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Growth management in preterm infants

Growth management in preterm infants
Literature review current through: Jan 2024.
This topic last updated: Feb 08, 2023.

INTRODUCTION — Growth impairment during early infancy, a period of substantial cellular hyperplasia and hypertrophy, can have permanent detrimental effects. Abnormalities in growth during this time period may persist into adulthood, especially in patients who were preterm infants.

Preterm infants are at risk for poor growth while in the neonatal intensive care unit (NICU) and after discharge from the NICU. They must be closely monitored and may require interventions to promote better growth.

Growth in the preterm infant, including monitoring of growth and managing growth impairment while in the NICU and after discharge, will be discussed here. Enteral and parenteral nutrition for preterm infants are discussed separately. (See "Approach to enteral nutrition in the premature infant" and "Parenteral nutrition in premature infants".)

NORMATIVE GROWTH DATA — Normative growth data are available for healthy term infants. However, data are limited for preterm infants during both hospitalization and after discharge. (See "Normal growth patterns in infants and prepubertal children", section on 'Evaluation of growth'.)

Term infants — Normative data are available for intrauterine growth in the last trimester and during infancy [1,2]:

Weight increases by 208 g/week from 28 weeks gestation to 6 months of age. After birth, infants typically gain 30 g/day until 3 months of age and 20 g/day between 3 and 12 months of age.

Length increases by 1.1 cm/week from 28 to 40 weeks gestation; after birth, growth is 0.75 and 0.5 cm/week for the first three and the following two to three months, respectively.

Head circumference increases by 0.75 cm/week during the last trimester, 0.5 cm/week from birth to three months of age, and then approximately 0.25 cm/week.

Preterm infants — Curves used to track growth of preterm infants are not ideal. Growth curves for very low birth weight infants that reflect neonatal intensive care unit (NICU) practices common during the 1990s have been reported by the National Institute of Child Health and Human Development Neonatal Research Network [3]. However, these curves do not necessarily describe optimal growth.

Once they regain their birth weight (BW), the growth of preterm infants is targeted to the following goals based upon the estimated intrauterine growth from historical cohort studies of live births of infants of varying gestational age (GA) [4,5]:

Weight – 15 to 18 g/kg per day

Length – 1 cm/week

Head circumference – 0.7 cm/week

However, this practice has resulted in inadequate growth, as most low BW infants have weights that are below the 10th percentile at the time of discharge [3,6]. In addition, growth through gestation and early infancy is not constant and the above rates appear to be accurate for limited time periods [7]. There are also often periods of slower growth that occur during episodes of infection or feeding intolerance that need to be compensated by accelerated growth during other time periods [6]. Furthermore, calculations of growth can be greatly affected by the exact method of calculation, something that is often overlooked when comparing different published studies [7]. As a result, although available evidence supports a minimum weight gain of 15 g/kg per day, which we use along with most centers, this minimal goal may not always be appropriate and targeting a higher goal of up to 20 g/kg per day may be more suitable for infants who are between 23 and 36 weeks postmenstrual age [7].

An alternative approach has been proposed that assessment of growth should be based on the growth of preterm infants with normal fetal development and little short-term morbidity [8]. However, available data using this approach are very limited and do not reflect long-term outcomes. Further studies are needed to establish appropriate growth targets in preterm infants to determine the optimal approach.

Growth chart — In the last decade, the number of high quality neonatal growth charts has increased greatly. These include the Olsen, Bertino, and Fenton growth charts, which use advanced mathematical modeling approaches such as the lambda-mu-sigma method (LMS) that allow the calculation of precise Z-scores and centiles [9-11]. As the number of charts has increased, so have questions about which ones should be used and when. Based on the available data, we continue to prefer the use of the Olsen and Bertino charts in our center. (See "Measurement of growth in children", section on 'Use of Z-scores'.)

The selection of growth chart used depends on local practice and preference. Based on the available charts, we suggest the following based on the age of the preterm infant:

Up to 36 weeks gestation – The Olsen (figure 1 and figure 2) and Bertino charts are the best growth charts to assess appropriate for gestational age (AGA), small for gestational age (SGA), or large for gestational age (LGA) status at all GAs [10,11]. They perform relatively poorly for growth monitoring for preterm infants beyond 36 weeks of age.

Between 36 to 50 weeks corrected age (10 weeks post-term), the Fenton chart is the best growth chart to assess longitudinal growth in preterm infants over this period [9].

