For Healthcare Professionals only

FAQ's in Preterm Care and Nutrition Answered by Experts
By - Dr. Pankaj Garg
Senior Consultant, Department of Neonatology, Sir Ganga Ram Hospital, New Delhi.
All preterm neonates are not same. How do we decide on feeding option for the preterm neonate?

Feeding option in the preterm neonate is decided on the basis of:

  • Gestational age at birth or birth weight.
  • Presence of euective sucking, swallowing, and coordination between suck, swallow, & respiration.
  • Presence or absence of risk factor for necrotizing enterocolitis (NEC).
AgeFeeding SkillsFeeding Method
< 28 weeksNo sucking efforts Poor gut motilityPN Initiate minimal EBM
29-31 weeksSucking burst develops
No coordination between sucking, swallowing, & breathing
Gavage feeding either orogastric (preferred) or nasogastric, continuous or intermittent Progressive feed (start with 20–30 ml/kg/day on first day if no risk factors for NEC)
30-34 weeksMature sucking begins Better coordination between swallowing and breathingTry feeding with spoon, paladai or cup feeding if no risk factors for NEC. If sucking, swallowing, & breathing co-ordination is not good or reassuring, resort to tube feeding. Encourage non nutritive sucking and KMC
> 34 weeksMature sucking begins
Better coordination between swallowing and breathing
Breastfeeding or direct feeding if hemodynamically stable
What are the benefits of feeding human milk to preterm infants?

Apart from usefulness and advantages of human milk in term and preterm neonates, additional benefits that human milk provides to this highly vulnerable preterm population include:

  • Prevention of NEC
  • Prevention of allergies and other atopic diseases
  • Prevention of bronchopulmonary dysplasia (BPD)
  • Prevention of retinopathy of prematurity
  • Better neurodevelopmental outcomes
  • Other benefits

include decreased rates of late-onset sepsis, fewer re-hospitalizations in the first year of life, lower rates of metabolic syndrome, lower blood pressure and low-density lipoprotein levels, and less insulin and leptin resistance when they reach adolescence, as compared to premature infants receiving formula.

What are the proposed benefits of human milk fortification? Which group of preterm neonates should be given human milk fortification?
When should one start & stop fortification?

Human milk is recommended for all neonates, including preterm infants, for the first 6 months of corrected age exclusively, but unfortified human milk may not meet the recommended daily allowances for preterm infants, which are as follows: Enteral fluid intake of 135–200 ml/kg/day,energy intake of 110–135 Kcal/kg/day, and protein intake of 3.5 to 4.5 g/kg/day.

The use of human milk fortifier (HMF) helps meet the additional high nutritional requirements in infants with:

  • Calcium and phosphate deficits leading to higher risk of low bone mineralization, metabolic bone diseases, and slow skeletal growth compared to infants born at term
  • Nutritional deficiency and growth restriction both in utero and in the early postnatal period,as they may have long-term metabolic and cardiovascular consequences
  • Very low birth weight (VLBW), as they may develop delays in growth and nutritional deficits

Studies have shown that the addition of HMF is associated with short-term improvements in weight, height, bone mineralization, neurologic outcome, and head growth.

Recommendation for HMF: Whom to start

The use of human milk fortifier (HMF) helps meet the additional high nutritional requirements in infants with:

  • As per the National Neonatology Forum, India, Evidence Based Clinical Practice Guidelines (2010) and World Health Organization, HMF is added to human milk in infants < 32 weeks or <1500 g who fail to gain adequate weight at full feed of 180–200 ml/kg/day.
  • Since contemporary clinical practice sees a very high percentage of preterm VLBW babies suffering from extrauterine growth restriction (EUGR), multicomponent fortification is started in all preterm neonates with birth weight <1800 g.

When to start HMF: At our center, we start fortification with bovine-based HMF when baby reaches 100 ml/kg/day of feed. Human milk based HMF is not available in India and is very expensive to import.

How long:There is no worldwide consensus on how long should fortification be continued; however, at most centers, fortifiers are discontinued when the weight of the baby reaches 2 kg. Our center has policy to continue fortification till baby is on tube, paladai, or bottle feeds and had reached or crossed the birth percentile or is on direct breast feeds, in which case other supplements (like Ca/P/Iron/Vit D) are added as drugs.

What are the standard practices for initiating & continuing enteral feeds?

