strengthening nicu healthcare professionals’ knowledge...

Strengthening NICU Healthcare Professionals’ Knowledge

NICUCurrentsJuly 2012 • Volume 3, Issue 2

Nutritional Discharge CriteriaOnline post test - see page 8 for details.1

HeadlineBy Author

Transitioning the Preterm Neonate from Hospital to Home: Nutritional Discharge Criteria By Andrea Adler, RD, CSP, LD and Sharon Groh-Wargo, PhD, RD, LD

LearnIng ObJectIVesAfter reading this article the reader will be able to:

• List potential nutrient deficits accumulated prior to discharge.

• Describe options and strategies for nutritional support at discharge.

• Identify issues related to feeding progression following discharge.

Infants born less than 37 weeks gestational age (GA) are considered premature and planning their discharge may require multi-

ple professional teams. Criteria for discharging a preterm infant are based on physiologic pa-rameters.1 These include stability (good weight gaining pattern, maintenance of body tem-perature, feeding without cardio-respiratory compromise), active parent involvement and medical follow-up appointments that include monitoring of growth and development.1

General InformationOptimal nutrition is essential for growth and development throughout infancy and into childhood.2 Babies born between 34 to 37 weeks GA are considered late-preterm (“near-term”) infants. These neonates are usually able to begin enteral nutrition after birth. Infants born less than 34 weeks GA usually begin parenteral nutrition (PN) within the first 24 hours of life.2 Enteral nutrition is initiated and advanced based on the neonate’s tolerance.2

Several growth charts are used in Neo-natal Intensive Care Units (NICU) and at discharge. The Fenton Growth Chart is used for preterm infants until they reach 50 weeks

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2 | July 2012 NICU Currents

Feature: Nutritional Discharge Criteria

post-conceptional age (Figure 1). Once a pre-term infant reaches 40 weeks GA, the American

Academy of Pediatrics (AAP) and the Center for Disease Control (CDC) recommend plot-

ting infants on the World Health Organization (WHO) growth chart rather than the CDC’s.4 (Table 1)

The nutrition goal is to bring the nutrient status of preterm infants to normal as soon as possible.10 Nutrition recommendations for catch-up growth of preterm infants exceed those for term infants.11 There are no evidence-based recommendations on when to transition from using preterm nutrient requirements, such as the recommendations from ESP-GHAN, Tsang, or the IOM nutrient require-ments.7,8,9 However, it is speculated that this change should take place after 40 weeks cor-rected GA based on the patient’s clinical status.

Feeding AbilitiesOral-motor skills develop as the fetus grows in-utero and during the postnatal period. The majority of preterm infants are not ready to feed orally at birth. Around 34 weeks GA, suck-swallow coordination and gag mecha-nisms mature; however; suck-swallow-breathe coordination does not fully develop until 37 weeks GA.12,13 Infants are transitioned from gavage feedings to breast or bottle feedings in preparation for discharge. Patients may be dis-charged home with nasogastric feeding tubes if they are physiologically ready, but still unable to completely orally feed.1

In rare instances, a gastrostomy tube (G-tube) may be needed for an infant to be dis-charged home sooner. Conditions that warrant such feedings include short bowel syndrome, neurological impairment, marked oral aver-sion, inability to consume sufficient volume from nipple feeding or congenital anoma-lies.12,14 Care is taken not to overfeed via the G-tube as that may cause the device to leak formula or gastric content onto the skin.14

Human Milk/BreastfeedingHuman milk has a unique composition, helping protect against childhood obesity, Crohn’s disease, lymphoma, leukemia and diabetes.2 It also decreases the incidence of diarrhea and necrotizing enterocolitis.2,12,15 Human milk contains docosahexaenoic acid (DHA) and arachidonic acid(ARA), two long chain poly-unsaturated fatty acids that play a role in visual acuity, growth and cogni-tive development.2,12

Figure 1: Fenton Growth Chart3

NICU Currents July 2012 | 3

As with full-term neonates, human milk offers advantages to preterm infants. Despite higher amounts of nutrients compared to term milk, preterm human milk does not contain optimal nutrition to promote growth in preterm in-fants.16 Preterm milk composition transitions to term milk composition around 4 weeks after a preterm infant is born.17 Cochrane Reviews re-port that fortifying human milk supports short-term weight gain, length and head circumfer-ence growth and possible increases in bone mineral content (BMC).10