After four to eight weeks post-term, the World Health Organization (WHO) growth charts for normal children can be used. (See "Measurement of growth in children", section on 'Infants 0 to 2 years'.)

However, despite these charts, growth monitoring remains challenging between 36 and 44 weeks corrected GA. For infants greater than 44 weeks corrected GA, the preterm infant is being compared with the term infant who has already undergone normal postnatal weight loss. For the infants below 36 weeks corrected age, the growing preterm infant (who has already undergone normal postnatal weight loss) is often compared with the newborn preterm who has not undergone normal postnatal weight loss. The Fenton chart smooths these two groups together, and as a result, upwards crossing of centile during these transition periods may not reflect true catch-up growth.

The Olsen (figure 1 and figure 2) and Bertino charts are based on large cohorts of newborn infants, and after excluding pregnancies with conditions likely to affect fetal growth, have constructed references for the BW of newborn infants across a wide GA range [10,11]. As a result, they are optimally suited to determine whether babies are born LGA, SGA, or AGA.

Of note, the Olsen and Bertino charts are not representative of the growth of preterm infants. These charts based on the BW have a sigmoid shape, with the gain in weight with gestation flattening out at older GAs. This may be due in part to developing placental insufficiency at the end of gestation, but part is an artifact as GA becomes more upwardly censored at higher GA. So, for example, for infants presumed to be 34 weeks GA, a similar number are probably greater than 34 weeks and less than 34 weeks gestation. However, at a higher GA of 40 weeks, more infants are probably truly less than 40 weeks than truly greater than 40 weeks gestation (as fewer infants are born at >40 weeks gestation than <40 weeks gestation). This causes the curve of BW against GA to flatten at both the higher and lower extremes of gestation. This flattening near term is not reflected in the growth of preterm infants, because their growth does not slow at this time point. As a result, these curves are less well suited to the longitudinal growth monitoring of preterm infants as they approach their expected term date at 36 weeks gestation.

To overcome this limitation, in the Fenton charts the BW cohorts were "smoothed" into reference charts of term-born infants (figure 3 and figure 4). Although this method has been criticized, the Fenton charts have been validated as a growth monitoring tool in preterm infants [12]. However, this smoothing approach means that they perform poorly in classifying newborn near-term and term infants as being AGA, SGA, or LGA. As a result, after four to eight weeks post-term, the WHO growth charts should be used.

Two additional reference charts have been published. However, both are limited by the narrow range of GAs that are covered, which limits their usefulness in tracking growth.

The INTERGROWTH-21st Consortium published reference charts for preterm infants with GA between 24 and 33 weeks, based on data collected from centers from eight different global locations (Brazil, Italy, China, India, the United Kingdom, Kenya, Oman, and the United States) and with diverse ethnic backgrounds [13,14]. The number of infants was substantially fewer for this international reference than the other two that were based in the United States (Olsen) and Italy (Bertino). In addition, there remain concerns that fetal growth parameters may differ based on ethnicity and that population-based growth references for infants with the same genetic and environmental backgrounds should be used [15].

Weight and head circumference charts for preterm infants with GA between 22 and 29 weeks were developed using data from the Vermont Oxford Network [16]. These charts are representative of a racially diverse dataset with similar measurements to the Olsen and Fenton charts.

There is limited evidence that poor growth determined using fetal growth references (eg, Fenton or Olsen curves) was more strongly associated with subsequent development outcome than the use of reference charts from the INTERGROWTH-21st dataset [17].

GROWTH IN THE NICU

Monitoring — Postnatal growth for the preterm infant is primarily monitored as weight gain, because it is more reliable and reproducible than measurements of length and head circumferences. Changes in length and head circumference also are inadequate measures during short time frames, whereas weight gain can be accurately measured on a day-to-day basis.

However, weight gain is expressed in a number of ways (g/kg/d, g/d, or change in Z-scores), making it challenging to compare growth rates from different studies and also resulting in clinical practice variation [18,19].

The easiest and probably best clinical measure of weight is expressed in g/kg/d using this equation, which is used in our center:

Measure of weight gain = (Weight at time 2 – Weight at time 1) / [(Weight at time 2 + Weight at time 1)/2) * days between time 2 and time 1)]

Variability is less the longer the time between the two time points, as the difference in weight usually increases, while the error in weight measurements remains the same. The optimal interval over which to measure weight gain is probably five to seven days [20].

