696330

research-article2017
PENXXX10.1177/0148607117696330Journal of Parenteral and Enteral NutritionBalakrishnan et al

Original Communication
Journal of Parenteral and Enteral
Nutrition
Growth and Neurodevelopmental Outcomes of Early, Volume XX Number X
Month 201X 110
High-Dose Parenteral Amino Acid Intake in Very Low 2017 American Society

Birth Weight Infants: A Randomized Controlled Trial for Parenteral and Enteral Nutrition
DOI: 10.1177/0148607117696330
https://doi.org/10.1177/0148607117696330
journals.sagepub.com/home/pen

Maya Balakrishnan, MD1,2,3; Alishia Jennings, MSW1; Lynn Przystac, RD1;

Chanika Phornphutkul, MD2,4; Richard Tucker, BA1; Betty Vohr, MD1,2;
Bonnie E. Stephens, MD1,2,5; and Joseph M. Bliss, MD, PhD1,2

Abstract
Background: Administration of high-dose parenteral amino acids (AAs) to premature infants within hours of delivery is currently
recommended. This study compared the effect of lower and higher AA administration starting close to birth on short-term growth and
neurodevelopmental outcomes at 1824 months corrected gestational age (CGA). Methods: Infants <1250 g birth weight (n = 168) were
randomly assigned in a blinded fashion to receive parenteral nutrition providing 12 g/kg/d AA and advancing daily by 0.5 g/kg/d to a goal
of 4 g/kg/d (standard AA) or 34 g/kg/d and advancing to 4 g/kg/d by day 1. The primary outcome was neurodevelopmental outcomes
measured by the Bayley Scales of Infant and Toddler Development, Third Edition at 1824 months CGA. Secondary outcomes were
growth parameters at 36 weeks CGA among infants surviving to hospital discharge, serum bicarbonate, serum urea nitrogen, creatinine, AA
profiles in the first week of life, and incidence of major morbidities and mortality. Results: No differences in neurodevelopmental outcome
were detected between the high and low AA groups. Infants in the high AA group had significantly lower mean weight, length, and head
circumference percentiles than those in the standard AA group at 36 weeks CGA and at hospital discharge. These differences did not persist
after controlling for birth growth parameters, except for head circumference. Infants in the high AA group had higher mean serum urea
nitrogen than the standard group on each day throughout the first week. Conclusion: Current recommendations for high-dose AA starting at
birth are not associated with improved growth or neurodevelopmental outcomes. (JPEN J Parenter Enteral Nutr. XXXX;xx:xx-xx)

