Extrauterine Growth Restriction: What Is the Evidence for Better Nutritional Practices in the Neonatal Intensive Care Unit?



NAINR. 2014;14(3):92-98. 

In This Article

Nutritional Management Guidelines

Clinical practice amongst NICUs across the nation continues to vary despite the amount of strong evidence presented in this article to support a comprehensive nutritional plan to promote adequate postnatal growth in small premature infants. This variation in clinical practice is due to a lack of knowledge, systematic planning, practice implementation, healthcare provider habit, unit history and a lack of evidence-based guidelines to standardize practice.[52–54] Even though an evidence-based guideline does not exist, practice standardization can still occur.

Hanson et al.[55] completed a retrospective chart review of before and after the implementation of a standardized plan to optimize nutrition in VLBW infants. The plan consisted of early aggressive parenteral nutrition, early enteral feedings, MEF, a continuous feeding regimen, protein fortification of human milk to 24 calories/ounce, and development of a feeding intolerance algorithm. After implementation of the standardized nutrition plan, EUGR decreased from 57% to 28%, and weight percentile ranking at 36 weeks gestational age increased from the 13th to the 27th percentile in infants weighing 1001–1500 g. Chronic lung disease, days of parenteral nutrition, and central line use also significantly decreased. The authors also noted there was no increase in the rate of NEC or in BUN levels.

Senterre and Rigo[56] conducted a prospective nonrandomized observational study to evaluate postnatal growth in VLBW infants after optimizing nutritional support based on current evidence-based recommendations. One hundred and two infants were included in the study over a two-year period and received a standardized nutritional regimen that consisted of early aggressive parenteral nutrition, MEF, and human milk feedings with individualized fortification that were increased by 10–20 ml kg−1 day−1 until reaching full feedings. Infants enrolled in the study experienced a decrease in postnatal weight loss that was limited to the first three days of age and regained their birth weight after seven days on average. Catch up growth started to occur during the second week of life and small for gestational age infants experienced earlier and higher weight gain.

The findings from these two quality improvement projects support the benefits of standardizing practice. Furthermore, the nutritional plans used in each study were based on the evidence discussed throughout this article. The results of implementing such evidence based plans further support the need for early aggressive nutrition to improve postnatal growth in small premature infants.

EUGR results when protein and energy deficits occur during the first weeks of life when early aggressive parenteral nutrition containing a high amount of amino acids and sufficient energy in the form of glucose and intralipids is not provided. Such deficits will continue postnatally if adequate parenteral and enteral nutrition is not provided. Fear of parenteral nutrition intolerance, lung injury and NEC prevent administration of early aggressive nutrition that would alleviate the deficits that occur during the first few week of life.

An exclusive human milk diet started early and advanced after the first few days of life actually prevents NEC and decreases the risk of late onset sepsis. However, plain human milk does not meet the nutritional needs of the small premature infant and requires fortification with additional protein, fat and minerals to promote adequate growth. Several human milk fortification methods exist today but as science continues to evolve, individualized human milk fortification looks to be the best method for promoting adequate growth.

Many clinical trials over the last several years have demonstrated the need for early aggressive nutrition to decrease EUGR. However, clinical practice is still dependent on individual opinion rather than current evidence. Therefore, as neonatal nurses and nurse practitioners, we must take the current evidence and work to improve postnatal growth in our own NICUs so that small premature infants will no longer suffer the consequences of EUGR.