Need for adequate intake — Both increased nutritional requirements due to stress (eg, episodes of sepsis) and inadequate nutritional intake contribute to the poor growth of hospitalized preterm infants [21-23]. Inadequate intake can occur with either enteral or parenteral nutrition [21]. Immature gastrointestinal function limits the advancement of enteral feedings, while poor tolerance of intravenous lipids and glucose limits the use of parenteral nutrition. As a result, in preterm infants, nutrient intakes often fail to meet the recommended dietary intakes, resulting in rapid accruement of protein and energy deficits [22]. The risk and extent of poor weight growth increase with decreasing gestational age (GA) and are most severe in extremely low birth weight infants (BW <1000 g).

Observational studies of large cohorts of preterm infants have reported improvement of growth, but there remains a substantial proportion of very low birth weight infants (birth weight <1500 g) at hospital discharge [24-26]. These results demonstrate the need for greater protein and energy intake on a body-weight basis in the preterm infant compared with term infants. Continued efforts to improve intake are required to ensure adequate growth for the preterm infant in the neonatal intensive care unit (NICU). A more detailed discussion on enteral nutrition and feeding for the preterm infant to maintain adequate growth is found elsewhere. (See "Nutritional composition of human milk and preterm formula for the premature infant" and "Approach to enteral nutrition in the premature infant".)

Caloric goals — The nutritional goal for most preterm infants during hospitalization is for an energy intake of 120 kcal/kg per day (table 1). This is equivalent to 160 mL/kg per day of preterm formula (24 kcal/oz) or fortified human milk. The target volume generally is one that supports a weight gain of more than 18 g/kg per day.

Ad libitum-fed preterm infants will often consume larger amounts [27]. As donor human milk becomes more widely used in the NICU, estimation of caloric intakes is more difficult, and higher intakes or increased levels of fortification may be needed.

Cue-based feeding — In some NICUs, a cue-based approach to in-hospital feeding based on recognizing the satiety cues from the infant has been adopted for more preterm infants who can feed orally. Limited data suggest that this infant-driven feeding practice shortens the length of time for infants to attain full feedings and reduces length of stay [28,29]. Infants had similar weight gains. However, it is not clear whether this method of feeding will improve overall growth, or reduce the number of infants diagnosed with poor oral feeding or the need for orogastric or nasogastric feeds after discharge. Nevertheless, further investigation of this feeding method is warranted to see if there is any additional benefit of cue-based feeding over the traditional feeding based on a fixed time schedule. (See "Initiation of breastfeeding", section on 'Feed with every cue'.)

DISCHARGE PLANNING — Prior to neonatal intensive care unit (NICU) discharge, infants should have a nutritional evaluation, and a feeding plan should be developed. This should account for factors that interfered with growth in the NICU and provide a baseline for serial monitoring of weight, length, and head circumference after discharge. Additionally, an assessment should be made of the home environment, including eligibility for government nutrition or medical assistance programs, as lack of social support may be associated with growth failure (eg, poor weight gain).

Prior to discharge, the infant should usually be able to consume ad libitum quantities of human milk or formula. Less commonly, fluid intake may be limited at prescribed levels, or tube feeding (or other artificial means of feeding) is used. Whatever the feeding plan is, appropriate growth should be demonstrated on the proposed discharge feeding regimen while the infant is hospitalized. The target volume generally is one that supports a weight gain of at least 15 g/kg per day or higher. (See "Nutritional composition of human milk and preterm formula for the premature infant" and "Care of the neonatal intensive care unit graduate".)

AFTER DISCHARGE — There are few data regarding the specific nutrient intakes required in preterm infants after discharge. The overall goal is to achieve the body composition and rate of growth of a normal fetus/infant of the same postmenstrual age during the first entire year of life [30]. As a result, ongoing monitoring of growth is the essential first step in the management of growth in these infants.

Monitoring of growth — Growth parameters include the infant's weight, length, and head circumference and should be monitored on a weekly to biweekly basis for the first four to six weeks after hospital discharge. After this initial period of close observation, infants who are growing normally can be monitored every month and then every two months.

Corrections for gestational age (GA) should be made for weight through 24 months of age, for stature through 40 months of age, and for head circumference through 18 months of age. We recommend using the Fenton preterm infant growth chart until the infant is 44 to 48 weeks postmenstrual age (figure 3 and figure 4), at which point the World Health Organization (WHO) growth curves for term infants can be utilized [31,32]. There is a 10-week transition period when both charts can be used simultaneously and Z-score values can be compared. (See 'Growth chart' above.)

