36 Chapter 2 Figure 2. Protein intake and change in weight z-sore. Protein intake (a) and change in weight z-score (b) in the first 6 weeks of life achieved by standard practice in our neonatal intensive care unit in Amsterdam, the Netherlands (■) (unpublished data) compared with that reported by Embleton (●) (56) before current ESPGHAN guidelines and Senterre (▲) (57) using current ESPGHAN guidelines. However after the initial period of weight loss, in which parenteral feeding is the primary source of nutrition, growth sets in. When growth occurs, protein requirements can be re-evaluated and slowly tapered off to reach 2-3 g/kg/day at term age (58). Caution is warranted to maintain an appropriate protein intake when transitioning from parenteral to enteral nutrition. However enteral and parenteral protein intake might not be similar. For instance, bypassing the enteral route is likely to lower the systemic availability of certain amino acids which are metabolised from other amino acids in the intestine and/or liver (54). In spite of several studies which did not find an increased growth after augmenting protein intake (59, 60), most studies demonstrate that increased protein intake in the neonatal period positively influences growth up to term age (61-65). These studies report improved absolute and standardized measures of weight, length and head circumference as well as an increased growth velocity. No intolerance of high protein diets has been reported (58, 66) and glycaemic control might actually be improved with a high protein intake (59, 60). However protein intake in the neonatal period will not necessarily have an impact on growth indices in childhood
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