The main concern regarding enteral feeding is the presumed association of enteral feeding with NEC and feed intolerance. Observational studies and systemic review showed that delayed introduction and slow advancement of enteral feed decreases the risk of NEC and feed intolerance. However, disadvantages of delaying enteral feeding include delay in functional adaptation of the gastrointestinal tract and prolong the need for parenteral nutrition with its attendant infectious and metabolic risks.
Suggested enteral feeding protocols

Neonates birth weight >1000 g />30 weeksNeonates 750–1000 g/28–30 weeksNeonates <750 g/<28 weeks
May be initiated on 60–80 ml/kg feed at birth
Subsequent increments 30–40 ml/kg/day
May be initiated with 20–30 ml/kg feed, on Day 1
Subsequent increments 20–30 ml/kg/day
More cautious regimen with close monitoring
Initiate early with human milk
How does a doctor decide the total volume of feeds in a particular neonate?

Modified fluid regimen for a neonate during the first week will be as follows: Maintenance fluid (1st week): Urine output + Insensible losses – 1%–2% of birth weight. Desired urine output is dependent upon solute load required to be excreted.

Birth weightDaily Fluid Requirements (mL/kg)
Day 1Day 2Day 3-7Day 7+
<750100–140120–160140–200140–160
750–1000100–120100–140130–180140–160
1000–150080–100100–120120–160150
>150060–8080–120120–160150

Source: Dell KM. Chapter 44: Fluid, Electrolytes, and Acid-Base Homeostasis. In: Martin RJ , Fanaroff AA, Walsh MC. (eds.) Fanaroff and Martin's Neonatal-Perinatal Medicine. Diseases of the Fetus and Infant. 9th edition. Volume 1. Philadelphia, PA: Elsevier health sciences; 2015. Pg. 615.

Is 2 hourly or 3 hourly feeds having same feeding intolerance?

Infants with a birth weight of 1250–1500 g regained their birth weight faster with 3-hourly feeding than with 2-hourly feeding

When should preterm infants <35 weeks with absent/reversed end diastolic flow (AREDF) be fed?

Our approach to preterm with AREDF: If the abdominal examination is normal, start enteral feeding 10-20 ml/kg/day starting on day 2 of life strictly on mother’s milk or donor human milk but progressive feed 30–40 ml/kg/day from day 3–4 of life has been found safe. More caution is needed while feeding small for gestational age SGA babies with AREDF and gestation <29 weeks.

What is the significance of DHA supplementation in preterm care?

Docosahexaenoic acid (DHA) is a long chain poly- unsaturated fatty acid (LCPUFA) that has a role in the cognitive and visual development, as well as in the immune function of newborns. Premature infants, especially those born before 30 weeks, have been shown to have a deficit in DHA shortly after delivery for several reasons, including foregoing third trimester DHA accretion, receiving enteral breast milk or donor milk feeds that are typically low in DHA, and having an increased risk of requiring prolonged total parenteral nutrition.

The addition of LCPUFAs has both theoretical and potential clinical benefit. A recent study of preterm infants of 24–32 weeks of gestational age using early and near-term magnetic resonance imaging and red blood cell membrane fatty acid composition showed that higher DHA and lower linoleic acid (LA) levels in the first few postnatal weeks were associated with decreased intraventricular hemorrhage, improved microstructural brain development, and improved neurodevelopmental outcomes.

Infants delivered at <33 weeks were provided with different doses of DHA (randomized to receive 40 mg/kg/day, 80 mg/kg/day or 120 mg/kg/day of DHA orally for 28 days) with the primary outcome being erythrocyte phospholipid DHA levels. Researchers concluded that supplementing infants with 120 mg/kg/day of DHA prevented the drop in DHA typically seen in premature infants at this age. The oral supplementations allowed infants to receive a larger amount of DHA early on than what they would receive from breast milk, even from breast milk obtained from mothers taking supplementation. The term infants are likely to achieve adequate DHA levels in breast milk through maternal supplementation.

On the other hand, preterm infants struggle to overcome their DHA deficit. Directly supplementing them with oral DHA does successfully increase the level. A study by Manley et.al. concluded that DHA supplementation for infants of <33 weeks'gestation reduced the incidence of bronchopulmonary dysplasia in boys and in all infants with a birth weight of <1250 g and reduced the incidence of reported hay fever in boys at either 12 or 18 months.

