Yin et al.

Trials (2015) 16:498

TRIALS
DOI 10.1186/s13063-015-1030-5

STUDY PROTOCOL Open Access

Application effect of extensively hydrolyzed

milk protein formula and follow-up in
preterm children with a gestational age of
less than 34 weeks: study protocol for a
randomized controlled trial
Li-Ping Yin†, Li-Juan Qian†, Huan Zhu, Yan Chen, Han Li, Ji-Nan Han and Li-Xing Qiao*

Abstract
Background: The average incidence of preterm birth in the world is up to 11.1 %, and deaths of preterm children
account for more than 50 % of neonatal deaths. Gastrointestinal function of preterm children with a gestational age
less than 34 weeks is immaturely developed. For preterm children who can only be fed with formula due to their
mothers’ sickness, choosing a suitable formula can not only meet the high nutritional needs of preterm children,
but also solve their low gastrointestinal tolerability, and is thus very important.
Methods/Design: The study is a prospective, randomized, single-blind and controlled clinical trial. Preterm children
with a gestational age less than 34 weeks meeting the inclusion criteria who cannot be breastfed will be included.
To demonstrate the application effect of extensively hydrolyzed milk protein formula on the target population,
preterm children will be randomized into two groups, 185 subjects in each group. The observation group will be
fed with extensively hydrolyzed milk protein (100 % whey protein) formula, while the control group will be fed with
preterm children’s formula until the children are discharged from the neonatal intensive care unit (NICU). All the
formula involved in this study will be from Dumex. After discharge, both groups will be uniformly fed with formula
for 0 to 6-month-old infants. For statistical analysis, a chi-square test and Student’s t test will be applied using SAS 9.4.
Discussion: This will be the first randomized controlled clinical study with long-term observation of the growth and
development of preterm children during the NICU stay and at 3-month follow-up after discharge from the NICU.
Results from this study will be used to determine whether the extensively hydrolyzed formula is more suitable for the
low gastrointestinal tolerability of preterm children, and also whether feeding preterm children who are fed with such
formula during the NICU stay with ordinary infant formula after discharge from the NICU would affect the normal
growth and development of preterm children in the early stage of their lives.
Trial registration: This study was registered with the Chinese Clinical Trial Registry (http://www.chictr.org.cn/) with
number ChiCTR-IOR-14005696, on December 22, 2014.
Keywords: Extensively hydrolyzed formula, Preterm children, Feeding intolerance, Growth and development, Follow-up

* Correspondence: [email protected]
†
Equal contributors
Department of Paediatrics, Zhongda Hospital Southeast University,
87 Dingjiaqiao, Nanjing 210009, China

© 2015 Yin et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Yin et al. Trials (2015) 16:498 Page 2 of 15

Background and the duodenum of preterm children with a gestational

The neonatal period is a special period of life, in which age of <32 weeks lacks the spread of migrating motor
the infant gradually transforms from complete depend- complex (MMC) [10]. Until after the gestational age of
ence on the mother for survival into a mature individual. 34 weeks, clear and ever-increasing MMC gradually
In 1976, the World Health Organization (WHO) defined emerge. The above mechanisms lead to prolonged gastric
preterm children as newborns with a gestational age of emptying time and intestinal transit time of food in
<37 weeks (<259 days) [1]. In 2005, the American Acad- preterm children, and thus preterm children with a
emy of Pediatrics and the American College of Obstetri- gestational age of less than 34 weeks are prone to gastro-
cians and Gynecologists [2] defined newborns with a esophageal reflux, feeding intolerance (FI), delayed meco-
gestational age of 34–36+6 weeks as late preterm birth, nium drainage, intestinal dilatation and other phenomena.
and less than 34 weeks as early preterm birth; in 2012, In addition, the development of digestive enzymes in pre-
the WHO [3] defined preterm children with a gesta- term children is also very immature, and preterm children
tional age of <28 weeks as extremely preterm birth, have inadequate secretion and low activity of gastric acid,
28–31+6 weeks as very preterm birth, 32–36+6 weeks as gastric protease-pepsin and pancreatic protease, which
moderate preterm birth, and 34–36+6 weeks as late pre- weaken the ability of the gastrointestinal tract to hydrolyze
term birth. The incidence of preterm birth varies greatly protein into peptides and amino acids [10]; the concentra-
in different countries. In 2010, the incidence of preterm tion of pancreatic lipases and duodenal bile acids is very
birth in 11 countries worldwide was ≥15 % [4]. The aver- low [11], which reduces the intestinal absorption of lipids,
age incidence of preterm birth all over the world is up to especially the long-chain fatty acids (LCT). Therefore, pre-
11.1 %. A total of 14.9 million preterm children are born term children are also prone to extrauterine growth re-
worldwide every year [5], and in these preterm live births, tardation (EUGR) caused by inadequate absorption of
more than 1 million preterm children eventually die [6], enteral nutrition. Currently, a large number of studies
accounting for more than 50 % of neonatal deaths. In have shown that extrauterine growth retardation has def-
China, there is little data on the incidence of preterm birth inite influences on the subsequent cognition and mental
nationwide. The WHO reported that the incidence of pre- development of preterm children [12].
term birth in China in 2010 was <10 % [4]. The num- Nutritional support in the neonatal period is one of
ber of preterm children in ten countries including China the basic conditions for survival of preterm children.
accounts for 60 % of the world’s total. The mortality of Preterm children born in advance for various reasons
preterm children in China is very high. From 2000 to need parenteml nutrition if enteral nutrition cannot
2008, preterm children led to 14–15 % of deaths of chil- meet their needs for growth and development. Although
dren younger than 5 years old in China [7]. The younger parenteral nutrition supplement can meet the temporary
the gestational age, the lower the birth weight is and the nutritional needs of preterm children, long-term paren-
higher the mortality is. According to the above data, we teral nutrition has brought a series of problems, such
find that in all medical problems of newborns, the im- as difficulties in peripheral venous puncture, suscepti-
provement of the survival rate and quality of life of pre- bility to complication by infections after central venous
term children is the target that the world focuses on catheterization, parenteral nutrition-associated cholestasis
tackling. (PNAC) and other complications. The ultimate goal of nu-
The fetus in utero obtains nutrition through the pla- tritional support in preterm children is to not only reach
centa as a parenteral nutrition (PN) pathway. After birth, the normal growth speed of normal fetuses of similar ges-
the newborns need to switch to enteral nutrition, while tational age in utero, but also have similar composition
the completion of enteral nutrition requires effective and and function to normal fetuses. The ideal growth rate of
coordinated sucking-swallowing, gastric emptying, intes- preterm/low-birth-weight children during the neonatal in-
tinal peristalsis and the digestion and absorption of nu- tensive care unit (NICU) stay, by referring to the growth
trients. However, these functions of preterm children are rate of normal fetuses in utero [13], is required as follows:
immature, and the younger the gestational age, the more average daily weight gain of 15 g/kg, weekly body length
immature these functions. First, the increase in the growth of 1 cm and weekly head circumference growth of
extensibility and absorption area (microvilli) of the gastro- 0.5–1 cm. However, preterm children after birth are faced
intestinal tract of preterm children is mainly completed in with respiratory, digestive and other problems. For pre-
the last 3 months of pregnancy [8]. Second, the sucking- term children with various immaturely developed systems,
swallowing-breathing action of preterm children with a how to solve the conflict between the high nutritional de-
gestational age of less than 32 weeks is much more unco- mands and low gastrointestinal tolerability of preterm
ordinated; only children with a gestational age of 34–35 children is a very realistic and important issue. Therefore,
weeks have coordinated nutritive sucking [9]. In addition, we need an appropriate early enteral nutrition manage-
the gastrointestinal motility of preterm children is weak, ment strategy for preterm children, although there is
Yin et al. Trials (2015) 16:498 Page 3 of 15

