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Recognising and addressing the nutritional challenges preterm infants face

8 mins


Nutritional challenges of a preterm infant

Infants build up their nutrient stores during the third trimester of pregnancy however, preterm infants miss several weeks to months in utero during this phase of fastest growth1. They are born with depleted nutrient stores and as a result their nutritional needs are high.

Around 8% of UK babies are born prematurely and could experience challenges such as developmental delays, growth failure, issues with their gastrointestinal (GI) tract, necrotising enterocolitis (NEC), low levels of important nutrients and other medical complications2.

Feeding intolerance in preterm infants is a major concern in neonatal care with up to 50% of premature infants struggling with delays in achieving full enteral feeding, a consequence of feeding intolerance is suboptimal nutrient intake and a decreased rate of growth3,4.

Preterm baby

Nutritional management of a preterm infant

The most important objective of nutritional management of the preterm infant is the prevention of growth failure in order to protect the infant’s brain5. More recently, research has demonstrated an association between increased nutrients such as protein and energy and positive developmental outcome6.

Breast milk is the best for preterm infant nutrition, it has been shown to confer improved short- and long-term outcomes such as lower rates of necrotising enterocolitis (NEC) and neurodevelopmental advantages7,8. If breast milk is in short supply or not available, a formula that has been designed for preterm infants1 and closely mimics breast milk should be used.

SMA Gold Prem® formulas are foods for special medical purposes, specially designed to meet the needs of preterm low birth weight infants. They offer a unique combination of nutrients and 100% whey, partially hydrolysed protein for improved tolerance9-12.

The chart below shows some of the developmental challenges faced by preterm infants and how the SMA Gold Prem® formulas have been designed to help with their nutritional management.

How SMA Gold Prem® formulas are designed to help overcome the nutritional challenges

Smaller stomach capacity but higher nutritional requirements than term infants
Feed intolerance is common in preterm infants and may be related to the feed volume being too large for their small stomach capacities. Feeds may be better accepted if given at volumes more closely aligned to their stomach capacity13 Protein 3.6g/100kcal -The level of protein allows for smaller volumes to be used to meet protein requirements.
-Provides superior weight gain and nitrogen retention without metabolic stress14.
-On the rare occasion where extra energy would be required beyond the recommended volume for protein amounts to be met, ESPGHAN (2010)1 do state that “Some excess protein intake over requirements was not shown to cause detrimental effects in pre-terms, BUT a small deficit will impair growth”
Immature peristaltic ability/motor function
Commonly causes enteral feed intolerance due to:
- Poor suck swallow co-ordination
- Inefficient oesophageal motility
- Delayed gastric emptying
- Slow intestinal transit time15.
Partially hydrolysed Protein Use of partially hydrolysed protein allows for gastric emptying time closer to that of breast milk16,17 .
Immature gastrointestinal functions
Inefficient digestion and absorption:
- Immature digestion of lactose, protein and fat
- Limited glucose absorption18,19.
- Partially hydrolysed protein helps with the digestion of protein
- Provision of maltodextrin as part of the CHO source and not all as lactose
- Provision of some of the fat as MCTs
Breast milk contains its own enzymes (proteases e.g., plasmin, lactase and lipase) to help with the digestion of breastmilk20,21. Therefore, if breast milk is not available we need to provide a product that helps to address these digestive capabilities.
Increased nutrient needs combined with depletion of nutrient stores
Growth failure & More vulnerable to brain injury and long-term neurological effects
- Protein 3.6g/100kcal
- Partially hydrolysed Protein
Improving nutrient intake through improved tolerance and also through being able to meet protein requirements at a lower volume means these needs are met sooner in the feeding regime. Full enteral feeds are also achieved more rapidly12. This may help to reduce the protein deficit these preterm infants so often struggle with.
  1. Agostoni C et al. J Pediatr Gastroenterol Nutr. 2010;50:85-91.

  2. WHO. What health challenges do preterm babies face? 2013. Available at: (Accessed December 2021).

  3. Senterre T. World Rev Nutr Diet 2014;110:201-14.

  4. Fanaro S. Early Hum Dev 2013;89 Suppl 2:S13-20.

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

  6. Stephens BE et al. Pediatrics 2009; 123: 1337-1343.

  7. Lucas A, Cole TJ. Lancet 1990; 336: 1519-1523

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

  9. SMA® Breast Milk Fortifier data card.

  10. SMA Gold Prem® 1 data card.

  11. SMA Gold Prem® 2 data card.

  12. Mihatsch WA et al. Pediatrics 2002; 110(6): 1199-1203.

  13. Bergman NJ. Acta Paediatrica 2013; 102:773-777.

  14. Cooke R. et al. Padiatric Research 2006; 59 (2) :1-6.

  15. Omari, T. I., Rudolph, C.D. (2011). Gastrointestinal Motility. In F. W. W. Polin R.A., Abman S.H. (Ed.), Fetal and Neonatal Physiology (Vol. 4th). Elsevier Saunders.

  16. Picaud JC. et al. Journal od Paediatric Gastroenterology and Nutrition 2001; 32:555-561.

  17. Mihatsch WA. et al. Acta Paediatrica 2001;90:196-8.

  18. Neu J. Am J Clin Nutr 2007; 85(2): 629s-634s

  19. Blackburn, S. T. (2013). Gastrointestinal and hepatic systems and perinatal nutrition. In S. T. Blackburn (Ed.), Maternal, Fetal and Neonatal Physiology: A Clinical Perspective (4th ed.). Elsevier Saunders.

  20. Amaforte E et al. International Dairy Journal 2010; 20:715-723

  21. Dallas D et al. J Nutr Disord Ther. 2012; 2(3): 112-124.


We believe that breastfeeding is the ideal nutritional start for babies and we fully support the World Health Organizations recommendation of exclusive breastfeeding for the first six months of life followed by the introduction of adequate nutritious complementary foods along with continued breastfeeding up to two years of age. We also recognize that breastfeeding is not always an option for parents. We recommend healthcare professionals to inform parents about the advantages of breastfeeding. If parents consider not to breastfeed, healthcare professionals should inform parents that such a decision can be difficult to reverse and that the introduction of partial bottle-feeding will reduce the supply of breast milk. Parents should consider the social and financial implications of the use of infant formula. As babies grow at different rates, healthcare professionals should advise on the appropriate time for a baby to begin eating complementary foods. Infant formula and complementary foods should always be prepared, used and stored as instructed on the label in order to avoid risks to a baby’s health. The following products must be used under medical supervision. ●SMA® GOLD PREM BREAST MILK FORTIFIER is a nutritional supplement designed to be added to expressed breast milk for the dietary management of feeding preterm low birthweight babies. It is NOT a breast milk substitute. ●SMA Gold Prem® 1 is a special formula intended for the dietary management of preterm low birthweight babies who are not solely fed breast milk. It is suitable for use as the sole source of nutrition for preterm babies from birth. SMA Gold Prem® 1 is not intended for use with older preterm babies, for whom a special catch-up formula such as SMA Gold Prem® 2 is more appropriate. ●SMA Gold Prem® 2 is a special catch-up formula intended for the dietary management of preterm low birthweight babies who are not solely fed breast milk. It is a nutritionally complete formula for use on discharge from hospital or when a low birthweight formula is no longer appropriate. It is suitable for use as the sole source of nutrition up to 6 months corrected age. SMA Gold Prem® 2 is not intended for use with new born preterm babies, for whom fortified breast milk or a low birthweight formula such as SMA Gold Prem® 1 is more appropriate.