Biweekly or monthly follow-up visits should continue for infants with slow weight gain who remain below the third percentile on a standard growth curve when they have reached 40 postmenstrual weeks, or who have chronic health problems (eg, bronchopulmonary dysplasia [BPD]). Close monitoring should continue until a steady adequate growth pattern is established [33].

Infants who fall off their growth curve are growing suboptimally (ie, failing to thrive due to inadequate weight gain) and should be evaluated and treated as soon as the poor growth is identified. Delays in instituting treatment simply worsen the degree of growth failure and increase the amount of catch-up growth that will subsequently be required to achieve normal growth. (See 'Interventions' below.)

Infants who are extremely short may need further evaluation for growth retardation, including consultation by a pediatric endocrinologist. Referral is based on the extent of the shortness, parental concern, and whether catch-up growth has occurred. (See "Diagnostic approach to children and adolescents with short stature".)

Head circumference — Slow head growth is associated with developmental delay. In one report, very low birth weight infants whose head circumferences were below normal by eight months corrected age had poor cognitive function, academic achievement, and behavior at eight years of age, compared with controls with normal head size [34]. A rapid increase in head circumference may indicate posthemorrhagic hydrocephalus. (See "Germinal matrix and intraventricular hemorrhage (GMH-IVH) in the newborn: Management and outcome".)

Infants with abnormal head growth should have neuroimaging studies to evaluate the cause.

Laboratory studies — Biochemical monitoring (eg, serum calcium, phosphorus, and alkaline phosphatase) is usually not helpful in the evaluation of the poorly growing neonatal intensive care unit (NICU) graduate. An exception is an elevation of serum alkaline phosphatase, which is associated with reduced stature later in life [6]. It remains uncertain whether targeted interventions (phosphorus, calcium, or vitamin D supplementation) in preterm infants with elevated serum alkaline phosphatase (>600 international unit) result in improved height in childhood or adulthood. (See "Management of bone health in preterm infants", section on 'Infants with rickets'.)

INTERVENTIONS

Routine nutrient supplementation — Routine nutrient supplementation is generally focused on very preterm infants (gestational age [GA] <28 weeks) with birth weights (BW) below 1500 g (ie, very low birth weight infants).

Formula-fed infants — For infants who receive formula, it remains uncertain whether the use of nutrient-enriched formula is beneficial after hospital discharge [30,35-37]. Nevertheless, the decision whether or not to use a nutritional enriched formula should be made as part of the discharge planning process of formula-fed preterm infants. In our institution, we recommend enriched formula for infants with weights below the 10th percentile for age and who were born with BWs below 1500 g. We also recommend changing to enriched formula in those infants who initially received standard formula if they fail to maintain adequate growth or fail to "catch up" after hospital discharge. In our practice, we typically use enriched formula for preterm infants until they are six months of age post-term or until they have achieved adequate catch-up growth.

The commercially available enriched formulas compared with standard formulas are calorically denser (75 kcal/100 mL versus 67 kcal/100 mL) and have a higher content of protein, calcium, phosphorus, zinc, and vitamins A, E, and D. In infants who receive standard formulas, additional vitamin D supplementation and iron may be required through the first year of life to meet the needs of preterm neonatal intensive care unit (NICU) graduates [30].

A systematic review of studies evaluated growth and neurodevelopmental outcome in infants who received nutrient-rich formula versus those who received standard full-term formula [37]. The quality of evidence was graded as moderate because of major potential bias due to the lack of allocation concealment and incomplete follow-up. The study found inconsistent results on the benefit of "postdischarge" formula (caloric density 74 kcal/100 mL) compared with standard formula on growth at 12 and 18 months of age postterm. However, there was evidence that the use of "preterm" formula (caloric density 80 kcal/100 mL), which is generally only available for in-hospital use, resulted in higher rates of weight gain at 12 to 18 months postterm.

It is the author's view that the balance of the evidence favors a small, but significant, growth advantage to enriched formulas after discharge. However, whether these benefits are sustained and whether they improve or worsen long-term health is unclear. An alternate approach is to provide enriched formulas to preterm infants who do not maintain adequate growth or fail to "catch up" after hospital discharge, although this approach has not been systematically studied.