already a lot of consensus [14, 15], such as breastfeeding, choosing a milk powder more suitable for the intestinal
initiation of microfeeding as early as possible, achieving function of preterm children with a gestational age of
full enteral nutrition as soon as possible, and shortening less than 34 weeks is very important.
the time of parenteral nutrition in order to reduce compli- Hydrolyzed formula is to hydrolyze protein in milk
cations. It is preferred to feed preterm children with their powder to polypeptides, peptides and free amino acids
mothers’ breast milk [14], because such feeding can re- with bio-lyase, heating, ultrafiltration and other special
duce the incidence of feeding intolerance, neonatal necro- technologies. The American Academy of Pediatrics (AAP)
tizing enterocolitis (NEC), nosocomial infections, and refers to formula whose peptide molecular weight is less
growth and developmental retardation in preterm children than 3000 Da as extensively hydrolyzed formula (EHF)
[16]. In the event of inadequate supply of breast milk due [26]. According to the protein ingredient therein, the for-
to various reasons or inability of breastfeeding due to mula can be divided into hydrolyzed protein formula, hy-
maternal diseases, breast milk provided by qualified drolyzed soy protein formula and hydrolyzed rice protein
breast milk donors becomes the second-best nutri- formula; according to the milk protein ingredient therein,
tional source for preterm children [17] During October the formula can be divided into hydrolyzed whey protein,
2010 to December 212, a multicenter double-blind con- hydrolyzed casein, and hydrolyzed whey protein/casein.
trolled study conducted in Canada [18] found that the The low-molecular-weight peptides and small amounts of
breast milk of donors was equally safe and effective as the free amino acids in extensively hydrolyzed milk protein
breast milk of preterm children’s mothers, and after long- formula have greatly reduced the conformation and se-
term follow-up and study, found that donor breastfeeding quence of allergen idiotope, and thus the antigenicity is
was favorable for the development of the nervous system greatly lowered. The milk powder is mainly used for the
in preterm children. In Taiwan, China [19], the breast milk treatment of cow’s milk protein allergy (CMPA) [27].
in the breast milk bank is mainly used for feeding preterm Researchers have fed preterm children in their early
children, infants with feeding intolerance and other infants stage of life with EHF to prevent the occurrence of CMPA
suffering from metabolic disorders. Currently, many de- [28, 29], but there is no conclusion on whether it is
veloped countries have established large breast milk effective.
banks, and breast milk can be shared even via the Internet EHF has cracked milk protein to low-molecular-
[20]. However, the breast milk in breast milk banks is weight peptides and partial amino acids, favorable for
mostly for full-term children, whose nutritional ingredi- the gastrointestinal tolerability of preterm children.
ents cannot meet the needs of growth and development of Frati et al. [30] and Staelens et al. [31] found by adopt-
preterm children. Breast milk banks have not been set up ing different methods that the gastric emptying of EHF
in most areas of China, and no unified standard donor was significantly faster than the ordinary formula
screening, breast milk collection, disinfection, preserva- group; Mihatsch et al. [32] used carmine as a fecal
tion and feeding practices have been established. The rural marker and found that in preterm children, the gastro-
population accounts for the majority in China. Rural areas intestinal transit time of extensively hydrolyzed formula
and small cities lack the capacity to treat preterm children, was 9.8 hours, while that of standard ordinary formula
so preterm children are often sent to NICU in large cities was 19 hours. The main mechanisms that EHF is fa-
for hospitalization. Their homes are often far away from vorable for the gastrointestinal tolerability of preterm
the hospital, and China’s NICUs are mostly accompany- children are summarized as follows: (1) it promotes
free wards, so family members cannot participate in feed- gastric emptying [30, 31, 33, 34]; (2) it accelerates
ing and care. Besides, many mothers cannot breastfeed gastrointestinal transit [32]; (3) it reduces the activity
because of their illness, and thus, preterm children hospi- of opioid receptor agonist-milk protein [35]; and (4) it
talized in NICUs in China are mostly fed with formula. induces motilin (MOT) and gastrin (GAS) secretion
In China, preterm children with a gestational age of [36], thereby reducing the incidence of gastroesopha-
less than 34 weeks are mostly fed with preterm chil- geal reflux (GER) [30, 34, 37], feeding intolerance, etc.,
dren’s formula, and such milk powder provides sufficient in preterm children [38] so as to achieve full enteral
energy, protein, vitamins and minerals and features a nutrition as soon as possible and reduce the time of
high growth rate in preterm children. However, excessive parenteral intravenous nutrition and a series of compli-
weight gain in early infancy will increase the risk of cations caused by parenteral nutrition.
metabolic diseases and cardiovascular diseases in adult- Each 100 ml of the EHF used in this study can provide
hood [21, 22]. The probabilities of feeding intolerance 66 kcal, whose protein-to-energy ratio (P/E) is 2.42 g/
and neonatal necrotizing enterocolitis and overall mor- 100 kcal, lower than the P/E recommended by the
tality in preterm children fed with preterm children’s European Society for Paediatric Gastroenterology, Hepa-
formula are significantly higher than in children fed with tology, and Nutrition (ESPGHAN) [39]. Can exten-
breast milk or donated breast milk [23–25]. Therefore, sively hydrolyzed milk protein formula meet the high
Yin et al. Trials (2015) 16:498 Page 4 of 15

