Early Protein Supplementation in Extremely Preterm Infants Fed Human Milk

Early Life Protein-enriched Human Milk Diets to Increase Lean Body Mass Accretion and Diversity of the Gut Microbiome in Extremely Preterm Infants: a Randomized Trial

The central hypothesis of this clinical trial is that, in extremely preterm infants, protein-enriched human milk diets compared to usual human milk diets during the first 2 weeks after birth increase fat-free mass (FFM)-for-age Z scores and promote maturation of the gut microbiome at term corrected age.

Study Overview

• Status: Active, not recruiting
• Conditions: Microbial Colonization; Growth Failure; Breast Milk Expression; Feeding Disorder Neonatal; Prematurity; Extreme
• Intervention / Treatment: Procedure: Protein-enriched human milk diet; Procedure: Usual human milk diet

Detailed Description

Masked randomized clinical trial in which extremely preterm infants fed human milk will be randomly assigned to receive either a protein-enriched diet (intervention group) or a usual diet (control group) within the first 96 hours after birth.

• Study Type: Interventional
• Enrollment (Actual): 150
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Alabama
    • Birmingham, Alabama, United States, 35233
      • University of Alabama at Birmingham

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 1 day to 4 days (Child)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Gestational age ≤ 28 weeks of gestation
• Postnatal age < 96 hours

Exclusion Criteria:

• Congenital malformations
• Chromosomal anomalies
• Terminal illness needing to limit or withhold support

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Protein-enriched human milk diet; Infants in this group will receive protein-enriched expressed human milk or donor human milk during the first 2 weeks after birth.	Procedure: Protein-enriched human milk diet; 1.2 g of human-based protein will be added to each 100 ml of human milk administered
Active Comparator: Usual human milk diet; Infants in this group will receive either expressed human milk or donor human milk during the first 2 weeks after birth.	Procedure: Usual human milk diet; Human-based protein will not be added to the human milk administered.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Fat-free Mass(FFM)-For-age Z-score	Estimated by air displacement plethysmography. FFM measurements were converted into Z-scores using updated, sex-specific reference curves of body composition in preterm infants (Norris et al, 2019). A Z-score of 0 represents the population mean. Z-score values closer to 0 represent a better outcome. No relevant thresholds have been defined.	36 weeks or hospital discharge, up to 120 days following birth, whichever is longer

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Fat Mass(FM)-For-age Z-score	Estimated by air displacement plethysmography. FM measurements were converted into Z-scores using updated, sex-specific reference curves of body composition in preterm infants (Norris et al, 2019). A Z-score of 0 represents the population mean. Z-score values closer to 0 represent a better outcome. No relevant thresholds have been defined.	36 weeks or hospital discharge, up to 120 days following birth, whichever is longer
Body Fat(BF)-For-age Z-score	Body fat estimated by air displacement plethysmography. BF measurements were converted into Z-scores using updated, sex-specific reference curves of body composition in preterm infants (Norris et al, 2019). A Z-score of 0 represents the population mean. Z-score values closer to 0 represent a better outcome. No relevant thresholds have been defined.	36 weeks or hospital discharge, up to 120 days following birth, whichever is longer
Anthropometric Measurements	Weight, length, and head circumference measurements. Measurements were converted into Z-scores based on Fenton growth curves (2013). They were calculated at birth and at 36 weeks. This outcome represents the change in weight, length, and head circumference Z-score during the course of the study (i.e., the Z-score at birth was subtracted from the Z-score at 36 weeks). A value of 0 represents that the infant's Z-score is the same at the beginning and the end of the study. Positive values indicate the increase in the infant's Z-score during the study; negative values indicate the decrease in the infant's Z-score during the study.	Birth to 36 weeks postmenstrual age or hospital discharge (whichever occurred first)
Growth Rate	Weight gain in g/kg/day	Birth to 36 weeks postmenstrual age or hospital discharge (whichever occurred first)
Number of Participants With Postnatal Growth Failure	Diagnosis of growth failure (weight < 10th percentile using the 2013 Fenton growth curves)	36 weeks or hospital discharge (whichever occurred first)
Number of Participants With Diagnosis of Necrotizing Enterocolitis	Diagnosis of necrotizing enterocolitis stage 2 or 3	From birth up to 120 days following birth
Number of Participants With Diagnosis of Intestinal Perforation	Diagnosis of intestinal perforation	From birth up to 120 days following birth
Death	Death prior to 121 days of life	Birth to 120 days
Culture-proven Sepsis	Diagnosis of sepsis with positive blood cultures	Birth to 120 days
Number of Days Alive and Receiving Full Enteral Feeding	Time to full enteral feeding days	Birth to 28 days
Number of Episodes of Feeding Intolerance	Interruption or cessation of enteral feeds for a period greater than 12 hours for abnormal abdominal examination	Birth to 28 days
Duration of Hospital Stay in Days	From day of admission to day of hospital discharge to home	Birth to 120 days or discharge, whichever occurs first
Serum BUN	Highest serum BUN value in the first 28 days after birth	Birth to 28 days

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Changes in Intestinal Microbiome	Determined by molecular analyses of fecal samples	Birth to 36 weeks postmenstrual age
Cognitive Outcomes	Determined by Bayley assessment	2 years of corrected age

Collaborators and Investigators

• Sponsor: University of Alabama at Birmingham
• Collaborators: Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
• Investigators: Principal Investigator: Ariel Salas, MD, MSPH, University of Alabama at Birmingham

Publications and helpful links

General Publications

• Salas AA, Gunawan E, Nguyen K, Reeves A, Argent V, Finck A, Carlo WA. Early Human Milk Fortification in Infants Born Extremely Preterm: A Randomized Trial. Pediatrics. 2023 Sep 1;152(3):e2023061603. doi: 10.1542/peds.2023-061603.
• Tucker MJ, Jeffcoat SH, Argent T, Travers CP, Salas AA. Severity of Bronchopulmonary Dysplasia in Infants Born Extremely Preterm and Randomized to Early Human Milk Fortification with a Donor Milk-Derived Fortifier for 2 Weeks. J Pediatr. 2025 Jul 24;287:114750. doi: 10.1016/j.jpeds.2025.114750. Online ahead of print.

Study record dates

Study Major Dates

• Study Start (Actual): August 13, 2020
• Primary Completion (Actual): January 2, 2023
• Study Completion (Estimated): September 30, 2026

Study Registration Dates

• First Submitted: March 25, 2020
• First Submitted That Met QC Criteria: March 25, 2020
• First Posted (Actual): March 27, 2020

Study Record Updates

• Last Update Posted (Estimated): September 23, 2025
• Last Update Submitted That Met QC Criteria: September 11, 2025
• Last Verified: September 1, 2025

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Urogenital Diseases; Pathologic Processes; Female Urogenital Diseases and Pregnancy Complications; Disease Attributes; Obstetric Labor, Premature; Obstetric Labor Complications; Pregnancy Complications; Infections; Pathological Conditions, Signs and Symptoms; Behavior; Signs and Symptoms; Feeding Behavior; Breast Feeding; Premature Birth; Communicable Diseases; Failure to Thrive; Breast Milk Expression
• Other Study ID Numbers: 300005089; K23HD102554 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No