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976 PEDIATRICS Vol. 75 No. 5 May 1985

AMERICAN ACADEMY OF PEDIATRICS

Committee on Nutrition

Nutritional Needs of Low-Birth-Weight Infants

Optimal nutrition is critical in the managementof the ever-increasing number of surviving smallpremature infants. Although the most appropriategoal of nutrition of the low-birth-weight (LBW)infant is not definitively known, achieving a post-natal growth that approximates the in utero growthof a normal fetus at the same postconception age

appears to be the most logical approach at present.’In uncomplicated cases, growth will usually beginby the second week after birth, after the initialchanges in body water distribution have takenplace, and after the infant has accommodated in anonstressful way to the provision of enteral feedsand parenteral supplements. The fetal standards ofgrowth that will be considered here include not only

weight and length, but also values for rate of reten-tion of individual nutrients and minerals (Table

1).2 The quality ofpostnatal growth may differ fromthe quality of fetal growth, depending on the type

of milk consumed, eg, ex utero weight gain of apremature infant given formula includes more fatgain than that of a fetus of the same maturity.3

CALORIC REQUIREMENT

Energy expenditure for maintenance and growth

determines the caloric requirements of the infant.The energy expenditure for growth includes boththe energy value of the new tissue and the energycost of the tissue synthesis. The estimated “basal”or maintenance metabolic rate of LBW infants,including an irreducible amount of physical activ-ity, is lower in the first week after birth than later,

and in a thermoneutral environment is approxi-mately 50 kcal/kg/d by 2 to 3 weeks of age.4’5 Each

gram of weight gain, including the stored energyand the energy cost of synthesis, requires 5 to 6kcal. Thus a daily weight gain of 15 g/kg requires acaloric expenditure of approximately 75 kcal/kgabove the 50 kcal/kg maintenance expenditure. Es-timated mean caloric requirements of prematureinfants during the neonatal period are shown inTable 2.

Individual infants vary in their activity, in their

ease of achievement of basal energy expenditure atthermoneutrality, and in their efficiency of nutrientabsorption. In practice, enteral caloric intakes of

approximately 120 kcal/kg/d enable most LBWinfants to achieve satisfactory rates of growth. Ahigher intake may be given if growth is unsatisfac-tory at these intakes, as may be seen with chronicillness such as bronchopulmonary dysplasia. New-

born infants with growth retardation often requirean increased caloric intake for growth, because ofboth higher maintenance energy needs and higherenergy costs of new tissue synthesis.4

Protein Amount and Type

Until the 1940s, premature infants were usuallyfed human milk. Then Gordon et al’ found thatLBW infants would gain more weight when fedvarious prepared formulas than when fed pooledhuman milk. Weight gain of the infants appeared

to correlate more with the electrolyte, or ash, intakethan with the protein intake.1 Protein intakes be-

tween 2.25 and 5.0 g/kg/d were apparently safe andwere recommended by Cox and Filer in 1969.’ The

estimated requirements based on the fetal accretionrate of protein are 3.5 to 4.0 g/kg/d (Table 1).2

The type of protein most suitable for LBW in-fants was studied by Gaull, Raiha, and their co-workers’ in a series of papers comparing whey-predominant formulas (60:40 ratio of whey:casein

protein) with casein-predominant formulas (18:82rotio of whey:casein protein). Each formula was

studied in two protein concentrations: 1.5 g/dL and3.0 g/dL. The metabolic effects and resultant

growth following feeding of each of the four for-mulas were compared with the effects of feedingpooled milk from mothers of term infants. TheBUN was higher in infants fed both of the 3.0-g/

dL formulas than with the 1.5-g/dL formulas, butthe significance of the differences was not given.Metabolic acidosis and elevated plasma tyrosineand phenylalanine levels were found with the 3.0-

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TABLE 1. Estimated Requirements and Advisable Intakes for Protein and Major Minerals by Infant’s Weight as

AMERICAN ACADEMY OF PEDIATRICS 977

Derived by Factorial Approach*

Tissue Dermal LossIncrement (/d)

(/d)

Urine Loss(/d)

IntestinalAbsorp-

tion(% In-take)

Estimated A dvisable IntakeRequirement

(/d) Per Day Per kgt Per 100 kcal�

800-1,200 g (26-28 weeks of gestational age)Protein 2.32 0.17Sodium (mEq) 1.63 0.06Chloride (mEq) 1.23 0.10Potassium (mEq) 0.87 0.12

Calcium (mg) 116 2

Phosphorus (mg) 75 1Magnesium (mg) 3.2 . . .

0.681.21

1.181.11

425

2.0

87�90

9083

658060

3.643.222.79

2.52

188126

8.7

4.03.53.1

2.5

210140

10.0

4.03.53.1

2.5

210140

10.0

3.12.72.4

1.9

160108

7.5

1,200-1,800 g (29-31 weeks of gestational age)

Protein (g) 3.01 0.25Sodium (mEq) 1.77 0.09

Chloride (mEq) 1.30 0.15Potassium (mEq) 1.03 0.18

Calcium (mg) 154 3Phosphorus (mg) 98 2Magnesium (mg) 4.0 . . .

