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Feeding the preterm infant

William McGuire, Ginny Henderson and Peter W Fowlie

BMJ 2004;329;1227-1230
doi:10.1136/bmj.329.7476.1227

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Clinical review

ABC of preterm birth This is the eighth in a series of 12 articles

Feeding the preterm infant

William McGuire, Ginny Henderson, Peter W Fowlie

Providing appropriate nutrition for growth and development is

a cornerstone of the care of preterm infants. Early postnatal
nutrition during this critical period of brain growth may have a
substantial impact on clinically important outcomes, including
long term neurodevelopment.
Preterm infants, especially those who have been growth
restricted in utero, have fewer nutrient reserves at birth than
term infants. Additionally, preterm infants are subject to
physiological and metabolic stresses that can affect their
nutritional needs, such as respiratory distress or infection. An
international consensus group has recommended nutritional
requirements for preterm infants. These recommendations are
based on data from intrauterine growth and nutrient balance
studies and assume that the optimal rate of postnatal growth for
preterm infants should be similar to that of normal fetuses of Infants with intrauterine growth restriction lack subcutaneous fat and other
the same postconception age. In practice, however, these target nutrient stores
levels of nutrient input are not always achieved and this may
result in important nutritional deficits.

Nutritional requirements for preterm infants*

x Energy—110-20 kcal/kg/day
x Protein—3-3.8 g/kg/day
x Fat—4.5-6.8 g/kg/day
x Calcium—120-230 mg/kg/day
x Phosphorus—60-140 mg/kg/day

*International consensus group recommendations

Enteral feeding
Well infants of gestational age > 34 weeks are usually able to
Infants can be fed using a gastric tube if they are unable to breast or
coordinate sucking, swallowing, and breathing, and so establish
bottle feed
breast or bottle feeding. In less mature infants, oral feeding may
not be safe or possible because of neurological immaturity or
respiratory compromise. In these infants milk can be given as a
continuous infusion or as an intermittent bolus through a fine
feeding catheter passed via the nose or the mouth to the
stomach.
Necrotising enterocolitis
A major concern with the introduction of enteral feeds
(especially to very preterm, growth restricted, or sick infants) is
that the additional physiological strain on the immature
gastrointestinal tract may predispose to the development of
necrotising enterocolitis. The risk of necrotising enterocolitis is
inversely related to gestational age and birth weight. The
incidence is 5-10% in very low birth weight infants. The
mortality rate is reported consistently as greater than 20%.
Long term morbidity may include substantial Preterm infant with necrotising enterocolitis—a syndrome of acute intestinal
neurodevelopmental problems, the consequence of necrosis of unknown aetiology

undernutrition and associated infection during a vulnerable

period of growth and development. Presenting clinical features of necrotising enterocolitis
Most preterm infants who develop necrotising enterocolitis x Abdominal distension
have received enteral feeds. At present, however, limited x Abdominal tenderness or rigidity
evidence exists that the way that we feed infants who are at risk x Lethargy, hypotonia, or apnoea
affects the incidence of necrotising enterocolitis. Large x Hepatic portal gas on abdominal x ray
x Intramural gas (pneumatosis intestinalis) on abdominal x ray
randomised controlled trials are needed to determine whether
x Intestinal perforation
strategies, such as delaying the introduction of milk feeds or x Blood or mucosa in stool
delivering only minimal enteral nutrition, influence clinically

