Nutrition Management of

the Premature Infant

Melissa Nash, MPH, RD

Washington County Field Team
melissa_nash@co.washington.or.us
Objectives
1. Describe appropriate growth in premature
infants, including growth charts.
2. Describe current practices for feeding and
supplementation for premature infants.
3. Understand how to better support the
breastfeeding premature infant.
4. Recognize potential feeding problems and
solutions in premature infants.
Newborn Classifications
LBW: Low Birth Weight
 <2500g (5 1/2 lbs)

VLBW: Very Low Birth Weight

 <1500g (3 1/3 lbs)

ELBW: Extremely Low Birth Weight

 <1000g (2 1/4 lbs)

Preterm: <37 weeks GA

Late Preterm: 34 0/7 – 36 6/7 weeks GA
 Typical Feeding Progression
Gestational Age (Weeks)
24 25 26 27 28 29 30 31 32 33 34 35 36 37 38
Pacifier Sucking (non-nutritive suck)

Gag Reflex
Rooting Reflex Early Intermediate Mature

Coordinate Suck,
Nutritive Suck Swallow, Breathe

TPN for 1-2 weeks as enteral Gradually start breast/ Infant nippling
feeds advance via tube bottle per infant cues all feeds
Post-Discharge Premature Infant
Nutritional Issues
Switch from ‘super-milks’ to standard milk
Slower growth in follow-up
Neonatal period critical for ‘programming’
of development and health
Limited information/research on post-
discharge nutrition
The Underlying Question…
“Do you want a smart, tall, fat
adult who will die prematurely
of cardiovascular disease or a
dumb, short, thin adult who
will outlive the other?”
Richard Schandler, MD
Neonatalogist
Developmental Origins of
Health & Disease
“Fetal Programming”
 Under-nutrition during pg & LBW are strongly
associated with HTN, obesity, insulin
resistance and dyslipidemia later in life
 Combination of poor growth & rapid catch-up
weight may increase risk
 Additional research is needed to determine
when catch-up growth is “excess growth”
What does the research say?
Weight Gain & Growth
 Feeding a post-discharge formula (PDF) for
9-12 months following discharge results in
improved wt, lt, & HC
 Greatest results in infants <1250-1500g

 Greater results in males vs. females

 Long-term developmental advantages

inconclusive
What does the research say?
Bone Mineral Content (BMC)
 BMC higher in premies receiving a PDF for 9
months post-discharge
 Highest Ca formulas = greatest BMC

Chan, J Pediatr 1993;123:439-43

Bishop, Arch Dis Child;1993:573-8
Carver, Pediatr 2001;107:683-689
Cooke, Pediatr Res 2001;49:717-722
Morley, Am J Clin 2001;71:822-8
Growth Charts
Recommended growth charts:
 2013 Fenton growth charts from birth to ~50 wks
 WHO growth charts from term to 24 months
 CDC growth charts from 24 months to 18 yrs old
Fenton Growth Grids
http://ucalgary.ca/fenton/2013chart
Why should we use the
updated Fenton charts?
Boys chart
Solid lines = 2013
Dashed lines = 2003
Growth Assessment
Start with correct growth parameters
Growth Term-
parameter 3 mo CA 3-6 mo CA
Weight Gain ~6-8 oz/wk ~4 oz/wk
Length Gain ~1 cm/wk ~0.5 cm/wk
HC Gain ~0.5 cm/wk ~0.2 cm/wk
Corrected Age
Use corrected age for all premature infants
<37 weeks until 24 months when assessing:
 Growth

 Nutritional needs

 Feeding (solids, cow’s milk)

 Developmental milestones
First Choice Formulas for
Premies: Post-Discharge Formula
 Post-Discharge (transitional) formulas
 Enfamil Enfacare*
 Similac Neosure*
 Good Start Nourish*
*WIC provides with an Rx

 Provide add’l vits & nutrients: Ca, Phos & Pro

 Whey-dominate, less lactose, 20% MCT oil
 Provide add’l calories: 22 vs. 20 kcal/oz
 May be mixed to 24 or 27 kcal/oz
 May be used to fortify EMM to 22, 24, 27 kcal/oz
Second Choice Formulas for
Premies: Term Formulas
 Standard Term Formulas
 Enfamil Premium
 Good Start Gentle; Good Start Protect
 Similac Advance (WIC)
 Reduced/No Lactose and/or Partially Hydrolyzed
 Enfamil Gentlease
 Good Start Sooth, GS Gentle, GS Protect
 Similac Sensitive, Similac Total Comfort (19 kcal/oz)