0.901.81

1.771.666

373.0

8790

908365

8060

4.784.08

3.47

3.45251

17111.7

5.24.5

3.8

3.4280185

13.0

3.53.0

2.5

2.3185123

8.5

2.72.3

2.0

1.8140

95

6.5

* Data from Ziegler et al.2

t Assuming body weight of 1,000 and 1,500 g, respectively, for the 800- to 1,200-g infants and 1,200- to 1,800-g infants.:1:Assuming calorie intake of 130 kcal/kg/d.

TABLE 2. Estimated Caloric Requirement in Typical,Growing Premature Infant*

Kcal/kg/d

Resting caloric expenditure 50Intermittent activity 15

Occasional cold stress 10

Specific dynamic action 8Fecal loss of calories 12Growth allowance 25

Total 120* Data from AAP Committee on Nutrition.’

g/dL 18:82 formula, whereas plasma taurine levelswere maintained longer with the 60:40 formulas.

Gaull et al concluded that there were no advantages,and some metabolic disadvantages, to the 3.0-g/dL

V the 1.5-g/dL formulas. Infants fed the whey-predominant formulas (60:40), with whey:caseinprotein ratios similar to that of breast milk, had

metabolic indices and plasma amino acid levelscloser to those of infants fed pooled mature humanmilk.

Fats

Fat provides the major source of energy for grow-ing premature infants. In human milk, about 50%

of the energy is from fat, and in commercial for-mulas fat provides 40% to 50% of the energy. The

LBW infant digests and absorbs poorly the predom-inantly saturated triglycerides of cow’s milk. The

0 recognition of the magnitude of this fat malabsorp-tion led to the use of low-fat formulas for feeding

premature infants in the 1940s and 1950s.’ By 1960,

after it was recognized that unsaturated long-chain

triglycerides from vegetable oils were much betterabsorbed than were cow’s milk fats,’ such fats were

used in commercial formulas for feeding prematureinfants. However, medium-chain triglycerides are

even better absorbed,’ presumably because theirdigestion and absorption are not dependent on duo-

denal intraluminal bile salt levels, which are low inthe premature infant. Thus, the recently developed

special formulas for premature infants contain amixture of medium-chain triglycerides and predom-

inantly unsaturated long-chain triglycerides. Theessential fatty acid requirement of at least 3% of

total calories in the form of linoleic acid is amplymet by this fat mixture. However, the gain in energy

through improved absorption of medium-chain tn-glycenides may be offset by an increased frequency

of intestinal disturbances (abdominal distention,loose stools, vomiting)6 attributable to the medium-chain triglycerides lipid.

The fat of human milk is well absorbed by theLBW infant if it is fed into the stomach and is notsubjected to heat treatment, which can denaturethe lipase in the milk. One reason for the relatively

efficient absorption of human milk fat is the distni-

bution of fatty acids in the triglyceride molecule.Palmitic acid in the fi position, as in human milkfat, leads to better absorption than is seen with

cow’s milk fat, which has stearic acid in the �

position. Lingual lipase acting in the stomach startsthe digestion,7 and bile salt-activated lipase in the


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milk continues the digestion in the duodenum.8

These lipase activities substitute for the low pan-

creatic lipase of premature infants and appear toproceed well despite the low intraluminal bile saltconcentrations of the premature infant.

Carbohydrates

The LBW infant may have difficulty in digesting

lactose in the first days of life due to low intestinalmucosal lactase activity.”9 In the absence of ade-

quate lactase activity, undigested lactose may bepresent in high concentrations in the lower intes-tinal tract and serve as a substrate for proliferation

ofpotentially pathogenic bacteria. Additionally, thelactose may cause intestinal distention by its os-motic effect. However, glycosidase enzymes for glu-

cose polymers are active in small premature in-fants,’#{176}and such polymers are well tolerated byLBW infants. Glucose polymers have the additionalbenefit of adding less osmotic activity to the for-mula per unit weight than does lactose or monosac-chanides. On the basis of these advantages, thecarbohydrate portions of the various special for-

mulas for premature infants contain approximately40% to 50% lactose and 50% to 60% glucose poly-mers.

Minerals

Sodium and Potassium. LBW infants, particu-larly those with birth weight less than 1,500 g, donot have well-developed renal sodium conservationmechanisms. The fractional excretion of sodium is

high for the first ten to 14 days after birth. Thus,the low sodium concentrations of mature humanmilk or of some commercial formulas designed forthe feeding of term infants lead to hyponatremiawhen these milks are used as the sole source of

sodium for a small premature infant. Special for-mulas for premature infants should provide 2.5 to3.5 mEcijkg/d of sodium at full feeding levels.”Very LBW (<1,500 g) infants, however, may require4 to 8 mEqJkg/d of sodium to prevent hyponatne-

mia.’2 The potassium requirement for LBW infantsappears to be similar to that of term infants, 2 to 3mEqjkg/d.

Cakium and Phosphorus. It is difficult to supplythe small LBW infant with adequate amounts ofcalcium and phosphorus for normal bone growth

and mineralization. As a result, osteopenia is afrequent feature in small premature infants andthey have a lower but definite frequency of rickets.