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Clinical review

important outcomes for preterm infants. Apart from assessing

Minimal enteral nutrition—main points
the impact of feeding strategies on short term outcomes, such
as growth, and the risk of necrotising enterocolitis, trials should x Also called trophic feeding, gut priming, hypocaloric feeding
x Feeds nutritionally insignificant volumes of enteral milk (0.5-1.0
also determine how various enteral feeding strategies affect
ml/hour)
mortality and long term neurodevelopment. x Aims to stimulate postnatal development of gastrointestinal system
x Used in parallel with total parenteral nutrition
x Enteral feeds’ volume increases after prespecified interval, typically
7-14 days
Which milk?
Human breast milk is the recommended form of enteral
nutrition for preterm infants. The milk could be from the
infant’s mother or expressed milk from donor mothers, who are
usually mothers who have delivered term infants. The nutrient
content of expressed breast milk varies depending on the stage
of lactation at which it is collected. Milk expressed from a
donor’s lactating breast has a higher calorie and protein content Typical nutritional contents of human expressed breast milk
than that collected from the opposite breast (drip breast milk). (per 100 ml)*
Human breast milk, particularly donated drip breast milk, Milk expressed Drip milk
may not consistently provide all of the nutrient requirements of from lactating expressed from
preterm infants. Multinutrient fortifiers are available to add to breast opposite breast
human milk to achieve these targets. Fortification of human Energy (kcal) 73 54
milk with calcium and phosphate may improve bone mineral Protein (g) 2.7 1.3
content. Protein and energy supplementation of human milk Fat (g) 3.0 2.2
increases the rate of weight gain and head growth, at least in the Calcium (mg) 29 28
short term. Long term follow up studies are needed to Phosphate (mg) 15 14
determine if nutrient fortification of human milk improves *Data from Rennie J, Robertson NRC. A manual of neonatal intensive care, 4th ed,
neurodevelopmental outcomes for preterm infants. London: Arnold, 2002
Human breast milk has non-nutrient advantages for
preterm infants, primarily through the delivery of
immunoprotective and growth factors to the immature gut
mucosa. Some evidence exists that preterm infants who receive
human breast milk rather than formula milk have a lower
incidence of feed intolerance and gastrointestinal upset, and a Study Relative risk (95% CI)
lower incidence of necrotising enterocolitis. Gross 1981
Lucas 1990
Supporting mothers to express breast milk Svenningsen 1982*
Mothers may be very anxious after preterm delivery, especially Tyson 1983
if their infant needs intensive care. Although feeding might not
be seen as an immediate concern, mothers should be aware that Pooled estimate: 0.25 (0.06 to 0.98)
providing breast milk is one of the most important parts of
their infant’s care. In developing countries, supporting mothers *Not estimable 0.001 0.02 1 50 1000
to provide expressed breast milk may be the most important Favours human milk Favours formula
intervention available for preterm infants. Feeding with
expressed human milk reduces the risk of serious infection, Relative risk of confirmed necrotising enterocolitis with human milk versus
which is a major cause of neonatal morbidity and mortality in formula. Adapted from McGuire W, Anthony MY. Arch Dis Child
2003;88:11-14
preterm infants in developing countries.
Various initiatives may help mothers who are expressing
breast milk:
x Early discussion of breast feeding
x Written information
x Frequent expression
x Simultaneous expression of both breasts
x Breast massage
x Use of electric pump
x Skin to skin contact
x Sucking from as early as 32 weeks after conception
x Cup feeding
x Continued support and education.
The initiation of skin to skin contact between mother and
infant (although not always possible for lengthy periods of time
with extremely preterm infants) can help with bonding, milk
production, and the subsequent establishment of breast feeding.
Milk can be delivered via a gastric tube or by cup feeding while
the infant is learning to suck at the breast. Bottle feeding should
be avoided as it may interfere with the establishment of breast Human breast milk can be expressed from the
feeding. infant’s mother or from a donor mother

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Clinical review

Donor milk banking

Use of donor milk for preterm infants has declined over the
past 20 years. This fall is caused by concerns about the
nutritional adequacy of donor breast milk, the resources needed
to pasteurise and store donated milk, and the cost and feasibility
of screening donors for transmissible infections, such as the
human immunodeficiency virus. In several countries, efforts
have been made to re-establish donor milk banks that were
closed in the 1980s. Economic studies show that the costs of this
service may be balanced by the potential health gains associated
with feeding with human milk—for example, a shorter stay in
hospital.