Which growth charts should be used for a preterm neonate <32 weeks?

For a neonate <33 weeks on birth, anthropometry is plotted on revised Fenton chart 2013 and continued to be plotted till 50 weeks postmenstrual age (PMA). But with the advent of intergrowth chart, which actually represents the population of both developed and developing countries, many institutes have started using this chart for growth monitoring till 64 weeks PMA and then WHO chart till 5 years of age.

How to decide a preterm formula for a preterm neonate?

The nutrient requirements for preterm infants that were used to develop the preterm formulas were based on the reference fetus defined by Ziegler et al. and fetal body composition data by Widdowson et al. Preterm formulas were developed to meet high protein, energy, and mineral requirements that were considered necessary to support a rate of growth in the preterm VLBW infant that would approximate with that of the normal healthy growing fetus in the third trimester of intrauterine life.

  • Fat: Source is blend of vegetable oils, including DHA: ARA (arachidonic acid) and medium chain triglycerides (MCTs). DHA and ARA in a ratio of 1:1 or 1:2 are used for optimal neurodevelopmental outcome. LCPUFAs have been added in amounts similar to those in human milk, producing higher tissue concentrations and reportedly better visual acuity.
  • Carbohydrate: Source is a combination of lactose and sucrose. The recent preterm formulas replace sucrose with relatively easily digestible low osmolar glucose polymers. Nevertheless, lactose remains important for normal nutrition and, especially, for the prevention of NEC by promoting the growth of bifido- and lactobacillus organisms and suppressing the growth of opportunistic bacteria by lowering distal intestinal pH. Therefore, it remains an important constituent of the preterm formulas.
  • Protein: Source is cows milk. Whey now predominates as the main protein rather than casein. Whey protein is more digestible than casein, and its use as markedly reduced the development of lactobezoars. The newer 60% whey to 40% casein composition ratio produces more rapid gastric emptying, digestion, and amino acid absorption, as well as less metabolic acidosis.
  • Minerals: Preterm formulas also are designed with much higher contents of sodium and potassium to compensate for renal losses characteristic of preterm infants with limited renal solute conservation capacity. Calcium and phosphorus contents are also higher to help promote bone mineralization.
  • Vitamins: The levels of vitamins are higher in preterm formulas (vitamins A and E) to compensate for more limited fat absorption in these infants and to help counter the many inflammatory conditions these infants experience. Even with these higher contents, vitamins A and D especially might require additional supplementation.
  • Micronutrients: Most micronutrients are adequately provided by preterm formulas, but 1.8 mg/100 kcal of iron contained in many preterm formulas might not be sufficient for rapidly growing preterm infants, who are not transfused.

Despite the higher mineral and vitamin contents of preterm formulas, most products have relatively safe osmolalities, from 210 to 220 mOsm/L at 20 kcal/oz to 250–270 mOsm/L at 24 kcal/oz. Preterm formulas are used in preterm infants whose mothers are unable to express sufficient milk for full enteral feeding, supplemented or not, or when fortified donor human milk is not available. While preterm formulas improve neurodevelopmental outcomes compared to term formulas and unfortified donor milk, they do not produce neurodevelopmental outcomes better than fortified human milk.

What is the concept of EUGR and why is it important?

The American Academy of Paediatrics recommends the goal for extrauterine growth to parallel the intrauterine growth trajectory of the fetus at a comparable gestational age. EUGR is defined as having a measured growth parameter (weight, length, or head circumference) that is ≤10th percentile of intrauterine growth expectation based on estimated PMA in premature (23–34 weeks estimated gestational age) neonates at the time of hospital discharge. The incidence of postnatal growth failure in VLBW infants ranges between 43% and 97% in various centers.
Also, VLBW infants are born with a multitude of nutritional disadvantages that place them at a high risk for EUGR. The VLBW infant has high metabolic needs and limited nutritional stores of protein, fat, and minerals to meet the demands of extrauterine life, making this goal difficult to achieve. EUGR is associated with an increased risk of poor neurodevelopmental outcome. Inadequate postnatal nutrition is an important factor contributing to growth failure, as most very preterm infants experience major protein and energy deficits during neonatal intensive care unit hospitalization. First-week protein and energy intakes are associated with 18-month developmental outcomes in very preterm infants. Early aggressive nutrition, including parenteral and enteral, is well tolerated in the very preterm infant and is effective in improving growth. Continued provision of appropriate nutrition (fortified human milk or premature formula) is important throughout the growing care during the hospitalization. After discharge, exclusively breast-fed infants require additional supplementation.

