Early, Aggressive Nutritional Management for Very Low Birth Weight Infants: What Is the Evidence?

Presented in part at the American Academy of Pediatrics National Conference and Exhibition, Section of Perinatal Medicine Educational Program, Atlanta, GA, October 8, 2006.
https://doi.org/10.1053/j.semperi.2007.02.001Get rights and content

The American Academy of Pediatrics Committee on Nutrition goal of providing nutrient intakes that permit the rate of postnatal growth and the composition of weight gain to approximate that of a normal fetus of the same postmenstrual age is rarely met by extremely low gestational age neonates. Therefore, postnatal growth failure or growth restriction continues to be a problem experienced by many of these infants, and they are often less than the 10th percentile of reference intrauterine curves at the time of hospital discharge. Variation in nutritional practices, especially those practices concerned with the initiation and advancement of parenteral and enteral nutrition, largely explain the difference in growth observed at different newborn intensive care units. Although limited, the evidence supports recommendations to administer early parenteral and enteral nutrition, specifically initiation of an amino acid infusion providing about 3 g protein/kg/d within hours of birth, initiation of a lipid emulsion of 0.5 to 1.0 g lipids/kg/d within 24 to 30 hours of birth, and the initiation of minimal enteral feedings within the first 5 days of life. It is important that neonatal clinicians recognize the barriers and obstacles to the implementation of these recommendations.

Section snippets

Observations from Postnatal Growth Studies

In 1948, Dancis and coworkers1 published weight gain curves (Fig. 1) that were derived from 100 preterm infants 1000 g to 2500 g birth weight (BW) plus several infants weighing less than 1000 g at birth who survived. As described, these infants “exhibited no untoward complications in the neonatal period,” and the curves were said to “represent what the premature infant who develops without complications will do when fed and handled in a certain arbitrary manner.” Enteral feedings with a

Nutritional Practice Variation and Growth Outcomes

The impact of nutritional practice variation, within and between centers, on growth outcomes has been described in a number of reports. Olsen and coworkers12 retrospectively studied the weight growth velocities of 564 infants <30 weeks gestation at birth and managed in 6 NICUs between 1994 and 1996. Multiple linear regression models designed to predict weight growth velocity between day 3 and day 28 of age were prepared from center, case mix, medical practices and complications, and nutritional

Evidence Base for Early Parenteral and Enteral Nutritional Management

The limited energy reserves of preterm infants at birth were estimated in a paper written by Heird and coworkers19 over 30 years ago. Using the energy reserves from all available nonprotein plus 1/3 of available protein, and assuming no nutritional supply, the survival time of a 3500-g term infant was estimated to be about 28 days. Preterm infants weighing 2000 g were estimated to have sufficient energy reserves to survive about 10 days, whereas those weighing about 1000 g had about 4 days. By

Evidence-Based Recommendations about Early Nutritional Practices

This overview of the evidence base for early parenteral and enteral nutritional management of VLBW infants has been focused at responding to the question raised above about the need to identify nutritional strategies that will provide the best foundation on which to improve growth and developmental outcomes and to reduce complications and morbidities. Recommendations have been classified according to the quality of the available evidence, as defined in a policy statement by the American Academy

Conclusions

Postnatal growth failure or growth restriction of VLBW, and especially of ELBW, infants is a morbidity that should be vigorously addressed. Achieving the American Academy of Pediatrics Committee on Nutrition goals to provide nutrient intakes that permit the rate of postnatal growth and the composition of weight gain to approximate that of a normal fetus of the same PMA and to maintain normal concentrations of blood and tissue nutrients is considered the best means of facilitating later growth

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