How can the Dietitian

Optimize Nutrition in
Preterm Infants?
Carly Johnston
September 2016

Why I chose this topic

Strong interest in
pediatrics
Two weeks of advanced
clinical rotation spent at

Women and Infants

Neonatal Intensive Care
Unit

Multidisciplinary
approach Nutrition
plays an immense role in
the outcome of preterm
infants

NICU RD = improved
outcomes, decreased
costs

Background
Preterm, preemie, neonate infants born at or
younger than 37 weeks gestation1
15 million infants (1 in 10) are born premature
each year 1
Potential causes of preterm labor:

Multiple births
Infections
Chronic conditions (preeclampsia, diabetes)
Trauma
Genetics
Often times there is no exact reason

Background
The chance of survival outside of the womb
increases with gestational age and birth weight
Infants born at or below 25 weeks gestation have
the highest mortality rate (50%) and greatest risk for
severe impairment2

Preterm infants are at an increased risk for

morbidity and mortality due to their
underdeveloped organ systems3

Bronchopulmonary dysplasia (chronic lung disease)

Delayed growth
Developmental delays
Neurological disabilities
Blindness/hearing loss

Nutrition Assessment
Weight is the most commonly
used measure of infant nutrition
status
Birth weight classifications:4
LBW = <2500g
VLBW = <1500g
ELBW = <1000g
Micro preemies = <750g
In utero growth classifications:4
SGA = <10th%ile
AGA = 10-90th%ile
LGA = >90th%ile
Weight, length and head
circumference are plotted on
growth charts to monitor for
major changes

Nutrition Assessment
Postnatal weight loss at 5
days of life due to shift in
body water
8-15% of body weight,
usually regained by 2-3
weeks of age6

Be mindful of inaccurate
weights from edema or
dehydration
Appropriate weight gain is
between 10g/kg/day and
35g/kg/day5
Those at risk for poor weight
gain:
Extreme prematurity, chronic

What you may see in the

NICU

Nutrition Support
Infants with a gestational age <30-32 weeks are
not mature enough to take PO feeds
Lack functional maturity of their GI tract
Lack coordination to suck, swallow and breathe or
become easily fatigued

Born with limited adipose tissue and inadequate

stores of nutrients including:
Protein, energy, vitamins and minerals8

Nutrition support is used to prevent

negative energy and protein balance

Current Research
Ehrekranz R, Das A, Wrage L, Poindexter B, Higgins R. Early
Nutrition Mediates the Influence of Severity of Illness on
extremely LBW infants. Pediatric Research. 2011;69(6):522-9
Retrospective analysis
Study size: 1366 ELBW infants on day of life 7
Found:
Early nutrition support provided to ELBW infants can act as a mediator of the
relationship between critical illness in the first several weeks of life and later
growth.
Early, aggressive parenteral and enteral nutritional support was associated
with lower rates of death and short-term morbidities and improved growth
and neurodevelopmental outcomes.
Earlier initiation of enteral nutrition was well tolerated and was associated
with an earlier achievement of full enteral nutrition, without affecting the rate
of NEC.

What the RD can do: Encourage feedings to start as soon as

possible. Preferably within 1 to 2 days.

Nutrition Support
Parenteral nutrition
Frequently infused immediately after
birth at 50-75ml/kg/day
Starter PN will usually provide
maintenance carbohydrates to
prevent low blood sugar and 1.53grams amino acids6
Components will be altered gradually
based on labs and access point

Access points: peripheral intravenous

(PIV), peripherally inserted central
venous catheter (PICC),umbilical
venous catheter (UVC)
Infants on PN longer than 2 weeks
should be monitored for signs of
osteopenia d/t solubility limitations of
calcium and phosphorus

Current Research
Moyses H, Johnson M, Leaf A, Cornelius V. Early
Parenteral Nutrition and Growth Outcomes in Preterm
Infants: A systematic review and meta-analysis. Am J Clin
Nut. 2013;97:816-26.
Meta analysis evaluating harms and benefits of early PN on
preterm infants
Study size: 13 observational studies, 8 randomized controlled
trials

