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Understanding the nutritional needs of premature babies: a discussion with Dr. Melinda Elliott

Babygaga spoke with Dr. Melinda J. Elliott, a neonatologist, in honor of March's National Nutrition Month.

March 31, 2012 -- Premature babies are infants born before 37 weeks of pregnancy. According to March of Dimes, 10 percent of babies born in the United States are premature. Since they are not fully developed at birth, premature babies are more likely to face health problems in childhood and later in life. As such, premature infants need specialized care in order to ensure they’re meeting their growth and developmental milestones.

The nutritional needs of a preterm baby will be different than an infant born at full-term. Babygaga recently had the chance to speak with Dr. Melinda J. Elliott, Neonatologist and Chief Medical Officer, Prolacta Bioscience, in honor of March’s National Nutrition Month. Proper nutrition in premature infants is imperative from day one, as it not only helps increase chances of survival but helps them flourish. Below, Dr. Elliott shares her expert advice for ensuring premature babies get the right nutrients to help them in their recovery.

Alexandra Sakellariou for Babygaga (BG): How do preemie nutritional needs differ from infants born at full-term?

Dr. Melinda Elliott (ME): Premature infants have significant nutritional needs compared to full-term infants due to the nutrition they miss out on in utero during the third trimester. In fact, premature babies require up to 40% more calories, protein, minerals, and nutrients than a full-term baby. These tiny infants grow at a very rapid pace, and they need extra nutritional support beginning from the first days of life. No matter how hard a premature baby’s mom tries to provide her milk, breastmilk alone doesn’t contain enough calories or protein to meet that baby’s nutritional needs, so mom’s milk must be fortified.

(BG): Can you explain why proper preemie nutrition is so important from day one?

(ME): Premature babies need to finish the growth they missed by being born too early. Everything is still growing rapidly – the lungs, eyes, brain, intestines, the whole body – so they need ample nutrition to reach their full potentials.

To provide this, neonatal intensive care units (NICUs) will supplement mom’s milk or donor milk with a fortifier to add much-needed extra calories, protein, and minerals. However, it’s important for parents to know what type of human milk fortifier their NICU is using: cow milk–based or donor breastmilk–based. Both are labeled “human milk fortifier,” so it is important for NICU moms and dads to ask their baby’s neonatologist or NICU nurse which type their baby is receiving.

Although cow milk–based fortifiers have been in use for many years, they have been linked to an increased risk of complications, many of them life-threatening as premature babies have trouble processing cow milk protein. After all, cow milk protein is very different from human milk protein.

Thankfully, there’s a well-established and clinically proven alternative to cow milk–based fortifiers. The nation’s leading NICUs are using Prolacta Bioscience’s 100% donor breastmilk–based fortifiers as the standard of care, and their patients are experiencing the benefits of avoiding cow milk–based products.

Clinical evidence shows the use of Prolacta’s donor breastmilk–based fortifiers result in better health outcomes and shorter hospital stays in the NICU. Many of the complications of prematurity are reduced, including:

  • Late-onset sepsis, a serious bacterial infection that can cause neurodevelopmental disabilities
  • Bronchopulmonary dysplasia (BPD), a chronic lung disease affecting mostly premature infants; retinopathy of prematurity (ROP), which can lead to blindness
  • Necrotizing enterocolitis (NEC), an intestinal disease and a leading cause of mortality in premature infants.

Only Prolacta’s human milk nutritional products are clinically proven, in more than 20 peer-reviewed studies, to improve growth and reduce complications of prematurity.

"I encourage NICU parents to advocate for 100% donor breastmilk–based fortifiers for their baby instead of cow milk–based fortifiers to help avoid these all-too-common complications of prematurity."

(BG): How many more calories do premature babies typically need in comparison to infants born at full gestational age?

