Prematurity- new 2025 VF -ENG - module 2.pptx

02.Nutritional management for preterm infants

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CHALLENGES THAT CAN BE OVERCOME WITH SPECIFIC NUTRITIONAL MANAGEMENT1,2

SUPPORT GROWTH

SUPPORT THE IMMUNE SYSTEM

COUNTERACT GASTROINTESTINAL IMMATURITY

COUNTERACT CEREBRAL IMMATURITY

REBALANCE THE GUT MICROBIOTA

INCREASE IN ENERGY AND PROTEIN REQUIREMENTS

INCREASE IN FATTY ACID NEEDS (INCLUDING LC-PUFA*)

ACCESSIBILITY AND EASE OF ABSORPTION OF NUTRIENTS

RESTORATION OF THE GUT MICROBIOTA

Adequate growth is fundamental to helping a preterm baby thrive

Objective: To achieve similar growth to that of a foetus of the same gestational age1

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*LC-PUFA: Long-chain polyunsaturated fatty acids

PREMATURE INFANTS HAVE HIGHER NUTRITIONAL NEEDS THAN FULL-TERM INFANTS

NEW ESPGHAN RECOMMENDATIONS 20222

1.5 X MORE ENERGY2.3*

2 X MORE PROTEIN2,4*

Achieving cognitive and immune growth and development goals1

Higher energy and protein requirements

2 to 20 X MORE MICRO- NUTRIENTS2.5

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4 X MORE DHA2.6

For more information: see the Pre Nursie or Aptamil Nutriprem module

*Based on infant's weight

THE SPECIFIC NEEDS OF PRETERM INFANTS REQUIRE SPECIFIC NUTRITIONAL MANAGEMENT

Objectives of nutritional management

Objective sought

Problem = specific physiological needs

• Rapid growth (catch-up)
• Immature organs and metabolism
• Low body reserves
• Susceptibility to disease

The nutrient and energy intake must allow a growth rate that is equivalent to what it would have been in utero

Monitoring growth

• Ideal weight gain = 18-20 g/kg/d (or twice as much as a full-term infant)
• Regularly monitor weight, height and head circumference (HC) growth.
• Weight should be measured 1 to 2 times per day for the first 1 to 2 weeks and then 2 to 3 times per week during the stable growth phase. Height and HC should be measured once per week unless the clinical condition warrants more frequent monitoring.

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Water and electrolyte requirements:

• Rapid growth + losses due to immature skin and renal function -> higher requirements
• But be careful of excess -> immature renal function!
• Most infants in the stable growth phase will require a fluid intake of 150-180 mL/kg/day to achieve adequate nutrient intakes

Sources: 1) American Academy of Pediatrics, 2004 (cf. PDF Medical Affairs, Preterm Nutrition Lesson 2); Embleton, et al., JPGN 2022; Oregon Pediatric Nutrition Practice Group, 2013 (https://public.health.oregon.gov/HealthyPeopleFamilies/wic/Documents/preterm.pdf)

NEW ESPGHAN RECOS 2022

FOCUS ON the new Espghan 2022 recommendations

In 2022, ESPGHAN updated its nutritional recommendations for preterm infants <1800g, replacing those established in 2010.

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Embleton ND, et al., Enteral Nutrition in Preterm Infants (2022): A Position Paper From the ESPGHAN Committee on Nutrition and Invited Experts. J Pediatr Gastroenterol Nutr. 2023 Feb 1;76(2):248-268.

NEW ESPGHAN RECOS 2022

WHAT 'S NEW IN 2022? OVERVIEW OF THE MAIN CHANGES MADE IN THE 2022 UPDATE OF THE RECOMMENDATIONS COMPARED TO THE 2010 VERSION.

EXPRESSION OF RECOMMENDED CONTRIBUTIONS

Recommended intakes are expressed per kilogram of body weight per day, and no longer per 100 kcal.

