premature infants and
infants is used. A single injection of vitamin K1 at concentrated feeding. Am J Dis Child 102:610,
birth and daily oral supplements of vitamins A, C, 1961.
D, E, and all the B group are recommended. 11. Flakner F, Steigman AJ, Cruise MO: The physical
The long-term effects of early nutrition are development of the premature infant: Some stan-
important and challenging aspects of infant nutri- dards and certain relationships to caloric intake. J
Pediatr 60:895, 1962.
tion. Early feeding of low-birth-weight infants 12. Keitel HG, Chu E: Premature infant feeding: I. The
entails a special responsibility because this is a clinical usefulness of caloric concentration of
crucial period of development when inadequa- formulas, of early vs. late feeding and of low
cies, excesses, or imbalances are most likely to stearic acid content formulas. Pediatr Clin North
influence permanent changes. Long-term studies, Am 12:309, 1965.
13. Fomon SJ, Filer LJ Jr, Thomas LN, et al: Relationship
still in progress, are attempting to relate feeding between formula concentration and rate of
practices in the premature nursery to subsequent growth of normal infants. J Nutr 98:241, 1969.
neurologic development, learning ability, behav- 14. Gordon HH, Levine SZ: The metabolic basis for the
ioral characteristics, and mental development in individualized feeding of infants, premature and
general. Other possible pathologic consequences full-term. J Pediatr 25:464, 1944.
15. Ziegler EE, Fomon SJ: Fluid intake, renal solute load,
of improper early nutrition that are legitimate and water balance in infancy. J Pediatr 78:561,
areas of concern for the pediatric nutritionist 1971.
include atherosclerosis, obesity, hypertension, 16. Aperia A, Broberger 0, Thodenius K, Zetterstrom R:
and renal disease. Developmental study of the renal response to an
COMMITTEE ON NUTRITION oral salt load in preterm infants. Acta Paediatr
Scand 63:517, 1974.
17. Aperia A, Broberger 0, Thodenius K, Zetterstrom R:
Members: Lewis A. Barness, M.D., Chairman; Alvin M. Renal response to an oral sodium load in newborn
Mauer, M.D., Vice-Chairman; Arnold S. Anderson, M.D.; full term infants. Acta Paediatr Scand 61:670,
Peter R. Dallman, M.D.; Gilbert B. Forbes, M.D.; James C. 1972.
Haworth, M.D.; Mary Jane Jesse, M.D.; Buford L. Nichols, 18. Radde IC, Chance GW, Bailey K, et al: Growth and
Jr., M.D.; Nathan J. Smith, M.D.; Myron Winick, M.D. mineral metabolism in very low birth weight
Consultants: William C. Heird, M.D.; 0. L. Kline, Ph.D.; infants: I. Comparison of the effects of two modes
Donough O'Brien, M.D. of NaHCO3 treatment of late metabolic acidosis.
Pediatr Res 9:564, 1975.
19. Suljok E: Sodium homoeostasis in preterm infants.
Lancet 1:930, 1975.
REFERENCES 20.. Ballabriga A, Conde C, Gallart-Catala A: Metabolic
response of prematures to milk formulas with
1. Holt LE Jr, Snyderman SE: The feeding of premature different lactic acid isomers or citric acid. Helv
and newborn infants. Pediatr Clin North Am Paediatr Acta 25:25, 1970.
13:1103, 1966. 21. Valman HB, Heath CD, Brown RJK: Continuous
2. Davidson M: Formula feeding of normal term and low intragastric milk feeds in infants of low birth
birth weight infants. Pediatr Clin North Am weight. Br Med J 3:547, 1972.
17:913, 1970. 22. Rhea JW, Kilby JO: A nasojejunal tube for infant
3. Babson SG: Feeding the low-birth-weight infant. J feeding. Pediatrics 46:36, 1970.
Pediatr 79:694, 1971. 23. Cheek JA Jr, Staub GF: Nasojejunal alimentation for
4. Dweck HS: Feeding the prematurely born infant: premature and full-term newborn infants. J
Fluids, calories and methods of feeding during the Pediatr 82:955, 1973.
period of extrauterine growth retardation. Clin 24. Benda GIM, Babson SG: Peripheral intravenous
Perinatol 2:183, 1975. alimentation of the small premature infant. J
5. Barness LA: Nutrition for the low birth weight infant. Pediatr 79:494, 1971.
Clin Perinatol 2:345, 1975. 25. Wilmore DW, Dudrick SJ: Growth and development
6. Sinclair JC, Driscoll JM Jr, Heird WC, Winters RW: of an infant receiving all nutrients exclusively by
Supportive management of the sick neonate: vein. JAMA 203:860, 1968.