(ME): Calorie intake in premature infants is actually counted based on the weight of the baby in kilograms (kg) (1 kilogram is equal to 2.2 pounds) per day rather than just per day (like in full-term healthy infants). This is due to the great variability in the birth weights of these babies. Some premature babies weigh less than 0.5 kg (little more than a pound), while others weigh much more.

Premature infants require 110 to 130 calories per kg per day, compared to 100 to 110 calories per kg per day for a full-term, healthy baby. While 10 to 20 calories more per day may not seem like a big difference, the more important nutritional need is protein. Premature infants need a much higher intake of protein compared to full-term infants.

A premature infant needs 3.5 to 4.5 grams (g) per kg per day of protein whereas a full-term baby needs only about 1.5 g per kg per day of protein from mother’s milk. This difference holds true for almost all of the major nutrients needed for growth (fat and carbohydrate, in addition to the protein).

Additionally, premature babies need much higher calcium, phosphorus, and other nutrients than full-term babies. Mother’s milk alone cannot meet these needs.

(BG): Before preemies come home from the hospital, how do staff in the neonatal intensive care unit (NICU) ensure premature infants get the right balance of fluids and nutrition? What technology or strategies do they use?

(ME): In the NICU, premature babies are monitored very carefully to ensure they receive the right nutrition at the right time, and to minimize any complications. Babies are usually weighed every day and have their head size and length measured every week. These measurements are compared to standard growth charts to assess how well the baby is growing.

In addition, many laboratory tests are checked on the baby’s blood in the first few days and weeks to ensure the baby is getting what he or she needs. Careful calculations of the amount of fortification needed to be added to the baby’s feedings are done every day to ensure appropriate intake.

As a very premature baby grows, matures, and becomes much more stable in the NICU, these lab tests are done less often. Remember that a very premature baby will likely be in the NICU until he or she is at or near his or her due date. If a baby is born very early, this can be four to five months.

(BG): What are some advances in neonatal nutrition that are available at the moment or are currently in development?

(ME): I consider the introduction of Prolacta’s 100% donor breastmilk–based fortifiers to be one of the biggest breakthroughs in NICU care in the last decade. These fortifiers remain the first and only well researched donor breastmilk–based fortifiers available. Before Prolacta, cow milk–based fortifiers were the only option, and they were also a main source of serious complications in premature infants. Fortification with Prolacta’s fortifiers has been a game-changer for my patients. I no longer have to worry about exposing these tiny babies to a foreign (cow milk) protein.

Since 2012, the American Academy of Pediatrics has recommended that all premature infants receive human milk. It only makes sense to use fortifiers that are also made from human milk. Since Prolacta’s fortifiers became available, multiple scientific papers have been published describing the benefits of these fortifiers over a diet that includes cow milk. In publication after publication, Prolacta’s donor breastmilk–based fortifiers, when used as part of an exclusive human milk diet, have been associated with decreases in many serious complications of prematurity, such as:

  • Bronchopulmonary dysplasia (BPD)9,6,7
  • Late-onset sepsis9,6,8
  • Retinopathy of prematurity (ROP)9,6,7
  • Necrotizing enterocolitis (NEC)3,6
  • Feeding intolerance 7

Additionally, the use of a completely human milk–based diet, free of cow milk, has been associated with shorter stays in the hospital for very premature babies.

A second big advance is the recognition of the importance of every NICU developing a feeding protocol for its premature patients. Studies have shown decreases in the rate of feeding intolerance simply with the presence of a feeding protocol that the clinical team follows. A feeding protocol also gives families a good idea of how and what their baby will be fed. It can also help mom know how much milk she will need and when.

Another relatively new advance is the ability to measure the nutritional components of donor or mother’s milk. Currently, this technology is available only in some of the bigger NICUs and often only as part of a research project. Having the ability to measure mom’s milk is a very valuable tool. Human milk varies from person to person, from day to day in the same person, and even from hour to hour.

