Evidence-Based Guidelines for Optimization of Nutrition for the Very Low

Birthweight Infant
Roberto Murgas Torrazza and Josef Neu
Neoreviews 2013;14;e340
DOI: 10.1542/neo.14-7-e340

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 Evidence-Based Guidelines for Optimization of Nutrition for the Very Low
Birthweight Infant
Roberto Murgas Torrazza and Josef Neu
Neoreviews 2013;14;e340
DOI: 10.1542/neo.14-7-e340

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Article evidence-based medicine

Evidence-Based Guidelines for Optimization

of Nutrition for the Very Low Birthweight
Infant
Roberto Murgas Torrazza, Educational Gaps
MD,* Josef Neu, MD†
1. Patients often do not receive optimal protein intake in the neonatal intensive care
unit (NICU) (i.e. protein initiated at 3.5 to 4 g/kg per day via parenteral nutrition in
Author Disclosure the first hour after birth).
Dr Murgas Torrazza 2. Patients often do not receive optimal lipid intake in the NICU (i.e. lipids initiated at 3
has disclosed no g/kg per day via parenteral nutrition on day one).
financial relationships 3. Temporary adjustment of lipids to 1 g/kg per day or use of alternative lipid solutions
relevant to this article. may be needed in infants with parenteral nutrition associated liver disease.
Dr Neu has disclosed 4. Although used frequently, the assessment of gastric residuals may not be useful
that he serves as indicators of feeding intolerance and/or risk of necrotizing enterocolitis.
a consultant to Abbott
Nutrition, Mead Abstract
Johnson, Medela, and Inadequate nutrition of the preterm infant, especially the very low birthweight
(VLBW) and extremely low birthweight (ELBW) infant, has long-lasting adverse con-
Fonterra Foods; he
sequences. Despite advancement in many aspects of clinical care of VLBW/ELBW in-
receives honoraria
fants, there is significant variability between neonatologists in the means of providing
from Nestlé and nutrition. More uniform guidelines based on the best available scientific evidence are
Danone; and he has needed. The objective of this review is to provide the neonatologist with evidence-
research grants with based guidelines for the nutritional management of VLBW/ELBW infants.
Covidien and Gerber.
This commentary does
contain a discussion of
Learning Objectives After completing this article, readers should be able to:
an unapproved/ 1. Establish adequate enteral and parenteral nutrition in the very low birthweight or
investigative use of extremely low birthweight infant from the day of birth.
a commercial product/ 2. Understand the rationale behind providing calories, proteins, and lipids as soon as
device. possible after birth.
3. Discuss the potential risk of delays in enteral feedings and the complications of
prolonged parenteral nutrition and ways to avoid them.
4. Understand the importance of establishing nutritional
guidelines with the best evidence available.
Abbreviations Introduction
AA: amino acid
The nutrition of the preterm neonate especially the very
BUN: blood urea nitrogen
low birthweight and extremely low birthweight (VLBW/
DHA: docosahexaenoic acid
ELBW) infants, should be considered a protein/energy nu-
ELBW: extremely low birthweight
tritional emergency. Because nutritional needs do not stop
MCT: medium chain triglyceride
at birth and VLBW/ELBW infants have minimal energy
NEC: necrotizing enterocolitis
stores, establishment of nutrient intakes equivalent to what
PMA: postmenstrual age
is delivered to the fetus in utero, had the pregnancy not been
PN: parenteral nutrition
prematurely interrupted, should be a high priority. It has
PNALD: parenteral nutrition associated liver disease
been shown that the first weeks of nutrition have important
REE: resting energy expenditure
implications for the development of preterm infants. Inade-
VLBW: very low birthweight
quate nutrition is associated not only with postnatal growth
failure where more than 90% of VLBW/ELBW infants will

*Department of Pediatrics, University of Florida, Gainesville, FL.

