Recommendations for feeding a preterm baby

Introduction

Preterm infant post-natal growth restriction (also referred to as extrauterine growth restriction) is a common phenomenon due to the many challenges in feeding this vulnerable group.1–3 Babies most at risk for growth problems include those born very prematurely and those who are critically ill.

The last trimester of pregnancy is a period when extensive development of the neural tract occurs.4 A consequence of prematurity and postnatal growth restriction is impaired neurodevelopment.4–6 Greater growth deficits seem to be associated with greater neurodevelopmental impairment.

Therefore the most important objective of nutritional management of the preterm infant is the prevention of growth failure in order to protect the infant’s brain.5 More recently, research has demonstrated an association between increased nutrients such as protein and energy and positive developmental outcome.7

 

Recommendations for feeding in hospital

The 2010 ESPGHAN recommendations on enteral nutrient supply for preterm infants:8

‘The preferred food for premature infants is fortified human milk from the infant’s own mother, or, alternatively, formula designed for premature infants.’

Fortified breast milk

All infants should receive breast milk. This is especially important for preterm infants where breast milk has been shown to confer improved short- and long-term outcomes in regards to:

  • Lower rates of necrotising enterocolitis (NEC)9
  • Neurodevelopmental advantages10

ESPGHAN recommends that preterm breast milk should be fortified8 – this is to correct for the decreasing protein content of breast milk with ongoing lactation.11 The primary outcomes of feeding fortified breast milk are that the baby receives the benefits of breast milk while its nutritional status and growth is improved.12

Formula designed for preterm infants

ESPGHAN recommends that if breast milk is unavailable, a formula designed for preterm infants should be used.8 Protein and energy are vital in the management of growth – the ESPGHAN recommendations include guidance on the macro- and micronutrient composition of preterm infant formula.8

ESPGHAN recommended intakes for energy and protein requirements of preterm infants:8

Infant weight

Energy (kcal/kg/d)

Protein (g/kg/d)

Protein (g/100kcal)

Protein energy ratio (PER)

Preterm infants <1 kg

110–135

4–4.5

3.6–4.1

14.4–16.4%

Preterm infants 1–1.8 kg

3.5–4

3.2–3.6

12.8–14.4%


Recommendations for feeding on discharge

The 2006 ESPGHAN guidance on feeding preterm infants on discharge from hospital:13

‘Infants discharged with a subnormal weight for postconceptional age are at increased risk of long-term growth failure...’

The following recommendations are made:

  • Breastfed preterm infants on hospital discharge should receive fortified human milk to provide an adequate nutrient supply
  • Formula-fed preterm infants on hospital discharge ‘should receive special post-discharge formula with high contents of protein, minerals and trace elements as well as a long-chain polyunsaturated fatty acid supply, at least until a postconceptional age of 40 weeks, but possibly until about 52 weeks postconceptional age’
References
  1. Ehrenkranz R et al. Pediatrics 1999; 104: 280–289.
  2. Clark RH et al. Pediatrics 2003; 111: 986–990
  3. Marks KA et al. Acta Paediatr 2006; 95: 236–242.
  4. Georgieff MK et al. J Pediatr 1985; 107: 581–587.
  5. Ziegler E. Ann Nutr Metab 2011; 58 (Suppl 1): 8–18.
  6. Ehrenkranz RA et al. Pediatrics 2006; 117: 1253–1261.
  7. Stephens BE et al. Pediatrics 2009; 123: 1337–1343.
  8. Agostoni C et al. J Pediatr Gastroenterol Nutr 2010; 50: 85–91.
  9. Lucas A, Cole TJ. Lancet 1990; 336: 1519–1523.
  10. Lucas A et al. Lancet 1992; 339; 261–264.
  11. Ballard O, Morrow AL. Pediatr Clin North Am 2013; 60: 49–74.
  12. Jones E, King C. Feeding and Nutrition in the Preterm Infant. Elsevier 2005.
  13. Aggett P et al. J Pediatr Gastroenterol Nutr 2006; 42: 596–603.

ESPGHAN, European Society for Pediatric Gastroenterology, Hepatology and Nutrition

IMPORTANT NOTICE: The World Health Organisation (WHO) has recommended that pregnant women and new mothers be informed on the benefits and superiority of breastfeeding – in particular the fact that it provides the best nutrition and protection from illness for babies. Mothers should be given guidance on the preparation for, and maintenance of, lactation, with special emphasis on the importance of a well-balanced diet both during pregnancy and after delivery. Unnecessary introduction of partial bottle-feeding or other foods and drinks should be discouraged since it will have a negative effect on breastfeeding. Similarly, mothers should be warned of the difficulty of reversing a decision not to breastfeed. Before advising a mother to use an infant formula, she should be advised of the social and financial implications of her decision: for example, if a baby is exclusively bottle-fed, more than one can (400 g) per week will be needed, so the family circumstances and costs should be kept in mind. Mothers should be reminded that breast milk is not only the best, but also the most economical food for babies. If a decision to use an infant formula is taken, it is important to give instructions on correct preparation methods, emphasising that unboiled water, unsterilised bottles or incorrect dilution can all lead to illness. These products must be used under medical supervision. SMA Breast Milk Fortifier is a nutritional supplement designed to be added to expressed breast milk for the dietary management of feeding preterm low birthweight babies. ● SMA PRO Gold Prem 1 is a special formula intended for the dietary management of preterm and low birthweight babies who are not solely fed breast milk. ● SMA PRO Gold Prem 2 is a special catch-up formula intended for the dietary management of preterm and low birthweight babies who are not solely fed breast milk. It is a nutritionally complete formula for use on discharge from hospital or when a low birthweight formula is no longer appropriate. It is suitable for use as the sole source of nutrition up to 6 months corrected age. SMA PRO Gold Prem 2 is not intended for use with newborn preterm babies, for whom fortified breast milk or a low birthweight formula such as SMA PRO Gold Prem 1 is more appropriate.