Little evidence is available to guide planning for the discharge of human-milk-fed preterm in-fants. O’Connor et al studied the effects of add-ing commercial human milk fortifier to half of human milk feeds for 12 weeks after discharge. The intervention group showed improvements over the first year of life in weight, length, BMC, and head circumference measurements,

compared to the control group receiving un-fortified human milk. The intervention group also showed a trend in successful completion of language and motor skills on the Bayley Index II scales.19 Even so, fortification did not increase percent body fat or trunk-fat mass.18,19

On the other hand, research by Zacharias-sen et al showed that small amounts of forti-fication added to human milk until 4 months CA did not significantly affect growth at 1 year CA, compared to feeding human milk alone.20 However, the increased amount of protein and phosphorus improved BUN levels—a marker for protein synthesis—and serum phosphorus levels, which may potentially improve growth.20

Birth weight, discharge weight, risk factors, and serum levels should all be taken into ac-count to determine if the preterm infant at dis-charge can be adequately fed with human milk alone. When indicated, fortification can be

added in several ways: (1) addition of commer-cial human milk fortifier to expressed human milk (under close medical supervision), (2) two to four feedings per day of nutrient-enriched formula along with breastfeeding or (3) addi-tion of nutrient-enriched formula powder to expressed human milk to increase the caloric density (more accurately called ‘enrichment’).

Option one, using commercial human milk fortifier, may be indicated for extremely low–birth-weight infants who are still small at discharge, infants who have continuing medical problems such as bronchopulmonary dysplasia (BPD), and/or have BUN levels less than 9 mg/dL, alkaline phosphatase levels higher than 600 U/L or phosphorus levels less than 5 mg/dL. Option three adds energy but little additional protein or micronutrient content. Although there are currently no recommendations about fortification of human milk after discharge,

Table 1: Description of Growth Charts3,4,5,6

growth chart type of curve age Pros cons

Fenton Intrauterine growth chart (representing ideal fetal growth) and postnatal growth chart

22–50 weeks • More recent chart • Data based on meta-analysis• Weight is smoothed between 36–46

weeks GA; length and head circumference are smoothed at 22 weeks, to connect intrauterine growth and post term growth.

• Follow-up limited to 2 months CGA• Does not account for initial

postnatal weight loss• Preterm infants’ growth typically

does not exceed the intrauterine growth curve

• Anthropometrics obtained from different infants with different gestational ages.

Olsen Intrauterine growth chart (representing ideal fetal growth)

23–41 weeks • Recent growth chart accounting for medical advances in the last 3-4 decades

• Large, racially-diverse population from US data

• Gender specific• Compares weight, length and head

circumference for the same infant• Newer statistics for birth classification by GA

(small, appropriate, or large)• Data validated on separate subsamples• Good chart for young babies at immediate

post-discharge.

• May not be representative of all infants, especially of older GA, as data was obtained only on infants admitted to the NICU.

World Health Organization (WHO)

Postnatal growth chart (reflects initial weight loss after birth)

Term and preterm infants at 40 weeks CGA- 23 months of age

• Shows how children should grow for best health outcomes

• Multi-regional data• Separate charts for boys and girls.

• Only used for preterm infants at 40 weeks corrected age

• Doesn’t show “catch-up” growth.



based on available research18,19,20 the authors rec-ommend the following parameters for consider-ation of fortification after discharge. See Table 2 for a nutrient comparison of the three options.

Infant FormulasPreterm infant formulas (Similac® Special Care® or Enfamil® Premature Formula) are recommended in the NICU if human milk is not available for infants with a birth weight <1,500g.12 These formulas are designed to meet the increased nutrient needs of prema-ture infants and contain higher amounts of macro- and micronutrients.12, 23 As they near weights of 2,500-3,500 grams (the weight depending on the brand of formula), pre-term infants must be transitioned from com-mercial preterm infant formulas to nutrient-enriched formulas, or the intake of Vitamins

A and D will become excessive.21,22,24 Infants on commercial preterm infant formula have been shown to have a growth rate at or above intrauterine growth.23