Parenteral calories, water, and electrolytes. Pedi- 26. Peden VH, Karpel JT: Total parenteral nutrition in
atr Clin North Am 17:863, 1970. premature infants. J Pediatr 81:137, 1972.
7. Hill JR, Robinson DC: Oxygen consumption in 27. Driscoll JM Jr, Heird WC, Schullinger JN, et al: Total
normally grown, small-for-dates and large-for- intravenous alimentation in low-birth-weight
dates new-born infants. J Physiol 199:685, 1968. infants: A preliminary report. J Pediatr 81:145,
8. Hardy JB, Goldstein EO: The feeding of premature 1972.
infants: The value of high caloric diets in reducing 28. Committee on Nutrition: Parenteral feeding-A note
the length of hospital stay. J Pediatr 38:154, of caution. Pediatrics 49:776, 1972.
1951. 29. Asch MJ, Sperling M, Fiser R, et al: Metabolic and
AMERICAN
Downloaded from http://pediatrics.aappublications.org/ March 4, 2018OF
ACADEMY
by guest on PEDIATRICS 527
hormonal studies comparing three parenteral content of plasma and red blood cells. Am J Clin
nutrition regimens in infants. Ann Surg 182:62, Nutr 23:890, 1970.
1975. 46. Snyderman SE: The protein and amino acid require-
30. Brans YW, Sumners JE, Dweck HS, Cassady G: ments of the premature infant, in Jonxis JHP,
Feeding the low birth weight infant: Orally or Vesser HRA, Troelstra JA (eds): Metabolic
parenterally? Preliminary results of a comparative Processes in the Foetus and Newborn Infant.
study. Pediatrics 54:15, 1974. Baltimore, Williams and Wilkins, 1971.
31. Lonnerdal B, Forsum E, Hambraeus L: The protein 47. Sturman JA, Gaull G, Raiha NCR: Absence of cysta-
content of human milk: I. Transversal study of thionase in human fetal liver: Is cystine essential?
Swedish normal material. Nutr Rep Int 13:125, Science 169:74, 1970.
1976. 48. Gaull G, Sturman JA, Raiha NCR: Development of
32. Gordon HH, Levine SZ, McNamara H: Feeding of mammalian sulfur metabolism: Absence of cysta-
premature infants: A comparison of human and thionase in human fetal tissues. Pediatr Res 6:538,
cow's milk. Am J Dis Child 73:442, 1947. 1972.
33. Kagan BM, Stanincova V, Felix NS, et al: Body 49. Valman HB, Brown RJK, Palmer T, et al: Protein
composition of premature infants: Relation to intake and plasma amino acids of infants of low
nutrition. Am J Clin Nutr 25:1153, 1972. birth weight. Br Med J 4:789, 1971.
34. Goldman HI, Karelitz S, Acs H, Seifter E: The 50. Przyrembel H, Bremer HJ: Cystathioninuria in prema-
relationship of the sodium, potassium, and chlo- ture infants. Clin Chim Acta 41:95, 1972.
ride concentration of the feeding to the weight 51. Raiha NCR, Heinonen K, Rassin DK, Gaull GE: Milk
gain of premature infants. Pediatrics 30:909, protein quantity and quality in low-birthweight
1962. infants: I. Metabolic responses and effects on
35. Kagan BM, Felix N, Molander CW, et al: Body water growth. Pediatrics 57:659, 1976.
changes in relation to nutrition of premature 52. Gaull GE, Rassin DK, Raiha NCR, Heinonen K: Milk
infants. Ann NY Acad Sci 110:830, 1963. protein quantity and quality in low birth weight
36. Davidson M, Levine SZ, Bauer CH, Dann M: Feeding infants: III. Effects on sulfur amino acids in
studies in low birth weight infants: Relationships plasma and urine. J Pediatr 90:348, 1977.
of dietary protein, fat, and electrolyte to rates of 53. Cox WM Jr, Filer LJ Jr: Protein intake for low-birth
weight gain, clinical courses and serum chemical weight infants. J Pediatr 74:1016, 1969.
concentrations. J Pediatr 70:695, 1967. 54. Fomon S, Ziegler E, Vazquez H: Human milk and the
37. Levin B, Mackay HMM, Neill CA, et al: Weight small premature infant. Am J Dis Child 131:463,
Gains, Serum Protein Levels and Health of Breast 1977.