Uses: GI upset, constipation, lactose sensitivity

Provides 20 kcal/oz
Can fortify EMM or be prepared to 22, 24, 27 kcal/oz
Contraindicated Formulas for
Premies: Soy Formula
AAP does not recommend soy formula for preterm
infants born <1800g
 Lower serum albumin levels
 High amts of phytates
 Lower levels of markers for bone formation
 Risks for aluminum toxicity
 Concerns w/ disruption of thyroid fct, suppression of
testosterone, & phytoestrogen-like effect

Examples: Isomil & Prosobee (WIC)

Bhatia, Pediatrics 2008;121:1062
Contraindicated Formulas for
Premies: Thickened Formulas
These “reflux” formulas contain rice starch with
thicken upon entering the stomach.

Contraindicated for premature infants <38 weeks

GA due to risk of the formation of lactobezoars
(hard clumps of undigested milk curds)

Examples: Enfamil AR* & Similac for Spit-Up*

*Available thru WIC w/ Rx
EMM & Formula Comparison
Values Term EMM EMM + Enfacare Enfamil
Per 100ml 20 kcal Enfacare 24 kcal/oz 20 kcal
24 kcal/oz
Calories 68 80 80 68

Pro, G 1 1.36 2.3 1.4

Ca, mg 28 44 97 53

Phos, mg 15 24 53 29

Iron, mg 0.04 0.3 1.4 1.2

 Breastfeeding the
Premature Infant
“The potent benefits of human milk are such that
all preterm infants should receive human milk.”

“Human milk should be fortified, with protein,

minerals, and vitamins to ensure optimal
nutrient intake for infants weighing <1500 g
at birth.”
Policy Statement: Breastfeeding and the Use of Human Milk, Pediatrics 2012; 129:e827

In general, the smaller infant, the higher the nutritional

needs & the longer they may need fortification.
Breastfeeding the
Preterm Infant
There are several significant short & long-term
benefits to feeding a preterm infant human milk:
 ↓ rates of sepsis & NEC
 Fewer hospital readmissions
 ↑ intelligence thru adolescents
 ELBW infants fed ↑ of human milk show significantly ↑
scores for mental, motor, & behavior ratings at ages 18
months and 30 months
• Even after adjusting for cofounders
• Outcomes assoc. w/ predominant human milk, not exclusive
 Lower rates of metabolic syndrome
Policy Statement: Breastfeeding and the Use of Human Milk, Pediatrics 2012;129:e827
Goals for Breastfeeding the
Premature Infant
 Promote adequate wt gain, including catch-up
 Ensure good nutritional status
 Maintain & increase breast milk supply
 Sustain or improve feedings at the breast
 Limit bottle & formula feedings
 Guidelines for Initiating &
Maintaining Milk Supply
First 2-3 weeks
 Use hand expression & compression w/ pumping
 http://newborns.stanford.edu/Breastfeeding/MaxProduction.html
 http://newborns.stanford.edu/Breastfeeding/HandExpression.html
 Pump w/ double electric pump
 Empty breasts at every pumping
 Pump q 2-3 hrs/day & 1x/night (not to exceed 4 hrs)
 Pump 7-10x/24 hours while establishing supply

After first 2-3 weeks (if adequate milk supply)

 Pump q 4hr/day & 1x/night (not to exceed 5 hrs)
 Pump 6-8x/24 hours
Ideas for Increasing Milk Supply
 Increase skin-to-skin contact
 Ensure adequate fluid intake
 Ensure optimal pump and/or flange
 Increase frequency of pumping, up to 10x/d
 Use breast massage/compression while pumping
 Discuss ways to decrease tension
 Try power or cluster pumping
 Discuss use of galactagogues/meds w/ LC
Breastfeeding the
Premature Infant
The ability to BF is multi-factorial, depends on:
 MOB’s milk supply & willingness to pump
 Birth weight & gestational age
 Complexity of NICU course
 Infant maturity
Breastfeeding the
Premature Infant
Typical plan of BF premature infant at discharge:
 BF 2x/d (with time limit)