Human milk and infant formulas designed for terminfants are both deficient in calcium and phospho-

flis relative to fetal accretion rates.’ The advisable

intake of calcium for 800- to 1,200-g prematureinfants is 210 mg/kg/d in order to meet the fetal

retention rate, while taking into account limitedintestinal absorption.2 The commonly used formu-

las for term infants contain 44 to 52 mg/dL of

calcium, and in LBW infants consuming such for-mulas, the bone mineral content by photon absorp-tiometry is far below the normal fetal values.13 But

with calcium intakes of 200 to 250 mg/kg/d andphosphorus intakes of 1 10 to 125 mg/kg/d, the bonemineral content of LBW infants increases at the

fetal rate.’4 The role of vitamin D and its activemetabolites in the genesis of osteopenia of smallpremature infants is discussed below.

There is good evidence that the special formulas

now available for premature infants, which have

been supplemented with calcium and phosphorus,can lead to postnatal bone growth and mineraliza-tion at fetal rates.’5 Overall growth and clinicalstatus of the infants fed these formulas have been

normal, and serum calcium and phosphorus con-centrations have been in the normal range.’6

Zinc and Manganese. Zinc metabolism is complex

in the LBW infant. Theoretically, the fetal reten-

tion rate of 250 .�g/kg/d’7 could be met by the LBWinfants’ consumption oftheir mothers’ milk.’8 How-

ever, when consuming heat-treated human milk,

LBW infants are in negative zinc balance untilabout 70 days of age, apparently because of limita-tions in intestinal absorption of zinc.’9 There isrecent evidence that zinc absorption in LBW in-

fants may be highly correlated with fat and nitrogenabsorption.2#{176} A positive zinc balance may appearearlier in the postnatal period when fat absorptionis improved by having 40% to 50% of the fat asmedium-chain triglycerides.20

The AAP Committee on Nutrition has pro-

posed”2’ that infant formulas for full-term infantssupply 0.5 mg of zinc and 5 �g of manganese per

100 kcal. There is no reason, at the present time,to modify these recommended levels for LBW in-fants.

Copper. Copper retention rate of the fetus is 51ag/kg/d.22 This amount of copper is available from

the milk of mothers of premature infants, with acopper content ranging from 58 to 72 zg/dL duringthe first month after birth.’8 However, copper bal-ances are negative in premature infants until thefifth week after birth.’9

Evaluation of copper nutrition in the neonatal

period is complicated by the primary correlation ofserum copper level with the serum ceruloplasminlevel, which rises after birth. The serum copperlevel may increase in the face of a negative copper

balance. Increases in copper concentration in for-mula from 50 �tg/dL to 160 �tg/dL did not lead to



higher serum copper levels,23 although huge dosesof 1,500 1zg/dL do increase serum levels.24

Because clinical neonatal copper deficiency can0 occur with low copper intakes, close attention to

the copper intake of LBW infants is important.

The current AAP Committee on Nutrition’ rec-

ommended copper intake of 90 �g/100 kcal contin-ues to be appropriate.

Iron. On a weight basis, the iron content ofpremature infants at birth is lower than that of

full-term infants. Much of the iron is in the circu-lating hemoglobin, so the frequent blood sampling

that the premature infant is often subjected to mayfurther deplete the amount of iron available for

erythropoiesis. The early physiologic anemia of pre-maturity is not benefited by iron therapy’ and thereare frequent clinical indications for maintaining the

LBW infants’ hematocrit above 40% by transfu-sions of RBCs (apnea of prematurity, long-termrequirement for supplemental oxygen, patent duc-tus arteriosus). In addition, high levels of oral iron

supplementation can interfere with vitamin E me-tabolism in the small premature infant. Thus thereis no clear indication for iron supplementation be-

fore 1 to 2 months of age. It has been suggested2’25that oral iron supplements be started at about 2weeks of age, or when enteral feedings are tolerated,

at a dose of 2 to 3 mg/kg/d. If iron is administered

this early, vitamin E supplements should be given.0 Once the LBW infant reaches about 2,000 g in

weight and/or goes home, iron supplementation is

definitely needed. Infants fed human milk shouldreceive 2 to 3 mg/kg/d of elemental iron as ferrous

sulfate drops; formulas with iron usually containsufficient supplemental iron.26 A somewhat highertotal daily dose of iron (supplemental plus iron inthe formula) for LBW infants has been recom-mended by Siimes27; this regimen should be started

by age 2 months and continued to age 12 to 15months: birth weight 1,500 to 2,000 g, 2 mg/kg/d;

birth weight 1,000 to 1,500 g, 3 mg/kg/d; birthweight less than 1,000 g, 4 mg/kg/d. There is,however, insufficient evidence that these increased

amounts are necessary.

Iodine. The recommended minimum requirementof iodine for normal infants (5 �g/100 kcal)2’ isbased on the iodine content of human milk. Theuptake of radioiodine by the thyroid gland of pre-

mature infants has been found to be in the normalrange for children and adults; therefore, it is as-sumed that 5 �zg of iodine per 100 kcal is alsoadequate for the low-birth-weight infant.

Other Trace Minerals. Although other minerals(such as cobalt, molybdenum, selenium, and chro-

0 mium) are probably essential in trace amounts forinfants, there is no information on which to base

recommendations at this time. Fluoride is usuallyprovided in supplements or as fluoridated water.

