Nutritional Needs of the Preterm Infant

 Nutritional Components
 Volume of Feedings
 Breast Milk and formula
 Laboratory Monitoring
 Resources
This resource assists primary care clinicians in monitoring for appropriate nutrition in
premature infants after discharged from care in the neonatal intensive care unit (NICU).
Nutritional Components
Energy
 120-130 kcal/kg/day to grow 15-20 g/day as they catch up to term (potentially more
for ELBW).
 The needs decrease as the infant nears 40 weeks gestational age, but the
recommendations do not account for “catch up” growth for SGA preterm infants or
infants with suboptimal weight gain in the NICU. [Martin: 2006] [Lapillonne: 2013]
Protein
 2-3 g/kg/day – on the lower end closer to term, on the higher end when around 34
weeks GA. [Lapillonne: 2013]
 However, for ELBW infants, protein requirements are higher and range between 3.5-
4.5 g/day. [Mehta: 2009]
Calcium
70-140 mg/kg/day – on the lower end closer to term, on the higher end when around 34
weeks GA. [Lapillonne: 2013]
Iron
 2-4 mg of elemental iron/kg/day – on the lower end for routine care of late preterm
infants.
 Start around 4 weeks of life and continue until approximately 12 months of age or
when the child can ingest adequate iron from food or formula. May require
monitoring to adjust. [Lapillonne: 2013] There is a lack of consensus on this,
however, and consideration must be given to use of iron-containing formulas,
fortifiers, multivitamins with added iron, and foods as well as the history of
erythrocyte transfusions, as premature infants may also develop iron overload.
Common formulations for babies contain 15 mg of elemental iron per 1 mL of liquid.
Iron supplementation can cause gastric upset and hard or darkened stools.
Lipids
Docosahexaenoic acid (DHA) and arachidonic acid (ARA) requirements are higher in
preterm (including late preterm) infants. Once infants reach 40 weeks GA, they are
considered the same as term infants.
Vitamin D
 Supplementation is recommended for all infants to help with bone development and
other aspects of immune function and development. Typical daily dosing is 400 IU
enterally. The Vitamin D3 formulation, cholecalciferol, tends to have more predictable
enteral absorption than Vitamin D2, ergocalciferol. Even when a breastfeeding mother
supplements her Vitamin D, the levels in breast milk do not meet the recommended
daily requirements. Formula-fed babies need to drink at least 34 ounces (1 liter) of
formula daily to obtain the recommended daily allowance of Vitamin D. Common
formulations of Vitamin D3 for babies contain either 400 IU per 1 mL or 400 IU per
drop. Side effects are uncommon; however, some infants find the supplement
unpalatable. Please see Calcium and Vitamin D for further information about
recommended intakes.
Volume of Feedings
Typically, 150-200 ml/kg/day for infants taking 20 kcal/kg/day, may be decreased for infants
taking increased caloric density breast milk or formula or with certain medical conditions
requiring volume restriction. [Lapillonne: 2013]
Breast Milk and formula
Breast Milk
Breast milk continues to be the best form of nutrition for the term infant when this is an
option for the mother and child. On average, breast milk provides 20 kcal of energy per 1
ounce. To meet the increased nutritional needs of preterm infants, breast milk may be
fortified with products, such as Enfamil or Similac Human Milk Fortifier, although these may
not be available for home use. Instead, infant formula powders can be added to expressed
breast milk to increase the caloric density. If increased calories are needed, breastfeeding
mothers can be encouraged to substitute a set number of the breastfeeding episodes with
feeds given by cup, spoon, syringe or bottle, or supplement through a tube attached at the
nipple during breastfeeds. [Phillips: 2013] In some facilities, breast milk composition can be
analyzed to make tailored adjustments; however, this is not yet in widespread practice in the
United States. If fortifiers are used, the clinician can calculate the added Vitamin D and iron
to determine if additional supplementation is indicated.
Formulas
The number of formulas approximating breast milk has increased over several decades.
Specialized formulas are created for preterm infants to match changing requirements and
respond to the increase in knowledge of the needs of the preterm infant. At the time of
discharge from the NICU, formula-fed preterm infants may continue to require added
nutrition to catch up to term weight and address their specialized nutritional needs. Preterm
formulas developed for after-hospital care include 22 kcal/30 ml formulations, such as
Similac Neosure Advance and Enfacare Lipil, and should be considered particularly for
infants with birth weights <1500g for 9-12 months. See Formulas and Fortifiers for
Premature and Low Birth Weight Infants (  94 KB).
Premature infant formulas are specially mixed to preserve the bone integrity of the newborn,
providing appropriate levels of vitamin D and calcium for the preterm infant. Without these,
or if infants experience complications that interfere with adequate nutrition, osteopenia may
result and fractures could occur. Fracture is an infrequent finding in premature infants and
warrants further investigation. See Formulas.
Laboratory Monitoring
In addition to assessing the infant’s measurements for appropriate growth (see Missing issue
with id: 44010697.xml), selective monitoring of blood urea nitrogen, complete blood count
with ferritin or reticulocyte hemoglobin, protein markers such as retinol-binding protein*
and/or prealbumin, alkaline phosphatase, and/or Vitamin D 25-OH may be valuable in
determining the nutritional status of high-risk infants. [Lapillonne: 2013]
*Like prealbumin, retinol-binding protein is a marker of protein stores; its deficiency may
also reflect an inflammatory state or Vitamin A deficiency.
Resources
Helpful Articles
Lapillonne A, O'Connor DL, Wang D, Rigo J.
Nutritional recommendations for the late-preterm infant and the preterm infant after
hospital discharge.
J Pediatr. 2013;162(3 Suppl):S90-100. PubMed abstract
Authors & Reviewers
Initial publication: January 2015; last update/revision: July 2020
Current Authors and Reviewers:
Authors: Jennifer Goldman, MD, MRP, FAAP
Sarah Winter, MD
Reviewer: Annette Haban Bartz, MS, RD, LD, CLC
Authoring history
Page Bibliography
Lapillonne A, O'Connor DL, Wang D, Rigo J.
Nutritional recommendations for the late-preterm infant and the preterm infant after
hospital discharge.
J Pediatr. 2013;162(3 Suppl):S90-100. PubMed abstract
Phillips RM, Goldstein M, Hougland K, Nandyal R, Pizzica A, Santa-Donato A, Staebler S,
Stark AR, Treiger TM, Yost E.
Multidisciplinary guidelines for the care of late preterm infants.
J Perinatol. 2013;33 Suppl 2:S5-22. PubMed abstract / Full Text
Gives guidelines for caring for late preterm infants in the hospital and after discharge.
Includes short- and long-term follow up; each care recommendation is associated with
counseling points to share with the family.