What is the recommended feeding strategy for preterm infants with feeding issues?

Feeding Strategy for Preterm Infants with Feeding Issues

Breast milk is the enteral feed of first choice for preterm infants with feeding issues, and if unavailable, start with elemental formula in severe illness, transitioning to extensively hydrolyzed then polymeric feeds as tolerated, while never maintaining complete enteral starvation even when parenteral nutrition is required. 1, 2

Immediate Nutritional Approach

Parenteral Nutrition Initiation

• Start parenteral nutrition within 8 hours of birth to prevent nutritional deficits 2
• Begin amino acids on the first postnatal day at minimum 1.5 g/kg/day, advancing to 2.5-3.5 g/kg/day from day 2 onwards 2
• Target energy delivery of 90-120 kcal/kg/day parenterally, with most practitioners aiming for at least 120 kcal/kg/day to facilitate catch-up growth 2
• Start intravenous lipid emulsions immediately after birth or no later than postnatal day 2, advancing to 3-4 g/kg/day 2

Critical Principle: Minimal Enteral Feeding

• Never maintain complete enteral starvation (total PN) when any amount of enteral feed can be tolerated 1, 2
• Introduce minimal enteral feeding even if only small volumes are tolerated, as this promotes gut maturation, reduces necrotizing enterocolitis, and improves neurodevelopmental outcomes 1, 3, 4
• Small oral bolus feeds during the day should be initiated as soon as possible to avoid tube-feeding complications and prevent oral hypersensitivity 1

Enteral Feeding Strategy

Feed Selection Algorithm

1. First choice: Mother's own breast milk for all preterm infants 1, 2, 3, 5

   • Breast milk reduces necrotizing enterocolitis, late-onset sepsis, chronic lung disease, retinopathy of prematurity, and improves neurodevelopment in very low birth weight infants (<1500g) 1
   • Breast milk is associated with shorter duration of parenteral nutrition 1

2. Second choice (if breast milk unavailable): Elemental (amino acid-based) formula in early infancy and severe illness 1, 2

   • Amino acid-based formulas are more efficient in decreasing parenteral nutrition requirements than extensively hydrolyzed feeds 1

3. Third choice: Extensively hydrolyzed formula as clinical condition improves 1, 2

4. Fourth choice: Polymeric feeds (standard preterm formula) when tolerance is established 1, 2, 5

Feed Delivery Method

• Continuous feeding: Introduce enteral feeding as liquid feed infused continuously by tube over 4-24 hour periods using a volumetric pump 2
• Continuous feeding improves enteral tolerance and weight gain in preterm infants with feeding issues 1
• Bolus feeding: Initiate small oral bolus feeds as soon as possible (usually as adjunct to continuous feeding during the night) to promote oral motor skills development and prevent oral aversion 1, 2
• For severe reflux, vomiting, or aspiration risk, consider nasojejunal feeding 2

Feed Concentration and Advancement

• Feed at normal concentrations (not diluted) to ensure adequate nutrition without excessive fluid volume 1, 2
• Make only one change at a time when increasing enteral feed to properly assess tolerance 2
• In severe intestinal failure or feeding intolerance, increase feed volumes slowly according to digestive tolerance 2
• Reduce parenteral nutrition in proportion to, or slightly more than, the increase in enteral nutrition 1, 2

Breast Milk Fortification for Very Low Birth Weight Infants

• Fortify human milk for infants <1500g or <34 weeks gestation to meet unique nutritional requirements and achieve adequate growth and bone mineralization 3, 5, 6
• Most common criteria for commencing fortification: tolerating 150 mL/kg/day, gestational age <34 weeks, birth weight <1500g 6
• Primary contraindication is necrotizing enterocolitis 6

Monitoring and Growth Targets

Laboratory and Clinical Monitoring

• Frequency of laboratory assessment based on clinical condition: once daily to 2-3 times per week 2
• Monitor sodium 4-7 mEq/kg/day, potassium 2-4 mEq/kg/day 2
• Ensure calcium intake of 2-3 mmol/kg/day (80-120 mg/kg/day) with calcium:phosphorus ratio of 0.8-1.2 2

Growth Parameters

• Target weight gain: 17-20 g/kg/day after initial postnatal weight loss 2
• Weight gain below 9 g/kg/day requires immediate intervention to prevent impaired neurodevelopment 2
• Accurate anthropometrics and thorough clinical evaluation should be undertaken by a skilled practitioner 2

Multidisciplinary Team Approach

• Supervision must be provided by a multidisciplinary nutrition support team including doctor, nurse, dietitian/nutritionist, and pharmacist 2
• This team-based approach is essential for optimizing outcomes in preterm infants with complex feeding issues 2

Common Pitfalls to Avoid

• Do not maintain complete enteral starvation: Even minimal enteral feeds (trophic feeding) are beneficial for gut maturation and reducing complications 1, 2, 4
• Do not dilute feeds: This results in inadequate nutrition despite normal fluid volume intake 1, 2
• Do not neglect oral stimulation: Maintain some degree of oral feeding or oral stimulation during tube feeding to prevent oral aversion and support oral development 1, 2
• Do not make multiple feeding changes simultaneously: This prevents proper assessment of tolerance 2

Discharge Planning Considerations

• Gavage feeding at home has limited role and should only be considered when feeding is the last issue requiring hospitalization 2
• When long-term tube feeding seems inevitable with little oral feeding progress, placement of gastrostomy tube provides an alternative 2
• Oral feeding should continue alongside tube feeding unless precluded by neurologic deficits threatening airway defense 2