Vitamins

Vitamin A, Vitamin K, Thiamin, Riboflavin, Nia-

cm, Pyridoxine, Pantothenic Acid, Vitamin B,2, Bio-

tin, and Folic Acid. The recommended oral intakesof these vitamins by LBW infants are the same asthose recommended for full-term infants.2’ It isessential that all LBW infants, as well as term

infants, receive at least 1 mg of vitamin K at birth.The AAP Committee on Nutrition recommends

that daily multivitamin supplements be considered,once enteral feedings are established, after takinginto account the vitamin content of the unsupple-

mented formula. The most appropriate supple-ments are those that contain the National ResearchCouncil Recommended Dietary Allowance of vita-

mins A, C, D, and E and the B vitamins. It is

important to realize that due to the instability offolic acid in solutions, the liquid multivitamin drops

for infants do not contain folic acid. The Committeesuggests that the National Research Council Rec-ommended Dietary Allowance for folic acid can be

added to the multivitamin preparation in the hos-pital pharmacy.tm

Vitamin C. There have been conflicting reports

on the need for high ascorbic acid intakes in pre-

mature infants to enhance the activity of hepatic

p-hydroxyphenylpyruvic acid oxidase and second-arily lower blood tyrosine and urinary tyrosine me-

tabolite levels. Light et altm found that 100 mg ofvitamin C per day was useful, but this has not been

substantiated by others.3#{176}In addition, most studies

show no detrimental effects of transient neonataltyrosinemia,3133 but one study showed a loweringof IQ values at age 7 to 8 years in affected children.34

Because of these uncertainties, there have not

been consistent recommendations regarding vi-tamin C supplementation. Although the NutritionCommittee of the Canadian Paediatric Society rec-ommended vitamin C supplementation of prema-ture infants in 1976,�� it did not do so in 1981.36

Ziegler et a12 recommend vitamin C intake of 60mg/d for premature infants. Because of the absence

of compelling evidence for a high vitamin C require-ment in LBW infants, the AAP Committee onNutrition does not recommend a supplement inaddition to the 35 mg of vitamin C in the daily oral

multivitamin mixture.Vitamin D. The role of vitamin D deficiency in

the development of osteopenia and rickets in the

small premature infant is uncertain. There have

been two case reports37’m suggesting that somesmall premature infants show a high vitamin Drequirement due to a relative insensitivity to active


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vitamin D metabolites. In addition, doses of 100 IU

of vitamin D per kilogram per day were found notto maintain serum 25-dihydroxyvitamin D in a

normal range, while 500 IU of vitamin D per kilo-

gram per day did maintain serum 25-dihydroxyvi-tamin levels.37 One series of balance studies onpremature infants has shown that an oral dose of

1,200 to 2,000 IU of vitamin D is needed to achieve

maximal calcium absorption.39 Studies of infantsreceiving a special formula for premature infants

that was high in calcium plus 600 to 700 IU ofvitamin D per day have shown maintenance ofnormal serum 25-dihydroxyvitamin D levels and

calcium balances similar to the fetal retentionrate.4#{176}

The prevention of severe bone disease in prema-ture infants appears to rely on both high oral in-

takes of calcium and phosphorus and at least 500

JU of vitamin D per day. The latter can be achievedby giving 400 IU of vitamin D per day in a multi-vitamin supplement in addition to the vitamin Din the formula. There is no evidence that adminis-

tration of the active vitamin D metabolites, 25-dihydroxyvitamin D or 1,25-dihydroxyvitamin D,

to LBW infants is necessary or advisable.Vitamin E. The requirement for vitamin E, a-

tocopherol, in the small premature infant is higher

than that of the term infant because the fat mal-

absorption of the premature infant also limits theabsorption of fat-soluble vitamins such as vitaminE. The signs of vitamin E deficiency in the LBW

infant include a mild hemolytic anemia4’ and mildgeneralized edema.42 Vitamin E deficiency is exac-

erbated by a high intake of iron or polyunsaturatedfatty acids, each of which increases the vitamin E

requirement.’The recommended intake of vitamin E is 0.7 IU

(0.5 mg of d-a-tocopherol) per 100 kcal and at least

1.0 IU of vitamin E per gram of linoleic acid.’ Inaddition, it has been suggested that the prematureinfant receive 5 to 25 IU of supplemental oralvitamin E per day, because of concerns about the

adequacy of its intestinal absorption.’ However, welack fundamental knowledge about the pharmacol-ogy of vitamin E and its esters, the differences inthe absorption and disposition of oral v intramus-cular v intravenous administration, and preserva-

tives and the vehicles required to solubilize the fattyvitamin. This is highlighted by the recently

reported43 premature infant deaths associated with

an intravenous preparation of the acetate ester ofvitamin E.

Folk Acid. Clinical deficiency of folic acid is

unusual, although premature infants are particu-larly prone to show laboratory evidence of folate

deficiency by hypersegmentation of their neutro-

phils. In LBW infants, a dose of 20 �ag/d does not

prevent low serum folate levels after 2 weeks, but50 �tg/d is effective, and Dallman’ has suggested

that premature infants weighing less than 2,000 greceive that amount. It is important to note that

due to the instability of folic acid in solutions, theliquid multivitamin preparations for infant use donot contain folic acid.