Knowing the components of the milk enables the medical team to tailor the fortification to that baby’s exact needs based on the mother’s or donor milk. There is currently research underway to make this technology easy to use and available at the bedside. I see a future where we can measure mom’s milk and add the exact right amount and concentration of Prolacta’s donor breastmilk–based fortifiers to it to meet that baby’s needs at that time.

(BG): What questions should parents ask their baby’s NICU care team before taking their baby home? What resources may the hospital have to support them?

(ME): Taking a premature baby home from the NICU is both a joyful and stressful experience. Hopefully, your baby’s NICU team has already been preparing you and your baby for discharge right from the beginning. As your baby has grown and recovered in the NICU, you have been doing all the things most parents do: changing diapers, feeding your baby, and getting to know your baby.

As your baby starts to feed by mouth (either at the breast or with a bottle or both), you should ask the health care team what type of milk will be needed at home. Make sure you have all the prescriptions or forms you will need to get the right medications and nutritional products your baby needs. Ask the team to teach you how to give the baby any needed medications. Make sure you have identified a pediatrician and made that first appointment for 24 to 48 hours after discharge.

Most NICU graduates qualify for a few visits from a home health nurse. Take advantage of that! The home nurse can be very helpful and reassuring as you are getting used to caring for your baby at home. Two excellent resources you can access before (and after) discharge are the Peekaboo ICU Preemie App and “The Preemie Parent's Survival Guide to the NICU” book.

And finally, one of the best things to do before discharge is to request to stay with your baby in the NICU for a couple of nights right before your baby goes home. Most NICUs support this request. This will give you a chance to take charge of your baby’s care while having the NICU staff there to answer any questions you may not have thought of before. It is a great way to “practice” taking over, yet still have the comfort of knowing help is just around the corner if you need it.

(BG): Is it sufficient to only breastfeed a newborn who was born prematurely? If not, what do parents need to supplement with to ensure their preemie’s nutritional needs are being met when they’re home from the hospital?

(ME): Breastmilk is vital nutrition for all babies, especially a premature baby. When a premature baby is ready for discharge home from the hospital, that baby likely will weigh nearly 5 lbs and will be feeding normally, either at the breast or with a bottle (ideally with pumped mother’s milk). Some babies will do very well with just breastfeeding.

Premature babies who were very immature and/or very small will likely need some form of supplementation. I recommend that parents ask the baby’s medical team what will be needed after discharge. If the baby is doing well with breastfeeding but still needs fortification, this might mean an extra bottle or two a day of either fortified mother’s milk or premature infant formula.

If the baby is bottle feeding, then this might mean fortifying every bottle. It is important to point out that, as important as an exclusive human milk diet (including donor breastmilk–based fortifiers) is for very premature infants in the weeks after birth, these fortifiers are designed for use only while babies are still in the NICU.

Most hospitals that use them transition the baby to a diet that can be used at home once the baby reaches around 34 weeks gestation. After this time, most or all of the problems associated with prematurity are greatly decreased, and it is OK to use a cow milk–based fortifier.

(BG): What advice would you give parents who cannot or choose not to breastfeed their premature baby? How can they ensure their preemie is getting enough nutrition through formula-feeding?

(ME): Breastmilk has many health benefits for the premature infant. It is not easy to pump and provide milk for an infant born prematurely. A new mom should never feel pressured to provide milk or made to feel like a failure if she is unable to provide milk for her baby. Because breastmilk is vital and recommended for all premature infants, many NICUs provide donor breastmilk and/or Prolacta’s donor breastmilk–based Ready to Feed (RTF) formulas if a mother’s milk supply is low or if she is unable to provide any milk for her baby.

For very premature babies, breastmilk is vital, and parents should advocate for their babies to receive nothing but breastmilk and clinically proven donor breastmilk–based products during those first critical weeks of life.

(BG): What sorts of feeding problems are common in babies born prematurely? How can parents help address these problems?

