Nutritional follow-up of the breastfeeding premature infant after hospital discharge

ABM Clinical Protocol #12: Transitioning the Breastfeeding Preterm Infant from the Neonatal Intensive Care Unit to Home, Revised 2018

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols, free from commercial interest or influence, for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Post-discharge nutrition and the VLBW infant: To supplement or not supplement?: a review of the current evidence

Due to advancements in neonatology, the survival of very-low-birth-weight infants, especially extremely low-birth-weight infants continues to rise. The goal of nutrition in these preterm infants is to match the intrauterine growth curves of the normally growing fetus. Despite this recommendation from the American Academy of Pediatrics Committee on Nutrition, neonatologists struggle daily to meet this goal, and as a result, postnatal growth failure and restriction are common. This article reviews post-discharge nutrition in the VLBW population, examining different types of post-discharge nutrition, current evidence, and future and remaining questions. In addition, recommendations are provided for post-discharge nutrition in this population.

Nutrient enrichment of mother's milk and growth of very preterm infants after hospital discharge

OBJECTIVE

To determine if the addition of a multinutrient human milk fortifier to mother's milk while breastfeeding very preterm infants after hospital discharge is possible and whether it influences first-year growth.

METHODS

Of a cohort of 320 infants (gestational age: 24-32 weeks; birth weight: 535-2255 g), breastfed infants (65% [n = 207]) were randomly assigned shortly before hospital discharge to receive either unfortified (n = 102, group A) or fortified (n = 105, group B) mother's milk until 4 months' corrected age (CA). The remaining infants were bottle-fed with a preterm formula (group C). Follow-up was performed at term and at 2, 4, 6, and 12 months' CA.

RESULTS

Mean duration of breastfeeding after term was not significantly different between groups A and B (11.8 and 10.6 weeks, respectively). Weight, length, and head circumference were not significantly different between groups A and B at 12 months' CA. Compared with groups A and B, infants in group C had a higher increase in weight z score until term and in length z score until 6 months' CA. At 12 months' CA, boys in group C were significantly longer and heavier compared with those in groups A and B, whereas girls in group C were longer and heavier compared with those in group A only. A higher protein intake was related to a higher serum urea nitrogen level and growth.

CONCLUSIONS

Fortification of mother's milk after hospital discharge while breastfeeding very preterm infants was possible without influencing breastfeeding duration but did not significantly influence growth parameters at 1 year of age compared with unfortified mother's milk.

Preterm infants with chronic lung disease: are protein and energy intakes after discharge sufficient for optimal growth?

AIM

To document post-discharge feeding practices of preterm infants with chronic lung disease (CLD) and determine if sufficient protein and energy is consumed for optimal growth.

METHOD

Protein and energy intakes of preterm infants with CLD were quantified through detailed analysis of measured food and fluid intakes at four corrected age (CA) assessments, post-discharge. Most of the infants were in hospital for the term assessment. Milk intake from breastfeeding was determined by test weighing. Protein and energy intakes were compared with the Australian and New Zealand Nutrient Reference Values (NRV) for healthy term-born infants, and CA z-scores for weight, length and head circumference were calculated using Australian national gestational growth data and Centre for Disease Control 2000 growth data.

RESULTS

Ten of the 28 CLD infants who were exclusively receiving expressed breast milk in hospital were transitioned to infant formula within 1 month of discharge. Complementary foods were introduced at a median CA of 3.6 months. Protein intakes almost always exceeded the NRV for healthy term-born infants, and at each assessment, at least 63% of infants met the energy NRV. Longitudinal growth data are available for 20 infants, four of whom had been small for gestational age. At the 12-month assessment, 10 of these infants weighed less than the 10th percentile.

CONCLUSION

Preterm infants who develop CLD do not always achieve reference growth in their first year following discharge, despite protein and energy intakes being mostly comparable to those recommended for healthy term-born infants.

Breast milk odor via olfactometer for tube-fed, premature infants

Human newborns use odor cues to orient to their source of nutrition. However, tube-fed, premature infants have restricted chemosensory experience. New methods of introducing breast milk odor to tube-fed premature infants will permit empiric tests of the effect of controlled exposure to nutrient odor. We therefore developed an infant olfactometer and piloted its use in 7 tube-fed, premature infants in the neonatal intensive care unit. Since nonnutritive sucking shortens the amount of time required to wean from tube-feeding, we tested the effect of breast milk odor on nonnutritive sucking. Six out of 7 subjects responded to breast milk odor with an increase in number of sucks. Statistical analysis supported the hypothesis that breast milk odor reinforces nonnutritive sucking. These results indicate the feasibility and potential of this experimental approach, and warrant further study of the effect of controlled nutrient odor exposure on feeding behavior of premature infants.

Enteral nutrition for premature infants: the role of human milk

Nutrition support of the premature infant must be designed to compensate for metabolic and gastrointestinal immaturity, immunologic insufficiency, and the demands of associated medical conditions. The beneficial effects of human milk extend to the feeding of premature infants. Although human milk enhances immunity, nutritional concerns arise because the milk might not meet the expanded nutrient requirements of very low birth weight premature infants. Human milk fortifiers are available to provide optimum nutrition. This chapter summarizes the benefits and limitations of human milk for the premature infant.

Post-discharge nutrition for the preterm infant

Newly designed, 'enriched,' formulas are now available for the formula feeding premature infant after hospital discharge. These new formulations add to the array of milks from which to choose when the discharge of the premature infant is approaching. However, the data to support optimal or reference nutrient intakes to use for the premature infant in the post-discharge are lacking. Breastfeeding should be encouraged as its beneficial effects may be related to the duration in which it is fed. Infants at risk for growth failure in the post-discharge period, such as infants unable to consume ad libitum intakes of milk, and who already have growth faltering or abnormal nutritional indices, may benefit for the addition of enriched formula. This review summarizes the recent data and comments on recommendations on post-discharge nutrition for premature infants.