nutritional needs of preterm children? Current study osmolality of 250 mOsmol/L, lower than traditional
findings have differing conclusions [40–44]. Some stud- preterm children’s formula. Another study has also
ies conclude, by detecting the concentrations of amino found that the higher the calories provided by each
acids in serum and urine and intestinal absorption of ni- 100 ml of formula, the slower the gastric emptying
trogen after preterm children are fed with different milk [46]. Therefore, in this study, the gastric emptying time
powders, that the protein content in hydrolyzed milk and gastrointestinal transit time in preterm children
protein formula should be higher than ordinary preterm fed with extensively hydrolyzed milk protein formula
children’s formula in order to meet the needs of preterm will be accelerated, thereby reducing the incidence of
children for growth and development [40–42]. However, feeding intolerance in the preterm children, achieving
these studies all have too small sample size (15 cases, 21 full enteral feeding as soon as possible, shortening the
cases, 16 cases), the period of literature [40] study is too time of parenteral nutrition, and reducing the oc-
short (the conclusion is drawn from determination of currence of complications associated with parenteral
plasma amino acid concentrations only after cross feed- nutrition. This formula has cracked milk protein to
ing with the two kinds of milk powder for 5 days), and low-molecular-weight peptides and partial amino acids,
in the above studies, the preterm children began to be it reduces the intestinal load of protein digestion in
fed with hydrolyzed formula after achieving full enteral preterm children, and is thus favorable for the gas-
feeding (EF) or 1 week after birth instead of feeding trointestinal capacity of preterm children for protein
with hydrolyzed formula immediately after birth. Sza- digestion and absorption. Moreover, medium-chain tri-
jewska et al. [43] conducted a randomized controlled glycerides fat (MCT) in the formula accounts for 40 %
study of up to 12 weeks. The authors randomized low- of total fat, which is favorable for preterm children’s fat
birth-weight children for feeding with different milk absorption and utilization. The energy and protein pro-
powders, then tracked and monitored the growth and vided by each 100 ml of the milk powder are lower
development (weight, body length and head circumfer- than traditional preterm children’s formula, but it may
ence growths) and all plasma parameter indicators (urea, not affect the early nutrition of preterm children due
albumin (ALB), prealbumin, transferrin, and concentra- to the abovementioned features. Can feeding preterm
tion of each amino acid) of these infants at the begin- children with a gestational age of less than 34 weeks
ning of feeding, 4 weeks, 8 weeks and 12 weeks after during the NICU stay with extensively hydrolyzed milk
feeding, and found that the nutrition of extensively hy- protein formula meet the preterm children’s needs for
drolyzed whey protein formula was equivalent to that of early normal growth and development during hospital
the standard preterm children’s formula. In China [44], stay and after discharge? In addition to observation of
a multicenter (eight domestic first-class grade 3 hospi- the preterm children’s growth and development during
tals) controlled clinical study from February 2012 to the NICU stay, our study will also track and follow up
December 2013 found that extensively hydrolyzed milk these preterm children for at least 3 months after they
protein formula could promote the gastrointestinal motil- are discharged from the NICU.
ity of preterm children and accelerate their metabolism
and excretion of bilirubin, without increasing the occur- Methods/Design
rence of EUGR at discharge. Besides, there is no study at A prospective, randomized, single-center, single-blind
home and abroad on whether feeding preterm children and controlled clinical trial will be conducted in preterm
with relatively low-energy low-protein extensively hydro- children with a gestational age of less than 34 weeks
lyzed milk protein formula in the early stage of life will meeting the inclusion criteria who cannot be breastfed.
affect their subsequent growth and development. Al- The implementer of the study will be the NICU of
though studies [28, 29] respectively followed up preterm Zhongda Hospital Southeast University. The majority of
children and extremely low-birth-weight children after the center’s preterm children are transferred from other
feeding with EHF for the early stage of life for 12 months hospitals in Nanjing or nearby towns, wherein most pre-
and 5–7 years, these two studies were conducted only to term children who cannot be breastfed because their
observe whether EHF could prevent the subsequent mothers suffer from infectious diseases or other severe
occurrence of CMPA in preterm children, without diseases requiring long-term medication are also trans-
tracking and observing the growth and development ferred to our hospital. Most preterm children hospital-
of those preterm children. ized in our hospital’s NICU can only be fed with
The protein in the extensively hydrolyzed milk protein formula. Every year, about 2,000 newborns are hospital-
formula used in this study is 1 % whey protein, without ized in our hospital’s NICU, and preterm children with a
containing casein. A study has found that the higher the gestational age of less than 34 weeks account for 10–
casein content, the slower the gastric emptying [45]. 15 % of the inpatients, of whom about two thirds can
Each 10 ml of the EHF we use provides 66 kcal with only be fed with formula.
Yin et al. Trials (2015) 16:498 Page 5 of 15

Objectives 1. Gestational age <34 weeks

Primary objective 2. Children who can only be fed with formula due to
To determine whether feeding preterm children with a their mothers’ sickness
gestational age of less than 34 weeks during the NICU 3. Children who are transferred to our hospital’s NICU
stay with extensively hydrolyzed milk protein formula immediately after birth, and have not started any
can reduce the rate of food intolerance or not. enteral feeding before and during transfer, including
water, glucose, formula, drugs, etc.
4. Children whose cardiovascular, blood and nervous
Secondary objective
systems are stable when transferred to the NICU
To test if the feeding preterm children with a gestational
age of less than 34 weeks during the NICU stay with ex-
Exclusion criteria:
tensively hydrolyzed milk protein formula can accelerate
the time to achieve full enteral feeding, shorten the time
1. Occurrence of vomiting, abdominal distension,
of parenteral nutrition and NICU stay, benefit spontan-
gastrointestinal hemorrhage or necrotizing enterocolitis
eous fecal discharge, reduce the occurrence of other
(NEC) before preparation for enteral feeding
complications associated with parenteral nutrition,
2. Occurrence of cardiovascular, blood and nervous
and meet the nutritional needs of preterm children
system instability (such as shock, disseminated
during the NICU stay, without affecting the early
intravascular coagulation (DIS), frequent
growth and development of these preterm children during
convulsions, coma) before preparation for enteral
hospitalization and after discharge.
feeding
3. Discovery of gastrointestinal malformations
Study population (esophageal atresia, esophageal fistula, biliary atresia,
Recruitment of participants Hirschsprung’s disease, anal atresia, omphalocele,
Preterm children hospitalized in the NICU of Zhongda gastroschisis, congenital malrotation, etc.) before
Hospital Southeast University in line with the inclusion preparation for enteral feeding or after feeding
criteria are recruited as participants (Fig. 1). 4. Children with congenital metabolic diseases and
Inclusion criteria: chromosomal disorders

Fig. 1 CONSORT flowchart of subject enrollment

Yin et al. Trials (2015) 16:498 Page 6 of 15

5. Children with other serious congenital disorders two formulae. Therefore, the study has chosen single-
(diaphragmatic hernia, cyanotic congenital heart blinding, which means that only the participants and
disease, moderate to severe Pierre-Robin syndrome, their guardians are unaware of the milk type.
etc.)
6. Renal failure due to various causes Ethical aspects and informed consent
7. Children whose head computed tomography (CT) The study has passed the review of the Clinical Study
or B-mode head ultrasound prompts serious Ethics Committee of Zhongda Hospital Southeast Uni-
intracranial hemorrhage or hydrocephalus versity, and the Ethics Committee’s approval number is
8. Use of drugs affecting gastric motility and gastric 2014ZDSYLL115.0. Only the preterm children whose
acid secretion (H2 receptor antagonists, proton guardians give informed written consent will be included
pump inhibitors, gastrointestinal drugs) in this trial.
9. Occurrence of stage III necrotizing enterocolitis
during hospital stay requiring transfer to a Study time
Children’s Hospital for observation and surgical The study started in November 2014 and is expected to
treatment end in November 2017.
10. Replacement for formula during hospital stay
11. Death during hospital stay Interventions
12. Early discharge against the criteria for discharge The observation group is fed with extensively hydrolyzed
from the NICU milk protein (100 % whey protein) formula, while the
13. Children who suffer from diseases requiring control group is fed with preterm children’s formula
parenteral nutrition or serious illness requiring until discharge from the NICU. After discharge, both
intensive care unit (ICU) hospitalization or groups are uniformly fed with ordinary formula (formula
requiring hospitalization and surgery for 0 to 6-month-old infants).