Nutrient-enriched infant formulas (Simi-lac Expert Care™ NeoSure® or Enfamil® En-faCare®) are recommended if human milk is not available for infants with a birth weight >2,000g, or as a transition formula from the hospital to home.21,22,24 These formulas contain a nutrient composition greater than term -infant formulas but less than preterm infant formulas. Depending on birth weight, nutrient enriched formulas are recommend-ed through 12 months corrected gestational age (CGA). Infants (especially those less than 1,250 grams at birth) on nutrient enriched formula until 9-12 months CGA show im-provement in bone growth/mineralization

and growth when compared to preterm in-fants fed standard term formula.24

Cochrane Reviews evaluated seven stud-ies of preterm infants fed either a nutrient-enriched formula or a standard term infant formula at discharge. The studies found no strong evidence that at 18 months CGA, nutrient-enriched formula supported better growth and development than standard-term formula.25 Between term and 6 months CA, preterm infants on nutrient-enriched formu-la may gain more lean mass and less fat mass than preterm infants fed standard-term for-mula.26 Regarding use of nutrient-enriched formulas, the AAP and the American College of Obstetricians and Gynecologists recom-mend that “Small, preterm neonates (born at or before 34 weeks of gestation, with a birth weight less than or equal to 1,800 g) and neo-

Table 2: Composition of Human Milk and Formulas21,22

Human Milk as the base Preterm Formula nutrient enriched Formula

nutrient per 100 calories

Human Milk

Human Milk + nutrient enriched Formula ~24 cal/oz

Human Milk alternating with nutrient enriched Formula ~

Human Milk + HMF ~24 cal/oz

similac® special care®

enfamil® Premature Formula

similac expert care™ neosure®

enfamil® enfacare®

Energy, Cal 100 100 100 100 100 100 100 100

Protein, g 1.5 1.8 2.2 2.9 3.0 3.0 2.8 2.8

Vit A, IU 331 344 366 1222 1250 1250 350 450

Vit D, IU 3 15 37 172 150 240 70 70

Calcium, mg 41 54 77 162 180 165 105 120

Phos, mg 21 29 43 89 100 83 62 66

Iron, mg 0.04 0.35 0.9 1.1 1.8 1.8 1.8 1.8

Zinc, mg 0.18 0.35 0.6 2.5 1.5 1.5 1.2 1

Mixing instructions

NA 75ml breast milk + 1 teaspoon nutrient enriched formula powder

Alternate feeds of human milk and nutrient enriched formula 22 calorie/ounce

25 ml breast milk + 1 packet per vial HMF

NA NA NA NA

Note: Human milk is based on assumed composition of term human milk~ indicates an average of Similac® and Enfamil® products; Similac® products are made by Abbott Nutrition in Columbus, Ohio and Enfamil® products are made by Mead Johnson Nutrition in Evansville, Illinois


Table 3: Commonly Used NICU Medications at Discharge and Nutrient Interactions32,34-37

Medication Usage Interaction

Caffeine Apnea of prematurity May cause nausea, vomiting, GI intolerance, necrotizing enterocolitis, or GI hemorrhage.

Chlorothiazide Diuretic Monitor electrolytes, Ca, Phos, glucose. Delay in growth due to low serum Na, K, and Cl, which may need to be supplemented. Decreases renal excretion of Ca. Caution with Ca supplements due to an increased risk for nephrocalcinosis. May cause nausea, vomiting, constipation, or GI intolerance.

Digoxin Antiarrhythmic May decrease K and Mg or increase Ca and Mg. May cause feeding intolerance, nausea, vomiting, or diarrhea. Caution with calcium and vitamin D supplements.

Erythropoietin Stimulates erythropoiesis Increased iron needs.

Famotidine H2 antagonist May cause constipation, diarrhea, nausea, or vomiting. Increased risk for late-onset bacterial and fungal sepsis, however no short-term adverse effects have been seen.

Furosemide Diuretic Monitor serum and urine electrolytes and renal function throughout duration of usage. May cause nephrocalcinosis or nephrolithiasis. Monitor weight and fluid status. Bone demineralization may occur with long-term usage.

Metoclopramide Prokinetic GI agent May improve feeding intolerance. May cause increase in irritability or vomiting, nausea, diarrhea or constipation.

Phenobarbital Anticonvulsant May decrease serum Ca, vitamin K, vitamin B12, vitamin C, vitamin D, and folate. May cause decreased bone density. May cause nausea, vomiting, constipation, or megaloblastic anemia.