Keywords
neonates; life cycle; parenteral nutrition; nutrition; proteins

Clinical Relevancy Statement
Early administration of parenteral amino acids to premature
infants is an important strategy to avoid catabolism, promote
growth, and improve development. Prior studies have not
been adequately powered to demonstrate whether high-dose
amino acid supplementation improves neurodevelopment in
this population. This study provides additional insight to clini-
cians considering the formulation of parenteral nutrition in
this population.
Introduction
Malnutrition in the early postnatal period has detrimental
effects on growth and neurodevelopment in very low birth
weight (VLBW) neonates.1,2 Optimizing nutrition in this vul-
nerable population requires a multifaceted approach, including
early initiation of adequate overall energy intake with appro-
priate ratios of macronutrients and routine, early provision of
trophic enteral feedings.3 Because insufficient protein adminis-
tration leads to a negative nitrogen balance in the early period
from which recovery is difficult, early provision of parenteral
amino acids (AAs) to preterm infants is recommended and has
become routine.4 A systematic review confirmed that early AA
administration within the first 24 hours of birth is associated
with a positive nitrogen balance.5 Additional studies have
addressed the issue of early AA administration but have varied
in design not only in regard to timing of AA initiation but also
From the 1Department of Pediatrics, Women & Infants Hospital of Rhode
Island, Providence, Rhode Island, USA; 2Warren Alpert Medical School
of Brown University, Providence, Rhode Island, USA; 3University of
South Florida Morsani College of Medicine, Tampa, Florida, USA;
4
Hasbro Childrens Hospital, Providence, Rhode Island, USA; and
5
Community Medical Center, Missoula, Montana, USA.
Financial disclosure: None declared.
Conflicts of interest: None declared.
Received for publication November 8, 2016; accepted for publication
February 6, 2017.
Corresponding Author:
Joseph M. Bliss, MD, PhD, Department of Pediatrics, Women & Infants
Hospital of RI, 101 Dudley St, Providence, RI 02905, USA.
Email: jbliss@wihri.org
2 Journal of Parenteral and Enteral Nutrition XX(X)
in the targeted goal dose, whether AA administration was initi-
ated at a low dose and incrementally advanced or initiated at
close to the target dose.612 Based on fetal accretion rates, cur-
rent recommendations suggest that AA administration be initi-
ated at birth with a minimum provision of 3.5 g/kg/d in
premature infants.4 However, fetal accretion occurs with an
adequate amount of each AA provided and with metabolic reg-
ulation from the placenta. In existing studies with preterm
infants, variability in study design has resulted in limited evi-
dence to support this recommendation, and thus the starting
dose and rate of advancement vary among centers.13
Furthermore, relatively few studies have prospectively evalu-
ated early initiation of AAs at doses in this range and its cor-
relation with outcomes.912 These discrepancies underscore the
need for careful evaluation of both short-term safety and lon-
ger term growth and neurodevelopment implications of admin-
istering higher levels of existing AA solutions, which are
designed for term infants, in preterm infants with immature
metabolic pathways early in life. This study was conducted to
test the hypothesis that administering AAs starting shortly after
birth at levels approximating fetal rates (3.54 g/kg/d) in neo-
nates with birth weights <1250 g will improve neurodevelop-
mental outcomes at 1824 months corrected gestational age
(CGA). We report the largest cohort of infants with neurode-
velopmental follow-up to date in a single-center, prospective,
blinded, randomized trial and also present the effect on AA
profile in a subset of these patients.
Methods
Study Design
This study was a single-center, birth weightstratified (400
750 g, 7511000 g, 10011250 g), double-blinded, parallel-
group, randomized controlled trial of VLBW infants admin-
istered 2 different doses of intravenous (IV) AA during the first
days of life. The protocol was approved by Women & Infants
Hospital Institutional Review Board, and after the nature of the
study had been explained, written informed consent was
obtained from the parents or guardians of all infants prior to
enrollment. The trial was registered with clinicaltrials.gov
(NCT01860573).
Patients
Eligible infants had a birth weight of 4001250 g and gesta-
tional age between 24 0/7 and 30 6/7 weeks (according to the
best obstetrical estimate). Written informed consent was
obtained for all enrolled patients within 18 hours of life. Both
inborn and outborn infants were eligible provided consent
could be obtained within 18 hours of delivery. Infants were
excluded if diagnosed with a chromosomal, structural, meta-
bolic, endocrine, or renal abnormality that could affect growth
or if the attending neonatologist considered survival beyond 72
hours of life to be unlikely.
Enrollment and Treatment
Prior to randomization, all infants were started on a standard
hyperalimentation (HAL) solution containing dextrose, cal-
cium, and 12 g/kg/d AA (depending on total volume ordered)
as the initial IV fluid. The total AAs received in the hours prior
to randomization and after initiation of study HAL were
recorded. After obtaining informed consent, infants were ran-
domized to receive either standard or high AAs in their
HAL within 1 hour of enrollment. Randomization sequences
were computer generated and stratified by birth weight (400
750 g, 7511000 g, 10011250 g). The clinical team caring for
study infants was blinded to the infants assigned study group.
The pharmacists and nutritionists who were responsible for the
daily HAL formulations were not blinded.
All HAL preparations included Premasol (Baxter Healthcare
Corporation, Deerfield, IL), a neonatal crystalline AA prepara-
tion. Standard HAL contained Premasol (2 g/100 mL), dex-
trose (10%), calcium gluconate (60 mg/kg/d), and an
approximate chloride/acetate ratio of 14%:86%. High HAL
differed only in the amount of Premasol (4 g/100 mL). All
infants also received IV lipid (Intralipid; Baxter Healthcare
Corporation) starting on days 01. Adjustment of HAL formu-
lations through the first week is depicted in Supplementary
Table S1. Enteral nutrition (EN) decisions made were at the
discretion of the medical team.
Assessments
VLBW neonates in our neonatal intensive care unit (NICU)
routinely have laboratory studies on days 1, 2, 3, 5, and 7. The
study investigators monitored laboratory values throughout the
hospital course on enrolled infants. The study protocol allowed
the attending neonatologist to decrease the amount of AAs
administered via HAL if an infant met 2 of the 3 following
predefined criteria: (1) metabolic acidosis (defined as a pH