Human milk-fed infants — Data are uncertain whether growth is poorer for infants fed fortified human donor milk compared with those who received preterm formula [38,39]. Nevertheless, maintaining human milk feeding of the preterm infant after hospital discharge should remain the goal due to the many non-nutritional advantages of human milk feeding. The choice of whether, how, and how long to supplement human milk-fed infants needs to be individualized based on the infant's own risk factors, prior and ongoing growth, and ability of the parents to carry out the suggested regimens. Some regimens (eg, fortification of expressed human milk) require significant effort with collection of pumped breast milk and addition of nutrients, and may be beyond some families to implement successfully. Use of unfortified human milk, with appropriate growth monitoring, remains a valid alternative for many preterm infants although growth may be poorer. However, if growth is inadequate, two or three feeds daily of a postdischarge enriched formula may be provided [36,40]. Post-discharge formula also may be used if the human milk supply is inadequate. There is no evidence to suggest how long fortified human milk feeds should be given, but the author's personal practice is to continue this practice until six months after the estimated date of term delivery or confinement (EDC). Growth monitoring should ensure that growth in weight and length are proportional. If excessive weight is gained compared with length, or if there is upwards crossing of weight-for-length centiles, consideration should be given to reducing nutritional fortification if infants are received enriched formulas or fortified human milk.

Human milk-fed preterm infants should receive iron after two weeks of age and vitamin D supplementation when the infant reaches 1500 g, as these two nutrients are inadequately supplied by human milk alone [41]. Exclusively human milk-fed infants appear to be at risk for osteopenia of prematurity, and biochemical evaluation will often detect an elevated serum alkaline phosphatase after discharge. Infants who receive non-fortified human milk have calcium and phosphorus deficiency and reduced bone mineral content [42]. Data, however, are lacking on what interventions to use in human milk-fed infants with evidence of poor bone health as well as in those who exhibit poor growth. In these infants, we will use fortified human milk or enriched formula recognizing that these interventions have not been adequately studied. Management of vitamin D supplementation and iron are discussed separately (See "Iron deficiency in infants and children <12 years: Screening, prevention, clinical manifestations, and diagnosis", section on 'Prevention of iron deficiency' and "Management of bone health in preterm infants".)

Poor oral feeding — Some preterm infants will struggle to maintain adequate enteral caloric intake due to poor oral feeding from developmental problems, oral aversion, or chronic medical problems. In particular, infants who were intubated and mechanically ventilated for a long time period may have difficulty with oral feeding, in part because of abnormal development of suck and swallow rhythms [43]. Neurologic impairment may also interfere with oral feeding and growth [44]. These patients may benefit from occupational or speech therapy to improve oral motor function. (See "Neonatal oral feeding difficulties due to sucking and swallowing disorders".)

In rare cases, infants with oral motor dysfunction may benefit from nasogastric or orogastric tube feeding while awaiting developmental improvement in the coordination required for oral feeding. All or a proportion of feedings may be provided by this route. In some cases, a gastrostomy may be preferred [44]. This approach may also decrease caloric expenditure in chronically ill infants, such as those with congenital heart disease or bronchopulmonary dysplasia (BPD).

In one report, fewer respiratory infections were seen in preterm infants discharged home with nursing care while they still required tube feedings compared with those who remained in the hospital until they could take full oral feeds [45]. There were no differences between the groups in infant health, surgical procedures, or medications. Despite these findings, the safety, efficacy, or cost-benefit ratio of gavage feedings at home is not clear, and this technique must be used with caution [46].

Bronchopulmonary dysplasia — Growth failure is common in infants with BPD, with reported rates of 30 to 67 percent [47]. Possible factors that contribute to poor growth in these infants include:

Increased energy expenditure [48,49].

Reduced fat absorption [50].

Chronic hypoxia or suboptimal tissue oxygenation [51].

Poor feeding endurance and performance with lower sucking pressure and decreased sucking frequency and swallowing in infants with severe BPD (requiring home oxygen therapy) compared with infants without BPD or with milder BPD [52].

Infants with BPD who received postnatal dexamethasone therapy appear to be especially susceptible to poor growth [53].

Although it is established that poor growth is a common problem in infants with BPD, there has only been one randomized controlled trial to study the efficacy of nutrient-enriched formula in affected patients. In this study of 60 infants with BPD, patients were randomly assigned to one of two different 30 kcal/oz formulas until three months corrected age. Infants receiving protein and mineral-enriched formula had better growth than control infants at three months corrected age. However, there was no difference in growth between the two groups at 12 months corrected age [54]. Whether this means that the benefits to the formula were transient, or whether the difference is dependent upon continued administration of nutrient-enriched formula beyond three months corrected age is not clear.