†
Associate Editor. Professor of Pediatrics, College of Medicine, University of Florida, Gainesville, FL.

e340 NeoReviews Vol.14 No.7 July 2013


be below the 10th percentile for weight by 36 weeks’
postmenstrual age (PMA), (1) but also with increased
risk for poor neurodevelopmental outcomes and other
morbidities. (2)(3) Therefore, the goals of early and ad-
equate nutrition, as described in the Table are to improve
neurodevelopment, to facilitate recovery or catch-up
growth, and to achieve a normal body composition while
minimizing undesirable effects of unbalanced nutrition
such as hyperglycemia or insulin resistance that can result
in metabolic and cardiovascular morbidities during hos-
pitalization in the NICU and later in adulthood.
Nutrient Requirements
The balance of protein, lipid, and carbohydrate in adequate
amounts will allow us to safely provide enough protein and
energy intake avoiding hyperglycemia and minimizing
postnatal growth failure.
The resting energy expenditure (REE) of a VLBW/
ELBW infant is approximately 50 kcal/kg per day. We
need to add to this the energy losses due to metabolic ac-
tivity. (4) It is estimated that if the infant is fed enterally
the fecal loss of energy is on average 10 kcal/kg per day
and to maintain growth, the preterm infant needs (REE

2) þ energy loss. If the infant is fed enterally, he or she
will require approximately 110 to 120 kcal/kg per day,
and if fed parenterally the infant will require approxi-
mately 80 to 100 kcal/kg per day. (5)(6)(7)
The fetus accretes approximately 2.5 g/kg per day of
protein at 26 weeks’ gestation, and protein losses are ap-
proximately 1 g/kg per day in these infants. (8)(9) The
placenta supplies approximately 3.5 g/kg per day of
amino acid (AA) to the developing fetus, and a preterm
delivery will abruptly interrupt this AA supply and protein
accretion. The developing gastrointestinal tract is not
Nutrition Goals in the
Table.
Preterm Infant
Start PN in the first hours after birth with a minimum
of 3.5 g/kg per day of protein
Start intravenous lipids at 3 g/kg per day
Enteral feeds as soon as possible, ideally with 10–20
mL/kg per day of human milk on day 1
Advancement of feeds at 20 mL/kg per day with goal
weight gain of 15–20 g/kg per day when at full
volume feedings
Human milk fortification to optimize protein and mineral
intake
Attainment of full enteral feeds >150 mL/kg per day
and caloric intake >100 kcal/day
evidence-based medicine nutrition
ready to accept full enteral feedings in most of these
infants immediately after birth. In order to meet the
protein/energy caloric needs, one should provide, from
the day of birth, parenteral nutrition (PN) solutions pro-
viding at least 3.5 to 4 g/kg per day of AAs, 3 g/kg per
day of lipids, and 5 to 6 mg/kg per minute of glucose.
This PN will provide approximately 15 kcal from protein,
30 kcal from lipids, and approximately 30 kcal from glu-
cose for a total of approximately 75 kcal/kg per day, just
above the REE.
Glucose is infused to provide adequate amount of cal-
ories. The endogenous production of glucose is approx-
imately 4 mg/kg per minute. (10)(11) The glucose
necessary for metabolism of each gram of protein is 2
to 3 mg/kg per minute. PN infusions for the VLBW/
ELBW infant are often started at a rate between 5 and
6 mg/kg per minute. It is recommended to not exceed
12 mg/kg per minute of glucose infusion, especially in
infants on mechanical ventilation and/or those with
chronic lung disease, since the respiratory quotient of
a mole of glucose is 1 and will therefore cause ventilation
problems with an increase in carbon dioxide retention.
(12) Lipids as a balanced source of energy are in these cases
desirable with a respiratory quotient of approximately 0.7,
potentially leading to less carbon dioxide retention. (13)
Adequate nutrition is not only important in terms of
minimizing postnatal growth failure but also for improv-
ing neurodevelopmental outcomes. A recent study re-
vealed that for each increment of 10 kcal/kg per day
of caloric intake in the first week after birth there is an
increase of 4.6 points at 18 months in mental develop-
ment index, and for each gram of protein this increase
is 8.2 points. (3)
Parenteral Nutrition
PN should be started immediately after birth. (7) Ideally
the infant should have an intravenous access providing
PN shortly after birth. Fluids are commonly initiated at
rates between 80 and 100 mL/kg per day. For PN to
be initiated in the immediate postnatal period, it is nec-
essary to have a stock solution of PN containing at least 3
g/80 mL of AAs. The VLBW/ELBW infant has high re-
quirements of proteins (w3.5–4 g/kg per day). (14)(15)
AAs supplied in excess of that needed for protein accre-
tion are oxidized and contribute to energy production.
Occasionally patients have a transient increase in their
blood urea nitrogen (BUN) concentrations that usually
does not exceed 50 mg/dL. (16) In the absence of an
inborn error of metabolism or renal disease, this is usually
of no known clinical significance, and preterm infants
NeoReviews Vol.14 No.7 July 2013 e341
evidence-based medicine nutrition