Caloric Density and Water Requirements

The caloric densities of preterm and term human

milk are given in Table 3. These caloric densitieshave been used for feeding LBW infants, but manyprefer to use more concentrated milks, 81 kcal/dL

(24 kcal/oz), when commercial formulas are used.

The increased concentration allows feeding vol-

umes to be smaller, an advantage when gastriccapacity may be limited. The volume given whenformulas of this concentration are fed at the rate

of 120 kcal/kg/d (150 mL/kg/d) provides mostLBW infants with sufficient water for the excretionof protein metabolic products and electrolytes de-

rived from the formula. However, if lower volumes

are given, there may be insufficient water providedfor renal excretion due to the relatively constantextrarenal losses.

Human Milk

A dramatic change in feeding of LBW infants

has taken place recently because a number of stud-ies have shown that LBW infants can be adequatelyfed with their own mothers’ milk. Their mothers’milk leads to a more rapid rate of growth in weight,

length, and head circumference, as well as a shortertime to regain birth weight, than does milk fromthe mothers of term infants.’” Pooled human milkfrom mothers of term infants does not meet all

nutritional requirements of LBW infants and itsuse results in a slower rate of growth than is foundwith consumption of either milk from mothers of

premature infants or commercial formulas.45�9 Thelow protein concentration of pooled term humanmilk is probably the major cause of the poor growth.

Metabolic complications seen when feeding veryLBW infants pooled human milk from mothers ofterm infants include hyponatremia at 4 to 5weeks,’2’�#{176}hypoproteinemia at 8 to 12 weeks,”51 andrickets at 4 to 5 months.52’53 An additional potential

problem seen with use of pooled human milk is thetransmission of cytomegalovirus through the milk

to the infant.Milk from mothers of premature infants, espe-

cially during the first 2 weeks after delivery, con-tains more calories; higher concentrations of fat,protein, and sodium; and lower concentrations of


Nutrient

3 Days

Days Postpartum

7 Days 14 Days 21 Days 28 Days

Calories (kcal/dL)Preterm 51.4 ± 2.4 67.4 ± 1.7 72.3 ± 3.0 65.6 ± 4.3 70.1 ± 3.3Term 48.7 ± 2.0 60.6 ± 4.3 64.2 ± 3.7 68.6 ± 4.0 69.7 ± 2.9

Fat (g/dL)Preterm 1.63 ± 0.23 3.81 ± 0.21 4.40 ± 0.31 3.68 ± 0.40 4.00 ± 0.33

Term 1.71 ± 0.24 3.06 ± 0.46 3.48 ± 0.40 3.89 ± 0.49 4.01 ± 0.30

Carbohydrate (lactose) (g/dL)Preterm 5.96 ± 0.20 6.06 ± 0.18 6.21 ± 0.18 6.49 ± 0.21 6.95 ± 0.27

Term 6.16 ± 0.10 6.52 ± 0.20 6.78 ± 0.19 7.12 ± 0.19 7.26 ± 0.17

Protein (g/dL)Preterm 3.24 ± 0.31 2.44 ± 0.15 2.17 ± 0.12 1.83 ± 0.14 1.81 ± 0.11

Term 2.29 ± 0.07 1.87 ± 0.08 1.57 ± 0.05 1.52 ± 0.06 1.42 ± 0.05

Sodium (mEqJL)Preterm 26.6 ± 3.0 21.8 ± 2.7 19.7 ± 2.3 13.4 ± 1.8 12.6 ± 2.5

Term 22.3 ± 2.4 16.9 ± 2.8 11.0 ± 1.7 10.8 ± 1.6 8.5 ± 1.8

Chloride (mEqJL)Preterm 31.6 ± 2.4 25.3 ± 2.2 22.8 ± 2.2 17.0 ± 1.7 16.8 ± 2.8

Term 26.9 ± 2.4 21.3 ± 2.7 14.5 ± 1.5 15.2 ± 1.9 13.1 ± 2.3

Potassium (mEqJL)

Preterm 17.4 ± 0.1 17.6 ± 0.5 16.2 ± 0.5 16.3 ± 0.9 15.5 ± 0.6

Term 18.5 ± 1.0 16.5 ± 0.5 15.4 ± 0.8 15.8 ± 0.6 15.0 ± 0.7

Calcium (mg/L)Preterm 208 ± 17 247 ± 16 219 ± 12 204 ± 15 216 ± 15

Term 214 ± 38 254 ± 11 258 ± 17 266 ± 25 249 ± 18

Phosphorus (mg/L)Preterm 95 ± 7 142 ± 10 144 ± 8 149 ± 13 143 ± 11

Term 110 ± 12 151 ± 18 168 ± 6 153 ± 14 158 ± 13

Magnesium (mg/L)

Preterm 28 ± 1 31 ± 1

Term 25±5 29±2

TABLE 3. Nutritional Composition of Milk from Mothers Delivering Preterm and at


Term*

*Data from Gross et al.5’ Values are means ±

lactose, calcium, and phosphorus than milk from

mothers of term infants5457 (Table 3). These dif-ferences in composition may be mainly a result of

the lower daily volume of milk produced by themothers of preterm infants as compared with moth-ers of term infants.58 The higher fat content leadsto the higher caloric density of milk from mothers

of preterm infants, which may be advantageous forthe small infant with limited gastric capacity. Thehigher protein content of this “preterm” milk is

sufficient to meet the fetal growth requirement of

nitrogen2 when the milk is consumed at a rate of180 to 200 mL/kg/d.