Ca: calcium; Cl: chloride; GI: gastrointestinal; K: potassium; Mg: magnesium; Na: sodium; Phos: phosphorous

nates with other morbidities (e.g. BPD) may benefit from the use of such formulas for up to 9 months after hospital discharge.”27

Standard term infant formula can be used if human milk is not available for late-preterm (near-term) infants.23 Standard term formu-las have compositions similar to that of term human milk. However, they are not recom-mended for preterm infants, even at discharge, because of their inadequate nutrient density.23

Soy infant formulas are also not recommend-ed for preterm infants. According to the 2008 AAP statement on soy infant formulas, preterm infants receiving soy infant formulas had lower serum phosphorous levels and higher alkaline phosphatase levels than preterm infants fed the standard term cow’s milk based formula.28 Even with calcium and Vitamin D supplementation, preterm infants fed soy formula are at risk for metabolic bone disease.28

Although hydrolyzed and elemental for-mulas are not intended for premature infants, sometimes they are better tolerated, allowing for more rapid advancement to full enteral feeding.30 Hydrolyzed formulas are hypoaller-genic; they reduce the risk of allergic reaction to cow’s milk protein.23 Elemental (amino acid-

based) formulas are non-allergenic; they do not contain milk protein, fructose, galactose, lac-tose, gluten or soy protein.22,29 These formulas are used for severe cow’s milk protein allergy or other food protein allergies. Additional vitamin and mineral supplementation may be necessary when hydrolyzed protein or elemental formu-las are fed to preterm infants.12

Table 2 lists common formulas used in the NICU and at discharge, along with their nutri-ent composition. Refer to product handbooks for specific recipes to enrich human milk with nutrient-enriched formula or for increased ca-loric density formula recipes.21,22

Vitamins and MineralsCommon supplements prescribed at discharge include Vitamin D and iron (Fe). Other sup-plements may also be prescribed, including cal-cium, phosphorous, zinc (Zn) and electrolytes.

Vitamin D deficiency is a common prob-lem across the human lifespan. In 2008, the AAP recommended supplementation of 400 International Units of vitamin D for all in-fants, starting within the first few days of life.31 Infants receiving human milk, even if supple-mented with some formula, should receive a

liquid multivitamin throughout the first year of life.31 Formula-fed infants should receive the vitamin D supplement until they con-sume at least 1 liter of formula a day.31

The AAP recommends that preterm in-fants receive 2-4mg Fe/kg/day.32 Commer-cial iron-fortified formula provides 2mg Fe/kg/day and unfortified breast milk provides 0.5mg Fe/kg/day (based on the infant’s receiving 150ml/kg/day). Preterm infants receiving human milk should continue Fe supplements until weaned to formula, or are eating 2mg Fe/kg in complementary foods.32 Ferrous sulfate is the most effectively ab-sorbed form of iron for the newborn.2

Depending on a diagnosis of illness (i.e. metabolic bone disease), medications used at discharge, or the formula being fed, prema-ture infants may require additional mineral supplementation. Since soy protein, hydro-lyzed protein and elemental formulas are not intended for premature infants, calcium and phosphorous supplementation may be needed. Supplemental Zn may be beneficial in preterm infants receiving unfortified human milk.33 Table 3 reviews the common medications that preterm infants may receive after discharge.



Table 4 lists the composition of the most com-mon vitamin and mineral supplements.

Nutrition Problems: Feeding intoleranceFeeding intolerance is common in preterm infants. The most common problems in-clude uncontrolled reflux, spit-ups and con-stipation. In addition, there may be medical conditions associated with feeding intoler-ance, such as gastroesophageal reflux disease or necrotizing enterocolitis associated with short bowel syndrome.

Gastroesophageal Reflux Prematurity is a risk factor for gastroesopha-geal reflux (GER). GER occurs when stom-ach contents move up the esophagus and possibly into the mouth. In some cases, GER is a symptom of gastroesophageal reflux dis-ease (GERD).38

Three to ten percent of premature infants weighing less than 1,500 grams have symp-tomatic GER.38 Positioning and dietary changes are two methods that may help treat

symptomatic GER. Interventions for GER are discussed in the article entitled: “Evidence-based treatment of gastroesophageal reflux in neonates” by Susan Pfister, RN, CNNP, MA in the June 2012 issue of Nurse Currents.

Compared to formula feeding, human milk feeding results in shorter episodes of reflux. It is controversial if changing the type of formula or milk alters the incidence or se-verity of reflux.35,38 In case of GER, the type of feed may be changed for a 1-2 week trial. If no improvement is seen, the infant should be changed back to the previous formula, as appropriate for age and other clinical con-ditions.35 Small, frequent feeds decrease the incidence of reflux.35,38

Thickening the feeds with rice cereal. It is not physiologically appropriate for preterm infants, and may cause constipation.38 Com-mercial anti-reflux formulas that thicken upon contact with gastric contents should be used with caution, as they do not meet the nutritional requirements of premature or former premature infants.35,38 Anti-reflux

formulas have been shown to reduce the amount and severity of reflux. However, the affect of the additional thickening in the anti-reflux formula may be reduced if the infant is on H2 blockers.35 In May 2011, the Food and Drug Administration (FDA) recommended that ‘Simply Thick’, a gum-based thickener, not be used in infants born premature (<37 weeks) while in the hospital and 30 days post-discharge.39