normally tolerate elevated BUN concentrations very well, have been associated with increased liver cholestasis.
without risk of encephalopathy. (17) (26) Fish oil, which is rich in omega-3 fatty acids, specif-
Lipids should be provided initially at approximately ically docosahexaenoic acid (DHA), has emerged as a pos-
3 g/kg per day. (7)(18) The need for stepwise incre- sible treatment and prophylaxis for PNALD. (27) Very
ments, as commonly practiced, is based on tradition long chain omega-3 fatty acids such as DHA, which
rather than science. Intravenous lipids constitute an im- are critical for retinal, brain, and other neural tissue devel-
portant source of calories and are also a rich source of es- opment, have been shown to have anti-inflammatory
sential linoleic and linolenic acids, which are necessary to properties as well as being hepatoprotective in animal
prevent essential fatty acid deficiency. (19) Routine mon- and in human studies. (28)(29)(30)(31) (Fig 1; proposed
itoring of triglycerides is not generally necessary in pre- beneficial effects of specific nutrients).
term infants who are tolerating enteral intake and are Other lipid solutions are also available as alternatives
weaning from PN. If triglyceride levels are to be mea- to Intralipid, in other countries. SMOFlipid (Fresenius
sured, they should be done randomly without stopping Kabi) is a mix of different oils such as soybean, medium
the lipid infusion. The whole idea of checking triglyceride chain triglycerides (MCTs), olive oil, and fish oil; a recent
levels is to do it in a manner that reflects the higher serum clinical trial revealed that this solution was well tolerated
levels reached in the infant. Triglyceride levels above 200 in preterm infants with a lower level of total bilirubin in
mg/dL are generally considered high level and should those infants who received SMOFlipid compared with
prompt the clinician to decrease the infusion rate or to stop Intralipid infusion. (32) ClinOleic (Baxter International,
the lipid infusion usually for no longer than 24 hours. High Inc, Deerfield, IL) solution, a mix of 80% olive oil and
serum triglycerides were more of a problem with 10% sol- 20% soybean oil, is also an available alternative in most
utions that had higher phospholipids, which were thought European countries. (33)
to inhibit hydrolysis and increase serum triglycerides. (20) For infants with short gut syndrome and severe
Currently we use 20% lipid solutions in neonates. PNALD, Omegaven (Fresenius Kabi), a pure fish oil solution
Infusion of lipids has been suggested to be associated
with certain complications, such as an increase in free bil-
irubin, increased risk of bronchopulmonary dysplasia,
increased free radical stress, worsening of pulmonary
vascular resistance, and sepsis. (21) Prolonged infusion
of lipids, generally for more than 2 weeks, has now been
implicated in the development of PN associated liver dis-
ease (PNALD). (22) It is recommended to infuse the
daily lipid dosage over 20 to 24 hours, at a rate not higher
than 0.2 g/kg per hour, because faster rates have been
associated with hyperlipidemia. (23)(24) If an infant de-
velops cholestasis or PNALD, it has been recommended
to decrease the amount of lipid infusion to 1 g/kg per
day, but this can also lead to caloric deprivation. (25)
The deleterious effects of caloric deprivation could be
minimized by optimizing other nutrients in the PN such
as protein and glucose and by advancing feeds at the rec-
ommended rates. PNALD usually resolves when the in-
fant is tolerating full enteral feeds. New lipid solutions are
available and can be used alone or in combination with
Intralipid (Fresenius Kabi, Uppsala, Sweden), and its
use can also improve the caloric intake. Currently in
Figure 1. Specific nutrients and proposed beneficial effects in the
the United States, we only have one commercial product
preterm infant and newborn in general. Amino acids such as
available to provide lipids in neonates. This product, In- arginine, glutamine, and leucine; long chain fatty acids such as DHA
tralipid, is a soybean-based oil and rich in omega-6 fatty (omega-3) and vitamins A and D; and minerals such as calcium and
acid (linoleic acid), which is considered to be more proin- iron can be provided as supplements and offer tremendous benefits
flammatory than omega-3 fatty acids. Soybean-based oils to the preterm infant. PHN[persistent pulmonary hypertension;
or plant-derived oils are also rich in phytosterols, which PN[parenteral nutrition; NEC[necrotizing enterocolitis.