In our institution, the nutritional management of these infants is highly individualized, especially in those with severe BPD. Fluid intake is largely determined by the baby's respiratory status. Enriched formulas or fortified human milk can be modified to meet the age-appropriate nutritional intakes of these infants with higher nutrient needs than preterm infants without chronic disease [55].

LONG-TERM OUTCOME

Growth — Limited data on the long-term growth in individuals who were born prematurely include the following:

Very low birth weight infants – At 20 years of age, adults who were very low birth weight (<1500 g) infants were twice as likely to have a height <3rd percentile than controls with normal birth weight (BW) (10 versus 5 percent) [56].

Extremely preterm infants:

In the prospective EPICure cohort, individuals who were extremely preterm compared with age-matched controls were on average 4 cm shorter, 6.8 kg lighter, and had a 1.5 cm smaller head circumference at 19 years of age [57].

In a study from Australia of patients born from 1991 to 1992, the mean heights of extremely preterm survivors (n = 166) were less than those of term controls (n = 153) at all ages through 18 years of age (at 18 years of age, mean height Z-scores of -0.47±1.14 versus 0.26±0.98) [58]. The extremely preterm survivors were also lighter than term controls, though this difference decreased with age so that body mass index (BMI) Z-scores were similar for the two groups by 18 years of age. (See "Measurement of growth in children", section on 'Use of Z-scores'.)

In a Swedish study of 123 children with a GA less than 26 weeks born between 1990 and 2002 [59]. The difference in mean Z-scores compared with normative standards decreased from when the patients were at term adjusted age to follow-up at 10 years of age for weight (-3 versus -0.2) and height (-3.8 versus -0.7).

Further investigation is needed to better understand the factors that alter growth trajectories for children who are born extremely preterm and to develop targeted interventions to improve overall growth.

Neurodevelopmental outcome — Greater weight gain before reaching term appears to be associated with improved neurodevelopmental outcome. This was illustrated in a study of 613 infants (GA below 33 weeks) that demonstrated greater weight gain, BMI, and head growth before 40 weeks postmenstrual age (ie, term) were associated with higher Bayley Mental and Psychomotor Developmental Indexes (MDI/PDI) scores at 18 months corrected age [60]. From term to four months corrected age, weight gain and linear growth were associated with higher PDI scores; however, there was not an associated improvement in either MDI or PDI scores with BMI. After four months corrected age, there was no association between any growth parameter and cognitive testing.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Nutrition support (parenteral and enteral nutrition) for neonates including preterm infants".)

SUMMARY AND RECOMMENDATIONS

Preterm infants are often significantly underweight at the time of hospital discharge. At discharge, they remain at increased nutritional risk and merit close growth monitoring after hospital discharge. (See 'Growth in the NICU' above and 'Preterm infants' above and 'Monitoring of growth' above.)

Enriched formula may improve the growth of preterm infants and is a reasonable option for formula-fed babies. For infants who were born with birth weights below 1500 g (very low birth weight infants), we suggest using enriched formula versus standard formula for infants with weights below the 10th percentile for age at the time of hospital discharge or until full feeds are established (Grade 2B). (See 'Formula-fed infants' above.)

After hospital discharge, exclusively human milk-fed preterm infants are at increased risk for suboptimal growth compared with formula-fed infants. If there is suboptimal growth, we suggest that infants receive two or three supplemental feedings of enriched formula daily (Grade 2C). The long-term goal is to maintain human milk feeding in these infants. (See 'Human milk-fed infants' above.)

Human milk-fed preterm infants should also receive iron and vitamin D supplementation, as these two nutrients are inadequately supplied by human milk alone. (See 'Human milk-fed infants' above.)

For formula-fed preterm infants, we suggest that they receive an enriched formula until six months of age postterm or until they have achieved adequate catch-up growth (Grade 2C). (See 'Formula-fed infants' above.)

Infants with bronchopulmonary dysplasia (BPD) are at increased risk of growth failure after hospital discharge. Protein and mineral-enriched feeds may provide short-term advantages in growth. In our practice, the feeding of these infants needs to be individualized before hospital discharge to ensure adequate growth within the fluid intake limits imposed by the chronic lung disease. (See 'Bronchopulmonary dysplasia' above.)

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