 Offer bottle of fortified EMM q feeding

 Give MVI w/ iron daily

 MOB pumps q feeding

Breastfeeding the
Premature Infant
Progression of BF plan:
 Add one additional BF q week
 Consider nipple shield
 Cont. to offer fortified bottles q feeding &
after BF
 Give 1 ml MVI w/ iron daily
 MOB to continue to pump at q feeding &
after BF until at least 40-44 weeks GA
 Support, support, support!!!
 Breastfeeding the
Premature Infant
Evaluation of readiness to reduce fortification:
 Ability to sustain growth
 Ability to sustain appropriate ad lib milk intake
 Lab values are WNL (ck’d one mo post-
discharge)

Methods to decrease fortification:

1. Decrease by 2 bottles q 4-6 days or
2. Drop fort bottles at night
* Check weight WEEKLY during transition
Vitamin/Mineral Supplementation
If infant is What supplements When can the
primarily on: are recommended? supplements be
stopped?
Breastmilk 1 ml daily infant MVI Continue until 12 mo
(Unfortified or with iron corrected age
Fortified) OR
1ml daily infant MVI
without iron +
separate iron
supplement
Iron-Fortified 0.5 ml daily infant Stop when intake
Formula MVI without iron reaches ~ 32 oz/d
*Poly vitamin = A, C, D, E, B vitamins + iron?
*Tri vitamin = A, C, D + iron?
Osteopenia of Prematurity
Condition of decreased bone density in
premature, LBW infants.

Characterized by low Ca, low P, and high ALP

Risk for bone fractures & growth stunting

Osteopenia of Prematurity
Risk factors:
 VLBW infants (<1500 g)
 Any IUGR infant with a BW <1800g
 Infants with CLD or BPD
 Infants requiring long-term TPN (>4 weeks)
 Infants on certain meds that affect mineral
absorption
 Infants starting feeds of unfortified breastmilk
or standard/soy formula
 Osteopenia of Prematurity
Indications for reassessment of bone labs:
 1 mo post discharge for infants w/ BW <1500g

 1 mo post discharge if any labs at discharge

were abnormal
 An infant <3 mo CA who is transitioning to
breast or term formula
 Infant with marginal intake & slow growth
Osteopenia of Prematurity
Some very small premature infants gain
weight well while taking only breastmilk,
despite having abnormal bone labs.

Tribasic:
 Ca/P supplement
 Standard dose is 1/8 tsp BID, up to TID
 Bone labs should be monitored q 4-6 wks while on
Tribasic
 Infant continues w/ Tribasic for 2-3 mo while EBF
Late Preterm Infant
Infants born between 34 0/7 – 36 6/7 weeks GA
Birth weights ~ 2000-3000g (4 ½ -6 ½ lbs)

No current recommendations for additional nutrient

requirements, besides a multivitamin.

At risk of inadequate nutrient intake due to:

 Immature gastrointestinal function
 Immature neural function
 Lower stamina
 Lower oral-motor tone
Late Preterm Infants
Breastfeeding:
 Many discharged home before MOB’s milk supply
established
 Late preterms may not be able to provide enough
stimulation to bring in adequate supply
 MOB will usually have to pump after BF for
several weeks to ensure adequate supply
 Infants can EBF, BF + bottle of EMM, BF + bottle
of fortified EMM to 22-24 kcal/oz
 Offer MVI until 12 mo CA
Late Preterm Infants
Formula Feeding:
 Offer TERM infant formula

 Offer MVI until volume reaches 32 oz/d

 May start/increase to 22-24 kcal/oz if infant

unable to consume enough volume to provide
adequate growth. Usually need inc. calories
for first month.
Feeding Progression/Solids
Feeding recommendations for premature infants
should be based on corrected age:
 Breastmilk/formula until at least 12 mo CA

 Solids may be introduced between 4-6 mo CA

(based on developmental stage & feeding skill)
 Withhold cow’s milk until 12 mo CA
Common Concerns in the
Premature Infant
 Constipation
 Spit-up &/or GERD
 Inadequate weight gain
 Rapid weight gain
Constipation
in the Premature Infant
Stools that are dry, hard & difficult to pass, independent of
frequency