e342 NeoReviews Vol.14 No.7 July 2013


containing no phytosterols and no omega-6 fatty acids, is
also available (34) for compassionate use in the United
States. When using Omegaven, follow-up of triene/
tetraene ratios is recommended. A triene/tetraene ratio
higher than 0.2 may indicate fatty acid deficiency. (35)
(36) These lipid solutions have been designed with the
principle that a change in parenteral lipid regimen, from
a predominance of omega-6 fatty acids to lipid emulsions
containing predominantly DHA, may be effective in the
prevention and treatment of PNALD. Beneficial effects
on liver function with a mixed emulsion containing soy-
bean oil, MCTs, olive oil, and fish oil were observed in
a few studies in adult and pediatric (37) patients: in adult
intensive care unit patients after major surgery, a lower rise
in liver enzymes and in the phospholipids/plasma apolipo-
protein A1 ratio (a surrogate marker of liver function) sug-
gested better liver function by PN with the test emulsion
than with a soybean oil emulsion. (38)
Enteral Nutrition Recommendations
The enteral route is the most physiologic and natural way
of administering nutrients to the neonate, and attaining
full enteral feedings can often be challenging to clinicians
who care for preterm infants, largely because many in-
fants show early intolerance to enteral feedings. The false
notion that enteral feedings cause necrotizing enteroco-
litis (NEC) has prevented the early use of the intestinal
tract in these infants. Since the early studies of Widdowson
et al (39), it has become clear that lack of enteral feedings
in several animal models is associated with intestinal atro-
phy and other major complications. Establishing enteral
feedings should be one of the most important goals espe-
cially in VLBW/ELBW infants, and guidelines to start
and advance enteral feedings are essential to achieve ad-
equate nutrition (Fig 2). Studies have revealed that when
a standardized feeding regimen is followed, the outcomes
improve and the incidence of NEC in preterm infants is
substantially reduced. (40)
Enteral nutrition can be safely started shortly after
birth. Human milk is the preferred source of milk but
if not available, enteral feeds should not be withheld
for more than 24 hours, awaiting mother’s milk availabil-
ity. Although there is no direct evidence from preterm
infants, studies in animals suggest that there may be del-
eterious effects of not receiving enteral feeds, such as in-
testinal villous atrophy. Enteral feedings in the preterm
infant have multiple benefits, even when minimal enteral
volumes are being used for nutrition as “gut priming.”
(41) The benefits include trophic signaling and matura-
tion with release of hormones that stimulate intestinal
evidence-based medicine nutrition
villous growth, an improvement in feeding tolerance,
and a decrease in the time required to reach full feeds,
therefore potentially reducing the time on PN and the
risk of PN-related cholestasis. (42)(43)
Thus, in the absence of data that demonstrate adverse
effects of providing some formula until mother’s milk is
available, the prolonged need for PN and other inherent
risks of not utilizing the intestine outweigh the risk of
feeding infant formula while waiting for the mother’s
milk to become available. (44)(45)
Mother’s own milk is the best source of enteral nutri-
tion unless known contraindications for its use clearly ex-
ist such as galactosemia, maternal HIV (in the United
States), and miliary tuberculosis. (46) Donor milk is an-
other type of human milk that is increasingly becoming
available in NICUs and currently is recommended in in-
fants less than 1,500 g or less than 32 weeks’ gestational
age. (46)(47) Although human milk has advantages over
formula milk, such as reduced rates of sepsis and NEC, one
should also be aware that human milk alone may not meet
the nutritional needs of the VLBW/ELBW infant. (9) Al-
though initially it is recommended to use only human milk,
at some point it will be appropriate to fortify it (see later).
All VLBW/ELBW infants will initially need PN until
an adequate volume of enteral intake is attained. Most
preterm infants will tolerate initiation of feeds at rates be-
tween 10 and 20 mL/kg per day, so called “trophic” or
“minimal enteral feeding” with subsequent advancement
of feeds at 20 mL/kg per day. (48)(49) During trophic
feeding, it is expected and not unusual to have gastric re-
siduals that are 50% of the amount of milk given per feed-
ing. Sometimes, clinicians confuse gastric residuals with
feeding intolerance and may withhold feedings unneces-
sarily. Although gastric residuals are covered in more de-
tail in an accompanying review by Parker et al (50) in this
issue, we wish to re-emphasize that the amount or char-
acteristic of gastric residuals have not been shown to be
predictive of feeding intolerance or increased risk of
NEC. (51) The value of routine measurement of gastric
residuals in the absence of other signs or symptoms is
controversial. There is no systematic evidence to support
withholding feeds based only on gastric residuals if there
are no other signs or symptoms, such as abdominal dis-
tension, bloody stools, emesis, hemodynamic instability,
and/or radiographic changes. (52)(53) In very specific
situations, where intestinal perfusion or critical clinical
condition warrants caution, feeds may be withheld for
longer periods or started and advanced at lower volumes
of 5 to 10 mL/kg per day. Figure 2 summarizes our rec-
ommended feeding algorithm in VLBW/ELBW infants.
In our feeding algorithm, we emphasize the recognition
NeoReviews Vol.14 No.7 July 2013 e343
evidence-based medicine nutrition

a
Figure 2. Feeding algorithm. If waiting for breast milk (BM) availability, initiation of feedings should not be delayed by more than 24
hours. CBC[complete blood count; CRP[C-reactive protein; IVF[intravenous fluids; KUB[abdominal x-ray; NG[nasogastric; OG[
orogastric. a,b In infants with a low Apgar score < 3, hypoxic-ischemic encephalopathy stage 2 or 3, or hypotensive, consider holding
off on initiating feeding for 48 hours or provide lower volumes. c For infants receiving trophic feedings, expect residuals to be the same
amount as feeding volume. Nonbilious residuals should be refed as part of total feeding volume. d Currently, in most NICUs, ampicillin
and gentamicin would be first-line antibiotics. Metronidazole administration should be considered in severe cases or if surgery is
needed. May consider screening laboratory results (CBC/CRP) and/or scheduling frequent KUBs. If abnormal, treat as NEC.

