Enteral Nutrition in Preterm Infants (2022): A Position Paper from the ESPGHAN

Overview

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Key numbers

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• electronically by all members of the working group between 2021-2022. Where >90%
• to level of evidence (LOE) and grade of recommendation (GOR), and all received >90%
• suggests a range for REE of 60-70kcal/kg/day, depending on growth rate.
• assuming the composition of that weight gain is 13% protein and 20-30% fat, the
• 106-138kcal/kg/day. Allowing for energy lost in stool (5-10%) (16, 17), this equates to a total
• extrapolated from higher rates of growth and fat deposition. A range of 115-140kcal/kg/day is
• R1: A reasonable range of total energy intake for most healthy growing preterm infants is
• energy intake. Protein quality is important (43). Human milk contains approximately 25%
• mature breastmilk and 1.5-2.0 g/100 mL in colostrum (46-48). This means that a typical
• Dietary fats provide about 50% of the energy needs of preterm infants as well as essential
• cholesterol and other highly active bioactive components (49). About 15-20% of FAs in HM are PUFAs
• 3.8-4.8 g/kg/d (18). Aiming for dietary fat to provide 45-55% of the energy intake, a minimum supply
• on the average value observed in human milk of 0.5% of FAs would equal 30 mg/kg/d ARA.
• R2: Amounts of medium chain triglycerides exceeding 40 % of total fat are not recommended GOR B
• R3: A Linoleic acid intake of 385 to 1540 mg/kg/d, a minimum linolenic acid intake of 55 mg/kg/d, and
• a linoleic acid to linolenic acid ratio of 5-15:1 (wt/wt) are considered acceptable GOR B
• R4: A DHA intake of 30 to 65 mg/kg/d is recommended assuming sufficient intake of ARA GOR A
• The carbohydrate concentration of human milk (HM) is quite stable and increases from ~6.2 g/100mL
• Carbohydrates constitute 45%-50% of non-protein calories in HM and standard preterm formulas. The
• composition contributing to 40-50% of non-protein energy intakes, a carbohydrate intake in the range
• optimal intake range is uncertain LOE 2
• infants with typical faecal Na excretion rates <10% of intake, but is higher in early postnatal life and
• daily turnover of Cl is high, and renal tubular reabsorption rate is 60-70%. Chloride content in HM is
• an enteral feed, 80% of the absorbed K enters the cells due to increased insulin concentrations
• challenging. Ca accretion in the bone accounts for ~ 98% of total Ca-stores, whereas P stored in bone
• only represents ~ 80% of the total P accretion. The remaining P, about 20%, is involved in lean mass
• rates may be quite variable, as Ca and P absorption rates range between 30-70% and 70-90%,
• intestinal absorption rate of 60% for Ca and 80-90% for P, we estimate that healthy growing preterm
• depending on Mg intakes but are typically around 40-50% (102, 114), and in preterm infants serum
• children. Ferritin concentrations <35-40 µg/L indicate iron deficiency while concentrations >300-350
• µg/L indicate iron overload (119-121). Ferritin is not useful as a biomarker of iron status in patients
• A daily iron intake of 2-3 mg/kg/day starting at 2 weeks of age is recommended for very low birth
• Infants who receive erythropoietin treatment need a higher dose (up to 6 mg/kg/day). LOE 1-,
• If ferritin is <35-70 µg/L, the iron dose may be increased up to 3-4 (or maximum 6) mg/kg/day
• ● Prolonged dietary iron intakes of >3 mg/kg/day should be avoided in most cases because of
• If ferritin is >300 µg/L, which in the absence of ongoing inflammation and liver disease usually is
• of at least 2.0-2.25 mg/kg/d are required (123) and up to 3 mg/kg/d in extremely preterm infants due
• to faster growth rates (88, 124). A small number of studies suggest an intake of at least 1.4-2 mg/kg/d
• ● We recommend an enteral zinc intake of 2-3mg/kg/d, based on the most recent randomized
• recommended copper intake has been increased to 120-230 µg/kg/d to compensate for the higher
• recommend an enteral selenium intake of 7-10 µg/kg/d, which has been shown to result in Se status
• and the lower range of manganese in current preterm formulas, an enteral manganese intake of 1-15

Methods (brief)

• comprise about 15-30% (48). Incomplete digestion of lactose (HM) or lactose/glucose polymers
• 21. Maas C, Mathes M, Bleeker C, et al. Effect of Increased Enteral Protein Intake on
• 59. Kien CL. Digestion, absorption, and fermentation of carbohydrates in the newborn.
• 64. Kien CL, McClead RE, Cordero L, Jr. Effects of lactose intake on lactose digestion
• 74. Klingenberg C, Muraas FK, Isaksen CE, et al. Growth and neurodevelopment in very
• 9-kilodalton calcium-binding protein, and calcidiol 24-hydroxylase in human intestine.
• 232. Maastrup R, Walloee S, Kronborg H. Nipple shield use in preterm infants:

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