Abstract
Every year, 15 million babies are born too soon. Many preterm babies now survive and grow up to have normal lives, but the smaller they are, the greater the challenges in establishing milk feeds. Nutrition for these tiny babies is critically important: they are born at a time when the brain is undergoing the most rapid growth of any time during life. Inadequate nutrition results in poor growth, including poor brain growth, and this is associated with poorer long-term neurodevelopmental outcomes. Unfortunately, faltering postnatal growth is the norm for many of these vulnerable babies, largely due to the difficulties in providing adequate protein intake in the first few days after birth. This results in an accumulating nitrogen deficit that is difficult to rescue. There are some relatively simple nutritional strategies that can be used to improve early protein intake, including concentrated standardized intravenous nutrition solutions commenced as soon as possible after birth, early initiation of enteral feeding with more rapid advancement of feeds as tolerated, early use of human milk fortifiers, and higher target feed volumes.We have shown through observational studies that using these strategies achieves currently recommended protein intakes in early life and prevents the downward crossing of centiles for weight that are almost universally reported for extremely-low-birth-weight babies. However, high-quality randomized controlled trials with a clinically important primary outcome are required to address definitively the role of higher protein nutrition in early life on long-term outcome. Such a trial currently is recruiting in New Zealand and should report within 5 years, with survival free of neurodisability at 2 years of age as the main outcome variable.