of early clinical and radiological signs of NEC and do not
hold feeds based solely on the presence of gastric resid-
uals. We also color coded the algorithm with “stop crite-
ria” where red areas are defined as definitive medical or
surgical NEC and these infants require more extensive
evaluation and follow-up.
Usually PN is stopped when the amount of enteral in-
take reaches 100 mL/kg per day. Fortification of human
milk or providing specialized formulas for VLBW/ELBW
infants is thought to provide benefits in terms of en-
hanced growth and bone density. (54) These are usually
fortified to provide between 22 kcal/oz and 30 kcal/oz.
Four packages of human milk fortifier per 100 mL of milk
will provide 24 kcal/oz. Weight gain is monitored and
should increase by 15 to 20 g/kg per day once the infant
is receiving full enteral feedings. Supplementation with
protein is important because for each gram of protein
there is an increase of 6.5 g/day of body weight and
0.4 cm/week of head circumference. (55)
We can also use an infant’s BUN concentration to ad-
just fortification; if an infant’s BUN is less than 9 mg/dL,
we suggest adding 1 package of human milk fortifier.
This recommendation derives from the assumption that
preterm human milk provides approximately 20 kcal/oz
and approximately 1.5 g/100 mL of protein. The fortifi-
cation is more predictable when using donor milk because
the amount of protein is more stable at approximately
0.9 g/100 mL.
Iron supplementation of 2 mg/kg per day and vitamin
D supplementation 400 IU per day is recommended for
human milk fed preterm infants. (56)(57) Many newborns
receive daily multivitamins, but no clear benefit has been
attributed to this practice. Supplementation of other prod-
ucts such as MCT oil, polycose, and corn oil should be

