Pediatric Annals

Special Issue Article 

A Guide to Feeding Term and Preterm Newborns

Sarah E. Kolnik, MD; Zeenia C. Billimoria, MD

Abstract

The management of feeding term and preterm newborns encompasses knowing the physiologic mechanics of nutritive feeding and requirements for good somatic and neurodevelopmental growth. Feeding in newborns can be fraught with challenges that each individual infant-family unit presents. Management is multifactorial and requires fluidity as the infant progresses. Pediatricians are tasked with one of the most important responsibilities in the newborn period—partnering with families to ensure optimal feeding regimen and infant growth. This article's aim is to outline general recommendations on evidence-based feeding practices in term and preterm infants with a goal to help guide pediatricians create an optimal individualized feeding regimen and address some known hurdles. [Pediatr Ann. 2020;49(2):e71–e76.]

Abstract

The management of feeding term and preterm newborns encompasses knowing the physiologic mechanics of nutritive feeding and requirements for good somatic and neurodevelopmental growth. Feeding in newborns can be fraught with challenges that each individual infant-family unit presents. Management is multifactorial and requires fluidity as the infant progresses. Pediatricians are tasked with one of the most important responsibilities in the newborn period—partnering with families to ensure optimal feeding regimen and infant growth. This article's aim is to outline general recommendations on evidence-based feeding practices in term and preterm infants with a goal to help guide pediatricians create an optimal individualized feeding regimen and address some known hurdles. [Pediatr Ann. 2020;49(2):e71–e76.]

The goal of optimal nutrition in newborns is to achieve adequate growth and promote development. These needs vary significantly based on the gestational age at birth and postmenstrual age of the newborn. In term newborns, this is based on the projected growth at a given postmenstrual age that gives adequate caloric intake and provides needed micro and macronutrients. Adequate nutrition in term newborns ensures symmetric growth in weight, length, and head circumference as followed on growth charts at scheduled outpatient visits. Caloric requirements of preterm newborns are much higher than term newborns. In preterm newborns it is recommended that feeding allows the infant to meet the growth rate and body composition that mimics a healthy fetus of similar gestational age.1

Mechanics of Feeding

Suck and swallow are present in-utero around 18 weeks gestation; however, many preterm infants struggle with this incoordination if born <32 to 34 weeks gestation. Some of this is thought to be secondary to underdeveloped orofacial musculature, which results in problems latching adequately with subsequently ineffective transferring of milk.2 Term newborns can inhibit respiration with swallowing which protects against aspiration. Preterm newborns have cardiorespiratory immaturity with an increased number of swallows with inspiration that increases their risk of apnea, bradycardia, or desaturation events with feeds. Therefore, many preterm infants require gastric tubes until 33 to 34 corrected weeks gestation. Infants that require gastric tubes are at risk for oral aversion due to the history of negative sensory stimuli. Thus, oral skill development and oral feeding if able are important in the preterm infant.3

Breast-feeding and bottle feeding have been shown to have different physiological mechanics. Studies have been done that assess differences between exclusive breast-feeding, exclusive bottle feeding, and mixed feeding. Infants who are exclusively bottle-fed have fewer sucks and the same number of pauses but of longer duration compared to breast-feeding. Interestingly, children with mixed feeding, exhibit both types of feeding, breast-feeding sucking movements and bottle-feeding sucking movements during the learning stage and eventually go on to implement their own unique hybrid pattern.4

Nutrition Type and Practices

Breast Milk

Breast milk is recognized as the best source of nutrition for all infants as it is associated with appropriate somatic growth and it modulates postnatal intestinal function. Breast milk has also shown benefits in immune ontogeny and neurodevelopment. Components of breast milk that are not present in formula include- secretory immunoglobulin A, lactoferrin, growth factors, and cytokines.5 Preterm human milk has higher concentrations of protein, sodium, zinc, and calcium compared to more mature human milk. Due to variability in breast milk components, it is recommended that supplementation be provided for all infants born <32 weeks gestation and those considered at higher risk between 32 and 36 weeks gestation (eg, small for gestational age infants).6 This could be in the form of fortified breast milk or formula.