It was found that early parenteral nutrition decreased the

time needed to regain body weight by 2.2-3.2 days,
decreased maximum percentage weight loss, and improved
weight at discharge. There was no evidence of parenteral
nutrition increasing morbidity or mortality
What the RD can do: If it is anticipated that feedings will
not be started or adequately advanced to meet nutritional
needs, parenteral (PN) should be started within the first 1 to

Nutrition Support
Enteral nutrition
EN in VLBW infants is often delayed
due to respiratory compromise and the
concern that early EN causes NEC
Gut motility and hormone secretion of
the ingestion of milk, delaying EN could
cause feeding intolerance later13
Trophic feedings of either formula or
breast milk should be initiated within 5
days of age to provide 1020mL/kg/day.14

Can be provided via gavage while the

infant is transitioning from PN to oral
feeds
Bolus feeds every 3 to 4 hours or
continuously overnight for those not
taking all of their oral feeds4

Human Milk
Preferred feeding for preterm infants
Can reduce the risk of NEC and late-onset sepsis
Does not provide adequate amounts of protein,
several vitamins, calcium, phosphorus, zinc and
iron 15,16
Human milk provided to <34 weeks or VLBW infants
should be fortified with human milk fortifiers to meet
needs

Human Milk Fortifier (HMF): powdered or liquid

multi-nutrient supplement that can be mixed
into breast milk to increase nutrient composition
Made of corn syrup solids, cows milk protein, a
variety of vegetable oils and MCT oils 17

An additional supplement such as Poly-vi-sol can

provide water- and fat- soluble vitamins and
minerals not adequately provided in breast milk.

Current Research
Fewtrell M. Does early nutrition program later bone
health in preterm infants. Am J Clin Nutr.
2011;99(suppl):1870s-3s

Randomized trial to examine the hypothesis that early

nutrition programs affect later bone health and peak bone
mass
Study size 923 preterm infants
Studied 20-y-old subjects who were born preterm and who
were randomly assigned to a diet during the neonatal period
The proportion of (unsupplemented) human milk in the
neonatal diet was significantly positively associated with
later whole-body bone size and mineral content.
What the RD can do: Encourage moms of preterm infants
to provide breast milk to provide their babies with the
several non-nutritive benefits of human milk that formula

Preterm Formula
Specialized preterm formulas are
recommended as a substitute for breast milk
Term formulas dont provide adequate
nutrients
Preterm formulas are similar to HM (20
kcal/oz., 2g pro/100ml) with the necessary
vitamins and minerals14
Used up until the time of discharge
transitioned to more affordable formula

Formulas can be concentrated to provide

higher energy for infants with higher needs
without additional volume
Congenital heart disease with heart failure,
chronic lung disease

Soy, protein hydrolysate and amino acid

based products are lower in protein and not
recommended unless necessary

Current Research
Cristofalo E, Schanler R, Blanco C, Sullivan S, Trawoeger
R, Kiechl-Kohlendorfer U, et al. Randomized Trial of
Exclusive Human Milk versus Preterm Formula Diets in
Extremely Premature Infants. J Pediatr. 2013;163:1592-5

Randomized controlled trial to compare duration of PN,

growth and morbidity in extremely premature infants fed
exclusive diets of either bovine milk based preterm formula
(BOV) or donor human milk and human based human milk
fortifier (HUM)
Study size: 53 infants
In extremely preterm infants given exclusive diets of preterm
formula vs. human milk, there was a significantly greater
duration of parenteral nutrition and higher rate of surgical
NEC in infants receiving preterm formula.