e344 NeoReviews Vol.14 No.7 July 2013


considered on a case by case basis and are generally used to
increase the caloric intake of the preterm infant.
When mother’s milk is not available, choosing the appro-
priate infant formula and adequate protein supplementation
becomes key in the nutrition and feeding tolerance of the
VLBW/ELBW infant. The protein content and compo-
sition of human maternal milk changes throughout the
lactation period from approximately 2 g/dL with a whey
to casein ratio of approximately 80:20 at the beginning of
lactation to a protein content of approximately 1 g/dL
with approximately 60:40 whey to casein ratio in the fol-
lowing weeks with the evolution of more mature milk.
Most preterm infant formulas are formulated to reflect
the latter whey-to-casein ratio. Whey proteins are consid-
ered “fast proteins” and will produce a rapid, high but
transient increase in circulating insulin and aminoacide-
mia, whereas casein proteins produce more gradual,
and relatively lower, but more sustained increase in insu-
lin and AAs. (58)
Transitioning to Oral Feeding
Preterm infants start enteral feeds by orogastric or naso-
gastric feeding tube. As they mature, oral feeds are grad-
ually introduced. Oral feeding is not typically initiated in
preterm infants before 32 weeks’ PMA mainly because
the coordination of sucking, swallowing, and respiration
is not established. (59)
Oral feeding, which includes either breastfeeding, bottle-
feeding, or cup-feeding, requires coordination of nutri-
tive sucking, swallowing, and breathing.
Rhythmic breathing during feeding is first acquired
between 34 and 36 weeks’ PMA, simultaneously with
the maturation of other physiologic processes. (59)(60)
Women who choose to breastfeed their preterm in-
fants are not always available, and an alternative approach
to feeding is often needed. Most commonly, milk (ex-
pressed breast milk or formula) is given by bottle, but
there is some concern about whether using bottles during
the establishment of breastfeeds is detrimental to breast-
feeding success. A Cochrane review of the literature re-
vealed that supplementing breastfeeds by cup-feeds
reduced the risk of “no breastfeeding or only partial breast
feeding” on discharge home. (61) However, cup-feeding
led to a longer hospital stay and was associated with
a higher amount of parental and staff noncompliance.
The use of exclusive tube feeding with the idea that by
avoiding the use of bottle-feeding or other alternative
methods to the bottle we will be able to promote breast-
feeding when the mother is not available or while
the infant establish adequate breastfeeding skills, and
therefore avoiding what some clinicians call “nipple
evidence-based medicine nutrition
confusion” is not evidence-based, may be associated
with some unintended complications, and is “medical-
izing” unnecessarily the infant. This approach is not cur-
rently the standard of care and we do not recommend it.
Different alternative methods have been studied to
stimulate oral feeding. Fucile et al (62) investigated the
impact of oral and particularly nonoral sensorimotor in-
put (tactile/kinesthetic sensorimotor input to the trunk
and limbs) on sucking, swallowing, and respiration. Pre-
term infants who received a combined (oral þ tactile/
kinaesthetic) intervention demonstrated more advanced
nutritive sucking, suck-swallow, and swallow-respiration