Micronutrients

Proteins

↗ Minimum intakes: K, P, Mg, Zn, Cu, Se, niacin, pantothenic acid, vitamin B6, vitamin C and biotin. Maximum ↗intakes: Na, K, Cl, Ca, P, Fe, Cu, Cr and certain vitamins. Maximum intakes↘: Mn, Mg, vitamin B12, and other vitamins. Vitamin D is now expressed based on body weight (kg). Minimum folic acid intake reduced.

Protein needs are no longer based on body weight but instead on the growth trajectory.

ENERGY

LIQUIDS (FLUIDS)

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Minimum intakes have been increased per kg/day

Minimum recommendation increased.

NUCLEOTIDES

Due to lack of evidence, they are no longer routinely recommended as a supplement

LIPIDS

NEW ADDITIONS

The maximum intake has been increased, The minimum levels of DHA and ARA have been increased.

Hydrolysed proteins & osmolality addressed; Position taken on clinical practice relating to the encouragement of enteral feeding and the fortification of breastmilk.

NEW ESPGHAN RECOS 2022

HOW DOES OUR FORMULA FOR PRETERM INFANTS COMPARE TO THE NEW RECOMMENDATIONS?

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Our preterm formula (PTF) complies with the recommendations for the consumption of 150 ml/kg/day, with the exception of selenium, zinc and vitamin D

NEW ESPGHAN RECOS 2022

Context and explanation for zinc (Zn), selenium (Se) and vitamin D.

Zinc

Vitamin D

The previous ESPGHAN recommendations were expressed as a fixed amount per day, not per kg of body weight. Given the variations in weight and volumes consumed in preterm babies, it was recommended that a formula for preterm infants should cover basic vitamin D requirements, with a separate supplementation. This practice remains common and is encouraged in our current portfolio for preterm infants

Zinc intake recommendations have been increased in the new guidelines for preterm infants. The updated minimum intake is now close to the old maximum level. Thus, products in accordance with the 2010 recommendations will need to be modified to meet the new recommended zinc intakes.

Selenium

Selenium deficiency is associated with increased morbidity in preterm infants, whereas excessive intakes are particularly toxic due to hepatic and renal immaturity. Since the concentration of selenium in breastmilk varies depending on the mother's diet, geography and environment, Nutricia provides conservative levels of Se in order to avoid any risk of toxicity.

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1. Domellöf and Georgieff, 2015; Domellöf and Sjostrom, 2017; Lapillonne, 2014 2. Agostoni et al., 2010; Klein (eds) 2002

NEW ESPGHAN RECOS 2022

KEY POINTS TO BEAR IN MIND

• BLEDINA/NUTRICIA bases the composition and positioning of its portfolio for preterm infants on the ESPGHAN recommendations.

• Compliance with these recommendations remains a key argument, both globally and locally.

• Our preterm infant formula (PTF) continues to be safe and suitable for the nutritional management of infants under 1800g.

• Our preterm formula (PTF) complies with the recommendations for the consumption of 150 ml/kg/day, with the exception of selenium, zinc and vitamin D

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THE SPECIFIC NEEDS OF PRETERM INFANTS REQUIRE SPECIFIC NUTRITIONAL MANAGEMENT

50th

10th

Weight (grams)

Specific nutrition in the event of continuing delayed growth

Specific nutrition in the event of continuing delayed growth

Enteral feeding

Parenteral feeding

Age (weeks)

PRETERM INFANT NUTRITION IS BASED ON TWO MAIN PRINCIPLES1,2

In the maternity unit, at an early stage, optimise parenteral feeding (if necessary and possible) As soon as possible, introduce adequate enteral nutrition, preferably breastmilk When leaving hospital, provide instructions about continuing a suitable diet for children >1800g with persistent delayed growth or at risk of nutritional deficiencies

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The transition between each phase should be gradual, with close monitoring of the infant's weight gain and food tolerance.

INTERNATIONAL RECOMMENDATIONS FOR THE NUTRITIONAL MANAGEMENT OF PRETERM INFANTS

Oral Nutrition (ON)

Enteral Nutrition (EN)

Parenteral Nutrition (PN)

Parenteral feeding is used if enteral feeding is not possible or is contraindicated or inadequate7.

