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Approach to enteral nutrition in the premature infant

Richard J Schanler, MD
Section Editor
Steven A Abrams, MD
Deputy Editor
Alison G Hoppin, MD


Premature infants have greater nutritional needs in the neonatal period than at any other time of their life. The nutrient needs are inherently high at this stage of development, to match the high rates of nutrient deposition achieved by infants in utero [1]. In addition, they often have medical conditions that increase their metabolic energy requirements, including hypotension, hypoxia, acidosis, infection, and surgery. Additional impediments to growth are physiologic immaturity of the gastrointestinal tract, including decreased gastrointestinal motility and reduced intestinal enzyme activity, and therapies such as corticosteroids.

Vigorous nutritional support is needed to correct growth restriction at birth and achieve appropriate rates of weight gain, which are almost twice that of a term infant [2,3]. However, it is also important to avoid rapid advances in feeding, which may result in feeding intolerance or necrotizing enterocolitis (NEC), and to recognize that excess of some nutrients may have toxic effects. Partial or total parenteral nutrition is necessary for infants whose immaturity or medical condition precludes full enteral feeding. (See "Parenteral nutrition in premature infants".)

Issues related to enteral nutrition in the premature infant are reviewed here. The composition of the feeding including human milk, formula, and human milk fortifiers is discussed elsewhere. (See "Nutritional composition of human milk and preterm formula for the premature infant" and "Human milk feeding and fortification of human milk for premature infants".)


The nutritional goal for premature infants is to achieve rates of growth and nutrient accretion that match those achieved by infants of similar gestational age in utero, while avoiding complications that can be caused by nutritional therapies.

Intrauterine growth and nutrient accretion — A national reference standard for fetal growth was developed from more than three million singleton births in the United States [4]. A new international standard (INTERGROWTH 21st Century) was developed in 2014 and is increasingly used [5,6]. Premature infants often are unable to attain this rate. As an example, in a study of 1660 premature infants with birth weight ≤1500 g at discharge, most infants born below 29 weeks gestation had not reached the median birth weight of the reference fetus at the same postmenstrual age [7]. Thus, even in the neonatal intensive care unit (NICU), premature infants did not receive adequate nutrition to successfully grow at a rate equivalent to the reference standard for fetal growth. Continual reassessment and delivery of adequate nutritional support are imperative to optimize the growth rate for premature infants. (See "Growth management in preterm infants", section on 'Normative growth data'.)

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Literature review current through: Nov 2017. | This topic last updated: Sep 28, 2017.
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