Criteria for discharge from the NICU or transfer to Study design and outcomes
direct rooming-in (DRI): Outcomes
The first endpoint variable is the rate of food intolerance
1. Corrected gestational age ≥34 weeks, and weight in preterm children. The second endpoint variables in-
≥1500 g clude (1) time to achieve full enteral nutrition; (2) time
2. No need for oxygen inhalation, stable vital signs, no of parenteral nutrition; (3) time of NICU stay; (4) meco-
apnea phenomenon nium drainage time; (5) daily spontaneous fecal discharge
3. Able to suck formula on their own, and coordinated conditions; (6) growth and development conditions during
sucking-swallowing-breathing action the NICU stay and within 3 months after discharge, in-
4. Having achieved full enteral feeding, daily milk volume cluding daily weight growth rate, weekly body length
≥150 ml/kg, no need for any intravenous medication growth rate and weekly head circumference growth rate;
5. Able to maintain normal body temperature at room (7) different plasma parameter indicators before discharge
temperature of 22–24 °C from the NICU (total protein (TP), albumin, calcium (Ca),
6. Each system is free from life-threatening pathological phosphorus (P), and alkaline phosphatase (ALP)). Other
conditions endpoint variables include the incidences of neonatal nec-
7. Birth weight has been restored, and weight begins to rotizing enterocolitis, cholestasis, parenteral nutrition-
grow steadily associated cholestasis and congenital hypothyroidism (CH).

Randomization and blinding Study design

Randomization will be conducted by a researcher not in- The study includes two stages. In stage I, the study ob-
volved in the recruitment and treatment of the partici- serves the incidence of feeding intolerance, parenteral
pants. Concealed allocation will be performed using a nutrition conditions, spontaneous fecal discharge condi-
set of random numbers placed in sealed opaque enve- tions, growth and development conditions and the inci-
lopes. The participants who meet the eligibility criteria dence of other preterm children’s complications in the
will be divided into two groups by the physicians on preterm children in the two groups during the NICU
duty via opening the envelopes. Reference to similar stay. In this stage, different feeding methods and paren-
study literature is made for randomization [28, 31]. As teral nutrition are regulated according to the gestational
extensively hydrolyzed milk protein formula and preterm age, birth weight and days after birth of the preterm
children’s formula are greatly different in color and children, and unified diagnostic criteria and treatment
smell, physicians and nurses can easily distinguish these methods for different complications are developed. In
Yin et al. Trials (2015) 16:498 Page 7 of 15

stage II, the study follows up the growth and development  Preterm children with a gestational age of 32–34
conditions of the preterm children in the two groups on a weeks are given direct bottle feeding.
regular basis after discharge from the NICU.  Children with weak sucking ability yet normal
gastric emptying are given bottle feeding first,
Introduction to the formulae and then the remaining milk is given by tube
The two kinds of formula for feeding during the NICU stay feeding.
and the formula for feeding after discharge from the NICU  Children with nasal continuous positive airway
are all Dumex, a brand of French Danone-Nutricia for early pressure (nCPAP) or intubation and mechanical
life nutrition. In this study, the gestational age of all preterm ventilation are given tube feeding;
children when discharged from the NICU is all ≥34 weeks,  During tube feeding or fasting period, the
and thus formula suitable for 0 to 6-month-old infants is children are given non-nutritive sucking (NNS).
uniformly chosen for them after discharge. The ingredients
of such formulae are shown in Table 1. 3. Feeding milk volume
 Initial feeding milk volume: according to birth
Stage I: NICU stay weight, the children are fed from different initial
milk volume once every two hours, as shown in
1. Feeding time Table 2.
 Preterm children without obvious high-risk  The milk volume begins to increase in the
factors are fed within 24 hours after birth. absence of feeding intolerance in 24-h
 The feeding of preterm children with birth observation, and the rates for milk increasing are
weight <1000 g, obvious history of asphyxia at shown in Table 2.
birth (Apgar score ≤5), severe infection (sepsis, 4. Fluid amount control [14, 47]
purulent meningitis, etc.), severe pneumonia or
neonatal respiratory distress syndrome (NRDS) Fluid amount includes the total amount of enteral
requiring intubation and mechanical ventilation nutrition, parenteral nutrition and all other intra-
should be postponed to 24–72 h after birth venous and oral medications. If birth weight is
according to the situation. <1500 g, the fluid amount in the first 24 hours after
 During the period when full enteral nutrition is birth is 80–100 ml/(kg/d); if birth weight is ≥1500 g,
not achieved, partial parenteral nutrition is given the fluid amount in the first 24 hours after birth is
according to the daily amount of fluid and energy 60–100 ml/(kg/d); then the amount is incremented at
required by the children; when the children a rate of 15–20 ml/(kg/d) to reach 150 ml/(kg/d) by
experience feeding intolerance and necrotizing the end of the first week; daily fluid amount is
enterocolitis and need to be fasting, complete increased or decreased by 10–20 ml/kg on the basis
parenteral nutrition is given; after the conditions of the fluid amount that day according to different
are stable, the children gradually switch to enteral clinical conditions (light therapy, incubator, ventilator,
nutrition and are fed until discharge or transfer heart and lung function, urine amount, systemic
into DRI. edema conditions, biochemical monitoring indicators,
 Children in the two groups are fed with ordinary etc.), usually no more than 180 ml/(kg/d).
formula after discharge or transfer to DRI.
5. Calorie control [14, 47]
2. Feeding methods
 For preterm children with a gestational age of Calorie includes the total calories provided by enteral
<32 weeks, since their sucking-swallowing action feeding and parenteral nutrition. The calorie on the first
is uncoordinated and respiratory function is not day is 40 kcal/kg and then incremented at a rate of
maturely developed, the children are given tube 10 kcal/(kg/d). Parenteral nutrition is stopped when en-
feeding (nasogastric tube or orogastric tube) teral nutrition reaches 80–100 kcal/(kg/d), and enteral
using the intermittent infusion feeding method. nutrition 100–120 kcal/(kg/d) is the criterion to achieve
Every time before feeding, the stomach contents full enteral nutrition.
are drawn to learn about gastric residual volume
(GRV) and nature. 6. Parenteral nutrition (PN) [14, 47]
 Children suspected of suffering from  Vessel selection: peripheral vein or central vein,
gastroesophageal reflux or delayed gastric emptying central vein includes peripherally inserted central
are fed by adopting intermittent/continuous catheter (PICC) and umbilical venous catheter
infusion feeding method with an infusion pump. (PVC).
Yin et al. Trials (2015) 16:498 Page 8 of 15