7.20 and a base deficit of 10) on at least 2 arterial blood
gases, (2) evidence of oliguria (defined as a urine output of <1
mL/kg/h) over a 24-hour period, and (3) serum urea nitrogen
>2 standard deviations (SD) above the mean or a bicarbonate
value <2 SD below the mean for the patients birth weight,
based on the normative values obtained previously in our
review.14 The attending neonatologist was free to decrease the
AA concentration by a percentage of his or her choosing and
thus did not necessitate unblinding of the neonatologist to the
patients study group.
Nutrition data recorded each day in the first week of life
included the amount of IV AAs (g/kg/d), glucose infusion rate
(mg/kg/min), and lipid (g/kg/d) administered; nonnutrition
fluid intake; and total kcal/kg/d (of protein and nonprotein
caloric intake). Additional nutrition data included duration of
IV nutrition support, presence or absence of a central line, age
of first enteral feeding, type and caloric intake of enteral feed-
ing, and time to full feeds (defined as the day HAL was discon-
tinued). The percentages of total fluids from IV vs enteral
Balakrishnan et al 3
sources in the first week of life, at day 28, and on the last day
on HAL were also calculated.
AA profiles on day of life 3 and 7 were obtained from 16
infants whose parents consented to this additional blood sam-
ple. The AA samples were shipped frozen on dry ice to a cen-
tral AA laboratory at New England Medical Center, Tufts
University, Massachusetts. AA concentrations were deter-
mined using standard ion-exchange chromatography method-
ology with postcolumn ninhydrin detection and an automated
AA analyzer (Beckman Instruments, Fullerton, CA).
A data safety monitoring board was established to review
interim results after 20, 50, and 75 infants were enrolled. The
committee included a neonatologist, pharmacist, nutritionist,
and metabolic specialist who were not affiliated with this
study. Safety parameters evaluated were evidence of renal
impairment (serum urea nitrogen, creatinine), acidosis (pH,
base deficit and bicarbonate), and death. No safety concerns
were identified by the board through the course of the study.
Growth Measurements
Growth parameters, including weight, length, and head circum-
ference, were measured at birth, day 7, and weekly throughout
the hospitalization. Weight was measured using a digital scale.
Length was measured using an infantometer with fixed head-
piece and moveable foot piece. Head circumference was mea-
sured using a paper measuring tape from the most prominent
part of the forehead to the widest part of the occiput. The Fenton
growth curve was used to calculate growth percentiles.15
Neurodevelopmental Assessments
The Bayley Scale of Infant and Toddler Development III
(BSID-III) was performed as part of standard care for infants
<1250 g in our NICU Follow-Up Program, where infants
receive a comprehensive neurological and developmental
assessment after hospital discharge. Two certified staff psy-
chologists, who were blinded to initial randomization alloca-
tion, administered the BSID-III at 1822 months of age. The
BSID-III is a standardized test for children 142 months that
includes scaled and composite scores, percentile ranks, and age
equivalents for cognitive, language, and motor scores.
Composite scores have a mean of 100 and an SD of 15. The
language and motor composite scores are further divided into
expressive and receptive language as well as gross and fine
motor scales. Each scale has a mean of 10 and an SD of 3, with
individual age equivalents.16,17 Losses to follow-up were pur-
sued by the Follow-Up Clinic administrator by multiple meth-
ods, including letters and phone calls.
Study End Points
The primary outcome measure was neurodevelopmental out-
comes at 1824 months CGA. Secondary outcomes included
growth parameters (weight, length, and head circumference) at
36 weeks postmenstrual age (PMA) among infants who sur-
vived to hospital discharge, laboratory measures in the first
week (serum urea nitrogen, creatinine, bicarbonate, glucose,
AA profiles), and rates of mortality and morbidities, including
bronchopulmonary dysplasia (BPD), sepsis, patent ductus arte-
riosus (PDA), intraventricular hemorrhage (IVH), necrotizing
enterocolitis (NEC), and retinopathy of prematurity (ROP).
Statistical Analyses
A power analysis to detect a difference in 8.5 points (0.57 SD)
on the Bayley Cognitive Composite score at 18/24 months indi-
cated that 50 in each group would be required to detect this
difference at 80% power and an of P = .05. Based on data at
our institution, the approximate mortality rate in infants <1250
g is 25%, and the estimated rate of follow-up for infants seen at
the Neonatal Developmental Follow-Up program is 80%. Thus,
168 infants (84 infants in each group) were needed to obtain 50
survivors not lost to follow-up at 18 months, per group.
Bivariate analyses were used to compare differences
between the 2 study groups with respect to the following vari-
ables: protein received during week 1, maternal demographic
and neonatal characteristics, growth parameters, rates of neo-
natal morbidities, laboratory parameters, and 18- to 24-month
cognitive and language scores. Repeated-measured analyses
and t tests were used for continuous variables and 2 analyses
for categorical variables. Multivariate regression models were
used to evaluate independent contributions of protein intake to
growth and development while controlling for factors noted to
be significantly different between the 2 groups.
Results
A total of 467 infants were screened through the study period
from November 2008 to November 2012, and 168 (36%) were
enrolled; 83 were randomized to the standard AA group and 85
to the high AA group. Reasons for nonenrollment included
declined consent (n = 102), parent unavailable within 18 hours
(n = 65), research staff unavailable (n = 90), congenital anom-
aly (n = 9), or unlikely to survive past 72 hours (n = 24). All
enrolled infants were included in the analyses with the follow-
ing exceptions: infants who died were excluded from growth
outcome and morbidity measures as well as 1 infant in the con-
trol group who had untreated hydrocephalus. Demographic
variables and growth measurements at birth are depicted in
Table 1. Despite randomization, there were more small for ges-
tational age (SGA, <10th percentile) infants among survivors
in the high AA group.
Infants in the high AA group had significantly higher total
AA intake on days 16 as depicted in Figure 1A. Total AA
intake reached equivalence between groups on day 7. Although
slight differences in total caloric intake, which included calories
from AAs, were noted as expected on days 13, groups were
similar after day 3 (Figure 1B). Total fluid intake was similar
between groups throughout the first week (Figure 1C). All other
4 Journal of Parenteral and Enteral Nutrition XX(X)