Human milk contains taurine, a sulfur-contain-ing amino acid present in low concentrations incow’s milk.’ The role of this amino acid in thehuman infant is not clear, and its essential naturehas not been established. Recent studies of prema-

ture infants receiving taurine-supplemented, wheyprotein-predominant-commercial formula have

shown that the added taurine did not enhance theirgrowth,59 production of taurine-conjugated bile

0 acids,�#{176}or fat absorption.6’The anti-infectious qualities of human milk are

30 ± 1

26 ± 2

SEM.

24±1 25±1

29±3 25±2

important attributes. The secretory immunoglobu-

lin A (IgA) in the milk inhibits adherence andproliferation of bacteria at epithelial surfaces andhas an important role in controlling the microbial

environment of the intestinal tract. The secretoryIgA is present in a higher concentration in milkfrom mothers of preterm infants than in milk from

mothers of term infants.62Chessex et al� have shown that the composition

of the weight gain in LBW infants fed their own

mothers’ milk was similar to that reported for fe-

tuses of similar postconceptional age. However, anote of caution has been raised regarding the feed-ing of their own mothers’ milk to premature infants.Forbes� is concerned by the marked variability in

composition of human milk aliquots, and thus thedifficulty of assuring an adequate nutrient intakefor the infant. In addition, it is important to reem-phasize that the nutritional advantages of the milkfrom the premature infant’s own mother are most

obvious in the first month postpartum (Table 3),and these advantages rapidly diminish thereafter.

Mixtures of whey-predominant protein, carbo-

hydrate, calcium, phosphate, trace minerals, and


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TABLE 4. Composition of Special Formulas for Premature Infants*

Ingredient Enfamil SMA SimilacPremature “Preemie” Special Care

Protein (g/dL) 2.4 2.0 2.2

Fat (g/dL) 4.1 4.4 4.4Medium-chain triglycerides 40% 12% 50%Oleo oil 0 20% 0Corn oil 40% 0 30%Oleic oil 0 25% 0Coconut oil 20% 25% 20%

SoyOil 0 18% 0

Carbohydrate (g/dL) 8.9 8.6 8.6Lactose 40% 50% 50%

Glucose polymers 60% 50% 50%

Minerals (mg/dL)tCalcium 95 [48] 75 [37] 144 [72]Phosphorus 48 . . . 40 . . . 72 ...

Sodium 32 [14] 32 [14] 35 [15]

Potassium 90 [23] 75 [19] 100 [26]Chloride 69 [19] 53 [15] 65 [18]Magnesium 8 7 10

Zinc 0.8 0.5 1.2

Copper 0.073 0.07 0.2Manganese 0.021 0.02 0.02Iron 0.13 0.3 0.3Iodine 0.006 0.008 0.015

Vitamins

A (lU/L) 2,540 3,200 5,500D (lU/L) 507 510 1,200E (IU/L) 16 15 30

C (mg/L) 69 70 300B, (mg/L) 0.63 0.8 2B2 (mg/L) 0.74 1.3 5

Niacin (mg/L) 10.1 6.3 40

B6 (mg/L) 0.53 0.5 2B,2 (g/L) 2.5 2 4.5

Ffolic acid (g/L) 240 100 300K, (mg/L) 0.08 0.07 0.1

Osmolality (mosm/kg of water) 300 270 300

* All formulas have a 60:40 whey protein:casein ratio; all contain 81 calories per deciliter.

t Values in brackets are milliequivalents per liter.


vitamins for addition to milk from the mothers ofpreterm infants have been developed by commercial

formula manufacturers. When the fortifiers areadded to milk from mothers in the first postpartum

month, the resultant nutrient, mineral, and vitaminconcentrations approach those of the formulas de-

veloped for feeding premature infants. There havebeen no published studies, as yet, on the nutritionaleffects of human milk fortified by these mixtures.

COMMERCIAL FORMULAS FOR LBW INFANTS

Many findings from studies on nutrient, electro-lyte, mineral, and vitamin needs and tolerances of

LBW infants, which have already been discussedabove, have been applied to the development offormulas specifically designed to meet the needs of

the small premature infant. The common features

of the formulas are whey-predominant proteins,carbohydrate mixtures of lactose and glucose poly-

mers, and fat mixtures containing combinations ofmedium-chain triglycerides and relatively unsatu-

rated long-chain triglycerides. The formulas differin their sodium, calcium, phosphorus, vitamin, andmineral content (Table 4). Each of the special for-

mulas has been shown to be associated with ade-

quate growth and metabolic stability.’6’44’45

METHODS OF ENTERNAL FEEDING

The method of enternal feeding chosen for eachbaby should be individualized on the basis of ges-

tational age, birth weight, clinical state, and expe-rience of nursing personnel. Coordination of suck-

ing, swallowing, and respiration appears at approx-

imately 32 to 34 weeks of gestation. Prematureinfants of this gestational age who are alert andvigorous may be fed by nipple. Babies who are less