Table 1 Table of ingredients of the three formulae

Ingredients Preterm children’s formula Extensively hydrolyzed formula Formula for 0 to 6-month-old
(/100 ml) (/100 ml) infants (/100 ml)
Energy (kcal/KJ) 80/336 66/278 67/282
Osmolality (mOsmol/L) 360 250 -
Fat (g) 3.8 3.5 3.5
α-linolenic acid (mg) 44 58 42
Linoleic acid (g) 0.6 0.41 0.42
Oleic acid (g) 1.3 1.2 -
Medium-chain triglyceride content (%) 30 % 40 % -
Protein (g) 2.6 (60 % whey protein and 40 % casein) 1.6 (100 % whey protein) 1.4
Carbohydrates 8.4 6.9 7.1
Lactose (g) 5.6 2.8 -
Prebiotics (galactooligosaccharides, 0.8 0.8 0.8
polyfructose) (g)
Arachidonic acid (mg) 19 6.6 12
Docosahexaenoic acid (mg) 15 6.6 12
Taurine (mg) 5.5 5.3 5.4
L-carnitine (mg) 1.8 1 1.5
Nucleotides (mg) 3.4 3.2 3.0
Vitamin A (μg) 359 52 65
Vitamin D (μg) 3 1.3 0.95
Vitamin E (mg) 3.5 1 1.2
Vitamin K1 (μg) 6 4.7 5.4
Vitamin B1 (μg) 139 50 58
Vitamin B2 (μg) 199 99 103
Vitamin B6 (μg) 119 40 48
Vitamin B12 (μg) 0.24 0.18 0.31
Nicotinamide acid (μg) 2352 432 517
Folic acid (μg) 35 9 11
Pantothenic acid (μg) 876 327 354
Vitamin C (mg) 17 9 9.2
Biotin (μg) 3.5 2.2 2.3
Choline (mg) 17 10 16
Inositol (mg) 24 3.2 3.8
Sodium (mg) 70 20 20
Potassium (mg) 80 75 69
Copper (μg) 80 40 48
Magnesium (mg) 8 5.1 5.7
Iron (mg) 1.6 0.53 0.71
Zinc (mg) 1.1 0.5 0.5
Manganese (μg) 10 7.4 7.5
Calcium (mg) 100 47 52
Phosphorus (mg) 56 26 31
Iodine (μg) 25 12 11
Chlorine (mg) 85 41 48
Selenium (μg) 4.5 1.5 2.2
Yin et al. Trials (2015) 16:498 Page 9 of 15

Table 2 Initial feeding milk volume and increasing rate in the 7. Diagnostic criteria for and treatment of various
two groups of preterm children complications:
Birth weight (g) Initial feeding milk Increasing rate 1. Diagnostic criteria for and clinical treatment of
volume (ml/kg) (ml/kg/d) feeding intolerance [48, 49]
<1000 1.0 12
1000–1500 1.0–2.0 12–24 Children in line with any of the following six criteria
1501–2000 2.0 24–36 can be diagnosed with feeding intolerance:
>2000 2.0 36
 Gastric residual liquid >50 % of the amount of
previous feeding
 Method: all children adopt “all in one” parenteral  Vomiting ≥3 times/day, or the vomitus is bile-like
nutrition. The nutrient solution used for daily  Gastric residual liquid or vomitus is bile-like or
parenteral nutrition is uniformly prepared inside coffee grounds-like
on a clean bench at the hospital’s Intravenous  Abdominal distension (abdominal girth is increased
Nutrition Preparation Center according to the by ≥1.5 cm within 24 hours, with intestinal type),
doctor’s instructions that day, and attention and abdominal distension caused by the use of
should be paid to the sequence of mixing during nCPAP should be ruled out
preparation. After preparation the solution is  Required fasting >2 meals
evenly infused via the infusion pump within  Blood in the stool or fecal occult blood positive, but
24 hours. The total amount of parenteral it is required to rule out NEC based on the general
nutrition fluid and compounding ratio of all conditions, blood indicators and abdominal X-ray
nutrients are calculated according to the child’s examination of children
total fluid amount required that day, total calorie,
milk intake the day before and possible total milk Clinical treatments:
intake that day.
 Children’s compound amino acid (6 %) 1.0–1.5 g/  Amount of gastric residue: for children with tube
(kg/d) is added within 24 hours after birth, which feeding, draw the residual milk in the stomach every
is later incremented up to 3.5–4.0 g/(kg/d) at a time before feeding.
rate of 0.5 g/(kg/d); medium and long-chain fat (a) If birth weight is <1500 g, and gastric residue is
emulsion 0.5 g/(kg/d) is added within 24 hours <2 ml or if birth weight is ≥1500 g and gastric
after birth, which is later incremented up to residue is <3 ml or gastric residue is <30 % of the
3.0 g/(kg/d) at a rate of 0.5 g/(kg/d). amount of previous feeding, continue feeding and
 Carbohydrates ≤15 g/(kg/d), providing 40–50 % closely observe.
of the total energy; amino acids ≤3.5–4.0 g/(kg/ (b)If gastric residue is 30–50 % of the amount of
d), providing 15–20 % of the total energy, fat previous feed, reduce the amount of feeding.
emulsion ≤3.0 g/(kg/d), providing 40–50 % of the (c) If gastric residue is >50 % of the amount of
total energy. previous feeding, fast for one meal, and continue
 Sodium ions 2.0–3.0 mmol/L and potassium ions feeding by the original feeding plan after the
1.0–2.0 mmol/L are supplemented daily, but condition is improved.
within 3 days after birth, no potassium is (d)If there is bile-like or coffee grounds-like liquid
supplemented in principle unless the child is in the gastric residual liquid or vomitus, stop
suffering from hypokalemia. feeding.
 A variety of water-soluble and fat-soluble  Abdominal distension: measure the abdominal
vitamins 0.5–1.0 ml/(kg/d) are supplemented. girth at fixed parts every time before feeding. If
 If the child has cholestasis, the amount of the abdominal girth is increased by ≥1.5 cm,
intravenous fat emulsion is reduced. reduce the amount of feeding or fast for one
 The concentration and rate of intravenous meal, and continue feeding by the original feeding
nutritive sugar are adjusted according to the plan after the abdominal distension condition is
child’s blood glucose monitoring. In case of improved.
PVC or PICC, the sugar concentration is  If daily vomiting occurs >3 times, do not
≤15 %; when peripheral intravenous infusion increase the milk volume or reduce the amount
is adopted, the sugar concentration is ≤12.5 %. of feeding.
The child’s blood glucose is controlled at  In the event of blood in the stool or fecal occult
3.0–7.0 mmol/L. blood positive, stop feeding.
Yin et al. Trials (2015) 16:498 Page 10 of 15

