Key Message

• It is vital that preterm and low birth weight infants have the right balance of nutrients; both insufficient and excessive amounts of iron and iodine can be harmful
• Getting the balance of nutrients right is essential to optimise infant growth and development, while excess amounts of some nutrients can result in health problems
• Products that contain probiotics are effective for preventing necrotizing enterocolitis in preterm infants but more research is needed before they can be used routinely

Leading international experts shared new scientific findings in Nutrition of the Preterm Infant at a Nestlé Nutrition Institute-sponsored satellite symposium in 2013 held at the European Society of Paediatric Research (ESPR) in Porto, Portugal.
 

Early Nutrient Needs of Preterm Infants

Dr Magnus Domellöf, Head of Pediatrics at Umeå University, Sweden, shared new findings demonstrating that the provision of appropriate amounts of nutrients to low birth weight (LBW) and preterm infants at an early stage can have positive long term effects on growth, behaviour and brain development. A recent study has shown that iron, which is known to be essential for myelin formation and neuronal growth, when given to LBW infants (2000-2500 g) as a supplement from months 1-6, significantly reduces behavioral problems. Of the 285 infants studied, 3% who received 1 mg/kg/day iron supplement showed behavioural problems according to the Achenbach Child Behaviour Checklist, compared with 13% of those who received placebo.¹

Dr Domellöf emphasized that iodine and phosphorus may also need supplementation as deficiencies can lead to hypothyroidism, mental retardation, heart damage and poor immune function.^2,3 However, “it is vital to provide the right balance of nutrients; excessive amounts of iron and iodine can be harmful to preterms and low birth weight infants”, said Dr Domellöf. It is important to monitor blood levels of iron and phosphate and avoid iodine-containing antiseptics. Total energy intake is also an important factor to consider. Dr Domellöf presented data showing that low energy intake increases the risk of growth failure and severe retinopathy of prematurity (ROP), a condition that affects the blood vessels in premature infants’ eyes, which may lead to blindness. “Using highly concentrated, standardized parenteral nutrition solution in combination with adequate enteral nutrition, it is possible to avoid early growth failure” said Dr Domellöf.
 

Improving growth in Preterm Infants

Professor Richard J Cooke (Professor of Pediatrics, Ireland) highlighted the continuing problem of post-natal growth failure in preterm and VLBW infants and the direct relationship between poor growth and poor outcomes. During this vital early period, malnutrition leads to a vicious circle of altered organ function, development of disease, increased nutrient needs and further malnutrition. He also noted that even after periods of poor early growth; i.e. in the first 28 days of life, ‘recovery’ or ‘catch-up’ growth, most of which occurs after hospital discharge is associated with better developmental outcome.

Referring to a fundamental principle in nutritional care; i.e., nutritional intake meets needs therefore ensuring the best outcome, he noted that it takes time to establish an adequate intake in the sick infant. In effect, infants accrue a significant nutrient deficit, the smaller and more immature the infant the greater the deficit. Yet, recommended dietary intakes are related to needs for maintenance and ‘normal’ growth, no allowance is made for ‘recovery’ or ‘catch-up’ growth, a contentious and confusing issue at the moment.

To improve growth, Prof. Cooke emphasized the importance of a) audit as means of quality assessment of growth in each neonatal intensive care unit, b) in the event that growth failure is a problem, then the determination of whether recent advances in nutritional care are being implemented; i.e., total parenteral nutrition from day 1, minimal enteral nutrition by days 2-3 and adjustable fortification of human milk and c) follow-up after discharge to ensure that infants are ‘thriving’ during this critical period of brain growth and development.

Adapting the WHO statement on nutritional care for infants and children, Prof Cooke notes that “Better nutrition is a prime entry point in limiting the effects of immaturity, illness and iatrogenic disease on organ growth and function, therefore development and ultimate productivity. Our imperative is to do better in these high-risk infants”.
 

Why, how and when should we use Probiotics in Preterm Infants?

Professor Jean-Charles Picaud (Department of Neonatology at Croix Rousse Hospital in Lyon, France) focused on the effects of probiotics, reviewing the evidence for mortality, infections, digestive tolerance, weight gain, hospital stay, and necrotizing enterocolitis (NEC) prevention. The latter remains a major cause of death, or significant short term (gut resection) and long term (cognitive development) morbidities in preterm infants. Specific probiotic strains have proven to be effective in reducing the risk of NEC, with mixed strains being more effective than single strains.

Although there is still no worldwide consensus about probiotic use in preterm infants, Prof Picaud said: “There is substantial evidence demonstrating that probiotics are effective and safe for preventing NEC in preterm and low birth weight infants.”

Prof Picaud concluded, “Experts should work with regulatory authorities to explain the benefit / risk ratio, and to support further studies to refine a probiotics regimen that can be used in routine practice”.