• PN should be initiated on the first day of life or as soon as possible2

• Use of a central lineis more efficient for nutrient delivery 3

• Transition to enteral feeding gradually and as soon as possible.

The baby can be breastfed or bottle-fed (usually around 34-35 weeks)7

• Depends on the infant's development
• Good coordination of sucking, swallowing and breathing2

• Check that on-demand feeding is ensuring adequate growth2

• Prioritise breastmilk (if possible) + fortification or preterm formula3

If the sucking and swallowing reflexes are absent, EN is the most suitable way to provide an adequate diet7.

• Initiate as early as possible depending on the infant’s general clinical condition and the availability of breastmilk4

• Do not prolong EN unnecessarily; initiate oral feeding as soon as possible (>32 weeks)

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Nutritional management must be aligned with the service protocol and adapted to take account of the weight, age and tolerance of each infant1

Questions

ESPGHAN* recommends various nutritional solutions

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*ESPGHAN: European Society of Paediatric Gastroenterology, Hepatology and Nutrition

ESPGHAN* recommends various nutritional solutions 1

For more information: see the PreNursie or Aptamil Nutriprem module

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FOR BABIES WHO CANNOT BE BREASTFED: FORMULA FOR PRETERM BABIES***a

PRIORITY TO BE GIVEN TO: FORTIFIED BREASTMILK**a

*ESPGHAN: European Society of Paediatric Gastroenterology, Hepatology and Nutrition ** If necessary, fortified with proteins, minerals and other elements such as appropriate quantities of long-chain polyunsaturated fatty acids ***The composition of preterm formulas infants must comply with ESPGHAN’s recommendations1 a. Breastmilk fortification or the duration of a specific preterm diet should be based on close monitoring of the infant's growth. Once growth targets are met and appropriate growth can be maintained by a standard infant formula or non-fortified breastmilk, these solutions should be offered. Growth should be monitored to ensure that proper growth is maintained.

ESPGHAN* recommends various nutritional solutions 1

Strategies to encourage breastfeeding2

Contraindications to breastfeeding1

Just a few conditions, in the infant’s interest:

GENERAL SUPPORT:

• Establishment of structured programs such as "kangaroo care"
• Family-centred
• Effectiveness widely demonstrated.
• Specific training for medical teams

SPECIFIC SUPPORT FOR BREASTFEEDING:

• Encourage the decision to breastfeed their baby
• Start and maintain lactation (facilitating the expression of milk)
• Promote unlimited skin-to-skin contact as soon as possible
• Start the first "feeds" at the breast in optimal conditions
• Allow the transition from scheduled feeding to on-demand breastfeeding
• Prioritise the use of alternative methods to the bottle with due consideration
• Prepare for the mother’s return home and organise follow-up and support once she is home

• Maternal HIV* infection (depending on the country)
• Classic variant of galactosaemia (if benign, the infant can be breastfed, at least partially)
• Human T-cell lymphotropic virus (HTLV) type I or II positive
• Herpes simplex lesion on a breast
• In infants <1500g or <32 weeks born to mothers who are CMV** positive: the benefit of breastfeeding should be balanced against the risk of CMV transmission
• LC-PUFA* oxidation disorders and related disorders
• Congenital lactase deficiency
• Receipt of diagnostic or therapeutic radioactive isotopes or those who have been exposed to radioactive material

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*HIV: human immunodeficiency virus **CMV: cytomegalovirus ***LC-PUFA: long-chain polyunsaturated fatty acids

FOCUS ON KANGAROO CARE

Benefits of Kangaroo Care

Main features

Kangaroo Care is an intervention for preterm infants weighing less than 2 kg. It should be implemented in healthcare establishments as soon as newborns are clinically stable1

No special equipment required.Simply rooms with comfortable beds, armchairs and pillows allowing an appropriate position1

Prolonged and continuous skin-to-skin contact 1

Exclusive breastfeeding (ideally) or fed with breastmilk1

TO FIND OUT MORE

Helps with breastfeeding

• This offers benefits in the event of severe morbidity2

Thermoregulation

• Provides physiological stability, in particular thermal stability, and is associated with a reduced risk of hypothermia2