2. Diagnostic and treatment reference criteria for  If blood TSH is >10 mU/L and FT4 is decreased, the
necrotizing enterocolitis (NEC) [50] are shown in child will be diagnosed with congenital
Table 3. hypothyroidism.
 If blood TSH is >10 mU/L and FT4 is normal, the
3. Diagnostic criteria for and clinical treatment of child will be diagnosed with high TSH
cholestasis: hyperlipidemia.
Diagnostic criteria [51]: in line with any of the first  If blood TSH is normal or decreased and FT4 is
two criteria: decreased, the child will be diagnosed with
 Total bilirubin (TB) <5 mg/dl and direct bilirubin secondary or central hypothyroidism.
(DB) >1.0 mg/dl
 TB >5 mg/dl and DB >20 % of TB Clinical treatment:
 Elevated total bile acid (TBA) levels alone cannot
serve as a diagnostic criterion for cholestasis  In line with criterion (1), levothyroxine (Euthyrox)
from a starting therapeutic dose of 10–15ug/(kg/d),
4. Diagnosis and clinical treatment of parenteral daily, by mouth.
nutrition-associated cholestasis (PNAC):  In line with criterion (2), retest 1 week later. If TSH
is still >10 mU/L, give Euthyrox 4–8ug/kg/d, daily,
Diagnostic criteria for PNAC [52]: by mouth.
 In line with criterion (3), retest 1 week later. If FT4
 Continuous parenteral nutrition ≥14 days is still decreased, give Euthyrox 4– 8ug/kg/d, daily,
 Serum DB >34umol/L (2 mg/d1) by mouth.
 Clinical manifestations of yellowish discoloration of  If TSH always maintains at 6–10 mU/L, without
skin, hepatosplenomegaly, elevated transaminase treatment, regularly follow up thyroid function.
levels and (or) lighter stool color  If FT4 and TSH are normal, children with decreased
 Exclusion of other diseases causing cholestasis TT3 or TT4 are given no treatment.
(various biliary malformations causing biliary  For children with abnormal test results, draw blood
obstruction, hereditary metabolic diseases and for retest in 1–2 weeks. Adjust the therapeutic dose
hepatitis caused by bacterial and viral infections) based on the concentrations of blood TSH and FT4
and the children’s weight.
Clinical treatment of PNAC:
6. Diagnostic criteria for and clinical treatment of
 Protect the liver and gallbladder: ursodesoxycholic hypocalcemia [54]
acid 15 mg/(kg/d), three times daily, by mouth
 Do not lightly fast; increase enteral nutrition, reduce Diagnostic criteria:
the proportion of parenteral nutrition, and medium
and long-chain fat emulsion ≤1 g/(kg/d) Total serum calcium is less than 1.75 mmol/L (7.0 mg/dl)
 Additionally supplement vitamin E 10 mg/(kg/d), or free calcium is less than 0.9mmom/L (3.5 mg/dl).
twice daily, by mouth
Clinical treatment:
5. Diagnostic criteria for and clinical treatment of
congenital hypothyroidism [53].  For children with clinical seizures or heart rhythm
disorders, which cannot be explained by other
Diagnostic criteria: 1 week after birth, draw blood diseases, give them slow intravenous injection of 10 %
to test serum thyroid-stimulating hormone (TSH), calcium gluconate 2 ml/kg, and use 5 % glucose
total triiodothyronine (TT3), total thyroxine (TT4), injection after dilution by onefold. Then according to
free triiodothyronine (FT3) and free thyroxine (FT4). the retest result, decide whether to continue
If blood test shows no abnormality but there are clin- intravenous injection or switch to oral medication.
ically suspicious symptoms of hypothyroidism, retest  For children with stable conditions, give them tube
the thyroid function. Suspicious symptoms of preterm feeding or oral 10 % calcium gluconate.
children’s hypothyroidism include persistent jaundice,
lethargy, less crying, low and weak crying, slow heart Stage II: follow-up period after discharge from the NICU
rate, low and blunt heart sounds, poor digestion
(weak sucking, feeding intolerance), recurrent hypo- 1. Develop a follow-up observation table for preterm
glycemia, etc. children <34 weeks, and require the children’s health
 Yin et al. Trials (2015) 16:498
Table 3 Modified Bell staging criteria for neonatal necrotising enterocolitis
Staging Systemic symptoms Gastrointestinal symptoms Radiological signs Treatment
IA Suspected NEC Temperature instability, apnoea, Gastric retention, mild abdominal distension, Normal or intestinal dilation, Absolute fasting, gastric decompression,
bradycardia, lethargy fecal occult blood positive mild ileus antibiotic therapy for 3 days, waiting for
pathogen culture results
IB Suspected NEC Same as IA Bright-red blood from rectum Same as IA Same as IA
IIA proven NEC (mildly ill) Same as IA Same as IA or IB, plus absent bowel sounds, Intestinal dilation, ileus, Same as IA, absolute fasting. If 24–48 h
and (or) abdominal tenderness, pneumatosis intestinalis culture shows no abnormality, use
antibiotics for 7– 10 days
IIB proven NEC (moderately ill) Same as IIA, plus mild metabolic Same as IIA,plus absent bowel sounds, definite Same as IIA, plus portal vein Same as IIA, absolute fasting. Supplement
acidosis and mild thrombocytopenia abdominal tenderness, and (or) abdominal gas, and (or) ascites blood volume, treat acidosis, and use
cellulitis or right lower quadrant mass antibiotics for 14 days
IIIA Advanced NEC Same as IIB, plus hypotension, Same as IIB, plus signs of generalized peritonitis, Same as IIB, ascites Transfer to the Surgical Department
(severely ill, bower intact) bradycardia, severe apnea, mixed abdominal distension or marked tenderness, of Children’s Hospital for observation
acidosis, DIC, neutropenia, anuria and redness and swelling of abdominal wall
IIIB Advanced NEC Same as IIIA, plus suddenly Same as IIIA, plus sudden aggravation Same as IIB, pneumoperitoneum Transfer to the Surgical Department
(severely ill, bowel perforated) aggravation of conditions of abdominal distension of Children’s Hospital for surgery
NEC necrotising enterocolitis, DIC disseminated intravascular coagulation

