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Feeding the preterm baby

10 mins
Parent hands supporting baby feet

Recommendations for feeding a preterm baby

Preterm baby postnatal growth restriction (also referred to as extrauterine growth restriction) is a common phenomenon due to the many challenges in feeding this vulnerable group.1–3 Babies most at risk include those born very prematurely and the critically ill.

The last trimester of pregnancy is a period when extensive development of the neural tract occurs.4 A consequence of prematurity and postnatal growth restriction is impaired neurodevelopment.4–6 Greater growth deficits seem to be associated with greater neurodevelopmental impairment.

Therefore, the most important objective of nutritional management of the preterm baby infant is the prevention of growth failure in order to protect the infant’s brain.5 More recently, research has demonstrated an association between increased nutrients such as protein and energy and positive developmental outcome.7

Recommendations for feeding in hospital

The 2010 European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) recommendations on enteral nutrient supply for preterm infants:8

‘The preferred food for premature infants is fortified human milk from the infant’s own mother, or, alternatively, formula designed for premature infants.’

Fortified breast milk

The advantages of breast milk are especially important for a preterm baby. Breast milk has been shown to confer improved short- and long-term outcomes in regards to:

  • Lower rates of necrotising enterocolitis (NEC)9
  • Neurodevelopmental advantages10

ESPGHAN recommends that preterm breast milk should be fortified8 – this is to correct for the decreasing protein content of breast milk with ongoing lactation.11 The primary outcomes of feeding fortified breast milk are that the baby receives the benefits of breast milk while its nutritional status and growth is improved.12

Formula designed for preterm infants

ESPGHAN recommends that if breast milk is unavailable, a formula designed for preterm infants should be used.8 Protein and energy are vital in the management of growth – the ESPGHAN recommendations include guidance on the macro- and micronutrient composition of preterm infant formula.8

ESPGHAN recommended intakes for energy and protein requirements of preterm infants:8

Infant weight

Energy (kcal/kg/d)

Protein (g/kg/d)

Protein (g/100kcal)

Protein energy ratio (PER)

Preterm infants    <1 kg





Preterm infants   1–1.8 kg





Recommendations for feeding preterm infants on discharge

The 2006 ESPGHAN guidance on feeding preterm infants on discharge from hospital:13

‘Infants discharged with a subnormal weight for postconceptional age are at increased risk of long-term growth failure...’

The following recommendations are made:

  • Breastfed preterm infants on hospital discharge should receive fortified human milk to provide an adequate nutrient supply
  • Formula-fed preterm infants on hospital discharge ‘should receive special post-discharge formula with high contents of protein, minerals and trace elements as well as a long-chain polyunsaturated fatty acid supply, at least until a postconceptional age of 40 weeks, but possibly until about 52 weeks postconceptional age’
  1. Ehrenkranz R et al. Pediatrics 1999; 104: 280–289

  2. Clark RH et al. Pediatrics 2003; 111: 986–990

  3. Marks KA et al. Acta Paediatr 2006; 95: 236–242

  4. Georgieff MK et al. J Pediatr 1985; 107: 581–587.

  5. Ziegler E. Ann Nutr Metab 2011; 58 (Suppl 1): 8–18.

  6. Ehrenkranz RA et al. Pediatrics 2006; 117: 1253–1261.

  7. Stephens BE et al. Pediatrics 2009; 123: 1337–1343.

  8. Agostoni C et al. J Pediatr Gastroenterol Nutr 2010; 50: 85–91

  9. Lucas A, Cole TJ. Lancet 1990; 336: 1519–1523

  10. Lucas A et al. Lancet 1992; 339; 261–264.

  11. Ballard O, Morrow AL. Pediatr Clin North Am 2013; 60: 49–74.

  12. Jones E, King C. Feeding and Nutrition in the Preterm Infant. Elsevier 2005.

  13. Aggett P et al. J Pediatr Gastroenterol Nutr 2006; 42: 596–603.


The World Health Organisation (WHO) has recommended that pregnant women and new mothers be informed on the benefits and superiority of breastfeeding – in particular the fact that it provides the best nutrition and protection from illness for babies. Mothers should be given guidance on the preparation for, and maintenance of, lactation, with special emphasis on the importance of a well-balanced diet both during pregnancy and after delivery. Unnecessary introduction of partial bottle-feeding or other foods and drinks should be discouraged since it will have a negative effect on breastfeeding. Similarly, mothers should be warned of the difficulty of reversing a decision not to breastfeed. Before advising a mother to use an infant formula, she should be advised of the social and financial implications of her decision: for example, if a baby is exclusively bottle-fed, more than one can (400 g) per week will be needed, so the family circumstances and costs should be kept in mind. Mothers should be reminded that breast milk is not only the best, but also the most economical food for babies. If a decision to use an infant formula is taken, it is important to give instructions on correct preparation methods, emphasising that unboiled water, unsterilised bottles or incorrect dilution can all lead to illness.