coordination than those who received an oral or tactile/
kinaesthetic intervention only.
Our recommendation is to start po (per mouth) di-
rectly by breastfeeding and supplementing with bottle-
feedings if necessary once the preterm infant is 32 weeks’
PMA. If the mother is not available or breastfeeding is
not a possibility, the recommended method of feeding
is bottle-feeding. Oral skills and readiness should be as-
sessed throughout the entire hospital course until dis-
charge. Early interventions to improve oral intake can
significantly impact outcomes.
Conclusions
PN must be started immediately after birth with an ad-
equate amount of nutrients; at least 3.5 to 4 g/kg per
day of proteins and 3 g/kg per day of lipids. Enteral nu-
trition should be started in the first 24 hours with hu-
man milk preferably at 10 to 20 mL/kg per day of
volume intake. Enteral feeds fortification will enhance
growth and should be added once feeds are at a volume
intake of 100 mL/kg per day. Advancement of feeds
following an algorithm and establishment of guidelines
results in better outcomes for the VLBW/ELBW infants.
American Board of Pediatrics Neonatal-Perinatal
Content Specifications
• Determine the nutrients and the relative
amounts required for normal fetal growth.
• Know the caloric requirements for optimal
postnatal growth of preterm and term
infants, accounting for caloric
expenditures needed for physical activity
and maintenance of bodily temperature.
• Know the protein requirements of preterm and full-term
infants.
• Know the fat requirements of preterm and full-term infants.
• Know the indications and advantages of total parenteral
nutrition and combined enteral and parenteral nutrition (PN).
NeoReviews Vol.14 No.7 July 2013 e345
evidence-based medicine nutrition
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NeoReviews Quiz
New minimum performance level requirements
Per the 2010 revision of the American Medical Association (AMA) Physician’s Recognition Award (PRA) and credit system, a minimum performance
level must be established on enduring material and journal-based CME activities that are certified for AMA PRA Category 1 CreditTM. In order to
successfully complete 2013 NeoReviews articles for AMA PRA Category 1 CreditTM, learners must demonstrate a minimum performance level of 60%
or higher on this assessment, which measures achievement of the educational purpose and/or objectives of this activity.
In NeoReviews, AMA PRA Category 1 CreditTM can be claimed only if 60% or more of the questions are answered correctly. If you score less than
60% on the assessment, you will be given additional opportunities to answer questions until an overall 60% or greater score is achieved.

1. You are caring for a newborn 26-week-gestational-age male. He is requiring mechanical ventilation, and he is
being started on parenteral nutrition. Which of the following is true regarding his nutrition/energy
requirements?
A. The resting energy expenditure for this infant is approximately 80 kcal/kg per day.
B. The fecal loss of energy is approximately 30 kcal/kg per day.
C. His requirement for protein accretion for optimal growth is 3.5 to 4 g/kg per day.
D. If he has a central line, his glucose infusion should be maximized to 15 mg/kg per minute.
E. The infant should be started on enteral feedings of donor breast milk at 120 mL/kg per day, and parenteral
nutrition can be used only if there is feeding intolerance.