Page 11 of 15
Yin et al. Trials (2015) 16:498 Page 12 of 15

care medical staff to record the data of follow-up 2. Collection of case data during the NICU stay:
every time in detail.
2. Require the preterm children to revisit the Incidence and outcome of feeding intolerance in preterm
hospital’s Child Health Clinic for referral 2 weeks, children, neonatal necrotizing enterocolitis, cholestasis,
4 weeks and 3 months after discharge, and follow parenteral nutrition-associated cholestasis and congenital
up once every 2–4 weeks according to the hypothyroidism
preterm children’s conditions 4 weeks later.
3. Call the children’s parents 1–2 day before every 3. Collection of enteral and parenteral nutrition and
referral and require them to bring the children to defecation conditions during the NICU stay:
our hospital for referral on time, and ask them to (a) Milk opening time (h), total amount of daily milk
bring all medical data. (ml) and calories (kcal), total amount of daily
4. Contents of referral at the Child Health Clinic parenteral nutrition (ml) and calories (kcal), total
include measurement of physical growth and volume of daily fluids (ml) and total calories (kcal)
development, assessment of neuropsychological (b)The number of daily bowel movements, times of
development, nutritional assessment and feeding daily enema, trait and color of stool every time,
guidance. According to different conditions of the meconium drainage time (h)
preterm children during hospital stay, choose (c) Gastric residual volume (ml) and nature, times
whether to conduct blood, liver function, thyroid and nature of vomiting, and abdominal distension
function, head B-mode ultrasound or cranial (d)Time to achieve full enteral nutrition (d), and
magnetic resonance imaging (MRI), retinopathy total time of parenteral nutrition
(ROP) screening, hearing screening and other tests.
5. Explain the current follow-up results in detail to the 4. Collection of physical growth and development
parents, and appoint the time and contents of next indicators during the NICU stay:
follow-up. (a) Weight: weight will be measured at admission,
6. Call the parents again on the night or the next day once every day during hospital stay and before
of follow-up every time to inquire about follow-up discharge with a baby electronic scale, and the
conditions in detail, and again record all follow-up data will be accurate to 10 g.
results. (b)Body length: body length will be measured at
7. Follow-up period: at least 3 months. admission, once every week during hospital stay
and before discharge, and the data will be
Data collection and management accurate to 0.1 cm.
Including the collection of clinical data of preterm chil- (c) Head circumference: head circumference will be
dren during the NICU stay and follow-up data after dis- measured at admission, once every week during
charge from the NICU. hospital stay and before discharge, and the data
will be accurate to 0.1 cm.
Collection of clinical data during the NICU stay
5. Collection of laboratory indicators during the NICU
1. Collection of general data of the objects of study: stay:
(a) Sex, gestational age, birth weight, birth head (a) Daily monitoring of peripheral blood glucose and
circumference, birth body length, mode of delivery, transcutaneous bilirubin
5-minute Apgar score, etc., of preterm children (b)Weekly detection of blood, liver and kidney function
(b)Mother’s pregnancy complications and (total protein, albumin, total bilirubin, direct
comorbidities: premature rupture of membrane bilirubin, alkaline phosphatase, bile acids, alanine
>24 hours, placental abruption, chorioamnionitis, aminotransferase, aspartate aminotransferase,
pregnancy-induced hypertension syndrome, γ-glutamyl transferase, urea nitrogen, creatinine)
preeclampsia, gestational diabetes, hyperthyroidism, and electrolytes (mainly calcium and phosphorus)
hypothyroidism, systemic lupus erythematosus, (c) Test of serum thyroid function 1–2 weeks after
kidney disease, cholestasis, acute liver failure, admission, including TSH, TT3, TT4, FT3 and FT4
syphilis infection, etc.
(c) Special treatment: nasal continuous positive airway Collection of follow-up data after discharge from the NICU
pressure (nCPAP), intubation and mechanical
ventilation (MV), use of pulmonary surfactant (PS), 1. Weight: weight will be measured once 2 weeks,
thoracentesis, bone marrow biopsy, thoracic 4 weeks and 3 months after discharge, respectively,
drainage, peritoneal dialysis, etc. and the data will be accurate to 10 g.
Yin et al. Trials (2015) 16:498 Page 13 of 15

2. Body length: body length will be measured once NICU and within 3 months of discharge will be analyzed
2 weeks, 4 weeks and 3 months after discharge, using repeated measurement analysis of covariance
respectively, and the data will be accurate to 0.1 cm. models. All analysis will be conducted using SAS 9.4
3. Head circumference: head circumference will be (SAS Institute, Cary, NC, USA).
measured once 2 weeks, 4 weeks and 3 months after
discharge, respectively, and the data will be accurate Discussion
to 0.1 cm. Extensively hydrolyzed milk protein formula can acceler-
ate gastric emptying and gastrointestinal transit time,
Sample size justification and promote gastrointestinal hormone secretion, and
We calculate the sample size based on the chi-square these mechanisms are conducive for the gastrointestinal
test comparison of the food intolerance rate during tolerability of preterm children, thereby lowering the in-
NICU between groups. Our previous pilot study shows cidence of gastroesophageal reflux and feeding intoler-
that the rate of food intolerance during NICU for con- ance in preterm children, achieving full enteral nutrition
trol patients is about 85 %. We expect that the interven- as soon as possible and reducing the time of parenteral
tion group will have a reduced intolerance rate to be nutrition. In China, more and more medical organiza-
75 %. With these assumptions, we will need 148 infants tions have started using extensively hydrolyzed milk pro-
in each group to finish the NICU part of the study to tein formula to feed preterm children, but so far there is
reach 80 % power and 5 % Type I error rate. Assuming no clear conclusion on whether low-energy low-protein
that the dropout rate to be 20 %, we will need to enroll extensively hydrolyzed formula can meet the high nutri-
185 infants in each group. tional needs of preterm children in the feeding period,
and there is a lack of relevant studies and conclusions
Statistical analysis on whether feeding with extensively hydrolyzed milk
Preliminary analysis protein formula in the early stage of life will affect the
Patients’ characteristics will be summarized using mean ± subsequent growth and development of preterm chil-
SD for continuous variables and frequency (percentage) dren. As the conflict between the high nutritional needs
for categorical variables by groups. Continuous variables and low gastrointestinal tolerability of preterm children
will be transformed if there is a normal assumption with a gestational age of less than 34 weeks is an un-
violation. avoidable issue, we have designed this study protocol,
aiming to increase a new and truly safe and effective en-
Primary outcome teral nutritional prescription. Our study observes the ef-
The rates of food intolerance during NICU will be sum- fect of extensively hydrolyzed milk formula on the
marized and compared using the chi-square test. A p feeding intolerance, enteral and parenteral nutrition,
value <0.05 indicates a significant difference in rates be- spontaneous fecal discharge and other complications in
tween the two groups. We will also fit the logistic re- preterm children with a gestational age of less than
gression model with food intolerance status as the 34 weeks during the NICU stay; it also is the first con-
outcome variable, and group as the main predictor adjust- trolled clinical study with long-term observation of the
ing for covariates. In the case that the number of intoler- growth and development of preterm children fed with
ance events is large enough, we will consider using a such formula in the early stage of life. Our study time in-
Poisson model to model the number of intolerances. cludes NICU stay and 3-month follow-up after discharge
of preterm children. The results of this study will con-
Secondary outcome firm that feeding preterm children with such formula
The time to reach enteral nutrition (parenteral nutri- during the NICU stay is safe and effective, and does not
tion), length of hospital stay, meconium drainage time affect the normal growth and development of preterm
during the NICU stay will be summarized and compared children in the early stage of their lives.
using Kaplan-Meier estimators and logrank tests. Cox
models will also be fitted for time-to-event data adjust- Trial status
ing for baseline covariates. The number of times of self- We started the enrollment in November 2014 and the
defecating per day will be compared using the Poisson trial is expected to end in November 2017.
model adjusting for baseline covariates. The rates of co-
Abbreviations
morbidity will be compared using Poisson models. The AAP: American Academy of Pediatrics; ALB: serum albumin; ALP: alkaline
plasma total protein, albumin level, calcium, alkaline phosphatase; Ca: calcium; CH: congenital hypothyroidism; CMPA: cow’s milk
phosphatase levels before discharge from the NICU will protein allergy; CT: computed tomography; DB: direct bilirubin; DRI: direct
rooming-in; EF: enteral feeding; EHF: extensively hydrolyzed formula;
be compared using t tests. Growth rates measure by ESPGHAN: European Society for Pediatric Gastroenterology, Hepatology, and
weight, body length, and head circumference during the Nutrition; EUGR: extrauterine growth restriction; FI: feeding intolerance;
Yin et al. Trials (2015) 16:498 Page 14 of 15