Formula

If formula is needed due to inadequate breast milk supply, breast milk is not suitable for an infant or fortification is required to achieve growth, there are a variety of industrially produced substitutes available. Table 1 depicts the nutritional requirements for term and preterm infants. The composition of formulas varies based on the expected needs of the infant (Table 2). Differences include energy provided, protein, carbohydrate, fat, calcium, and phosphorus based on needed lean mass and skeletal growth.7,8 Formula is based on cow's milk or soymilk and attempts to mimic breast milk.9 In preterm infants, it is vital that preterm formulas are used to ensure adequate and consistent delivery of nutrients. Preterm formulas have been shown to improve growth and neurodevelopmental outcomes compared to term formulas and unfortified donor breast milk in preterm infants.10 A recent Cochrane review demonstrated higher rates of weight gain, linear growth, and head growth in preterm newborns receiving formula compared with donor breast milk. However, there was also higher risk of developing necrotizing enterocolitis and there were no sustained effects on long-term growth or neurodevelopmental outcomes.11 Another consideration is the use of hydrolyzed formulas in preterm infants due to decreased activity of enterokinase and other peptidases to improve nutrition and tolerance. Although some studies have shown that this population tolerates hydrolyzed protein formula better with less time to full feeds compared to standard formulas, no consensus has been reached on practice recommendations.3,12

Nutritional Requirements for Term and Preterm Newborns

Table 1.

Nutritional Requirements for Term and Preterm Newborns

Differences in Term and Preterm Formula Composition

Table 2.

Differences in Term and Preterm Formula Composition

Managing Parental Expectations

As a pediatrician, framing conversations regarding expectations of feeding in both preterm and term infants can help with successful feeding. The choice to breast-feed, formula feed, or a combination of the two is a multifactorial decision and should be tailored to the infant and family. In a cohort of over 2,500 mother-infant dyads, it was found that the majority of infants were initially breast-fed at approximately 97% with approximately 75% of them continuing through age 6 months; however, infants who were exclusively breast-fed were approximately 18%.13 Parental feeding practices examined in the first 2 years of life showed a correlation between levels of maternal stress and feeding issues in preterm infants. This stress continued among parents of preterm infants as the infants got older and with the introduction of solid food. Solids were found to start later in preterm infants with a decrease in food variation.14 This could be interpreted as an increase in anxiety about inadequate consumption among parents of preterm infants, and thus, a lack of sustained introduction of new food types.

Nutrition Recommendations Based on Gestational Age at Birth

Preterm Infants

In preterm infants, the preferred diet is fortified breast milk, which is the infant's own mother or donor breast milk fortified with supplemental nutrients or, alternatively, formula designed for preterm infants.15 Optimal nutrition in preterm infants promotes positive energy and protein balance, which has shown to improve long-term neurodevelopmental outcomes and later to prevent chronic diseases.16 However, often these goals are not met due to feeding intolerance, poor growth on maximal calories, or poor absorption that leads to suboptimal growth rates resulting in growth restriction during hospitalization. Protein deficiency results in long-term short stature, organ growth failure, and neurodevelopmental deficits. Increased carbohydrate and lipid supply to preterm infants often produces increased fat in organs such as heart, liver, and accumulation of adipose tissue.1,16 This high caloric density of feeds is inversely related to gastric emptying speed, especially for infants between 32 and 39 weeks gestation.3 Although catch up growth is necessary, growth that is too rapid in early stages of life have been associated with obesity and metabolic syndrome.17 Frequent monitoring of weight, length, and head circumference after discharge is important to ensure appropriate gain trends. Fortification should be decreased or discontinued accordingly.

Late Preterm Infants

Late preterm (LPT) infants make up the largest population of preterm infants, yet there are significant gaps in the literature regarding best feeding practices for this population. Late preterm infants tend to have poor rates of breast-feeding initiation and duration when compared to term infants. LPT infants' low rate of breast-feeding initiation is complex and heterogenous including issues such as reduced milk supply and poor initial ability to latch. Tailored support to promote breast-feeding is recommended in this at-risk population.18 LPT infants frequently exhibit postnatal growth restriction. The recommendation is to continue to promote breast-feeding with mothers of LPT infants by providing extended lactation support and frequent follow-up. The importance of individualized plans in this population is paramount as many need fortifier and additional supplements depending on gestational age, birth weight, and comorbidities. The benefits of nutritive additives versus risks of interrupting breast-feeding in this population remains unclear.8

Term Infants

Based on current recommendations of the American Academy of Pediatrics, term infants should be breast-fed exclusively until age 6 months if possible.19 Breast milk is the normative standard and given the body of evidence of the short and long-term medical and neurodevelopmental advantages, it should be routinely recommended to families. Breast-feeding is recommended to be continued for 1 year or longer with the introduction of complementary foods around age 6 months. The goal of the Centers for Disease Control and Prevention Healthy People 2020 initiative is to improve the rates of breast-feeding at age 6 months and age 12 months.20 Concern has previously arisen that use of formula supplementation will decrease those rates. However, it has been found that early, limited formula feeding was not associated with a change in breast-feeding duration.21,22 Pediatricians play a vital role to promote breast-feeding by informing families of the benefits and optimizing infants' ability to breast-feed, from helping with lactation techniques to advocating for work-place flexibility for mothers to pump milk at work for continued breast milk supply.19

Dietary Supplements

Vitamin D

Vitamin D is an important supplement in both term and preterm infants. For healthy infants 400 IU is appropriate supplementation with additional amounts not showing benefit in the short-term.23 Supplementation should be started as soon as feedings are tolerated.