Table 1.Demographics.

Characteristic Standard AA (n = 83) High AA (n = 85) P Value

Maternal age, mean SD, y 27 7 28 6 .58
Race, No. (%) .80
White 45 (54) 51 (53)
African American 10 (12) 8 (9)
Hispanic 9 (11) 8 (9)
Other/unknown 18 (22) 18 (21)
Male sex, No. (%) 46 (55) 39 (46) .22
Gestational age, mean (range), wk 26.6 (2430) 26.9 (2430) .22
Cesarean delivery, No. (%) 17 (20) 24 (28) .24
Any prenatal steroid, No. (%) 81 (98) 82 (96) .67
Apgar, 1 min, median 5 5 .85
Apgar, 5 min, median 7 7 .91
Surfactant, No. (%) 63 (76) 60 (71) .51
Birth weight, mean (range), g 888 (4001250) 877 (4951243) .74
Birth length, mean (range), cm 34.1 (2540) 34.1 (2842) .95
Birth HC, mean (range), cm 24.0 (1928) 24.2 (2028) .53
Birth weight, z score, mean SD 0.28 0.85 0.5 0.79 .09
Birth length, z score, mean SD 0.57 1.1 0.77 1.1 .24
Birth HC, z score, mean SD 0.38 0.89 0.5 0.75 .37
SGA, No. (%) 10 (12) 17 (20) .16
SGA, No. (%) of survivors 6 (8) 16 (21) .03
Mortality, No. (%) 10 (12) 9 (11) .77

AA, amino acid; HC, head circumference; SGA, small for gestational age.

