Enteral Nutrition in Preterm Infants (2022): A Position Paper From the ESPGHAN Committee on Nutrition and Invited Experts

Abstract

Objectives: To review the current literature and develop consensus conclusions and recommendations on nutrient intakes and nutritional practice in preterm infants with birthweight <1800 g. Methods: The European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee of Nutrition (CoN) led a process that included CoN members and invited experts. Invited experts with specific expertise were chosen to represent as broad a geographical spread as possible. A list of topics was developed, and individual leads were assigned to topics along with other members, who reviewed the current literature. A single face-to-face meeting was held in February 2020. Provisional conclusions and recommendations were developed between 2020 and 2021, and these were voted on electronically by all members of the working group between 2021 and 2022. Where >90% consensus was not achieved, online discussion meetings were held, along with further voting until agreement was reached. Results: In general, there is a lack of strong evidence for most nutrients and topics. The summary paper is supported by additional supplementary digital content that provide a fuller explanation of the literature and relevant physiology: introduction and overview; human milk reference data; intakes of water, protein, energy, lipid, carbohydrate, electrolytes, minerals, trace elements, water soluble vitamins, and fat soluble vitamins; feeding mode including mineral enteral feeding, feed advancement, management of gastric residuals, gastric tube placement and bolus or continuous feeding; growth; breastmilk buccal colostrum, donor human milk, and risks of cytomegalovirus infection; hydrolyzed protein and osmolality; supplemental bionutrients; and use of breastmilk fortifier. Conclusions: We provide updated ESPGHAN CoN consensus-based conclusions and recommendations on nutrient intakes and nutritional management for preterm infants

Supplementation of Mother’s Own Milk with Preterm Donor Human Milk: Impact on Protein Intake and Growth in Very Low Birth Weight Infants—A Randomized Controlled Study

“…It is worth noting that on the day of initiation of human milk fortification, protein intake was significantly higher in Group A compared to Group B (3.57 g/kg/day vs. 2.92 g/kg/day, p = 0.006) which indicates the higher provision of protein by preterm donor milk per se . Although both groups achieved over 3 g/kg/day of protein intake during the first vulnerable week of life, as well as throughout the whole donor milk period, only Group A surpassed the amount of 3.5 g/kg/day which is in line with the most recent recommendations [ 24 , 40 ]. However, more studies are needed to determine the exact protein requirement for this population and whether it should be different in the extrauterine environment compared to the intrauterine one.…”

“…The above results demonstrate that feeding VLBW infants with PDM, when MOM is not sufficient, and starting fortification when the quantity of enteral feeds reaches 50–100 mL/kg/day, protein intake surpasses the amount of 3.5 g/kg/day as ESPGHAN (2022) recommends [ 40 ]. The precise time to commence fortifiers is not known.…”

“…Few data exist whether early (<40 mL/kg/day) versus delayed (>75 mL/kg/day) initiation of fortification may be beneficial [ 41 ]. Current recommendations of ESPGHAN propose starting a fortifier when enteral intakes reach 40–100 mL/kg/day [ 40 ]. An individualized fortification strategy (i.e., adjustable or targeted) was also proposed [ 40 ].…”

Vitamin A Status in Preterm Infants Is Associated with Inflammation and Dexamethasone Exposure

“…In this cohort of preterm infants, the majority exhibited vitamin A deficiency (retinol < 0.7 µmol/L) despite vitamin A intakes within the upper range of recommendations after the first week of life [ 31 ]. We observed a two-fold transient increase in retinol concentrations during dexamethasone exposure.…”

“…Our data suggest that vitamin A intakes within the current range of recommendations (400–1000 µg/kg/d) are insufficient to provide adequate blood levels in preterm infants <29 weeks gestation. Overall, eight out of ten infants had retinol concentrations <0.7 µmol/L at 36 weeks PMA despite vitamin A intakes in line with guidelines [ 31 ]. In a randomized controlled trial (RCT) of extremely preterm infants, daily enteral doses of 3000 µg/kg/d resulted in retinol concentrations >0.7 µmol/L in less than 50% of the supplemented infants [ 36 ].…”