Strengthens the bond between parents and infant

• Improves the bond between parents and baby in low- and high-income countries 2

Reduces stress in the mother

• Mothers gain confidence, self-esteem and greater satisfaction, thanks to the active role they play in the care of their infant

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BREASTMILK REMAINS THE FOOD TO BE PRIORITISED, BUT IS NOT SUFFICIENT TO COVER THE INCREASED NEEDS OF PREMATURE INFANTS

Breastmilk is a source of nutritional bioactive compounds1

With numerous benefits2-6

Lipids: - LC-PUFA* - MCT**

Carbohydrates

Live bacteria, immune cells, other

Vitamins and minerals

Proteins

Nucleotides

Human milk oligosaccharides (HMOs)

Long term

Prevents obesity

Lower cholesterol

Better intellectual performance

Short term

Growth

Brain development

Immune protection

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… its protein and energy concentration does not cover the increased needs of preterm infants: fortification is necessary7,8

*LC-PUFA: long chain polyunsaturated fatty acids **MCT: medium-chain triglycerides

A RICH LIPID PROFILE TO SUPPORT BRAIN DEVELOPMENT AND TO RESPECT THE METABOLIC IMMATURITY OF PRETERM INFANTS

*LC-PUFAs: long chain polyunsaturated fatty acids **DHA & ARA: docosahexaenoic acid and arachidonic acid

Essential to brain and visual development1-3

LC-PUFAs*

Preterm babies lack reserves of essential fatty acids and do not have the enzymes for conversion to LC-PUFAs*2,4

A dietary source of LC-PUFA*, in particular ARA and DHA**, is crucial1

Breastmilk

Lipids- LC-PUFA* - MCT

In breastmilk, LC-PUFAs come in 2 forms:

phospholipid-bound and triglyceride-bound.

Phospholipid-bound LC-PUFAs are more easily absorbed and incorporated in the brain than triglyceride-bound LC-PUFAs5,6

Breastmilk

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A RICH LIPID PROFILE TO SUPPORT BRAIN DEVELOPMENT AND TO RESPECT THE METABOLIC IMMATURITY OF PRETERM INFANTS

Breastmilk

MCTs: medium-chain triglycerides

Lipids- LC-PUFA* - MCT

A readily accessible energy source1

• Aid digestion
• Are easily absorbed

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*LC-PUFAs: long chain polyunsaturated fatty acids **DHA & ARA: docosahexaenoic acid and arachidonic acid

AN ENERGY AND PROTEIN CONTENT THAT ADAPTS TO THE NUTRITIONAL NEEDS OF INFANTS...

A PROTEIN CONTENT THAT CHANGES OVER TIME The amount of protein is higher in the first few weeks compared to the rest of the of the breastfeeding period1,3,4

Respects the metabolic immaturity2

AN APPROPRIATE CASEIN-TO-SOLUBLE PROTEIN RATIO (40:60 in mature breastmilk)3 An AA* composition regarded as THE REFERENCE for the evaluation of infant formulas for preterm infants2

Adapts to functional and nutritional needs2

... But that is not enough to help preterm babies grow and develop in an optimal way5-7

Breastmilk

Proteins

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*AA: amino acids

NUCLEOTIDES TO SUPPORT THE IMMUNE RESPONSE AND THE DEVELOPMENT OF THE GUT MICROBIOTA

Breastmilk

Nucleotides play an important role in biological mechanisms1-4:

Energy metabolism

Gut microbiota

Immune response

↗ antibodies

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Nucleotides 1

INSPIRED BY BREASTMILK: INFANT FORMULAS FOR PRETERM INFANTS ARE SPECIALLY DESIGNED TO COVER THE NUTRITIONAL NEEDS OF NON-BREASTFED INFANTS

