Bridging the Protein Gap: Navigating Variable Milk Composition and Delivery in High-Risk Neonates and Infants

This education is about:

• The neonatal protein gap in preterm and medically complex infants receiving human milk
• The role of protein in lean body mass accrual and neurodevelopment in preterm infants
• Biologic variability in human milk composition by gestational age, stage of lactation, and other factors
• Metabolic consequences in medically complex infants
• Individualized fortification approaches for preterm infants
• Recognizing and addressing protein deficits in the NICU and PICU

Why it matters:

Optimizing protein delivery is critical to supporting growth, neurodevelopment, and recovery in preterm and medically complex infants. However, variability in human milk composition and reliance on standard fortification strategies can lead to unrecognized protein deficits and suboptimal outcomes. This activity addresses emerging evidence and practical strategies to help clinicians identify and close this clinically important “protein gap.”

What you will learn:

This activity explores the emerging concept of the “protein gap” in neonatal and pediatric critical care, highlighting how variability in human milk composition, including differences between mother’s own milk and donor human milk, can lead to unintended protein deficits despite seemingly adequate feeding plans. Faculty review current evidence supporting protein requirements for preterm infants, examine the clinical consequences of cumulative protein deficits, and discuss practical approaches to fortification and protein delivery in NICU and PICU settings. Through this discussion, participants gain clinically actionable strategies to better recognize protein shortfalls, individualize nutrition support, and align feeding practices with evolving guideline-based protein targets to improve growth, recovery, and developmental outcomes in high-risk infants.

Faculty

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  Sarah Fleet, MD, PNS

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  Dr. Sarah Fleet is a Pediatric Gastroenterologist and Physician Nutrition Specialist, specializing in pediatric feeding disorders and inpatient nutrition support at Boston Children's Hospital. Dr. Fleet obtained her MD at the University of Connecticut, and completed her residency and fellowship at Columbia University Medical Center in New York. She then pursued her board certification from the National Board of Physician Nutrition Specialists.  She is the Program Director for the Advanced Nutrition Training Program at Boston Children's Hospital, and Division Director of Medical Student Education. Dr. Fleet is also an Assistant Professor of Pediatrics at Harvard Medical School where she teaches in all phases of the curriculum and holds several leadership roles including pediatrics clerkship core faculty, course co-director for Integrated Human Pathophysiology 1, the required GI physiology course for first year students, and course co-director for several advanced nutrition courses for 3rd and 4th year students. She currently serves as the Past President of the International Association of Pediatric Feeding and Swallowing and is working towards her Masters of Medical Science in Medical Education at Harvard Medical School.  With her collaborators, she recently developed and launched an online simulator for pediatric parenteral nutrition.  Her current research centers around improving pre-clerkship education in medical school through both faculty development efforts and curriculum design. 

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  Sarah Fleet, MD, PNS

  Program Director, Advanced Nutrition Training Program
  Pediatric Gastroenterology, Hepatology & Nutrition
  Boston Children’s Hospital
  Assistant Professor of Pediatrics
  Harvard Medical School
  Boston, Massachusetts

• Profile

  Ting Ting Fu, MD, MS

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  Ting Ting Fu is an Associate Professor of Pediatrics at Cincinnati Children’s and University of Cincinnati. She studied biology at MIT and obtained her medical degree from the University of Kentucky. She completed her pediatric residency at Maine Medical Center and neonatal-perinatal medicine fellowship at Cincinnati Children’s. Currently she is Co-Director of the Infant Nutrition Research & Clinical Hub. She oversees nutrition management and interventions across the region’s six Level III/IV NICUs and leads the CCHMC Human Milk Research Biorepository. As an academic neonatologist, she is dedicated to improving our understanding of the nutritional needs and growth of preterm infants. Her current research efforts focus on human milk composition and strategies to optimize human milk feedings to modulate growth and improve the utilization of donor milk in the preterm population.

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  Ting Ting Fu, MD, MS

  Division of Neonatology
  UC Department of Pediatrics
  Cincinnati Children's Hospital Medical Center
  Cincinnati, Ohio