nutrition intakes, including carbohydrate and lipids, were simi-
lar between groups. A subset of infants (standard AA, n = 7;
high AA, n = 9) consented for serum AA profile analysis on
days 3 and 7. Infants in the standard and high AA groups ranged
from 2630 and 2430 weeks gestation with birth weights
from 7601150 g and 6001215 g, respectively. One infant in
the high AA group died of late-onset sepsis remote from the
first week. No significant differences in essential or nonessen-
tial AA profiles were noted between groups on either day, and
the values were similar to published AA profiles drawn on day
2 in a cohort of 17 infants 1500 g birth weight who received
2.4 g/kg/d AA from birth (Supplementary Figure S1).7
Laboratory parameters were followed closely through
the first week in all patients (Table 2). Patients in the high
AA group had higher mean serum urea nitrogen than the
standard group on each day throughout the first week,
although both the mean value and the difference between
groups decreased by day 7. Four infants in the high AA
group and none in the standard AA group had their AA dose
decreased by 50% at the discretion of the attending neona-
tologist for high serum urea nitrogen (range, 6084 mg/dL)
and/or low serum bicarbonate (range, 1113 mmol/L). Their
gestational ages ranged from 2529 weeks and birth weights
7681070 g. None of these infants had AA profiles per-
formed. Creatinine values were similar between groups but
were slightly lower in the high AA group on day 5. There
were no significant differences between groups on any day
for serum bicarbonate or glucose. Measurement of serum
phosphate was not specified in the protocol, but data were
collected where obtained. Serum phosphate was measured
on 83% of patients on day 7, and there was no difference
between groups (4.5 vs 4.4 mg/dL in standard and high AA
groups, respectively; P = .59).
Growth
Growth measurements, percentiles, and z scores among survi-
vors at 36 weeks PMA and at hospital discharge are depicted in
Table 3. At 36 weeks PMA, infants in the high AA group had
significantly lower mean weight, length, and head circumfer-
ence percentiles than those in the standard AA group. These
differences persisted at hospital discharge.
As shown in Table 1, more SGA infants surviving to dis-
charge were randomized to the high AA group. Because SGA
infants are likely to have altered growth trajectories relative to
appropriate-for-gestational-age infants, additional analyses
were conducted to control for this unexpected finding. All of
the growth parameters that were significantly different between
the high AA and standard AA groups (Table 3) were no longer
significantly different after controlling for birth parameters,
with the exception of discharge head circumference z score,
which was borderline (P = .05). The analysis was also repeated
after excluding SGA infants (Table 4). Although there were no
differences in any growth parameter noted at 36 weeks PMA,
Balakrishnan et al 5
Figure 1. Nutrient and fluid intake. (A) The total mean amino
acid (AA) intake for each day of the first week is plotted by group
assignment. As expected, infants in the high AA group had higher
mean AA intake than infants in the standard AA group until
day 7. Error bars represent standard deviations. (B) Mean total
caloric intake, inclusive of calories from AAs, is plotted by group
assignment for each day of the first week and weekly through
week 6. *P < .05. Error bars represent standard deviations. (C)
Mean total fluid intake is plotted by group assignment for each
day of the first week. Error bars represent standard deviations.
the head circumference percentile and z score among survivors
at discharge remained significantly lower in the high AA group.
Morbidities and Other Outcomes
Additional outcome comparisons between groups are shown in
Table 5. There were no differences in any morbidities. Other
nutrition outcomes, including days to regain birth weight and
days to full feeds, were also similar between groups. Volume of
breast milk intake among study subjects was recorded at
weekly intervals throughout the study, and there were no dif-
ferences between groups. Overall length of stay, chronological
age, and CGA at discharge were likewise similar.
Neurodevelopmental Outcomes
Subjects were evaluated using the Bayley Scales of Infant and
Toddler Development, Third Edition (Bayley III) at a corrected
gestational age of 1824 months. Follow-up rate among survi-
vors was 78%. Results of neurodevelopmental assessments are
shown in Table 6. There were no differences in any component
of the Bayley III between groups. Rates of patients scoring <1
SD below the mean (85) or <2 SD (70) were likewise similar
between groups. Rates of cerebral palsy, blindness, or deafness
were low and similar between groups.
Discussion
This study prospectively compared premature infants starting
close to a targeted goal of 4 g/kg/d of parenteral AA on the first
day of life with a group that started at a lower dose and achieved
the goal in incremental fashion over several days. Despite
effectively providing higher doses of AA to the high AA group
for most of the first week, this approach was not associated
with improved growth or improvements in neurodevelopmen-
tal outcomes at 1824 months corrected age. In addition,
infants in the high AA group had substantially higher serum
urea nitrogen levels and smaller head circumference z scores at
hospital discharge after excluding infants who were SGA at
birth. These data suggest that initiating AA infusions in pre-
term infants at goal intakes on the day of birth rather than
working up toward that goal over several days is not associated
with improved outcomes.
The American Academy of Pediatrics Committee on
Nutrition recommends that nutrition be provided to the preterm
infant with the goal of approximating the rate of growth and
composition of weight gain for a normal fetus at the same post-
menstrual age.18 Fetal protein accretion rates require infusion
rates of 3.85 g/kg/d if this remains the goal.19 Early studies
demonstrated that contemporary AA preparations administered
within hours of delivery could be provided safely and without
the short-term markers of metabolic perturbation that were
associated with older sources of parenteral protein.68,2023
These findings led to earlier provision of AA to premature
6 Journal of Parenteral and Enteral Nutrition XX(X)

Table 2. Laboratory Values in the First Week.a

Serum Urea Nitrogen, mg/dL Creatinine, mg/dL Bicarbonate, mmol/L Glucose, mg/dL

Day Standard High P Value Standard High P Value Standard High P Value Standard High P Value
1 19 7 22 8 .03 1.0 0.2 1.0 0.2 .65 21 3 22 2 .18 95 44 89 47 .37
2 26 9 36 10 <.001 1.1 0.2 1.1 0.3 .88 21 3 21 3 .28 96 40 85 40 .06
3 30 11 44 14 <.001 1.2 0.3 1.1 0.3 .14 20 4 20 4 .95 97 33 93 36 .47
5 35 16 49 18 <.001 1.2 0.3 1.1 0.3 .02 19 4 18 4 .27 100 28 103 33 .62
7 33 16 39 19 .04 1.0 0.3 0.9 0.3 .06 19 4 18 4 .58 119 36 122 48 .67
a
Values are means standard deviations.