GROWTH AND METABOLISM

Energy and protein in accordance with the ESPGHAN* recommendations1

ARA/DHA**2 MCT*** To get close to the composition of breastmilk

A unique mix of scGOS/lcFOS (9:1)****3,4 Inspired by the oligosaccharides in breastmilk

BRAIN DEVELOPMENT

HEALTH DIGESTION AND IMMUNITY

> To provide nutrients in sufficient quantities

> To support increased growth needs and brain development

> To ensure the development of a healthy gut microbiota, similar to breastfed babies

3 CHALLENGES

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*ESPGHAN: European Society for Paediatric Gastroenterology Hepatology and Nutrition **ARA/DHA: arachidonic acid / docosahexaenoic acid***MCT: medium-chain triglycerides****scGOS/lcFOS: short-chain galacto-oligosaccharides / long-chain fructo-oligosaccharides

scGOS/lcFOS* (9:1): CLINICALLY PROVEN BENEFITS TO SUPPORT GUT, MICROBIOTIC AND IMMUNE FUNCTIONS IN PRETERM INFANTS

GUT FUNCTIONS

MICROBIOTIC AND IMMUNE FUNCTIONS

Improvement in intestinal transit5

Improvement in faecal characteristics (viscosity and pH)5 Stool frequency and consistency similar to those observed with breastmilk1

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Lower incidence of infectious episodes3,4

Stimulate the growth and/or activity of bacteria beneficial to the gut microbiota in preterm infants1

Reduce the presence of pathogens in the faecal flora of preterm newborns2

*scGOS/lcFOS: short-chain galacto-oligosaccharides / long-chain fructo-oligosaccharides

scGOS/lcFOS * (9:1) stimulate the growth and/or activity of bacteria beneficial to the gut microbiota in preterm infants

BOEHM & AL 20021

Randomised clinical intervention study of 30 preterm babies <32 weeks Group 1 (N= 15): fed a preterm infant formula with scGOS:lcFOS* prebiotic (9:1) for 28 days Group 2 (N=15, control): fed a preterm infant formula with maltodextrin (placebo) for 28 days The infants’ faecal flora was recorded on days 1, 7, 14 and 28.

Preterm infants fed a formula containing scGOS/lcFOS* (9:1) have shown, to a significant degree, a higher number of bifidobacteria

A microbiota composition similar to that of breastfed babies

BIFIDOBACTERIAL COLONISATION IN PREMATURE INFANTS FED INFANT FORMULA CONTAINING scGOS/lcFOS*

Bifidobacteria (milligrams)

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Days

Control

scGOS/lcFOS*

*scGOS/lcFOS: short-chain galacto-oligosaccharides / long-chain fructo-oligosaccharides

scGOS/lcFOS* (9:1) reduce the presence of pathogens in the faecal flora of preterm newborns

KNOL & AL 2005 1

Randomised clinical intervention study of 25 preterm babies <32 weeks Group 1: fed a preterm infant formula with scGOS:lcFOS* (9:1) prebiotic for 28 days Group 2 (control): fed preterm infant formula with maltodextrin (placebo) for 28 days Faecal pathogens were recorded on days 1 and 28.

Stimulation of bifidobacteria by a formula for preterm infants containing prebiotic oligosaccharides scGOS/lcFOS* (9:1) reduces the presence of pathogens in the faecal flora

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The number of pathogens was significantly lower in the group of babies fed formula containing scGOS:lcFOS* prebiotics (9:1) compared to the group fed the control preparation

total number of microbes (%)

control

*scGOS/lcFOS: short-chain galacto-oligosaccharides / long-chain fructo-oligosaccharides

Summary of nutritional options for the preterm newborn

Breastmilk fortifiers

Post-hospital formula

Weight <1000g

<1800g

<2500g

PREMATURE <37 weeks

FULL-TERM

≥1800g and if support for growth is needed after leaving hospital

<1000g

Breastmilk fortifiers (BMF)

Preterm formula

>1000g-1800g

Breastmilk

Protein supplements

Breastmilk

Preterm formula

Breastmilk

BMF

Proteins

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Delayed growth may continue after leaving hospital

Growth of the preterm infant (change in Z-score) from birth to 18 months

Growth resumed

Faltering growth

The period from one to two months (corrected age) is very important for preventing faltering growth. When they come home from hospital, most preterm infants show suboptimal growth. Suboptimal growth may continue for months or even years.