2. Your neonatal intensive care unit (NICU) has started to use a stock solution of parenteral nutrition fluid. There
is a newborn 30-week-gestational-age infant for whom you have established umbilical arterial and venous
access. Which of the following is true regarding management of parenteral nutrition for this patient?
A. The blood urea nitrogen should be followed closely, and if it exceeds 25 mg/dL, the protein concentration
should be lowered to 1 g/kg per day.
B. The stock parenteral nutrition fluid should have at least 3 g per 80 mL of amino acids.
C. Lipids should be started on the second day at 0.5 mg/kg per day and advanced gradually by 0.5 mg/kg per
day every other day to a goal of 3 g/kg per day.
D. Amino acid and lipid infusion should be avoided until the second day after delivery in order to avoid
interference with respiratory function.
E. The initial fat provision should be via a 5% or less concentrated lipid solution.

3. A 5-week-old 25-week-gestational-age female had necrotizing enterocolitis earlier in her clinical course and
remains dependent on parenteral nutrition. The blood urea nitrogen level is 30 mg/dL. She has also developed
cholestatic jaundice, which appears to be due to prolonged parenteral nutrition. Which of the following is an
appropriate step in her nutrition regimen?
A. Protein infusion should be decreased to 2g/kg per day until the blood urea nitrogen level decreases below
25 mg/dL.
B. Lipid infusion should be halted indefinitely until the direct bilirubin level decreases to normal levels.
C. Although liver function has traditionally been followed for patients on parenteral nutrition, there is no
basis for this testing, and the nutrition regimen should not be adjusted based on the finding of cholestasis.
D. If available, lipid solutions containing predominantly omega-3 fatty acids, and less or no omega-6 fatty
acids, may provide an alternative source of lipid nutrition that may minimize liver disease.
E. While anecdotal reports link lipid infusion to liver disease, there is not clear evidence regarding this link,
and as liver disease may be due to malnutrition, the lipid concentration should be increased.

4. A 1-day-old 31-week-gestational-age male has respiratory distress syndrome and is on mechanical

ventilation. He has an umbilical line catheter in place and is receiving parenteral nutrition. The mother has
expressed a small amount of colostrum/breast milk. Which of the following is an appropriate aspect of
nutrition management for this infant?
A. The patient can now be started on enteral feedings at 10 to 20 mL/kg per day with maternal breast milk,
and addition of donor human milk if there is not yet enough maternal breast milk.

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 evidence-based medicine nutrition

B. Enteral feedings can be started once the patient has been extubated and noted to be stable from
a respiratory standpoint.
C. As parenteral nutrition provides adequate nutrition at this stage during the first week after delivery,
enteral feedings should be withheld until 4 to 6 days after delivery in order to avoid increasing the risk of
necrotizing enterocolitis.
D. Once this infant has completed his course of parenteral nutrition, human milk should provide adequate
nutrition for this infant until he is discharged from the hospital, except for the need for iron
supplementation.
E. During the course of hospitalization for this preterm infant, infant formula should be used only in cases
when the mother has HIV or hepatitis infection.

5. A 4-week-old 28-week-gestational-age infant is in room air, having occasional apnea and bradycardia events,
and is transitioned to full enteral feedings by gavage. Which of the following regarding transition to oral
feeding is correct?
A. Due to the risk of aspiration and exacerbation of apnea, oral feedings should not be attempted until 37
weeks’ postmenstrual age.
B. In order to promote breastfeeding, bottle-feeding should be avoided at all costs until the infant has been
evaluated to have a good latch and suck when breastfeeding for at least 1 week.
C. Oral skills and readiness should be assessed throughout the entire hospital course until discharge, as early
interventions to improve oral intake can impact outcomes.
D. Cup-feeding is more likely to reduce reflux and shorten hospital length of stay.
E. Breastfeeding should be avoided until 37 weeks’ postmenstrual age because it will prevent caloric
supplementation and not allow for the protein load required for growing preterm infants.

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