Complementary Feeding in Preterm Newborns

10 min read /

 

Key messages:

  • Timing for the introduction of complementary feeding (CF) in preterm infants is still a matter of debate. An individualized approach based on the acquisition of oral and developmental skills is suggested.
  • Food choices, sequence and speed of introduction may be considered the same as for term infants currently.
  • There are no links between early CF in preterm newborns and obesity, nor between CF and allergy.


Complementary feeding (CF) is a crucial step in nourishing the changing needs of an infant as they grow. While for preterm infants, the timing for initiating CF for preterm infants is still unclear, an individualized approach depending on the infant’s oral and developmental skills is suggested. Current studies also show early CF has no links to obesity nor allergy development in preterm infants. With regards to food choices, sequence and rate of introduction for preterm infants, the same standards as full-term infants are accepted.

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Key Messages:

  • Timing for the introduction of complementary feeding (CF) in preterm infants is still a matter of debate. An individualized approach based on the acquisition of oral and developmental skills is suggested.
  • Food choices, sequence and speed of introduction may be considered the same as for term infants currently.
  • There are no links between early CF in preterm newborns and obesity, nor between CF and allergy

 

Appropriate management of early nutritional needs is crucial for preterm infants, a vulnerable population that features specific nutritional requirements which differ from those of term neonates. Complementary feeding (CF) (also called weaning) is defined by the World Health Organization as “the process starting when breast milk alone is no longer sufficient to meet the nutritional requirements of infants” so that “other foods and liquids are needed, along with breast milk”.

What is known is that guidelines for CF in term infants 1,2 are not appropriate for preterm neonates, hence the urgency for specific recommendations for premature babies.3 A position paper shared by joint societies4 (Italian Paediatric Society – SIP, Italian Society of Neonatology – SIN, and Italian Society of Paediatric Gastroenterology, Hepatology and Nutrition – SIGENP) summarizes the current evidence regarding CF in preterm newborns, and provides recommendation for pediatricians, healthcare providers and families. The final aim is to reduce the variability of attitude and timing5 among professionals.

 

When should complementary feeding be started? 

Currently, and due to extreme variability in achieving neurodevelopmental and oral skills, there is insufficient evidence to draw final conclusions regarding timings for starting CF in preterm infants. We therefore suggest an individualized approach based on the accurate evaluation of the infant development and attitude towards semi-solid foods. Corrected or postnatal age should be employed as an indicative reference rather than a mandatory schedule.

It’s noteworthy that continuation of breastfeeding should be encouraged while introducing solid foods. The timing for the introduction of solid foods in preterm infants is still a matter of debate. Different time frames have been suggested by different groups, including 5-8 months chronological age, and more recently from 3 months of corrected age. The most important thing is to evaluate the acquisition of developmental skills (FIG. 1.), which allow the consumption of solid foods. (Certainty of evidence: Moderate. Grade of recommendation: Strong). 

 

Acquisition of developmental skills that allow the consumption of solid foods (Adapted from: bliss.org.uk)
Figure 1. Acquisition of developmental skills that allow the consumption of solid foods (Adapted from: bliss.org.uk)

 

Are there specific recommendations for preterm infants with oral dysfunction or comorbidities?

Preterm infants with oral dysfunctions or comorbidities may require a multidisciplinary assessment to evaluate when and how CF should be started. (Certainty of evidence: Low. Grade of recommendation: Weak). 

 

What food types should be recommended?

Recommendations for preterm infants regarding food choices, sequence and speed of introduction may be considered the same as for term infants currently. Consider starting CF encompassing sources of carbohydrates, proteins and vegetable fats (extra-virgin olive oil) and paying special attention to the intake of micronutrients (e.g., iron and vitamins). (Certainty of evidence: Low. Grade of recommendation: Weak). 

 

Is there a link between early CF and obesity?

The timing of CF start in preterm infants is unlikely to influence the incidence of overweight and obesity in childhood and adulthood. The start of CF in preterm infants should not be delayed, with the aim to prevent overweight and obesity. (Certainty of evidence: Moderate. Grade of recommendation: Strong). 

 

Is there a link between early CF and allergy?

The introduction of allergenic foods (e.g., eggs, fish, tomato, peanuts) may not be delayed in preterm infants. (Certainty of evidence: Very Low. Grade of recommendation: Weak).

 

References

  1. Fewtrell M, Bronsky J, Campoy C, et al. Complementary feeding: a position paper by the European Society for Paediatric Gastroenterology, hepatology, and nutrition (ESPGHAN) committee on nutrition. J Pediatr Gastroenterol Nutr. 2017;64:119–32. 
  2. Alvisi P, Brusa S, Alboresi S, et al. Recommendations on complementary feeding for healthy, full-term infants. Ital J Pediatr. 2015;41:36. 
  3. Liotto N, Cresi F, Beghetti I, Roggero P, Menis C, Corvaglia L, et al. Complementary feeding in preterm infants: a systematic review. Nutrients. 2020;12:1–13. 
  4. Baldassarre ME, Panza R, Cresi F, Salvatori G, Corvaglia L, Aceti A, Complementary feeding in preterm infants: a position paper by Italian neonatal, paediatric and paediatric gastroenterology joint societies. Ital J Pediatr. 2022 Aug 5;48(1):143. 
  5. Baldassarre ME, Di Mauro A, Pedico A, Rizzo V, Capozza M, Meneghin F, et al. Weaning time in preterm infants: an audit of italian primary care paediatricians. Nutrients. 2018;10:616.