Metabolic Bone DiseasePreterm infants are at risk for developing metabolic bone disease (MBD), formerly known as osteopenia of prematurity. MBD is diagnosed by clinical and biochemical findings.35,36 Preterm infants miss the rapid third trimester fetal accretion of calcium and phosphorous which accounts for ~80% of the mineral stores available at term.35,36,40

If the infant with a history of MBD is dis-charged on unfortified human milk, serum phosphorous and alkaline phosphate should be checked at four- and eight-weeks post dis-

Table 4: Common Vitamin and Mineral Supplementation for Discharge21,34

Product enfamil® Poly-Vi-sol® (with Fe) #

enfamil® tri-Vi-sol® (with Fe) #

enfamil® D-Vi-sol™ #

enfamil® Fer-In-sol® #

aquaDeKs™ * ergocalciferol **

Dosage 1 ml 1 ml 1 ml 1 ml 1 ml 1 ml

Vit A 1500 IU 1500 IU - - 5751 IU (87% beta carotene)

-

Vit D 400 IU 400 IU 400 IU - 400 IU 8000 IU

Vit K - - - - 400 mcg -

Vit E 5 IU 35 IU - - 50 IU -

Vit C 35 IU - - - 45 IU -

Thiamin 0.5 mg - - - 0.6 mg -

Riboflavin 0.6 mg - - - 0.6 mg -

Biotin - - - - 15 mcg -

Niacin 8 mg - - - 6 mg -

Vit B6 0.4 mg - - - 0.6 mg -

Vit B12 2 mcg (0mcg) - - - 0 mcg -

Fe 0 mg (10mg) 0 mg (10mg) - 15mg - -

Zn - - - - 5 mg -

Note: # Mead Johnson Nutrition in Evansville, Indiana; listed nutrients are from elemental Fe and D3* Yasoo Health Inc in Johnson City, Tennessee [Other brands of water-soluble vitamin supplements are available; nutrient concentrations may vary.]** Vitamin D2 – Drisdol® by Sanofi Aventis US LLC in Bridgewater, New Jersey; Calciferol™ by Schwarz Pharma in Milwaukee, Wisconsin.


charge.41 Since some infants who go home on unfortified breast milk develop MBD post-discharge, continuation of human milk fully or partially fortified with commercial human milk fortifier should be considered, especially for extremely low birth weight in-fants or infants with abnormal phosphorus and/or alkaline phosphatase levels.41

Commercial human milk fortifiers are difficult to obtain outside of the hospital. Infants who are provided with human milk fortifiers at hospital discharge must be closely monitored. Formula-fed infants with a history of MBD are candidates for con-tinuation of preterm infant formula. Picaud et al found that two months after discharge, preterm infants fed commercial preterm formula had better gains in weight, head circumference, and bone mineral content (BMC) and BMD, compared to the infants fed term formula.42

Treating MBD may be accomplished in several ways. Infants who weigh <3.5kg can be discharged on human milk fortified with commercial human milk fortifier or commercial premature infant formula, and receive close monitoring/follow-up from a registered dietitian. Other options for the human milk-fed infant include alternating each feed of unfortified human milk with a feeding of a nutrient enriched formula, or enriching expressed human milk with nutrient-enriched formula powder. All of these feeding plans increase protein as well as calcium and phosphorous intake. Formu-la-fed infants with MBD are discharged on a commercial preterm or nutrient-enriched formula. If a soy protein, hydrolyzed pro-tein or elemental formula is required, cal-cium, phosphorous, and possibly vitamin D supplementation is recommended to increase levels to the commercial preterm or nutrient-enriched formula content. Supplementation is generally continued until biochemical and radiographic findings determine healing.