Table 3. Growth Measurements at 36 Weeks PMA and at Hospital Discharge.a

Characteristic Standard AA High AA P Value

36 weeks PMA
Weight, n 67 72
Mean, g 2212 389 2128 311 .16
Percentile 17.9 19.2 12.0 12.1 .03
z score 1.23 0.90 1.41 0.75 .21
Length, n 60 63
Mean, cm 43.7 2.6 42.6 2.8 .02
Percentile 18.6 20.7 11.6 14.2 .03
z score 1.24 1.02 1.68 1.07 .02
HC, n 66 67
Mean, cm 31.6 1.6 31.3 1.2 .21
Percentile 31.1 25.4 22.1 19.3 .02
z score 0.67 0.97 0.88 0.75 .16
Discharge
Weight, n 72 76
Mean, g 3103 1128 2780 866 .05
Percentile 30.4 25.7 20.5 18.3 .006
z score 0.71 0.94 1.07 0.82 .01
Length, n 70 74
Mean, cm 48.0 4.2 46.5 4.1 .02
Percentile 26.0 27.8 17.0 20.4 .02
z score 1.04 1.28 1.39 1.07 .06
HC, n 70 75
Mean, cm 34.2 3.0 33.2 2.8 .03
Percentile 40.1 25.8 30.3 21.7 .009
z score 0.34 0.91 0.65 0.76 .02

AA, amino acid; HC, head circumference; PMA, postmenstrual age.

a
Values are means standard deviations unless otherwise indicated.

infants to avoid development of the nitrogen deficit, and rec-
ommendations for doses of a minimum of 3.5 g/kg/d in early
parenteral nutrition (PN) formulations in the first hours after
birth to approximate fetal accretion rates followed.4 However,
delivery of current AA formulations postnatally to premature
infants is an inherently different process than transplacental
delivery of AAs from mother to fetus with the benefit of meta-
bolic regulation from the placenta. Furthermore, evidence is
lacking that AA infusion rates of 3.5 g/kg/d in the NICU setting
initiated within hours of birth will adequately and safely mimic
fetal protein accretion rates.
These recommendations have been tested in several more
recent prospective, randomized trials, and these studies have
not demonstrated the anticipated benefit on growth.
Importantly, each of these studies had design differences that
also differ from the current study. Burattini etal9 reported no
differences in growth or neurodevelopmental outcomes
between groups of infants randomized to AAs started at birth
Balakrishnan et al 7

Table 4. Growth Measurements at 36 Weeks PMA and at Hospital Discharge Excluding SGA Infants.a

Characteristic Standard AA High AA P Value

36 weeks PMA
Weight, n 61 60
Mean, g 2267 350 2238 241 .59
Percentile 19.6 19.3 14.9 12.2 .12
z score 1.10 0.79 1.16 0.61 .65
Length, n 55 48
Mean, cm 44.0 2.5 43.2 2.7 .12
Percentile 20.1 21.0 14.2 15.2 .10
z score 1.13 0.97 1.48 1.06 .08
HC, n 60 51
Mean, cm 31.7 1.5 31.5 1.18 .42
Percentile 33.1 25.5 26.0 20.1 .11
z score 0.56 0.89 0.75 0.73 .24
Discharge
Weight, n 66 60
Mean, g 3012 971 2885 848 .44
Percentile 31.8 26.1 24.6 18.2 .07
z score 0.65 0.92 0.83 0.67 .22
Length, n 64 59
Mean, cm 47.9 3.8 47.2 3.9 .30
Percentile 28.3 27.9 20.5 21.1 .08
z score 0.84 1.11 1.08 0.87 .18
HC, n 64 60
Mean, cm 34.0 2.6 33.4 2.7 .20
Percentile 41.6 25.7 32.6 21.0 .03
z score 0.26 0.84 0.56 0.72 .03

AA, amino acid; HC, head circumference; PMA, postmenstrual age; SGA, small for gestational age.
a
Values are means standard deviations unless otherwise indicated.

Table 5. Morbidities and Other Outcomes.

Characteristic Standard AA High AA P Value

Regain BW, mean SD, d 12.2 5.4 11.2 5.2 .27
Full feeds, mean SD, d 29.8 23.2 31.0 27.9 .83
Sepsis, No. (%)a 24 (33) 16 (21) .11
NEC, No. (%)b 11 (15) 12 (16) .90
PDA, No. (%)c 9 (12) 11 (14) .70
Any IVH, No. (%) 14 (19) 11 (14) .44
IVH, grades 3 and 4, No. (%) 5 (7) 2 (3) .22
PVL, No. (%) 4 (6) 2 (3) .38
Any ROP, No. (%) 32 (44) 29 (38) .48
BPD, No. (%)d 28 (38) 32 (42) .64
Postnatal dexamethasone, No. (%) 11 (13) 16 (19) .33
Length of stay (range), d 90 (13265) 84 (13173) .29
Chronologic age at D/C (range), wk 12.9 (1.937.9) 12.0 (1.924.7) .29
Corrected age at D/C (range), wk 39.6 (31.666.9) 39.0 (30.949.7) .43

AA, amino acid; BPD, bronchopulmonary dysplasia; BW, birth weight; D/C, discharge; IVH, intraventricular hemorrhage; NEC, necrotizing
enterocolitis; PDA, patent ductus arteriosus; PVL, periventricular leukomalacia; ROP, retinopathy of prematurity.
a
Sepsis was defined as a positive culture obtained from the blood, urine, or cerebrospinal fluid that was treated for at least 7 days with an antibacterial or
antifungal agent.
b
NEC was defined as any diagnosis of NEC documented by the clinical team for which the patient was nil per os and received antibiotics for a minimum
of 5 days.
c
PDA was defined as any documented PDA detected by echocardiogram.
d
BPD was defined as receiving >30% supplemental oxygen at 36 weeks or the need for positive pressure support. In those infants requiring <30%
oxygen, it was defined as the need for any supplemental oxygen at 36 weeks after an attempt at withdrawal of oxygen.
8 Journal of Parenteral and Enteral Nutrition XX(X)

Table 6. Neurodevelopmental Outcomes at 1824 Months Corrected Gestational Age.