Causes/Assessment:
 Immature GI tract
 Medications
 Inadequate fluid intake
 Calorie-dense formulas
 Improper formula preparation
 Transitioning from breastmilk to formula
 Early intro to cereals in bottle
 Neurological delays
Constipation – Feeding Plan
 Maximize breastmilk
 Warm bath, infant massage, bicycle movements
 Iron:
 Iron supplements may cause constipation

 Check hematocrit -if formula is meeting iron needs &

hct is WNL: Switch to MVI w/o iron
 Juice (if infant is >40 weeks):
 Mix ½ oz prune, pear or apple juice with ½ oz water

 Start 1 oz diluted jc qod, inc to 1 oz diluted jc qd prn

 Max 1 oz full-strength jc qd
Constipation – Feeding Plan
 If taking PDF mixed >24 kcal/oz:
 Decrease from 27 kcal/oz to 24 kcal/oz to 22 kcal/oz
 If infant BW >1500-1800g & if gaining weight well,
consuming good vol, and nutritional needs met:
 D/C fortifier & offer 100% breastmilk
 Change to routine term formula
 Always check wt gain/intake wkly after making change
 If infant BW <1500g & <3 mo CA:
 Talk w/ RD who has experience with premature infants
 Always check bone labs before making a formula
change
 If constipation continues, talk to MD re: stool softeners
Spit-up and/or GERD
in the Premature Infant
Assessment:
 Assess weight gain
 Assess nipple flow
 Assess feeding behaviors and positioning
 Back arching?
 Volume in bottle slowly increasing or decreasing?
 Volume of spit-up
 Parental concerns
Spit-up and/or GERD
in the Premature Infant
Feeding Plan:
 Parental reassurance if growth ok
 Smaller, more frequent feeds
 Keep upright for 20 min after a feeding
 Educate on proper positioning
 No solids in bottle
 Limited use of added starch formula &
only if > 40 wks CA
 Reflux meds needed?

Poets, Pediatr 2004;112:212-217

Carroll, Arch Pediatr Adolesc Med 2002;156:109-11
Lightdale, Pediatr 2013; 131:1684-95
Inadequate Weight Gain in
the Premature Infant
Assessment:
 Infrequent bottle feeding (> Q 3-4 hr)

 Improper mixing formula/fortifying EMM

 Lower kcal/oz formula

 Easily exhausted or not interested in breast, bottle

 Slow nipple flow on bottle, tight suction on cap

 Minimal BF skills

 Constipation affecting volume consumed

 GERD affecting volume consumed

 Neurological delays & limited coordination

 Recent illness
Inadequate Weight Gain
in the Premature Infant
Feeding Plan:
 Observe feeding, trial of nipples
 If trying to transition to breast, make sure baby is
offered bottle after BF, put time-limit on BF
 Switch to 24-27 kcal/oz
 Calculate catch-up needs
 Give parents a goal intake volume
• Parents to keep diary for 2 weeks
 Weekly weight checks
 Discuss plan w/ MD
Rapid Weight Gain
in the Premature Infant
Assessment:
 Improperly mixing formula

 Improperly fortifying EMM

 Large volumes consumed

 Feeding schedule vs. hunger cues

 Cereals in bottle

 After successful BF reached, cont. to offer bottle

after BF
Rapid Weight Gain
in the Premature Infant
Feeding Plan:
 Discuss feeding cues & volumes w/ family

 Switch kcal level down

• 27-24-22 kcal/oz
 If >1500g-2000g BW & if growth ok:

• Switch to term formula

 If <1500 BW & if growth ok, ck bone labs:

• If WNLs, switch to term formula; re-ck labs in 1 mo

• If abnormal, continue w/ PDF & re-ck labs in 1 mo
Coordination of Care
 Family
 Pediatrician
 Nurses: PMD office & PHN
 Dietitians: NICU,
out-patient, WIC
 Lactation consultants
 Neurodevelopmental/
Feeding clinic

 Get involved!
 Nutrition Practice Care Guidelines for
Preterm Infants in the Community
http://public.health.oregon.gov/HealthyPeopleFamilies/WIC/Pages/index.aspx

 Click on “For Medical Providers”

 Double click on “Nutrition Practice Care Guidelines…”

OR

 Click on “For Oregon WIC Staff” on left-side column

 Click on “WIC Staff Resources”
 Scroll down to “Nutrition Information” header
 Double-click on “Nutrition Guidelines: Preterm Infants” &
“Oregon Appendix”