The importance of nutrition after hospital discharge in pre-term infants

Improvements in neonatal care over the past few decades mean that a greater number of pre-term infants (defined as those born before 37 weeks gestation), are surviving in the UK; this is particularly the case for extremely low birth weight infants.

Information for primary care
Although many pre-term infants go on to lead normal lives they often remain growth restricted in comparison to their term peers1-3. Research has shown that those who fail to achieve their growth potential during the first few weeks after birth have less favourable outcomes, particularly with respect to neurodevelopment4-6. The window for catch-up growth in low birth weight pre-term infants seems to be narrow and if catch-up growth does not occur in early life then the chances that it will occur later are limited7.

At discharge, pre-term infants often have not reached term and are still low birth weight (<2500g). In addition, nutritional deficits at birth may still be present despite optimal hospital care8. Thus these infants often have higher energy and nutrient requirements per kilo body weight than healthy term infants. Ongoing nutritional support of pre-term and low birth weight infants after discharge is important to ensure adequate growth, and development and to minimise adverse health consequences in the long term.

Feeding options after hospital discharge
Breastmilk is the preferred source of nutrition for all infants, and especially in those born prematurely. Mothers should therefore be encouraged to continue to breastfeed once their baby has been discharged from hospital (along with the use of additional supplements as advised). If a baby is not being breastfed, or formula is required to supplement breastfeeds, then specific nutrient-enriched post-discharge formulas (e.g. Cow & Gate Nutriprem 2) are available on prescription. These formulas are tailored to meet the high nutritional requirements of pre-term infants after hospital discharge. Compared to term formulas they contain more energy, protein and micronutrients to help support adequate development and catch-up growth in pre-term infants.

Studies have shown that pre-term infants fed a nutrient-enriched formula post-discharge have improved growth (weight, length and head circumference) and improved bone mass compared to infants fed standard term formula9-14. Boys and lower birth weight infants seem to benefit the most from the use of post-discharge formula.

A study by Cooke et al investigated the effect of feeding a nutrient-enriched formula, compared to a standard term formula, from hospital discharge to 6 months corrected age on growth in pre-term infants with a birth weight less than 1750g10-12.  At 18 months corrected age, boys fed the nutrient-enriched formula post-discharge were heavier, longer and had a larger head circumference (p<0.0001) than those fed a standard term formula12. Body composition measures using DEXA taken at 12 months corrected age indicated weight gain was due to an increase in lean body mass and bone mass and was not purely the result of additional fat mass11.

As a result of the body of research, and given the importance of nutrition in early life, a number of expert groups recommend the use of a nutrient-enriched formula after hospital discharge in formula fed pre-term infants. The European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN)7 recommend the use of a post-discharge formula in pre-term infants until at least 42 weeks post-conception or possibly until 52 weeks (3 months corrected age) in infants with suboptimal weight for age. Tsang et al15, an international group of experts in the field of pre-term nutrition, recommend that a post-discharge formula should be used during the first year of life.

Post-discharge formula available in the UK (e.g. Cow & Gate Nutriprem 2) can be prescribed for catch-up growth in pre-term infants up to 6 months corrected age if required. Continued weight and length monitoring of infants in the community is important to meet individual nutritional needs and to avoid either under or over nutrition.

When it's appropriate for infants to move on from a post-discharge formula, a standard term formula containing prebiotic oligosaccharides (OS) will be beneficial in helping support their natural immune system16,17.

For more information, visit www.in-practice.co.uk

Important Notice: Cow & Gate Nutriprem should only be used under medical supervision, after full consideration of the feeding options, including breastfeeding. Cow & Gate Nutriprem is suitable as the sole source of nutrition for infants and as a principle source of nourishment with other foods for children.

References

  1. Clark RH et al. Extrauterine growth restriction remains a serious problem in prematurely born neonates. Pediatrics 2003;111:986-990

  2. Ehrenkranz RA et al. Longitudinal growth of hospitalized very low birth weight infants. Pediatrics 1999;104:280-89

  3. Hack M et al. Growth of very low birth weight infants to age 20 years. Pediatrics 2003;112:e30-e38

  4. Franz AR et al. Intrauterine, early neonatal and post-discharge growth and neurodevelopmental outcome at 5.4 years in extremely pre-term infants after intensive neonatal nutritional support. Pediatrics 2009;123:e101-e109

  5. Isaacs EB et al. The effect of early human diet on caudate volumes and IQ. Pediatr Res 2008;63:308-314

  6. Isaacs EB et al. Early diet and general cognitive outcome at adolescence in children born at or below 30 weeks gestation. J Pediatr 2009;155:229-234

  7. ESPGHAN Committee on Nutrition, Aggett PJ et al. Feeding pre-term infants after hospital discharge: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2006;42(5):596-603

  8. Embleton NE et al. Postnatal nutrition and growth retardation: an inevitable consequence of current recommendations in pre-term infants? Pediatrics 2001;107:270-273

  9. Carver JD et al. Growth of pre-term infants fed nutrient-enriched or term formula after hospital discharge. Pediatrics 2001;107:683-689

  10. Cooke RJ et al. Feeding pre-term infants after hospital discharge: effect of dietary manipulation on nutrient intake and growth. Pediatr Res 1998;43:355-360

  11. Cooke RJ et al. Feeding pre-term infants after hospital discharge: effect on diet and body composition. Pediatr Res 1999;46:461-464

  12. Cooke RJ et al. Feeding pre-term infants after hospital discharge: growth and development at 18 months of age. Pediatr Res 2001;49:719-722

  13. Lucas A et al. Randomized trial of nutrient-enriched formula versus standard formula for postdischarge pre-term infants Pediatrics 2001;108:703-711

  14. Picaud JC et al. Growth and bone mineralization in pre-term infants fed pre-term formula or standard term formula after discharge. J Pediatr 2008;153:616-621

  15. Carlson SE. Feeding after discharge: Growth, development and long-term effects. In:Tsang RC, Uauy R, Koletzko B, Zlotkin SH. (2005) Nutrition of the pre-term infant. Scientific basis and practical guidelines (2nd edition) Digital Educational Publishing, Inc., Cincinnati

  16. Bruzzese E et al. A formula containing galacto- and fructo-oligosaccharides prevents intestinal and extraintestinal infections: an observational study Clin Nutr 2009;28(2):156-161

  17. Arslanoglu S et al. Early dietary intervention with a mixture of prebiotic oligosaccharides reduces the incidence of allergic manifestations and infections during the first 2 years of life.  J Nutr  2008:138;1091-1095 

 

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