Strategies For Feeding The Preterm Infant: Review
Strategies For Feeding The Preterm Infant: Review
Strategies For Feeding The Preterm Infant: Review
© 2008 S. Karger AG, Basel William W. Hay, MD, Perinatal Research Center
1661–7800/08/0944–0245$24.50/0 Department of Pediatrics, Colorado Clinical Translational Science Institute
Fax +41 61 306 12 34 University of Colorado School of Medicine, University of Colorado Denver
E-Mail karger@karger.ch Accessible online at: 13243 East 23rd Avenue, PO Box 6508, Aurora, CO 80045 (USA)
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more aggressive introduction of enteral feeding. Finally, many diseases and adverse conditions that such infants
overfeeding has the definite potential to produce adipose experience, the normally growing fetus provides a rea-
tissue, or obesity, which then leads to insulin resistance, glu- sonable estimate of the nutrition it would take to at least
cose intolerance, and diabetes. This scenario occurs more provide for such growth. It is, therefore, a guideline, not
commonly as infants are fed more and gain weight more a requirement.
rapidly after birth, regardless of their birth weight. Infants
with IUGR and postnatal growth failure may be uniquely ‘set
up’ for this outcome, while infants with in utero obesity, such Consequences of Not Meeting the Goal of Normal
as infants of diabetic mothers, already are well along this ad- Fetal Growth Rate
verse outcome pathway. Copyright © 2008 S. Karger AG, Basel
With such a guideline, though, how well are we doing
in terms of feeding preterm infants and achieving the
goal of the normal rate of fetal growth? Clearly, data from
Introduction all around the world indicate that we have considerable
room for improvement, as the growth of nearly all pre-
Over the past 20 years, neonatal mortality rates for term infants, especially those at the earliest gestational
preterm infants, particularly those born extremely pre- ages and lowest birth weights, lags behind fetal growth
term (23–28 weeks’ gestational age) and of very low birth curves during the period between their birth and term
weight (!1,000 g), have decreased steadily. Most of the gestational age, when nearly all are, as a result, growth-
major advances in this remarkable improvement have restricted [9, 10]. The same phenomenon was observed
come from specialized techniques, such as high-frequen- over 60 years ago, indicating that despite major advances
cy ventilation, continuous positive airway pressure appli- in neonatology, strategies to nourish preterm infants and
cations, prenatal corticosteroid treatment of the mother achieve better rates of growth has not kept pace with their
about to deliver, postnatal artificial surfactant treatment, survival [11].
and an increasingly sophisticated array of medications. Why is this the case? The principal answer appears to
Improved experience of neonatologists, neonatal nurses, be that, for a variety of reasons (but not intent), neonatolo-
and many other healthcare workers has played a major gists have not fed infants enough protein and enough en-
role. Added to this growing capacity to improve health- ergy to meet the requirements for fetal growth. Over time,
care of such fragile infants also includes an expanding therefore, preterm infants accumulate large protein and
array of nutritional strategies, including new formulas, calorie deficits (negative areas under the nutrient require-
supplements to milk, and intravenous nutrient solutions. ment minus nutrient intake vs. time relationships), which
Active research now is determining the most effective of so far have only been ameliorated, not removed by more
these nutritional strategies, and to determine which of appropriate and complete nutritional regimens [12].
these strategies, as well as their optimal use, lead to the Why is slower than normal rate of growth in preterm
most effective outcomes in terms of body growth, body infants from insufficient nutrition a problem? Many
composition, and neurodevelopmental outcomes. Sever- studies now show clearly that specific nutritional deficits
al recent reviews provide excellent in depth coverage of at critical stages of development limit fundamental com-
this topic [1–7]. ponents of growth that have long-lasting influences.
Smart [13, 14] showed years ago that undernutrition of rat
fetuses reduced brain growth overall as well as neuronal
Goal of Nutrition for Preterm Infants number and synapses, leading to later life reductions in
brain size, cognitive capacity, and specific behaviors,
Most neonatologists have accepted the recommenda- such as learning. More recently, several groups have
tion of the American Academy of Pediatrics that growth shown that brain growth of preterm infants is less than
of the postnatal preterm infant, both their anthropomet- that of normally grown infants born at term, that this re-
ric indices and body composition, should be the same as duced brain growth is associated with cognitive delays,
the normal fetus of the same gestational age growing in and that nutrition of the preterm infant with enriched
its mother’s uterus [8]. While an imperfect guideline, diets (supplemented milk or preterm formulas, both with
since clearly there are different energy expenditures im- more protein) leads to larger brains and improved cogni-
posed by the neonatal intensive care environment and tive function, even into adolescence [15–17].
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