mature, are weak, or are critically ill will requirealternate modes of feeding by tube in order to avoid



the risk of aspiration and to conserve energy.Gastric feeding of boluses of milk can lead to

disturbances of blood gas tensions in infants with� 0 respiratory problemssc67; thus, in some, continuous

transpyloric feedings by nasal or oral tubes may bebetter tolerated.’ Clinical results of this feeding

mode have been excellent in many centers, but

there has been some criticism that bypassing the

stomach and duodenum by a jejunal tube may causeinefficient utilization of the nutrients in the for-mula.ss69 Continuous gastric feeds may be toleratedby many small infants better than are bolus gastric

feeds, and are satisfactory if gastric emptying is notlimiting in the infant. Bolus feeds into the stomachvia gavage tube or by nipple, every two to three

hours, is the goal once the LBW infant has showna clearing of the respiratory distress and gastric

emptying is not a problem. Whatever the mode offeeding, the formula volume should be advanced

slowly-over at least ten to 14 days in infantsweighing less than 1,000 g and over six to eightdays in LBW infants weighing more than 1,500 g.This allows adaptation of the intestinal tract to

enteral feeds without the development of vomiting,

distention, and diarrhea.

PARENTERAL NUTRITION

Parenteral administration of glucose, fat, and

amino acids is frequently an essential part of the0 nutritional care of premature infants, particularly

those weighing less than 1,500 g. The high incidenceof respiratory problems, limited gastric capacity,and intestinal hypomotility in very small prematureinfants dictates the need to advance the volume of

enteral feeds slowly. The availability of parenteralnutritional components enables supplementation of

the slowly advancing enteral feedings so that thetotal daily intake by both routes meets the nutri-tional needs of the infant. When necessary, full

nutritional requirements can be met for long pe-nods by the parenteral route alone.

A positive nitrogen balance, and thus the achiev-

ing of an anabolic state, can occur with parenterallipid and/or glucose caloric intakes of 60 kcal/kg/dand amino acid intakes of 2.5 to 3.0 g/kg/d.70’71With higher nonprotein caloric intakes of 80 to 85

kcal/kg/d and amino acid intakes of 2.7 to 3.5 g/kg/d, nitrogen retention occurs at the fetal rate.72’73

Growth requires a minimal parenteral nonproteincaloric intake of 70 kcal/kg/d.

The nonprotein caloric sources are glucose andlipid. Use of glucose as the sole nonprotein caloric

source presents several problems. The osmolality

of a solution, dependent largely on the glucose

0 content, limits to about 13 g/dL the concentrationthat can be used via peripheral veins. Higher con-

centrations cause undue local irritation. In addi-tion, small premature infants have a poor glucose

tolerance in the first days of life, with hypergly-cemia (>125 mg/dL) appearing frequently at glu-cose infusion rates exceeding 6 mg/kg/mm.74 Thus,in order to avoid the potentially damaging effects

of widely varying serum osmolality, and in order toavoid the dehydrating effects of an osmotic diuresis

from significant glycosuria, glucose infusion should

start at a rate less than 6 mg/kg/mm. Usually asteady increase of the glucose infusion rate stimu-lates endogenous insulin secretion and an infusion

rate of 11 to 12 mg/kg/mm (130 to 140 mL/kg/d ofa 13-g/dL solution) is tolerated after five to sevendays. If not, insulin may have to be administered

to achieve a caloric intake sufficient for growth.Care must be exercised in the use of insulin because

the very low-birth-weight infant may experiencewide swings of blood glucose level with resulting

periods of hypoglycemia. Blood glucose levels also

may be augmented by intravenous lipid supple-

ments through effects of serum free fatty acids onglucose and insulin metabolism.75

The availability of intravenous lipid preparations

has allowed the provision of calories adequate forgrowth via peripheral veins. The lipids have a highconcentration of calories, 1.1 kcal/mL in the 10%preparations, and the solution is isosmotic withplasma and thus is not irritating to the veins. The

tolerance for parenteral fat is less in the newbornthan in the older child and is further diminished in

the very small premature infant.76’77 In addition,

intrauterine growth retarded infants have even lessparenteral fat tolerance than would be predictedfrom their gestational ages.76’78 Thus, in LBW in-

fants, lipids should be administered around the

clock, should be started at 0.5 to 1.0 g/kg/d, andshould be increased by 0.5 g/kg/d to a maximum of2.0 to 3.0 g/kg/d. To avoid hyperlipemia, the rate

of lipid infusion should not exceed 0.25 g/kg/h. Fattolerance can be only roughly assessed on the wardbecause visual estimation of plasma lactescence in

a spun hematocrit tube is not reliable.79 Thus, suchmonitoring can be supplemented by periodic esti-mations of the serum triglyceride levels, whichshould be kept below 150 mg/dL.