Suggested readings:-

  1. Herrmann K, Carroll K. An exclusively human milk diet reduces necrotizing enterocolitis. Breastfeed Med. 2014 May 1;9(4):184–90.
  2. Tawia S. Development of oral tolerance to allergens via breastmilk. Breastfeed Rev. 2015 Nov;23(3):35–9.
  3. Dogaru CM, Nyffenegger D, Pescatore AM, Spycher BD, Kuehni CE. Breastfeeding and childhood asthma: Systematic review and meta-analysis. Am J Epidemiol. 2014 May 15;179(10):1153–67.
  4. Spiegler J, Preuß M, Gebauer C, Bendiks M, Herting E, Göpel W; German Neonatal Network (GNN); German Neonatal Network GNN. Does breastmilk Influence the development of bronchopulmonary dysplasia? J Pediatr. 2016 Feb;169:76–80.e4.
  5. Harris WS, Baack ML. Beyond building better brains: Bridging the docosahexaenoic acid (DHA) gap of prematurity. J Perinatol. 2015 Jan;35(1):1–7.
  6. Bharwani SK, Green BF, Pezzullo JC, Bharwani SS, Bharwani SS, Dhanireddy R. Systematic review and meta-analysis of human milk intake and retinopathy of prematurity: A significant update. J Perinatol. 2016 Nov;36(11):913–20.
  7. Horta BL, Victora CG. Long-term effects of breastfeeding: A systematic review. Geneva, Switzerland: World Health Organization, 2013.
  8. Agostoni C, Buonocore G, Carnielli VP, De Curtis M, Darmaun D, Decsi T, et al; ESPGHAN Committee on Nutrition. Enteral nutrient supply for preterm infants: Commentary from the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition Committee on Nutrition. J Pediatr Gastroenterol Nutr. 2010 Jan;50(1):85–91.
  9. Arslanoglu S, Moro GE, Ziegler EE, The Wapm Working Group On Nutrition. Optimization of human milk fortification for preterm infants: New concepts and recommendations. J Perinat Med. 2010 May;38(3):233–8.
  10. Thoene M, Hanson C, Lyden E, Dugick L, Ruybal L, Anderson-Berry A. Comparison of the effect of two human milk fortifiers on clinical outcomes in premature infants. Nutrients. 2014 Jan 3;6(1):261–75.
  11. Oddie SJ, Young L, McGuire W. Slow advancement of enteral feed volumes to prevent necrotising enterocolitis in very low birth weight infants. Cochrane Database Syst Rev. 2017 Aug 30;8:CD001241.
  12. Leaf A, Dorling J, Kempley S, McCormick K, Mannix P, Linsell L, et al; Abnormal Doppler Enteral Prescription Trial Collaborative Group. Early or delayedenteral feeding for preterm growth-restricted infants: A randomized trial. Pediatrics. 2012 May;129(5):e1260–8.
  13. Richard C, Lewis ED, Field CJ. Evidence for the essentiality of arachidonic and docosahexaenoic acid in the postnatal maternal and infant diet for the development of the infant’s immune system early in life. Appl Physiol Nutr Metab. 2016;41:461–75.
  14. Tam EW, Chau V, Barkovich AJ, Ferriero DM, Miller SP, Rogers EE, et al. Early postnatal docosahexaenoic acid levels and improved preterm brain development. Pediatr Res. 2016 May;79(5):723–30.
  15. Ziegler EE, O'Donnell AM, Nelson SE, Fomon SJ. Body composition of the reference fetus. Growth. 1976 Dec;40(4):329–41.
  16. Widdowson EM, McCance RA, Spray CM. The chemical composition of the human body. Clin Sci. 1951 Feb;10(1):113–25.
  17. Shenai JP, Dame MC, Churella HR, Reynolds JW, Babson SG. Nutritional balance studies in very-low-birth-weight infants: role of whey formula. J Pediatr Gastroenterol Nutr. 1986;5:428e33.
  18. Brown LD, Hendrickson K, Masor ML, Hay Jr WW. High protein formulas - Evidence for use in preterm infants. Clin Perinatol. 2014;41:383–403.
  19. Fenton TR, Premji SS, Al-Wassia H, Sauve RS. Higher versus lower protein intake in formula-fed low birth weight infants. Cochrane Database Syst Rev. 2014 Apr 21;(4):CD003959.
  20. Clark RH, Thomas P, Peabody J. Extrauterine growth restriction remains a serious problem in prematurely born neonates. Pediatrics. 2003 May;111(5 Pt 1):986–90.
  21. Stoll BJ, Hansen NI, Bell EF, Shankaran S, Laptook AR, Walsh MC, et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics. 2010 Sep;126(3):443–56.
  22. Smith SL, Rouse CA. Docosahexaenoic acid and the preterm infant. Maternal Health, Neonatology and Perinatology. 2017;3:22. doi:10.1186/s40748-017-0061-1.
  23. Manley BJ, Makrides M, Collins CT, McPhee AJ, Gibson RA, Ryan P.et.al High-Dose Docosahexaenoic Acid Supplementation of Preterm Infants: Respiratory and Allergy Outcomes. Pediatrics Jul 2011, 128 (1) e71-e77.