Characteristic Standard AA High AA P Value

Scores, mean SD (n)
Cognitive composite 90.2 10.3 (59) 90.6 12.7 (55) .86
Language composite 88.0 13.4 (58) 90.3 16.2 (55) .41
Receptive communication scale 8.3 5.6 (59) 8.1 3.0 (55) .77
Expressive communication scale 8.2 2.4 (58) 8.8 2.6 (54) .21
Motor composite 93.1 12.3 (59) 93.0 13.7 (55) .99
Fine motor scale 9.7 2.0 (58) 9.8 2.1 (55) .75
Gross motor scale 8.3 2.1 (58) 8.2 2.3 (54) .76
Scores <85 (1 SD), No. (%)
Cognitive composite 9 (15) 12 (22) .37
Language composite 24 (41) 22 (40) .88
Motor composite 10 (17) 9 (16) .93
Scores <70 (2 SD), No. (%)
Cognitive composite 3 (5) 3 (5) .93
Language composite 3 (5) 4 (7) .64
Motor composite 4 (7) 3 (5) .77
Cerebral palsy, No. (%) 6 (10) 4 (7) .50
Blind, No. (%) 0 1 (2) .30
Deaf, No. (%) 1 (2) 0 .32

AA, amino acid.

and targeting goals of 2.5 g/kg/d vs 4 g/kg/d achieved on days
34. In this study, both groups started below the goal and were
advanced to different targets. The high AA group did have
higher serum urea nitrogen concentrations. In another study
investigating the effects of early AAs as well as early paren-
teral lipid delivery, infants were randomized to start AAs at 2.4
g/kg/d plus lipids staring on day 2, AAs at 2.4 g/kg/d plus lip-
ids shortly after birth, or AAs at 3.6 g/kg/d plus lipids shortly
after birth.10 This study found improved nitrogen balance when
lipids were started earlier relative to later but no contribution of
increased AA dose to this outcome. Again, higher serum urea
nitrogen concentrations were noted in the high AA group, and
no difference in growth was detected. The NEON (Nutritional
Evaluation and Optimisation in Neonates) trial used a 2-by-2
factorial design to investigate both high AAs at birth as well as
the effects of the soybean oilbased Intralipid to the alternative
SMOFlipid with its altered ratio of -6/-3 fatty acids.12 AA
intake starting at 1.7 g/kg/d and increasing to a maximum of
2.7 g/kg/d on day 3 was compared with 3.6 g/kg/d from day 1
onward. The high AA group showed no improvement in non-
adipose mass at term but again showed elevated serum urea
nitrogen concentrations. Although design differed in each trial,
the current study had very similar findings to the above trials in
that patients in the high AA group had higher mean serum urea
nitrogen than the standard group on each day throughout the
first week and also failed to show a benefit in growth or neuro-
developmental outcome. In several cases in the high AA group,
the serum urea nitrogen was high enough to prompt a reduction
in AA delivery. Increases in serum urea nitrogen likely reflect
increased oxidation of AAs as their availability increases and
mirror fetal metabolism of AAs as an energy source, albeit
without the benefit of placental regulation.
More concerning are reports suggesting that higher doses of
AAs may have a negative impact on growth. In a single-center
study comparing a starting dose of 1 g/kg/d AA with 3 g/kg/d
and advancing both groups to 4 g/kg/d, the high AA group had
lower gains in weight, length, and head circumference at 28
days than the low AA group.24 However, this study was con-
ducted in a resource-limited setting with infrequent IV lipid
use, resulting in suboptimal ratios of protein to total calories.
The NEON study reported a smaller head circumference at
term in infants in the high AA group.12 Blanco etal25,26 studied
61 infants who were randomly assigned to AAs starting at 0.5
g/kg/d in the first 2436 hours and advanced by 0.5 g/kg/d to a
maximum of 3 g/kg/d vs starting at 2 g/kg/d at enrollment and
advanced by 1 g/kg/d to a maximum of 4 g/kg/d. They found a
lower mental development index in the high AA group at 18
months, although the difference was no longer seen at 2 years
corrected age. One additional study described randomization
of infants to a SCAMP (standardized, concentrated with added
micronutrients parenteral) nutrition solution that offered a
maximum of 3.8 g/kg/d AA and lipid vs 2.8 g/kg/d of each,
with infants in both groups achieving their specified goal after
day 4.11,27 This study reported an increased change in head cir-
cumference at 28 days and 36 weeks corrected age in the
SCAMP group relative to control. Notably, the higher target
group in the SCAMP study was similar to the control group in
the current study because both achieved targets of approxi-
mately 4 g/kg/d AA after day 4. Infants in the high AA group of
our study were randomized to this target shortly after birth
Balakrishnan et al 9
without incremental increases and had significantly smaller
growth percentiles at 36 weeks PMA and at discharge than
those in the standard AA group. This result could be con-