The use of intravenous lipids should be restricted

in the presence of hyperlipemia. Hyperlipemiashould be avoided because it can interfere withpulmonary gas diffusion.�#{176}’8’ Additional possible

pulmonary complications of parenteral lipid in pre-

mature infants include fat globules in capillaries oralveolar macrophages82’� and fat in pulmonary ar-

teriolar lining cells.M However, such changes canalso occur in premature infants who have not re-

ceived parenteral lipids.ss The relationship of car-


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REFERENCES

1. American Academy of Pediatrics, Committee on Nutrition:Nutritional needs of low-birth-weight infants. Pediatrics1977;60:519-530

2. Ziegler EE, Biga RL, Fomon SJ: Nutritional requirementsfor the premature infant, in Suskind RM (ed): Textbook ofPediatric Nutrition. New York, Raven Press, 1981, p29

3. Reichman B, Chessex P, Putet G, et al: Diet, fat accretion,and growth in premature infants. N Engi J Med

1981;305:1495-15004. Brooke OG, Alvear J, Arnold M: Energy retention, energy

expenditure, and growth in healthy immature infants. Pe-diatr Res 1979;13:215-220

5. Reichman BL, Chessex P, Putet G, et al: Partition of energymetabolism and energy cost of growth in the very low-birth-weight infant. Pediatrics 1982;69:446-451

6. Okamoto E, Muttart CR, Zucker CL, et a!: Use of medium-chain triglycerides in feeding the low-birth-weight infant.Am J Dis Child 1982;136:428-431

7. Hamosh M, Scanlon JW, Ganot D, et al: Fat digestion in


nitine deficiency to poor lipid tolerance of the par-

enterally fed premature infant is uncertain. Suchinfants are not receiving carnitine in the parenteral

solutions and their blood and tissue carnitine levelsare low.� However, there is no evidence thatproviding carnitine would be beneficial.

The use of intravenous lipids should be restricted

in the presence of hyperbilirubinemia.The nitrogen in parenteral nutrition solutions is

most commonly provided as a mixture of crystallineamino acids. Such amino acid mixtures have gen-

erally replaced the protein hydrolysates used pre-viously. Not only is the nitrogen of the amino acid

solutions utilized better than the nitrogen of pro-tein hydrolysates,72 there is also a lower incidenceof hyperammonemia. However, hyperammonemia

as well as metabolic acidosis can be seen whenparenteral amino acids are given at a rate exceeding

3.5 g/kg/d.The commercially available parenteral amino

acid solutions are not specifically designed for thepremature infant. Moreover, the ideal composition

of these solutions for the premature infant is notknown. In addition, it is not clear whether specificamino acid requirements for newborn infants ex-

tend to parenteral amino acid needs. Cysteine hasbeen considered to be an essential amino acid fornewborn infants because of low activities of cysta-

thionase, the enzyme that converts methionine tocysteine, in newborn hepatic tissue.’ However, cys-

teine supplementation of cysteine-free parenteral

amino acid solutions did not improve nitrogen bal-ance or growth of a group of premature and termnewborn infants.89

The intravenous requirement of elemental cal-

cium and phosphorus is at least 30 to 40 mg/kg/deach. The estimated intravenous requirement ofmagnesium is 15 to 25 mg/d.

The parenteral trace metal requirements for in-

fants have been estimated by Shils et al#{176}#{176}to be:

zinc, 300 �g/kg/d; copper, 20 �sg/kg/d; chromium,0d4 to 0.2 �ig/kg/d; and manganese, 2 to 10 �g/kg/

d. Approximate amounts, based on these estimates,should be added to each daily fluid volume. Morerecent studies by Zlotkin and Buchanan,9’ however,

suggest that higher intakes, 438 �g/kg/d of zinc and63 �ag/kg/d of copper, are needed for LBW infantsto duplicate intrauterine accretion rates of thesemetals.

Other trace elements, the need for which is basedon animal experiments or presence in human en-

zyme systems, include selenium, vanadium, molyb-

denum, nickel, tin, silicon, and arsenic. Specificrecommendations for their use await further stud-

ies.Recommended vitamin requirements for infants

can be met by giving the daily amount recom-

mended for children,92 now available commerciallyin a lyophilized preparation (MVI-Pediatric). Theprovision of fat-soluble vitamins parenterally is

complicated by adherence of some of the adminis-

tered vitamins to the plastic bags and tubing.93

CONCLUSION

Nutrition supply to LBW infants plays a major

role in the ultimate outcome of the ever-increasing

number of surviving prematurely born infants. Rec-ognizing the potential damage from inadequate nu-

trition during the early neonatal period, the di-lemma of feeding the premature infant is that of

attempting to provide sufficient nutrition to assureoptimal development without additional morbidityor mortality associated with feeding. Nutritional

needs can be provided by enteral or parenteralmeans or a combination of both. Current researchhas focused on the promising use for premature

babies of their own mothers’ milk as well as newspecial formulas for those babies needing breastmilk substitutes. The use ofparenteral supplements

and, indeed, long-term total parenteral nutritionhas allowed for the more optimal provision of nu-trition to these vulnerable infants.

COMMITTEE ON NUTRITION, 1984-1985

Alvin M. Mauer, MD, Chairman

Harry S. Dweck, MDLaurence Finberg, MD

Frederick Holmes, MD

John W. Reynolds, MDRobert M. Suskind, MDCalvin W. Woodruff, MD

Section LiaisonStanley Hellerstein, MD



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: 12. Kumar SP, Sacks LM: Hyponatremia in very low birth: weight infants and human milk feedings. J Pediatr: 1978;93:1026-1027

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