Preemies on unfortified human milk or standard formula need MVI until at least 2.5 kg
Preterm formulas. After discharge use 22 kcal formula (or up to 24 kcal/oz) for at least the first 9 months of life. Will not need add’l vitamin supplement while on preterm formula.
Similac Special Care Advance 24
Enfamil Premature Lipid 24
Similac Neosure 22
Enfamil Enfacare 22
Human Milk: Nutritional needs of the preterm infant exceed those in human milk for protein, calcium, phosphorus, Mg, Na, copper, Zn, folic acid, vitamins B2, B6, C, D, E, K. In the supplemented preterm infant, watch for hyponatremia at 4-5 wks, hypoproteinemia at 8-12 wks, osteopenia at 4-5 mos and Zn deficiency at 2-6 mos. HMF is recommended
Human milk fortifier (usually 1 packet to 25 mL)
Enfamil HMF
Similac HMF
Preemies (and immunocompromised) should not receive formula prepared from powder because they are not sterile. HMF is exempted because there is no other choice.
Soy based formulas are not recommended for preterm infants because optimal carbohydrate, protein and mineral absorption and utilization are not well documented.
Energy requirement
105-130 kcal/kg/day. More calories can be given if growth is unsatisfactory.
Fat: 40-50% of commercial formulas); 50% of breast milk. 5-6 g/kg/d
DHA, ARA (LCPUFA): contained in small amounts in breast milk. Some studies suggest exogeneous sources may be needed. However many studies are conflicted on the effect of ~ on visual outcome and neurodevelopmental outcome.
Carb: 40-50% of calories (10-14 g/kg/d)
Sodium and potassium: Preterm esp <1500 g BW have high fractional excretion of sodium in first 10-14 days. Human milk, standard formula and even HMF w/ EBM may lead to hyponatremia during this time. K+ requirements are similar to term infants.
Ca/Phos/Mg: 80% of these are accrued during the last trimester. Need more of this, which is provided by preterm formula. Solely breastfeeding has been associated w/ impaired bone mineralization and rickets.
Iron: during the first 2 weeks of life, no clear indication exists for iron supplementation. However after 2 weeks of age 2-4 mg/kg/day should be supplemented (those on preterm formula do not need supplementation). All preterm infants should receive at least 2 mg/kg/iron until 12 months of age. Epo is controversial.
Trace minerals: preterm formula and HMF contains the necessary Zn; Copper need is met by human milk alone or preterm formula; Iodine need is met by preterm formula but HMF doesn’t contain extra iodine however supplementation needs have not been identified.
Water soluble vitamins and supplementation (overall have decreased reserves and relatively few vitamins are provided by standard oral MVI. However there are no guidelines or published studies re: supplemental water soluble vitamins)
Ascorbic acid is present in HMF and preterm formula. No published studies have assessed the ascorbic acid status of enterally fed preterm infants.
Vitamin B1 (thiamine): there’s enough in br milk, formula and HMF
Vitamin B2 (riboflavin): same
Vitamin B6 (pyridoxine): same
Vitamin B3 (niacin): inadequate information
Biotin: the only reports of biotin deficiency have occurred among infants supported on biotin free TPN for several weeks
Pantothenic acid: there’s enough in br milk, formula and HMF
Folic acid: increased risk for deficiency d/t decreased stores and rapid postnatal growth: Human milk ( 7 ug/100 kcal) contains less than the recommended amount (25-50 ug/100 kcal). HMF and preterm formula: adequate.
Vitamin B12 (cobalamin): Clinical sx of deficiency have been reported among infants who were exclusively breastfed by vegetarian mothers. Otherwise, no deficiency should occur.
Fat soluble vitamins (in general, if br fed, supplementing A,D,E avail in oral solutions; preterm formulas are self-sufficient; standard formula? Needs supplementation)
Vitamin A: Preterm infant is at risk for deficiency d/t limited reserves and sometimes depletion. Human milk does not supply the recommended intake. This is an IM injection though.
Vitamin E: Need supplementation. Present in preterm formula 4-6 IU/100 kcal/day (recommended 6-12). Mature human milk: variable content. HMF recommended.
Vitamin D: 400 IU per day. Supplied by HMF and preterm formula.
Vitamin K: dose 1 mg IM if > 1 kg. 0.3 mg phylloquinone if < 1 kg. Preterm formulas and HMF provide sufficient.
Updated Apr 2009.
From Pediatric Nutrition Handbook, 6th Ed. 2009.