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Important Notice:

The World Health Organization (WHO)* has recommended that pregnant women and new mothers be informed of the benefits and superiority of breast-feeding, 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 the 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 breast-feeding. 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 (500g) per week will be needed, so the family circumstances and cost should be kept in mind. Mother should be reminded that breast milk is not only the best but also the most economical food for babies. If a decision to use infant formula is taken, it is important to give instruction on correct preparation methods, emphasizing that unboiled water, unsterilized bottles or incorrect dilution can lead to illness.

*See: International Code of Marketing of Breast Milk Substitutes, adopted by the World Health Assembly in Resolution WHA 34.22, May 1981.

    Mothers should be explained the following advantages & nutritional superiority of breastfeeding:

  1. Immediately after delivery, breast milk is yellowish and sticky. This milk is called colostrum, which is secreted during the first week of delivery. Colostrum is more nutritious than mature milk because it contains more protein, more anti-infective properties which are of great importance for the infant's defence against dangerous neonatal infections. It also contains higher levels of, Vitamin 'A'
  2. Breast miIk:
    1. is, a complete and balanced food and provides all the nutrients needed by the infant (for the first six months of life)
    2. has anti-infective properties that protect the infants from infection in the early months
    3. is always available
    4. needs no utensils or water (which might, carry germs) or fuel for its preparation
  3. Breastfeeding is much cheaper than feeding infant milk substitutes as the cost of the extra food needed by the mother is negligible compared to the cost of feeding infant milk substitutes
  4. Mothers who breast-feed usually have longer periods of infertility after child birth than non-lactators

    Details of management of breast feeding, as under:

  1. Breast-feeding.
    1. Immediately after delivery enables the contraction of the womb and helps the mother to regain her figure quickly
    2. is successful when the infant suckles frequently and the mother wanting to breast-feed is confident in her ability to do so
  2. In order to promote and support breast-feeding the mother's natural desire to breast feed should always be encouraged by giving, where needed, practical advice and making sure that she has the support of her relatives
  3. Adequate care for the breast and nipples should be taken during pregnancy
  4. It is also necessary to put the infant to the breast as soon as possible after delivery
  5. Let the mother and the infant stay together after the delivery, the mother and her infant should be allowed to stay together (in hospital, this is called "rooming-in")
  6. Give the infant colostrum as it is rich in many nutrients and anti-infective factors protecting the infants from infections during the few days of its birth
  7. The practice of discarding colostrum and giving sugar water, honey water, butter or other concoctions instead of colostrum should be very strongly discouraged
  8. Let the infants suckle on demand
  9. Every euort should be made to breast-feed the infants whenever they cry
  10. Mother should keep her body and clothes and that of the infant always neat and clean
  11. Breast-feeding is the best form of nutrition for babies and provides many benefits to babies and mothers. It is important that, in preparation for and during breast-feeding, you eat a healthy, balanced diet. Combined breast and bottle feeding in the first weeks of life may reduce the supply of your own breast-milk, and reversing the decision not to breast-feed is diflcult.Always consult your Healthcare Professional for advice about feeding your baby. The social and financial implications of using infant formula should be considered. Improper use of an infant formula or inappropriate foods or feeding methods may present a health hazard. If you use infant formula, you should follow manufacturer's instructions for use carefully - failure to follow the instructions may make your baby ill.