(ME): Preterm birth has many effects on a baby’s health, development, and behavior — and feeding is no exception. The biggest feeding problem with premature infants is feeding intolerance, because their gastrointestinal systems are not fully developed. The most severe type of feeding intolerance in premature infants is a severe injury to the intestines called necrotizing enterocolitis or NEC. This problem causes babies to become very sick and can even lead to the need for surgery or worse.

NEC has been shown to be decreased with the use of Prolacta’s products (formulas or fortifiers) rather than cow milk–based ones. You know your baby best, so if you see something that changes in your baby, alert the medical team. I always ask parents how they think their baby is doing. They are often the first ones to notice a very small change. Never be afraid to speak up!

Premature babies also are too immature to be able to be able to feed by mouth like full-term babies. For the first few weeks of life, premature babies are fed with small feeding tubes, inserted through the mouth or nose. Most babies start to learn to coordinate feeding by mouth around 34 weeks gestation. This is when babies will start to learn how to breastfeed. Even before this, however, if the baby is stable, he or she should be going skin to skin with mom and practicing breastfeeding after mom pumps. This really helps the baby and the mom to prepare for breastfeeding when the time comes.

(BG): What are signs that may indicate a premature baby isn’t getting enough nutrition? When should parents consult a doctor?

(ME): When a premature baby goes home, there is usually a good safety net around that family. Your baby should be seen by his or her pediatrician within 24 to 48 hours of going home. The doctor will get a weight at that time and examine your baby closely.

Depending on how premature your baby was and whether there were any other problems related to prematurity, the next visits will be scheduled. You will be given guidelines on how much to feed your baby and how often. Generally speaking, very premature babies will still need to be fed every three hours for a few more weeks until they get bigger.

If your baby is feeding well and having normal stools, then it is likely that things are going well. It is important to keep in close communication with the pediatrician to make sure things continue progressing well.

(BG): On a similar note, how can parents ensure their premature baby is gaining weight at an adequate rate? What signs may indicate they’re having trouble with this?

(ME): Parents will be given good guidance about what and how much to feed their NICU graduate. There will often even be home nursing visits where the baby will get a few extra weigh-ins by the visiting nurse. Clues to a problem are changes in the baby’s behavior, decreases in the amount the baby usually eats, not waking up for feeds, or decreases in stool or urine output. As long as your baby is eating well, stooling well, and waking for feeds, it is likely that he or she IS doing well.

The medical team wants every baby to thrive, so there is usually a lot of support at home from the visiting nurse and pediatrician. You know your baby best and should never hesitate to call the doctor if you are worried. You and your baby fought long and hard to get out of the NICU and home.

(BG): What’s your best advice for parents who recently welcomed a premature baby? What should they know or expect about their little one’s nutritional needs?

(ME): The first thing I advise is to listen to your heart. Don’t let the equipment and activity in the NICU scare you. You are your baby’s parents, so get involved and do whatever you can for your baby. Ask the nurses for help in changing your baby’s diaper. Ask if you can hold you baby skin to skin (this will help stabilize your baby and will help with your milk production). Remember that your baby has the best possible medical care team taking care of him or her while you’re not there in the NICU, so try not to worry. Ask any and every question that comes to mind. This is your baby, and you need to know everything you can about him or her.

Provide breastmilk for your baby if you can. Additionally, to give your baby the best chance to avoid many of the common complications of prematurity such as BPD, neurodevelopmental delays, ROP, and NEC, advocate for your baby to receive 100% donor breastmilk–based fortifiers or formulas that have been clinically proven instead of cow milk–based products.

Lastly, be sure to record information, such as your baby’s daily stats on growth (weight, head circumference, length), medications or treatments received, complications, names of medical staff, and any questions. Consider using an app like Peekaboo ICU to keep track of all that is going on.

Most of all, just love and enjoy your baby.

Thank you so much to Dr. Melinda Elliott for speaking to Babygaga. To learn about the  nutritional needs of premature babies, be sure to speak with your doctor.