Necrotizing EnterocolitisNecrotizing enterocolitis (NEC) is a disease affecting any part of the GI tract.35 Most commonly, NEC affects the ileum, jejunum or colon.43 Twenty to forty percent of all in-

fants with NEC will need surgery. Surgery may lead to short bowel syndrome (SBS) or, one to two months after the operation, development of strictures.44 Very low birth weight infants who survive NEC are at risk for neurodevelopmental, neurosensory and functional disabilities, as well as feeding is-sues (oral aversion or malabsorption).44

Initial nutrition management of a preterm infant with surgical NEC includes PN. Most infants are either transitioned off PN onto enteral feeds before discharge from the hospital, or transferred to an inpatient rehabilitation center. If human milk is not available, a hydrolyzed or elemental formula may result in better feeding tolerance than a formula with intact proteins. In any case, the choice of formula must be individual-ized.35,43 Preterm infants with NEC or SBS should be followed after discharge by a reg-istered dietitian. Anthropometrics and signs of GI disturbances and nutrient deficiencies, especially if the infant was discharged home on a non-nutrient enriched formula, should be monitored.35

As with adults, preterm infants who have a bowel resection or an ostomy are at risk for nu-trient deficiencies. Infants with an ostomy may require additional Na, Zn and copper supple-mentation.35,43 Fat-soluble vitamins need to be replaced in addition to Fe, B12, and trace elements.35,43 It is also important to monitor serum electrolytes, Ca, Phos, and Mg.35,43

Bronchopulmonary Dysplasia/Chronic Lung DiseaseBronchopulmonary dysplasia/chronic lung disease ((BPD/CLD) is a diagnosis of prema-ture infants that has nutritional implications. BPD is defined as either an oxygen require-ment for longer than 28 days of age or an oxygen requirement lasting for more than 36 weeks CGA in a baby born before 32 weeks’ GA.35 Most infants with BPD/CLD are growth delayed and stunted in length when they reach 40 weeks CGA, especially if steroids were used in their treatment. 45,46

Infants with BPD/CLD have increased energy expenditure, possibly due to the increased work of breathing.43 A baby may require as much as 25% more energy than basal needs. To offset this, the infant will

need additional nutrients from enteral nu-trition.43 Infants with BPD/CLD may need formula, concentrated to 27 calories/ounce or more, in the hospital and after discharge. It is necessary to fortify human milk or concentrate formulas to higher calories to provide appropriate micronutrient balance.35 If modular products are added, additional vi-tamin/mineral supplements may be needed. Infants with BPD/CLD may develop feed-ing aversions and may benefit from a feeding clinic (see post-discharge follow-ups).35

Growth Related IssuesIt is difficult to recreate in-utero fetal growth rates in preterm infants. Accumulated post-natal growth deficits are common and these infants are often discharged home weighing significantly less than expected.15,47 Extra-uterine growth restriction is defined as an-thropometric measurements below the tenth percentile at discharge when the patient’s anthropometric measurements at birth were greater than the tenth percentile. Poor head circumference growth by 8-months of age is associated with neurological and sensory deficits and poor school performance.47

Preterm and term infants have different anticipated growth parameters. Appropriate growth for the preterm infant between 24-40 weeks GA should be 15-20g weight/kg/day, 1.1cm length/week, and 0.5cm head circumference/week.40 Growth parameters for term newborns and former preterm in-fants at term CGA are listed in Table 5.48

The nutrition goal for a preterm infant after discharge is to achieve the body composi-tion and rate of growth for a term infant at a comparable age.24

Catch up growth, an infant growing at an accelerated rate, usually occurs follow-ing hospital discharge, and may continue for the first two years of life.3,43 One author defines catch-up growth as “height velocity above normal statistical limits for age and/or maturity during a defined period of time, following a transient period of growth in-hibition,” that is, occurring in both weight and length.49 Catch-up growth is usually obtained by providing appropriate nutrition so that body composition is comparable to that of a term infant at a comparable



age.2 Nutrition intervention after hospital discharge is crucial to improve long-term growth and neurodevelopment.50,51 About 80% of very low birth weight and/or small for SGA infants who experience postnatal growth failure show catch-up growth by two to three years of age.51 Occasionally, catch-up growth may occur between eight years of age and adolescence.11 In rare cases little catch-up occurs and the child remains small into adulthood.15,50,52

There is increasing evidence that very rapid catch-up growth may have adverse long-term effects, including increased risk for hypertension, cardiovascular disease, diabetes, and osteoporosis.51 Catch-up growth associated with an increase in cen-tral fat mass, but not lean mass and gains in length, leads to metabolic syndrome later in life.53 Once the infant is term-cor-rected age, it is important to monitor the weight-to-length ratio. Cooke et al showed that earlier catch-up growth was healthier and more complete when infants were fed commercial preterm infant formula until 6 months CA. These babies showed an increase in fat-free and peripheral fat mass without an increase in adiposity.53

According to Lucas [W]hile slow growth (below the intrauterine rate) has some ben-efit for later cardiovascular outcome, it risks under-nutrition and its adverse consequences,

and has a profound adverse effect on later cognition. Currently, the balance of risks fa-vors the brain, and preterm infants should be fed with specialized products to support rapid growth (at least at the intrauterine rate).4 If there is concern for rapid weight gain on a nutrient-enriched formula, it may be diluted from the standard concentration of 22 calories/ounce to 20 calories/ounce. The lower caloric density of the nutrient enriched formula will continue to provide higher protein and micronutrient density compared to standard term formula.