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TO FIND OUT MORE

RECOMMENDATION REGARDING VITAMIN AND MINERAL SUPPLEMENTATION

AAPb (USA)

ESPGHANa (Europe)

Vitamin and mineral supplementation should be harmonised with local and national protocols

• Preterm infants who are breastfed or fed an infant formula should receive 2 to 2.5 mg/kg/day of iron from the age of 8 postnatal weeks (at the latest) through to 12-15 months3

• LMPTs <2500g at birth should receive 1 to 2 mg/kg/day (2 to 3 mg/kg/day for LMPT* >2000g) of iron from 0-6 months1

• Initiated in oral form after 3 weeks of well-tolerated enteral feeding 2

• LMPTs* require a daily vitamin D supplement of at least 400 IU/day throughout childhood1

• Breastfed preterm infants should receive 1 to 2 mg/kg/day of elemental iron from 1 postnatal month to 12 months of age2

• Infants fed infant formula should receive 1 mg/kg/day of iron from 1 month to 12 months of age3

• LMPTs* require a daily vitamin D supplement of at least 400-800 IU/day throughout childhood4

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1. ESPGHAN - The European Society for Paediatric Gastroenterology, Hepatology and Nutrition
2. AAP – American Academy of Pediatrics
3. LMPT – late or moderate prematurity (preterm infant born between 32 and 36 weeks)

The preterm infant’s diet after leaving hospital

The type of food given to a baby after leaving the hospital depends on:

• birth weight
• weight when leaving hospital
• infant’s condition during the time in the neonatology unit

Recommendations in this regard are scarce and there is no consensus.

One thing is certain: breastmilk is strongly recommended! To be encouraged, if possible, with a lactation consultation to provide support with the difficulties frequently encountered following a premature birth (sucking problems, refusal of the breast after bottle-feeding, regurgitation, etc.)

Some babies are at risk of nutritional deficiencies => they need fortified milk for a longer period

• Birth weight <1 kg
• Exclusive parenteral feeding >1 month
• Weight when leaving hospital <10th percentile
• Abnormal bone mineralisation markers
• Growth support is still needed

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The preterm infant’s diet after leaving hospital

Monitoring an infant's growth after leaving hospital requires the use of appropriate graphs, such as those of Olsen et al. that:

• distinguish between boys and girls
• continue until the infant is one year old

Monitoring recommendations for the first weeks:

• Weigh the baby every two days
• Encourage on-demand breastfeeding (every 1.5 to 3 hours)
• Assess feeding methods at the end of the first week
• Give parents useful contacts for support (specialised dietician, lactation consultant, etc.) => need for personalised advice
• Identify possible nutritional deficits in the event of risk (inappropriate growth) => biological dosage (ferritin, vitamin D, alkaline phosphatase, etc.)
• Adapt diet to quickly correct any deficiencies => fortification of breastmilk, preterm formulas
• Then normalise the diet to avoid over-nutrition or acceleration of growth

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TO FIND OUT MORE

Key MESSAGES

• Preterm infants have higher nutritional needs than full-term infants who require appropriate nutritional management.

• Breastmilk is the food to be prioritised but it is not always sufficient to help preterm infants grow and develop optimally. Fortification is needed.

• Where breastfeeding is not possible, preterm formulas are inspired by breastmilk and comply with ESPGHAN* recommendations to meet the increased growth challenges and to respect the physiological immaturity of the preterm infant.

• Preterm formulas enriched with scGOS/lcFOS** prebiotics (9:1) have demonstrated clinical benefits in supporting the gut, microbiotic and immune functions of preterm infants.

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*ESPGHAN: European Society of Paediatric Gastroenterology, Hepatology and Nutrition

**scGOS/lcFOS: short-chain galacto-oligosaccharides / long-chain fructo-oligosaccharides