Formula milks
Despite optimal maternal support, expressed breast milk may
not always be available. As an alternative, preterm infants may
Skin to skin care promotes bonding and milk production (left). The infant
be fed with a variety of artificial formula milks, mainly modified
can be cup fed (right) until breast feeding is established
cow’s milk. Broadly, these may be “term” formulae (based on the
composition of mature breast milk), or calorie, protein, and
mineral enriched “preterm” formulae (tailored to support
intrauterine nutrient accretion rates). Some evidence exists that
feeding very preterm infants with preterm formula milk Typical content of nutrient enriched preterm formula milk
increases the rate of weight gain and head growth, at least in the compared with standard term formula (per 100 ml)*
short term, and improves some neurodevelopmental outcomes.
Preterm formula Term formula
No evidence exists that feeding preterm infants with formula
Energy (kcal) 80 67
milk supplemented with long chain polyunsaturated fatty acids
Protein (g) 2.0 1.4
is beneficial.
Fat (g) 4.5 3.6
Calcium (mg) 77-110 39-66
Phosphate (mg) 33-63 27-42
Parenteral nutrition *Data from Rennie J, Robertson NRC. A manual of neonatal intensive care, 4th ed,
London: Arnold, 2002
Very preterm infants, who often have relatively delayed gastric
emptying and intestinal peristalsis, may be slow to tolerate the
introduction of gastric tube feeds. These infants may need
intravenous nutrition while enteral nutrition is being
established or when enteral nutrition is not possible—for Complications of total parenteral nutrition
example, because of respiratory instability, feed intolerance, or Catheter related complications
serious gastrointestinal disease. x Bacteraemia (staphylococcal)
Total parenteral nutrition consists of a glucose and amino x Invasive fungal infection
acid solution with electrolytes, minerals, and vitamins, plus fat as x Thrombosis
x Extravasation injuries
the principal non-protein energy source. The solutions are x Cardiac tamponade
usually prepared in a specialist pharmacy to minimise the risk
Metabolic complications
of microbial contamination. Bloodstream infection is the most x Cholestatic jaundice
common important complication of parenteral nutrition use. x Hyperglycaemia or glycosuria
Delivery of the solution via a central venous catheter rather x Vitamin deficiencies or excesses
than a peripheral catheter is not associated with a higher risk of x Hyperammonaemia
infection. Extravasation injury is a major concern when
parenteral nutrition is given via a peripheral cannula.
Subcutaneous infiltration of a hypertonic and irritant solution
can cause local skin ulceration, secondary infection, and
scarring.

Nutrition after hospital discharge

Most preterm infants, and especially very preterm infants, have
an accumulated nutritional deficit when they are discharged
from hospital. Iron and vitamin supplementation is necessary
until infants are at least six months old, especially if they are fed
on breast milk only. Protein and energy enriched formula milk
may improve catch-up growth, at least in the short term. This Extravasation injury
may be of particular importance for infants with additional may occur when a
peripheral cannula is
metabolic requirements, such as those caused by chronic lung
used to deliver the
disease. Further research is needed to determine if breast milk parenteral nutrition
should be fortified after the infant is discharged. solution