FT3: free triiodothyronine; FT4: free thyroxine; GAS: gastrin; 11. Riskin A, Agostoni C, Shamir R. Physiology of the gastrointestinal. In:
GER: gastroesophageal reflux; GRV: gastric residual volume; LCT: long-chain Buonocore G, Bracci R, Weindling M, editors. Neonatology: a practical
fatty acids; MCF: medium-chain triglycerides fat; MMC: migrating motor approach to neonatal diseases. 1st ed. Milan: Springer; 2012. p. 263–80.
complex; MOT: motilin; MRI: magnetic resonance imaging; MV: mechanical 12. Franz AR, Pohlandt F, Bode H, Mihatsch WA, Sander S, Kron M, et al.
ventilation; nCPAP: nasal continuous positive airway pressure; Intrauterine, early neonatal, and postdischarge growth and
NEC: necrotising enterocolitis; NICU: Neonatal Intensive Care Unit; NNS: non- neurodevelopmental outcome at 5.4 years in extremely preterm infants
nutritive sucking; NRDS: newborn respiratory distress syndrome; after intensive neonatal nutritional support. Pediatrics. 2009;123:e101–9.
P: phosphorus; P/E: protein-to-energy ratio; PICC: peripherally inserted central 13. Greer FR, Olsen IE. How fast should the preterm infant grow? Current
catheter; PN: parenteral nutrition; PNAC: parenteral nutrition-associated cho- Pediatrics Reports. 2013;1:240–6.
lestasis; PS: pulmonary surfactant; PVC: percutaneous umbilical vein catheter; 14. Hay Jr WW. Aggressive nutrition of the preterm infant. Current Pediatrics
ROP: retinopathy; TB: total bilirubin; TBA: total bile acid; TP: total protein; Reports. 2013;1:229–39.
TSH: thyroid-stimulating hormone; TT3: total triiodothyronine; TT4: total 15. Montenegro BL, Martin CR. Impact of feeding and medical practices on the
thyroxine; WHO: World Health Organization. development of necrotizing enterocolitis. Current Pediatrics Reports.
2014;2:255–63.
Competing interests 16. Meier PP, Engstrom JL, Patel AL, Jegier BJ, Bruns NE. Improving the use of
The authors declare that there are no conflicts of interests regarding this human milk during and after the NICU stay. Clin Perinatol. 2010;37:217–45.
study. 17. Simmer K, Hartmann B. The knowns and unknowns of human milk banking.
Early Hum Dev. 2009;85:701–4.
Authors’ contributions 18. Unger S, Gibbins S, Zupancic J, Deborah L. DoMINO: donor milk for
LPY, LJQ and LXQ designed the study and wrote the protocol. HZ and JNH improved neurodevelopmental outcomes. BMC Pediatr. 2014;14:123.
revised the manuscript. LXQ is the leader and supervisor of the project. LPY 19. Chang F, Cheng S, Wu T, Fang L. Characteristics of the first human milk
and LJQ are the main persons responsible for the whole study. LPY, HZ and bank in Taiwan. Pediatr Neonatol. 2013;54:28–33.
HL will do the data collection and statistical analysis. LPY, LJQ, YC and JNH 20. Keim SA, McNamara KA, Jayadeva CM, Braun AC, Dillon CE, Geraghty SR.
are the physicians who will conduct this study in the hospital. All authors Breast milk sharing via the internet: The practice and health and safety
read and approved the final version of the manuscript. considerations. Matern Child Health J. 2014;18:1471–9.
21. Tudehope D, Vento M, Bhutta Z, Pachi P. Nutritional requirements and feeding
Acknowledgements recommendations for small for gestational age infants. J Pediatr. 2013;162:S81–9.
We would like to thank Prof. Meng Tang from department of virology, 22. Lapillonne A, Griffin IJ. Feeding preterm infants today for later metabolic
Southeast University, China, for his help in the design of this trial. We also and cardiovascular outcomes. J Pediatr. 2013;162:S7–16.
appreciate the constructive advice from Prof. Hongli Tang from Zhongda 23. Meinzen-Derr J, Poindexter B, Wrage L, Morrow A, Stoll B, Donovan E. Role
Hospital for the ethical review of this study. Li-Xing Qiao is funded by the of human milk in extremely low birth weight infants’ risk of necrotizing
National Natural Sciences Foundation of China under the number 81370739. enterocolitis or death. J Perinatol. 2009;29:57–62.
Li-Juan Qian is funded by the Natural Sciences Foundation of Jiangsu 24. Lin PW, Stoll BJ. Necrotising enterocolitis. Lancet. 2006;368:1271–83.
Province, China, with number BK20151420. There is no specific funding 25. Boyd CA, Quigley MA, Brocklehurst P. Donor breast milk versus infant
support for the present study. formula for preterm infants: systematic review and meta-analysis. Arch Dis
Child Fetal Neonatal Ed. 2007;92:F169–75.
Received: 22 April 2015 Accepted: 23 October 2015 26. Greer FR, Sicherer SH, Burks AW. American Academy of Pediatrics
Committee on Nutrition, American Academy of Pediatrics Section on
Allergy and Immunology. Effects of early nutritional interventions on the
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