Corrected Gestational AgePreterm infants should not be expected to reach developmental milestones at the same time as term infants. Adjusting for prematurity or referring to the CGA is recommended for at least the first year, possibly up to 3½ and, in some instances, through seven years of life.3,40 Table 6 pro-vides the equation to calculate CGA, in-cluding an example.

A preterm infant’s CGA is used to assess developmental milestones, growth, and feeding. Once a preterm infant reaches 40 weeks GA, growth can be plotted on the WHO growth chart.40 Developmental age is used to evaluate readiness for spoon feed-ing.55 Most authorities recommend initiat-ing solid food from a spoon at 4-6 months

CGA.24,40,56 Starting spoon feedings before recommended CGA may contribute to feeding problems. Introducing solid foods into the infant’s diet may decrease formula consumption and, if the solid foods are of poor nutritional quality, may compromise growth.52 The use of whole milk is not rec-ommended until one year CGA.24,40,56

Post-discharge Follow-Up After discharge from the hospital, prema-ture infants should be examined and tested to identify any medical or neurodevel-opmental problems.40,57 Some follow-up clinics also monitor growth, development and nutrition.56 In addition to medical appointments, participation in programs offering home visiting nurses, Early Inter-vention, and Women, Infants, and Chil-dren (WIC) services are available. These provide support to low-income families in need of therapies, infant formulas and nu-tritious food.40,56,58

A preterm infant should be seen within one week of discharge.40 NICU follow-up clinics are often multidisciplinary in na-ture, and frequently include dietitians.56 Improving the nutritional status of the pre-term infant obviously minimizes adverse developmental outcomes.56 A dietitian should be consulted for the following: ab-sence of catch-up growth, weight loss after hospital discharge, falling off the attained growth curve or falling below the fifth per-centile on the growth chart.40 Follow-up by dietitians facilitates the catch-up growth of very low birth weight infants through 12 months CGA.57 A dietitian should see any patients who are on concentrated or spe-cialty formulas, on PN, or who have a G-tube to assess tolerance. These infants need to be monitored for electrolyte disturbanc-es and tolerance of formula.40 Where the infant is seen is also important. One study reports that infant growth parameters were significantly better at a comprehensive care (NICU follow-up) clinic than at a general practice clinic.57

The infant may also need follow-up appointments with subspecialists, such as cardiologists, gastroenterologists, neurolo-gists or surgeons, or at a multi-disciplinary

Table 6: Calculating Corrected Gestational Age (CGA)

(Weeks premature + weeks old) – 40 weeks = CGA in weeksExample: An infant was born at 28 weeks GA and is now 16 weeks old. (28 weeks + 16 weeks) – 40 weeks = 4 weeks old (1 month old) CGA

On the growth chart, this infant would be plotted at 1 month to correct for prematurity.

Table 5: Growth Parameters for Term Infants or Preterm Infants Corrected to Term48

age Weight Length Head circumference

0-3 months 25-35 grams/day 2.5-3.5 cm/week 0.5 cm/week




Complete the quiz on line at www.anhi.org at no charge. Please note online questions or answers are randomized and may not appear in the same sequence below. Do not assume that the “letter” preceding the correct response will be identical to the online version.

Post-Test: Transitioning the Preterm Neonate from Hospital to Home: Nutritional Discharge Criteria

abbott nutrition Health Institute, is an approved provider of continuing nursing education by the california board of registered nursing Provider #ceP 11213.

credit: 1 contact

hour

1. There are no up-to-date, easily accessible national standards for nutrient require-ments in preterm infants in the US.

a. True b. False

1. Which of the following diagnoses are common for a preterm infant?

a. Metabolic bone disease b. Necrotizing enterocolitis c. Bronchopulmonary dysplasia d. All of the above

2. All of the following provide complete nutrition for preterm infants except:

a. Human milk b. Enriched formula c. Preterm formula

3. All of the following are nutritional compli-cations of necrotizing enterocolitis except:

a. Feeding intolerance b. Ostomy c. Lung disease d. Short bowel syndrome 4. Including a dietitian in the NICU fol-

low-up program: a. Decreases weight gain b. Improves the nutritional status of pre-

term infants. c. Decreases the nutritional status of pre-

term infants. d. Ensures provision of infant formula

samples.