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Clinical review

Conclusion Further reading

The nutritional management of preterm infants may have a x Anderson GC, Moore E, Hepworth J, Bergman N. Early skin-to-skin
contact for mothers and their healthy newborn infants. Cochrane
major impact on growth and development. Various feeding
Database Syst Rev 2003;(4):CD003519
strategies are available, including the use of expressed maternal x Ainsworth SB, Clerihew L, McGuire W. Percutaneous central
milk, donor human milk, breast milk fortifiers, adapted formula venous catheters versus peripheral cannulae for delivery of
milks, and total parenteral nutrition. A lack of robust evidence parenteral nutrition in neonates. Cochrane Database Syst Rev
exists to guide practice for many of these interventions. Large, 2004;(2):CD004219
pragmatic randomised controlled trials are needed to assess the x Kennedy KA, Tyson JE, Chamnanvanakij S. Rapid versus slow rate
of advancement of feedings for promoting growth and preventing
effects of a number of these feeding strategies on clinically
necrotizing enterocolitis in parenterally fed low-birth-weight infant.
important outcomes for preterm infants. Cochrane Database Syst Rev 2003;(4):CD001241
x Kennedy KA, Tyson JE, Chamnanvanikij S. Early versus delayed
Ginny Henderson is a neonatal nurse in the Neonatal Intensive Care initiation of progressive enteral feedings for parenterally fed low
Unit at Ninewells Hospital and Medical School, Dundee. birth weight or preterm infants. Cochrane Database Syst Rev
2003;(4):CD001970
The ABC of preterm birth is edited by William McGuire, senior x Tyson JE, Kennedy KA. Minimal enteral nutrition for promoting
lecturer in neonatal medicine, Tayside Institute of Child Health, feeding tolerance and preventing morbidity in parenterally fed
Ninewells Hospital and Medical School, University of Dundee; and infants. Cochrane Database Syst Rev 2004;(2):CD000504
Peter W Fowlie, consultant paediatrician, Perth Royal Infirmary and x Morley R, Lucas A. Randomized diet in the neonatal period and
Ninewells Hospital and Medical School, Dundee. The series will be growth performance until 7.5-8 years of age in preterm children.
published as a book in spring 2005. Am J Clin Nutr 2000;71:822-8
x Lucas A, Morley R, Cole TJ. Randomised trial of early diet in
Competing interests: For WMcG’s competing interests see first article in preterm babies and later intelligence quotient. BMJ
the series. 1998;317:1481-7
x Cooke RJ, Embleton ND. Feeding issues in preterm infants. Arch Dis
The photographs showing a woman expressing breast milk, skin to skin Child 2000;83:215-8
contact, and cup feeding are courtesy of the Health Promotion Agency for x McGuire W, Anthony MY. Formula milk versus term human milk
Northern Ireland. for feeding preterm or low birth weight infants. Cochrane Database
Syst Rev 2003;(4):CD002972
BMJ 2004;329:1227–30

A memorable patient
With a pinch of salt

Some years ago I was asked by a family doctor to visit a In the end I decided to share my dilemma with the
69 year old man at home to take a history and carry patient, and we agreed that I would be guided by him
out a physical examination and to perform an after he had had time to reflect on the matter. To this
electrocardiograph to rule out myocardial infarction end I arranged to see him in my outpatient clinic three
after an episode of chest pain the previous day. weeks later with the results of the appropriate blood
The patient said that 50 years previously, he had tests.
been told that he had Addison’s disease, but when I On the appointed day he told me that he had
asked him about drugs he looked at me blankly and decided to try the modern treatment. I gave him a
said that he had never heard of cortisol or steroid prescription, and we agreed a policy for tailing off the
replacement therapy: “No, doctor, in those days there salt over a period of about 10 days.
was no treatment for the condition, and I was told that When I next saw him, three weeks later, I didn’t
my only chance of staying alive was to take a whole recognise him, he looked so different. His face was
packet of salt a day.” fuller and his complexion brighter, and when I asked
To confirm this, he led me through to his kitchen, him how he felt he said, “I feel splendid. You know,
where he opened a cupboard to reveal several large doctor, I now realise that for 50 years I haven’t felt
cardboard boxes containing packets of salt, each of quite well.”
which weighed about a pound. “For the past 50 years,”
Douglas Model retired physician, Ebury Bridge Road,
he said, “I’ve taken one of these every day.”
London ([email protected])
I was now faced with an ethical dilemma. The
patient had clearly not had a myocardial infarction. His We welcome articles up to 600 words on topics such as
chest pain was worse with movement and pressure A memorable patient, A paper that changed my practice, My
over the left upper chest and was obviously of most unfortunate mistake, or any other piece conveying
musculoskeletal origin. Apart from this and Addison’s instruction, pathos, or humour. Please submit the
disease, which seemed to be well controlled with a article on http://submit.bmj.com Permission is needed
packet of salt a day, he was a well man. Should I from the patient or a relative if an identifiable patient is
interfere and offer him treatment with cortisol and referred to. We also welcome contributions for
fludrocortisone, or should I leave well alone? “Endpieces,” consisting of quotations of up to 80 words
Hippocrates’ words—“First do no harm”—echoed in (but most are considerably shorter) from any source,
my mind. ancient or modern, which have appealed to the reader.

1230 BMJ VOLUME 329 20 NOVEMBER 2004 bmj.com