Common Problems
Among Preterm Infants
Physical, cognitive, motor, and
neurologic delays puts preterm infants
at an increased risk for feeding
problems and intolerances.
Vomiting: may be caused by overfeeding,
improper mixing of formula, uncontrolled
reflux, bowel strictures/obstruction
Zantac, volume vs.. calories

Constipation: rare in infants fed HM. Iron

supplements, medications, milk protein
allergies
Lactulose, 1-2 oz./day prune or pear juice19

Poor feeding: Fatigue, poor oxygenation

in infants with cardiorespiratory disease,
constipation, and infection
Feeding specialists, such as occupational
and speech therapists, can help develop
treatment plans in order to improve
feeding skills and the endurance of the
baby.

Pulling it all together..

Preterm infants need better nutrition during the
neonatal period than any other time of their life in
order to achieve optimal growth
The NICU dietitian is an integral member of the
treatment team

Assessing growth
Interpreting lab results
Reviewing feeding intolerance
Offering guidance to other practitioners
Infants discharged from the NICU should be
frequently followed up by the dietitian

Questions???

https://www.youtube.com/watch?v=3IkPu5tOWLE

References
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7.

World Health Organization. Preterm Birth. November 2015.

Mardy G. Incidence and Mortality of the Preterm Infant. Up-to-Date. 2016
Kaneshiro N. Premature Infant. 2014. https://medlineplus.gov/ency/article/001562.htm
Carney N. Neonatal Nutrition Support. 2009.
Academy of Nutrition and Dietetics. Nutrition Care Manual: Anthropometrics.
McKee-Garret T. Overview of the Routine Management of the Healthy Newborn Infant. Up-to-date. 2016
Moyer-Mileur. Anthropometric and Laboratory Assessment of Very Low Birth Weight Infants: The Most Helpful Measurements and
Why. Semin Perinatol. 2007;31(2):96-103.
8. Embleton N. Optimal Protein and Energy Intakes in Preterm Infants. Early Hum Dev. 2007;12:831-7
9. Ehrekranz R, Das A, Wrage L, Poindexter B, Higgins R. Early Nutrition Mediates the Influence of Severity of Illness on Extremely
LBW Infants. Pediatric Research. 2011;69(6):522-9
10.Moyses H, Johnson M, Leaf A, Cornelius V. Early Parenteral Nutrition and Growth Outcomes in Preterm Infants: A systematic
review and meta-analysis. Am J Clin Nut. 2013;97:816-26.
11.Academy of Nutrition and Dietetics. Nutrition Care Manual: Parenteral Nutrition
12. Pereira-da-Silva L, Costa A, Pereira L, Filipe A, Virella D, Leal E, et al. Early High Calcium and Phosphorus Intake by Parenteral
Nutrition Prevents Short-term Bone Strength Decline in Preterm Infants. JPGN. 2011;52:203-9
13. Kennedy K, Tyson J, Chamnanvanildj S. Early Versus Delayed Initiation of progressive Enteral Feedings for Parenterally Fed Low
Birth Weight or Preterm Infants. Cochrane Database System Review. 2000;2
14.Su B. Optimizing Nutrition in Preterm Infants. Pediatrics and Neonatology. 2014;55:5-13
15.Academy of Nutrition and Dietetics. Nutrition Care Manual: Human Milk.
16.Morgan J, Young L, McCormick F, McGuire W. Promoting Growth for Preterm Infants Following Hospital Discharge. Arch Dis Child
Fetal Neonatal Ed. 2012;97:F295-8
17.Academy of Nutrition and Dietetics. Nutrition Care Manual: Enteral Nutrition
18.Fewtrell M. Does Early Nutrition Program Later Bone Health in Preterm Infants. Am J Clin Nutr. 2011;99(suppl):1870s-3s
19.Academy of Nutrition and Dietetics. Nutrition Care Manual. Discharge/Follow-up
20. Cristofalo E, Schanler R, Blanco C, Sullivan S, Trawoeger R, Kiechl-Kohlendorfer U, et al. Randomized Trial of Exclusive Human
Milk versus Preterm Formula Diets in Extremely Premature Infants. J Pediatr. 2013;163:1592-5
21. Hay W, Lucas A, Heird W et al. Workshop summary: nutrition of the extremely low birth weight infant. Pediatrics.
1999;104:1360-1368
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