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Seminars in Perinatology

Gastrointestinal and feeding issues for infants <25 weeks of gestation

Abstract

Appropriate nutrition is essential for optimal development and growth of preterm infants. Infants less than 25 weeks corrected gestational age are frequently the most difficult group for which to provide adequate nutrition due to minimal energy stores and high fluid losses. Nutrient delivery becomes an integral, but also very challenging part in their management. Early administration of intravenous nutrients provides a critical bridge to full enteral nutrition . However, enteral feeding is challenging due to immaturities of the intestinal tract, feeding intolerance and the risk of catastrophic gastrointestinal disease such as necrotizing enterocolitis (NEC). Decreased gastric acid production, increased gut permeability, reduced immunoglobulins, immature intestinal epithelia and a decreased mucin barrier all contribute to weakness to gastrointestinal insult. This review aims to illustrate the importance of enteral feeding and the common challenges and approaches in the nutrition of infants born at this age.

Section snippets

Approaches to nutritional management of infants less than 25 weeks of gestation

The immaturity of premature infants' gastrointestinal tract predisposes it to vulnerabilities and difficulty with providing suitable enteral nutrition. Gastric acid production is limited in this population which may impair host defenses against harmful organisms, predisposing to necrotizing enterocolitis (NEC).1 The developing premature infant has increased gut permeability, reduced immunoglobulins, immature intestinal epithelia and a decreased mucin barrier.2 They are widely known to have

Colostrum oral care

Oropharyngeal administration of colostrum (OPC) within the first 24 h after birth has multiple health benefits for those born extremely premature5 and has emerged as a standard practice in some neonatal intensive care units (NICUs). Full of many bioactive factors, colostrum (early milk) provides protection in a multifactorial manner.5 , 6 Cytokines stimulate oropharyngeal-associated lymphoid tissue and secretory immunoglobulin A prevents pathogens from adhering to the mucosa.5 Milk

Human milk

Mother's own milk is the preferred dietary choice for preterm infants. The World Health Organization (WHO) and the American Academy of Pediatrics (AAP) currently recommend a human milk diet for all infants under 1500 g.10 Sometimes mothers are unable to provide milk or there are contraindications to the use of their milk. If baby's own mother's milk is unavailable, the AAP recommends administration of pasteurized human donor milk.10 Human milk has been associated with reduced rates of sepsis,

Nutritional demands

The optimal nutritional strategy for infants born under 25 weeks gestation attempts to mimic fetal growth.20 Birth forces these infants to rely on limited energy stores while having extra energy demands that were previously regulated by the intrauterine environment, including: breathing, thermoregulation, and feeding. Protein, lipid, and carbohydrate provide the caloric requirements needed to obtain appropriate postnatal growth. Current guidelines when at full enteral feeding promote a protein

Overview

Human milk fortifier (HMF), depending upon the type used, can increase caloric density of feeds between 22 kcal/oz and 30 kcal/oz as well as supply vitamins and minerals, such as sodium, phosphorus, calcium, and iron.14 This allows feeding to be tailored to the needs of individual infants. While the use of HMF is recommended by the AAP for all infants under 1500 g who are fed human milk,10 there remains a difference in opinion on the type and timing of fortification. The most frequently used

Summary of current guidelines

The standardization of enteral feeding guidelines in the NICU promises to decrease the risk of NEC and optimizes nutrition to this vulnerable population.61 The following recommendations are made after this review:

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Human milk is the preferred diet; if maternal milk is unavailable, pasteurized human donor milk should be utilized if under 1500 g.

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Aggressive and early enteral nutrition is recommended and should be advanced as rapidly as tolerated.

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Early introduction of enteral feeding is important for

Disclosures

Laura Patton declares no conflicts of interest.

Diomel de la Cruz declares no conflicts of interest.

Josef Neu discloses the following: a research grant for infant bacterial therapeutics; member of the Scientific Advisory Boards for both Astarte and Medela.

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