Pediatric Nutrition in Practice

216 Ziegler^

proves, it is assumed that the ability to digest and
absorb nutrients is also improving. Gastric emp-
tying thus serves as an important clinical guide in
early enteral feeding. The risk of NEC is quite low
with trophic feedings, but it somewhat increases
subsequently as feeding volumes increase.
The preferred feed for gastrointestinal prim-
ing is maternal milk or, if not available, donor
milk. Donor milk is pasteurized and free of vi-
ruses such as HIV and cytomegalovirus. Al-
though pasteurization diminishes some of the
protective and trophic factors of human milk, do-
nor milk retains its protective effect against NEC
[4] and sepsis and has strong trophic effects.
When human milk is not available, formulas can
also be used for gastrointestinal priming.

Transition Phase
Feeding volumes are usually kept low for several
days and are gradually increased as gastric residu-
als diminish. At each new level, the adequacy of
gastric emptying (absence of gastric residuals)
must be ascertained before the feeding volume is
further increased. The presence of gastric residu-
als does not require cessation of feedings as long
as there are no signs suggestive of NEC. The use
of gastrointestinal priming has been shown to
lead to earlier establishment of full feedings and
to earlier hospital discharge without an increase
in NEC [5]. In fact, earlier achievement of full
feedings has been shown to decrease the risk of
sepsis [6]. Feeding volumes can be increased by
20 ml/kg each day as gastric residuals permit. Al-

though more rapid increases are safe, intestinal

maturation requires time and therefore more rap-

id increases are not necessary. When feeding vol-

umes are 80–100 ml/kg/day, fortification of breast

milk is usually initiated, although in some units

fortification is started much earlier. Parenteral

nutrition can be discontinued when enteral feed-

ings are at least 90% of the full amount.

Late Phase

The late phase begins when full feedings are es-

tablished and parenteral nutrition is discontin-

ued. The objective of nutrition is to allow growth

to proceed parallel to intrauterine growth. The

energy and protein intakes listed in table  1 are

needed to support growth at the intrauterine rate.

If the infant is to catch up in growth, intakes must

be increased by perhaps 10–20%. Intakes below

those listed in table 1 lead to extrauterine growth

failure with all its negative consequences. Feed-

ings are fortified human milk or, when not avail-

able, special formulas.

With standard preterm formulas with a pro-

tein/energy ratio (3.0 g/100 kcal) protein intakes

are marginally adequate. Formulas with higher

protein content (3.3–3.6 g/100 kcal) are therefore

preferable in order to achieve appropriate ‘catch

up’ growth of lean body mass.

Breast milk must be fortified (supplemented)

with nutrients in order to meet the preterm in-

fant’s high needs ( table 1 ). Fortifiers are available

as powders and as liquids. Commercially available

fortifiers provide the necessary nutrients in suffi-

Ta b l e 1. Requirements for protein and energy (best estimates by factorial and empirical methods)

Body weight

500 – 1,000 g 1,000 – 1,500 g 1,500 – 2,200 g 2,200 – 3,000 g

Fetal weight gain, g/kg/day 19.0 17.4 16.4 13.4
Protein, g/kg/day 4.0 3.9 3.7 3.4
Energy, kcal/kg/day 106 115 123 130
Protein/energy, g/100 kcal 3.8 3.4 3.0 2.6

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 214–217

DOI: 10.1159/000360342