5. Risk factors for metabolic bone disease include:

a. Prematurity b. Preterm infant receiving unfortified

human milk c. Preterm infant receiving

hydrolyzed formula d. All of the above

6. Preterm infants have lower nutrient re-quirements than term infants because they are smaller.

a. True b. False

7. Gastroesophageal reflux is a common problem with preterm infants.

a. True b. False

8. Preterm infants who suffer from SBS due to NEC:

a. Are at risk for developing strictures b. Are not known to have

nutritional deficiencies c. Easily tolerate any type of formula

(if human milk is not available)

9. Infants with severe BPD have higher calorie needs.

a. True b. False

10. Few preterm infants develop extrauterine growth restriction.

a. True b. False

11. Corrected gestational age should be used in: a. Adjusting for developmental milestones b. Deciding when to initiate solid foods c. Assessing growth d. All of the above

12. Common vitamin and/or mineral sup-plements for preterm infants are:

a. Zinc, Na and Cl b. Vitamin D and Fe c. Vitamin D and Vitamin A

13. Anthropometrics for a preterm infant prior to term corrected age should be as-sessed on:

a. CDC growth chart b. WHO growth chart c. Fenton growth chart d. None of the above

14. Preterm human milk transitions to term human milk composition around:

a. 2 weeks b. 4 weeks c. 6 weeks d. 8 weeks

15. Ideally, preterm infants are followed by a multidisciplinary team.

a. True b. False



infant feeding clinic.40,55 Feeding clinics often have both inpatient and outpatient programs to manage feeding disorders.

These are common in premature infants due to repeated exposure to noxious oral stimuli and the greater length of time until oral feeding skills develop.55 Feeding disorders usually start as a physiologi-cal problem and can then develop into a behavioral or psychological problem.55 Identification of the particular problem and corrective actions by a feeding clinic team have a significant impact on the growth and development of the premature infant.56 Left untreated, feeding problems can lead to failure to thrive, malnutrition, or impaired intellect.55

ConclusionPremature infants have higher nutritional needs than term infants. Preterm infants are at high nutritional risk following hos-pital discharge. Human milk is the ideal feeding after discharge but it may require fortification or enrichment to meet the nu-tritional needs of the preterm. Appropriate choices at discharge of the preterm infant are nutrient-enriched formulas, for most babies, or specialized preterm formulas, for selected babies. Routine supplementation should include vitamin D and iron. Pre-term infants who are discharged without nutrient-enriched formulas may require ad-ditional vitamin and mineral supplements. Several conditions that are diagnosed in preterm infants during the NICU hospi-tal stay, including GER, MBD, NEC, and BPD, may be impacted by their nutrition following discharge. Preterm infants are of-ten involved in several follow-up programs, many of which are multidisciplinary. Con-tinued research and expanded evidence-based practices are needed to improve the post-hospital nutritional management and long-term outcome of preterm infants.

About the AuthorsAndrea Adler RD, CSP, LD is a neona-tal dietitian at the Cleveland Clinic with 7 years of clinical experience. She is the cur-rent secretary of the Ohio Neonatal Nu-tritionists group. She also presents lectures about neonatal nutrition to interdisciplinary medical teams.

Sharon Groh-Wargo, PhD, RD, LD has practiced as a neonatal dietitian for more than 25 years. As a recognized expert in the field of neonatal nutrition, Dr. Groh-Wargo has written numerous publications and speaks widely on the topic of nutrition for the high-risk newborn. She is a contribu-tor to the American Dietetic Association’s (ADA) online Pediatric Nutrition Care Manual and is an editor of the ADA’s Pocket Guide to Neonatal Nutrition.

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References: 1. Rubin LP, et al. Journal of Perinatology advance online publication, 14 July 2011; doi:10.1038/jp2011.87. 2. Kanako IN, et al. Arterioscler Thromb Vasc Biol. 2007;27:2555-2562. 3. Can�eld LM, et al. Eur J Nutr. 2003;42:133-141. 4. Schweigert FJ, et al. Eur J Nutr. 2004;43:39-44. 5. Patton S, et al. Lipids. 1990;25: 159-165. 6. Jewell VC, et al. Proc Nutr Soc. 2001;60:171-178. 7. Connor SL, et al. FASEB. 2008;22:451-454.

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