LioNeo Project – A randomized double-blind phase 2 clinical trial for nutrition of very-low-birth weight infants: A new gold standard?

Fortification of human milk (HM) is essential to meet the nutritional needs of very low birthweight infants (VLBWI). Most available fortifiers are derived from cows milk, raising concerns about tolerability, immunogenicity and access in low-resource settings. LioNeo is a novel multinutrient fortifier produced exclusively from freeze-dried donor HM by a certified Human Milk Bank in Brazil. Preclinical and Phase 1 testing demonstrated safety and tolerability. This Phase 2 trial evaluated the efficacy and safety of LioNeo and assessed its non-inferiority compared to a standard hydrolysed cows milk-based fortifier. We conducted a double-blind, randomized controlled Phase 2 trial at a tertiary university hospital in Brazil. Hemodynamically stable VLBWI receiving [≥]100 mL/kg/day of HM were randomized 1:1 to receive either HM fortified with freeze-dried donor HM (LioNeo) or a with a commercial HM additive (HMCA). The intervention lasted 21 days. Primary outcomes were changes in z-scores for length and head circumference. Secondary outcomes included weight gain, adverse events, and serum zinc and copper levels. A total of 129 infants were enrolled. Mean changes in z-scores for length (-0.08; 95% CI -0.29 to 0.12) and head circumference (-0.07; 95% CI -0.35 to 0.21) demonstrated non-inferiority of LioNeo versus HMCA. Weight gain was comparable between groups. Serum zinc concentrations decreased significantly in both groups. Copper levels were significantly higher in the LioNeo group (p < 0.01) within normal range. Adverse events occurred at comparable rates between groups, although the absolute number of events was higher in the HMCA group. LioNeo, a human milk-based fortifier, was non-inferior to a commercial cows milk-based additive in supporting growth of VLBWI, with a comparable safety profile. It may represent a promising, locally producible, and ethically compliant alternative for fortification in resource-limited contexts. The trial was registered with the Universal Trial Number: U1111-1220-0550. Protocol version 1.