Iron

Increased demands of iron in infancy for hematopoiesis and growth and development has given iron supplementation much attention. The standard supplementation of infants is 2 to 3 mg/kg/day. Premature infants with birth weights <1,800 g who are given <2 mg/kg/day of iron develop iron deficiency as much of the iron stores are accrued during the third trimester. Premature infants may require doses ranging from 3 to 12 mg/kg/day.24 Iron supplementation should begin at age 2 to 6 weeks. Infants who receive erythropoietin treatment or had uncompensated blood losses may need higher doses. Iron supplementation should be continued until age 6 to 12 months depending on diet.15 Early studies have shown that not only low iron status, but high iron status can result in adverse outcomes including growth and gastrointestinal health.25 Therefore, in infants who are iron replete, the amount of supplementation should not be given in excess. There is strong evidence that foods containing iron (eg, fortified cereal) are advantageous to maintain adequate iron status to prevent deficiency in the first year of life in infants at risk of insufficient iron stores or with low intake. However, for infants with sufficient iron stores (eg, infants that consume formula) the benefit of foods containing iron are not as clear.26

Other Micronutrients

Micronutrient status has emerged as a growing crucial parameter for appropriate growth and development in early life; these micronutrients include zinc, vitamin B12, folate, and fatty acid status. The US Department of Agriculture and the Department of Health and Human Services Pregnancy and Birth to 24 Months Project concluded that there is moderate evidence suggesting that introducing foods containing zinc (eg, meat) help improve zinc status in the first year along with complementary foods being indicative of the fatty acid composition in infants. There is a lack of evidence regarding complementary foods and vitamin B12 or folate status.26

Common Challenges in Feeding Term and Preterm Infants

Impaired Oral Coordination

Developmental changes in infant swallow physiology is linked to nutritive swallowing. Moreover, preterm infants have shown poor pharyngeal pressures at the laryngeal inlet with poor coordination of pharyngeal propulsion with upper esophageal sphincter relaxation, explaining why preterm infants frequently fatigue with feeding due to lack of effective coordinated swallow. However, as the infant ages these pressure patterns improve, and infants become more efficient at feeding.27 Dysfunctional feeding patterns, however, can carry over into infancy and toddler age groups and vary depending on the individual patients leading to significant heterogeneity. If the pathophysiologic basis of neonatal dysphagia can be characterized based on the infant's unique physiology (eg, birth asphyxia, congential anomalies), it should be identified with the help of a speech specialist. The specialist should work with the infant-family unit on a regular basis until a feeding strategy is established.28

Gastroesophageal Reflux

The movement of gastric contents into esophagus is a normal physiologic process that occurs daily in infants. The lower esophageal sphincter relaxes transiently in both preterm and term infants. However, in infants with motility problems, the vagal nerve triggers this relaxation more often due to more frequent proximal stomach distention thus increasing reflux. This poor motility coupled with lower esophageal sphincter resting pressure makes reflux in preterm infants much more frequent. If this reflux is associated with discomfort or complications it is called gastroesophageal reflux disease. Assessing this difference can be difficult so augmenting feeds and/or adding anti-reflux medication many times is done empirically. In the preterm infants, the addition of anti-reflux medication can be particularly detrimental and should be used with caution.29

Poor Growth

One of the primary concerns of preterm newborns once they are transitioned to outpatient care is optimal growth. Many of these infants, especially those <1,000 g, are growth restricted at the time of hospital discharge. Catch-up growth with fortified breast milk or preterm formula with nutrient supplementation is given; however, this does not always lead to appropriate lean mass or skeletal growth.7 Most preterm infants are unable to achieve this growth rate and catch-up growth is needed.16,30 Evidence has shown that catch-up growth prior to 2 years of life results in better long-term renal and general health outcomes.30Table 3 lists factors associated with poor postnatal growth in preterm newborns with a prescribed appropriate feeding regimen. Trials have tried to assess which method of supplementation is optimal with no current clear answer. For example, infants that feed ad libitum have demonstrated decreased volumes of high caloric compared to normal caloric density of milk, thus negating the intention of higher overall caloric intake. New regimens where protein rather than carbohydrate enrichment to formula is given are being trialed to determine if the volume of feeds can be maintained while increasing caloric density.7

Factors Associated with Postnatal Growth Restriction in Preterm Newborns

Table 3.