founded in that despite randomization, the high AA group had
a higher number of SGA infants. However, after removal of the
SGA infants from analyses, a difference in head circumference
persisted. The lack of a difference in later neurodevelopmental
outcomes is reassuring in this regard, although the current
study was underpowered to detect smaller differences in neu-
rodevelopment, and no benefits of immediate high-dose AA
could be ascertained. Taken together, these results suggest that
achieving a goal of 4 g/kg/d AA in an incremental fashion after
birth may be a safer approach.
Similar to most other studies, rates of neonatal morbidities
were similar between the groups, including culture-proven
late-onset sepsis. This result is reassuring in light of a previous
study in which higher parenteral AA provision was included in
a randomized fashion among a number of strategies to increase
nutrition and growth. The study was stopped early when the
intervention group was noted to have a higher rate of late-onset
sepsis and electrolyte disturbances (hypophosphatemia, hypo-
kalemia, and hypercalcemia).28 The authors speculated that the
phosphate disturbances may have contributed to the sepsis
risk. Serum phosphate concentrations were not different
between groups in our study.
Direct comparisons between the results of our study and
those of previous studies are confounded by differing study
designs, including dose of amino acids and rate of advance-
ment as well as different outcomes. In addition, many previ-
ous studies used Trophamine AA rather than Premasol,
although the AA formulations are identical between these
products. Overall, our findings are similar to those of recent
prospective studies in that starting PN with AAs approaching
4 g/kg/d rather than 2 g/kg/d within hours of birth does not
improve short-term growth or longer term neurodevelop-
mental outcomes. This study contributes the largest single-
center cohort from whom 18- to 24-month neurodevelopmental
follow-up is available. In addition, unlike earlier studies
comparing early, more modest doses of AAs, contemporary
studies demonstrate a significant increase in serum urea
nitrogen in the high AA groups likely reflective of AA oxida-
tion. Taken together, these studies suggest that starting at
doses of parenteral AA >2 g/kg/d may not provide an incre-
mental benefit.
Although this study was designed to interrogate the effect
of maximizing AA administration in the early neonatal period,
this design is also a limitation in that it focused on a single
macronutrient. Providing more AAs alone failed to improve
growth or neurodevelopment. Contemporary evidence sug-
gests that optimizing growth outcomes relies on careful atten-
tion to both protein and total energy intake in the first week and
emphasizes the importance of both EN and PN.3 Suboptimal
energy intake in the first week in our study may have contrib-
uted to the increased AA oxidation manifested by the higher
serum urea nitrogen in the high AA group. In addition, the AA
formulation of current products may not be optimal for the
unique nutrition requirements of the preterm infant. These
issues may have contributed to the observed impairments in
growth in the high AA group. Although the amino acid profiles
obtained in this study did not show abnormalities, this result
should be interpreted cautiously as the sample size was quite
small. Another limitation is that the inclusion of SGA infants
was not included in the power calculation, which limits the
conclusions that can be drawn from post hoc analyses exclud-
ing these infants. Nevertheless, our results contribute to this
growing literature, suggesting that facilitating growth in
these patients most vulnerable to malnutrition will require a
multifaceted approach that includes determining optimal
macronutrient formulations, the timing of their initiation, and
advancement and enteral feeding strategies.
Supplementary Material
Figure S1 and Table S1 are available with the article online at
http://journals.sagepub.com/home/pen.
Statement of Authorship
M. Balakrishnan, B. E. Stephens, and J. M. Bliss equally contrib-
uted to the conception and design of the research; M. Balakrishnan,
A. Jennings, L. Przystac, B. Vohr, B. E. Stephens, and J. M. Bliss
contributed to the acquisition and analysis of the data; C.
Phornphutkul and R. Tucker contributed to the analysis and inter-
pretation of the data; and M. Balakrishnan and J. M. Bliss drafted
the manuscript. All authors critically revised the manuscript, agree
to be fully accountable for ensuring the integrity and accuracy of
the work, and read and approved the final manuscript.
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