Fed and Artificially Fed Infants, special report 55. Tidwell HC, Holt LE Jr, Farrow HL, Neale S: Studies
series No. 296. London, Medical Research Coun- in fat metabolism: III. Fat absorption in prema-
cil, 1959. ture infants and twins. J Pediatr 6:481, 1935.
38. Babson SG, Bramhall JL: Diet and growth in the 56. Gordon HH, Levine SZ, Wheatley MA, Marples E:
premature infant: The effect of different dietary Respiratory metabolism in infancy and in child-
intakes of ash-electrolyte and protein on weight hood: XX. The nitrogen metabolism in premature
gain and linear growth. J Pediatr 74:890, 1969. infants-comparative studies of human and cow's
39. Omans WB, Barness LA, Rose CS, Gyorgy P: milk. Am J Dis Child 54:1030, 1937.
Prolonged feeding studies in premature infants. J 57. Soderhjelm L: Fat absorption studies in children: I.
Pediatr 59:951, 1961. Influence of heat treatment of milk on fat reten-
40. Goldman HI, Freudenthal R, Holland B, Karelitz S: tion by premature infants. Acta Paediatr 41:207,
Clinical effects of two different levels of protein 1952.
intake on low birth weight infants. J Pediatr 58. Davidson M, Bauer CH: Patterns of fat excretion in
74:881, 1969. feces of premature infants fed various prepara-
41. Nichols MM, Danford BH: Feeding premature infants: tions of milk. Pediatrics 25:375, 1960.
A comparison of effects on weight gain, blood and 59. Watkins JB, Szczepanik P, Gould JB, et al: Bile salt
urine of two formulas with varying protein and metabolism in the human premature infant.
ash composition. South Med J 59:1420, 1966. Gastroenterology 69:706, 1975.
42. Snyderman SE, Boyer A, Kogut MD, Holt LE Jr: The 60. Fomon SJ: Infant Nutrition, ed 2. Philadelphia, WB
protein requirement of the premature infant: I. Saunders Co, 1974, p 101.
The effect of protein intake on the retention of 61. Widdowson EM: Absorption and excretion of fat,
nitrogen. J Pediatr 74:872, 1969. nitrogen and minerals from "filled" milks by
43. Levine SZ, Gordon HH, Marples E: Defect in the babies one week old. Lancet 2:1099, 1965.
metabolism of tyrosine and phenylalanine in 62. Freeman CP, Jack EL, Smith LM: Intramolecular
premature infants: II. Spontaneous occurrence fatty acid distribution in the milk fat triglycerides
and eradication by vitamin C. J Clin Invest of several species. J Dairy Sci 48:853, 1965.
20:209, 1941. 63. Mattson FH, Volpenhein RA: Rearrangement of glyc-
44. Menkes JH, Welcher DW, Levi HS, et al: Relationship eride fatty acids during digestion and absorption. J
of elevated blood tyrosine to the ultimate intellec- Biol Chem 237:53, 1962.
tual performance of premature infants. Pediatrics 64. Gordon HH, McNamara H: Fat excretion of prema-
49:218, 1972. ture infants: I. Effect on fecal fat of decreasing fat
45. Snyderman SE, Holt LE Jr, Norton PM, Phansalkar intake. Am J Dis Child 62:328, 1941.
SV: Protein requirement of the premature infant: 65. Powers GF: Some observations on the feeding of
II. Influence of protein intake on free amino acid premature infants, based on twenty years' experi-
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Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright ©
1977 by the American Academy of Pediatrics. All rights reserved. Print ISSN: .
The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/60/4/519
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has
been published continuously since . Pediatrics is owned, published, and trademarked by the American
Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright ©
1977 by the American Academy of Pediatrics. All rights reserved. Print ISSN: .