Factors Associated with Postnatal Growth Restriction in Preterm Newborns

Overeating

The issue of overeating has arisen in developed countries among both preterm and term infants. The largest general population-based birth cohort study in Canada of approximately 3,500 infants' feeding practices were documented including weight and body mass index (BMI) z scores at age 1 year.13 After adjusting for confounders such as maternal BMI, breast-feeding was found to be protective against obesity. With exclusive breast-feeding, infants at age 3 months have a lower BMI compared to either formula or combination breast-fed and formula-fed infants. This inverse association between breast-feeding and weight gain velocity and BMI was slightly diminished if breast milk was given from a bottle and more significantly diminished if there was formula supplementation after the neonatal period.13 In infants born ≥4,000 g, it has been shown that they are at an increased risk for obesity, but the exact mechanism has not yet been elucidated. A recent small study showed that infants that maintained a weight-for-length percentage ≥85% at age 7 to 8 months had a lower maternal-reported satiety responsiveness and maternal social interactions during feeding than infants born appropriate for gestational age.13,31 This suggests an environmental component to continued elevated weight gain after birth.

Oral Aversion

Newborns, especially preterm, required long-term enteral nutritional support while in the neonatal intensive care unit (NICU), can experience oral aversion in the absence of a medical reason. In a prospective study32 that consisted of 711 newborns who were tube dependent, the leading risk factor for development of tube dependency was prematurity, with extreme prematurity associated with the highest risk. Besides nasogastric tube feeding, tube feeding can consist of nasoduodenal, nasojejunal or gastrostomy tube depending on clinical preference of providers and patient's condition. Nasogastric tubes are currently most frequently seen.32 It is now becoming the standard of practice in some NICUs to send newborns home with tube feeds. Furthermore, a recent study has shown that nasogastric tube feeds are safe with the proper parental training, decrease hospital length of stay, and lead to high parental satisfaction.33 It is important that the pediatrician partners with occupational therapy and if available, a feeding specialist and nutritionist to help safely wean tube feeds while increasing oral feeds. Home care with pediatric nurses has been shown to improve safety and parental satisfaction if available to help manage these feeding regimens.33

Summary

The management of feeding in newborns, term or preterm, is one of the major responsibilities of the pediatrician to optimize growth. The preterm infant has a unique set of comorbidities that provides challenges to achieve the current gold standard, which in term healthy infants is breastfeeding. Regardless of gestational age, challenges can arise that require tailored feeding regimens and may benefit from the input of other specialists, lactation consultants, pediatric gastrointestinal specialists, or speech and occupational specialists. Feeding is a personal choice for every family and their input is vital. The pediatrician partners with the family to establish newborn-appropriate feeding practices while closely monitoring growth and development.

References

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Nutritional Requirements for Term and Preterm Newborns

Nutritional Needs Per Day Term Newborn Preterm Newborn
Total energy (kcal/kg) 100–110 120–125
Protein (g/kg) 1.5–2 3–4
Fat (g/kg) 3 3–3.5
Carbohydrate (g/kg) 9–10 10–13
Calcium (mg/kg) 55–120 120–140
Phosphorus (mg/kg) 30–75 60–90

Differences in Term and Preterm Formula Composition

Nutritional Needs Term Formula Preterm Formula
Total energy (kcal) 68 80
Protein (g) 1.4 2.4
Fat (g) 3.6 4.3
Carbohydrate (g) 7.3 8.6
Calcium (mg) 50 140
Phosphorus (mg) 30 75

Factors Associated with Postnatal Growth Restriction in Preterm Newborns

<list-item>

Lower birth weight and gestational age at birth

</list-item><list-item>

Illness severity at birth

</list-item><list-item>

Early-onset infection (congenital)

</list-item><list-item>

Late-onset infection (nosocomial)

</list-item><list-item>

Necrotizing enterocolitis (if surgical treat- ment higher risk)

</list-item><list-item>

Prolonged respiratory support

</list-item><list-item>

Postnatal exposure to corticosteroids

</list-item><list-item>

Bronchopulmonary dysplasia

</list-item>
Authors

Sarah E. Kolnik, MD, is a Neonatology Fellow. Zeenia C. Billimoria, MD, is an Assistant Professor of Pediatrics. Both authors are affiliated with the Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital.

Address correspondence to Sarah E. Kolnik, MD, Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105; email: sekolnik@uw.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/19382359-20200123-01

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