Human milk, fortification and preterm nutrition

Clinical Case

History

This former 27-week gestation female infant was born at 780 g to a 34-year-old primigravida following preterm prelabour rupture of membranes with histological chorioamnionitis. She required initial continuous positive airway pressure and one dose of surfactant. Enteral mother's milk was started on day two and advanced; bovine multicomponent fortifier was introduced once volume exceeded 100 mL/kg/day (within the ESPGHAN 40 to 100 mL/kg/day window). NICU course included a patent ductus treated with ibuprofen and late-onset sepsis at day eighteen, during which feeds were held for 48 hours. Ehrenkranz associated late-onset sepsis with slower subsequent weight gain. Mother's own milk supply has been maintained ^[4].

Examination at 36 weeks PMA

The infant is in room air, taking 150 mL/kg/day of fortified mother's milk. Weight is 1950 g. Weekly weight gain over the last two weeks has been 9 g/kg/day, below Ehrenkranz's 14.4 to 16.1 g/kg/day after birth-weight regain and below the ESPGHAN foetal guide of about 13 to 17 g/kg/day at 30 to 34 weeks (and 10 to 13 g/kg/day at 35 to 37 weeks). Head circumference is lagging the weight centile. Abdomen is soft. Tone is appropriate for corrected age. This is growth faltering in ESPGHAN terms: she is not growing parallel to a centile during established growth ^[2].

Key Questions

1. What is this infant's nutritional status and what is the problem? She has postnatal growth faltering at 36 weeks PMA, with velocity below both Ehrenkranz's observed post-regain rates and the gestation-specific foetal bands ESPGHAN quotes. Embleton showed that early energy and protein deficits accumulate and track with falling z-scores (dietary intake explained 45 percent of z-score variation). Do not diagnose “EUGR equals tenth centile therefore cerebral palsy” — Ehrenkranz did not report 18-to-22-month outcomes, and ESPGHAN warns that growth-faltering/neurodevelopment associations may be confounded ^[1].