1. Nutrition Management of the Premature Infant
Melissa Nash, MPH, RD
Washington County Field Team

2. Objectives
Describe appropriate growth in premature infants, including growth charts.
Describe current practices for feeding and supplementation for premature infants.
Understand how to better support the breastfeeding premature infant.
Recognize potential feeding problems and solutions in premature infants.

3. 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

4. Typical Feeding Progression
Gestational Age (Weeks)
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

5. 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

6. 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

7. 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”

8. What does the research say?
Weight Gain & Growth
Feeding a post-discharge formula (PDF) for months following discharge results in improved wt, lt, & HC
Greatest results in infants < g
Greater results in males vs. females
Long-term developmental advantages inconclusive

9. 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:
Cooke, Pediatr Res 2001;49:
Morley, Am J Clin 2001;71:822-8

10. 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

11. Fenton Growth Grids http://ucalgary.ca/fenton/2013chart
•Based on the recommended growth goal for preterm infants: The fetus and the term infant
•Girl and boy specific charts
•Equivalent to the WHO growth charts at 50 weeks gestational age (10 weeks post term age).
•Large preterm birth sample size of 4 million infants;
•Recent population based surveys collected between 1991 to 2007
•Data from developed countries including Germany, Italy, United States, Australia, Scotland, and Canada
•Curves are consistent with the data to 36 weeks, thus can be used to assign size for gestational age up to and including 36 weeks.
•Chart is designed to enable plotting as infants are measured: actual age vs. completed weeks.

12. Why should we use the updated Fenton charts?
Boys chart
Solid lines = 2013
Dashed lines = 2003

13. Growth Assessment Start with correct growth parameters
Term-
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
~0.2 cm/wk

14. 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

15. 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
Reduce Lactose:
Controls osmolality
Enhances tolerance (dec stool output & fussiness)
Inc. absorption of Ca, Pro & min
Intake & wt gain improved
MCT:
readily absorbable fat, fat absorption 40-90% reflects immaturity
Inc. Ca absorption
Whey:
Fewer , smaller curds, avoid lacto bezoars.
Faster emptying from stomach
Softer stools
40% more protein
Lactose:
first seen at 26 weeks
Not functional until 32 wks
Continue to inc. until 1 mo CA

16. 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
Wait 7-10 days before changing formula – takes 5 days to re-grow intestinal cells.
“I am changing this formula because…”

17. 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
potential negative effects on sexual development and reproduction, neurobehavioral development, immune function, and thyroid function
Pytates binds with Phos, Ca, iron & zinc
120 kccal/kg = 330 kcal 120 kcal/kg = 8200 kcal
Bone markers = lower phos & higher alk phos = risk of osteopenia
Even after Ca & phos supply, x-ray showed signs of osteopenia
Aluminum competes with Ca for absorption
Inc’d aluminum deposition in bone & CNS, esp in infants w/ compromised renal fct like premies

18. 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
Rice cereal NOT indicated to thicken feeds:
Displaces nutrients
Reduces symptoms, not episodes
Changes body composition w/ added cals by CHO

19. EMM & Formula Comparison
Values
Per 100ml
Term EMM 20 kcal
EMM + Enfacare 24 kcal/oz
Enfacare
24 kcal/oz
Enfamil
20 kcal
Calories 68 80
Pro, G 1
1.36
2.3
1.4
Ca, mg 28 44 97 53
Phos, mg 15 24 29
Iron, mg
0.04
0.3
1.2

20. 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.

21. 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

22. 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

23. Guidelines for Initiating & Maintaining Milk Supply
First 2-3 weeks
Use hand expression & compression w/ pumping
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
Preterm mothers are able to express twice as much breastmilk with hand expression and pumping combined to pumping alone
Preterm milk x 2 wks = higher in Pro, Ca, Phos
Pump for min or for 2 min after the last drop of milk

24. 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
Cluster pumping: pump, nurse, pump q 1/2 -1 hr for several hours
Power Pumping:
1. Pump for 10 min, rest for 10 min, repeat for 60 min, 1-2x/d
2. Pump every 2 hours during waking hours for 1 full day

25. 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

26. 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
Rarely, previously frozen milk that has been thawed may smell or taste soapy and/or smell rancid. This milk is sage and most babies will continue to drink it
Some women have milk high in an enzyme called lipase which causes the breakdown of the milk fats (lipolysis).
To prevent this, before freezing lots of milk, freeze a batch or two and then thaw it.
If the milk smells or if a baby refuses it, future batches can be heated to scalding (180 degrees) after expression, then quickly cooled and frozen which deactivates the lipase enzyme.

27. 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 weeks GA
Support, support, support!!!
If needed, use of nipple shields to increase milk transfer: 8.4 ml w/ shield vs. 3.9 ml w/o (Meier, J Hum Lact 2000;16:106-14)

28. 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:
Decrease by 2 bottles q 4-6 days or
Drop fort bottles at night
* Check weight WEEKLY during transition

29. Vitamin/Mineral Supplementation
If infant is primarily on:
What supplements are recommended?
When can the supplements be stopped?
Breastmilk (Unfortified or Fortified)
1 ml daily infant MVI with iron OR
1ml daily infant MVI without iron + separate iron supplement
Continue until 12 mo corrected age
Iron-Fortified Formula
0.5 ml daily infant MVI without iron
Stop when intake reaches ~ 32 oz/d
*Poly vitamin = A, C, D, E, B vitamins + iron?
*Tri vitamin = A, C, D + iron?

30. 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

31. 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
Meds: diuretics & corticosteroids

32. 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

33. 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

34. Late Preterm Infant Infants born between 34 0/7 – 36 6/7 weeks GA
Birth weights ~ g (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

35. 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 kcal/oz
Offer MVI until 12 mo CA

36. Late Preterm Infants Formula Feeding: Offer TERM infant formula
Offer MVI until volume reaches 32 oz/d
May start/increase to kcal/oz if infant unable to consume enough volume to provide adequate growth. Usually need inc. calories for first month.

37. 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

38. Common Concerns in the Premature Infant
Constipation
Spit-up &/or GERD
Inadequate weight gain
Rapid weight gain

39. 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

40. 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
Juices have higher sorbitol content & inc water in stools

41. 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 > g & 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

42. 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
Lower esophogeal sphyncter tone in premies – tone r/t GA
Delayed gastric emptying- can be altered by numerous things:
Fat
Acid
Osmalality
Caloric density

43. 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: Carroll, Arch Pediatr Adolesc Med 2002;156:109-11
Lightdale, Pediatr 2013; 131:
Thickened feeds may reduce symptoms, not episodes

44. 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

45. 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 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

46. 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

47. Rapid Weight Gain in the Premature Infant
Feeding Plan:
Discuss feeding cues & volumes w/ family
Switch kcal level down
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

48. Coordination of Care Family Pediatrician Nurses: PMD office & PHN
Dietitians: NICU, out-patient, WIC
Lactation consultants
Neurodevelopmental/ Feeding clinic
Get involved!

49. Nutrition Practice Care Guidelines for Preterm Infants in the Community
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”