Premature Baby Questions
My baby is a premature infant. What kind of special diet is needed?
The nutritional needs of the premature infant are much greater than those of the full-term infant. For that reason, special milks have been developed for feeding the premature infant during hospitalization. For example, if you wish to provide breast milk for your infant, additional nutrients in the form of minerals, protein, and vitamins (fortifiers) are available for adding to the milk. Infants who do not receive breast milk are fed specialized formulas which contain more nutrients and energy, designed for premature infants. These special formulas are available for the hospitalized infant.
There are so many different kinds of formulas available. How does my doctor know which one to use?
Your doctor will select the best type of milk based on his or her experience, the way it is to be fed, and the particular condition of your infant. Most commonly, if you wish to breastfeed, the physician will use your milk to feed your infant. In many cases, breast milk fortifiers will be added to your milk to give the infant more protein and minerals. If you choose to bottle feed, your infant’s doctor will select one of the specialized formulas that have been developed specifically for the premature infant. Breast milk fortifiers and specialized formulas for premature infants differ from breast milk and routine formula. These special preparations contain more calcium, phosphorus, sodium, protein, other minerals, vitamins, and energy.
They tell me that it is especially important to give enough calcium to my baby because he is premature. How should I make sure my baby gets enough calcium?
Calcium is a nutrient that the fetus receives mostly in the last trimester of pregnancy. Therefore, because your infant was born early, and in many cases, just at the beginning of the last trimester of pregnancy, he was unable to receive a good supply of calcium. Calcium is stored in bone. Premature infants tend to have poor mineral formation in bone, which weakens their bones unless they receive specialized milk preparations that provide additional calcium and phosphorus. These unique preparations are specifically designed for the premature infant as commercial formulas or as fortifiers for breast milk. All of these specialized preparations contain greater amounts of calcium and phosphorus than those found in routine infant formula or in breast milk itself. Your infant’s calcium requirements, therefore, will be met by feeding these specialized formulas or fortified human milk.
Generally, after hospital discharge, the additional calcium and phosphorus sources are no longer needed. After discharge, your infant may receive unfortified breast milk or routine infant formula. These preparations would supply sufficient calcium and phosphorus for your infant’s needs after hospital discharge.
Your infant’s doctor will order laboratory tests to monitor the mineral status. These tests usually include measurements of the blood levels of calcium, phosphorus, and a chemical that shows the condition of bone, called alkaline phosphatase.
They tell me that because my baby is premature, he may have rickets. I thought rickets was an “old” disease. I don’t understand.
Rickets is a condition that is characterized by abnormal development of bones, such as bumps on the chest and bowed legs. There is also muscle weakness. Usually rickets is due to vitamin D deficiency. However, the premature infant has great needs for calcium and phosphorus, and if these needs are not satisfied, calcium and phosphorus deficiency might occur and result in rickets. Rickets can be prevented by supplying sufficient amounts of calcium, phosphorus, and vitamin D to the premature infant.
The premature infant has greater needs for calcium and phosphorus than at any other time in his development. This is because the infant was born in the early part of the last trimester of pregnancy, and it is in the last trimester of pregnancy that the infant receives the majority of the calcium for deposit in the skeleton. There are specialized formulas, either breast milk fortifiers or specially designed formulas for premature infants, that contain greater amounts of calcium and phosphorus. Your infant also will be supplied with vitamins in these formulas or an additional vitamin supplement in the diet. These multivitamin sources contain sufficient amounts of vitamin D. Therefore, because adequate amounts of calcium, phosphorus, and vitamin D are supplied to premature infants, severe rickets is less common today than it once was.
What about vitamin C? Should my premature baby be protected against infections with vitamin C?
Special formulas, either breast milk fortifiers or specially designed formulas for premature infants, contain adequate amounts of vitamin C. If for any reason your infant does not receive these milk formulas, your physician will order a multivitamin supplement that contains vitamin C. In these ways, your infant will receive the appropriate amount of vitamin C. High doses of vitamin C have not been found to protect infants from infection. More importantly, high doses of vitamin C may harm their kidneys and lead to abnormalities in their urine. Therefore, only adequate doses of vitamin C are recommended for the premature infant.
I also hear that lots of vitamin A may protect the lungs of premature infants. Is that true?
Vitamin A deficiency may occur in the premature infant. The infant, however, receives an adequate amount of vitamin A in breast milk fortifiers and specially designed formulas for premature infants. Parenteral (intravenous, or through the vein) nutrition solutions now are designed to provide more vitamin A than previously. Therefore, vitamin A deficiency is less likely to occur.
There are some very new studies that have shown possible protection of the lungs of premature infants when they receive high doses of vitamin A. In those studies, infants received high doses of vitamin A for long periods. However, the risks from receiving very high doses of vitamin A may be significant. Further studies are needed to determine the risks and benefits of high doses of vitamin A.
What about protein? Should I give more protein to my baby because he is premature?
The protein needs of the premature infant are much greater than the protein needs of full-term infants. Because their growth rate is so rapid, they have a greater need for protein. This need is supplied by either breast milk fortifiers or specially designed formulas for premature infants. If infants receive an adequate volume of these formulas, they will receive adequate amounts of protein. If infants receive parenteral (through the vein) nutrition solutions, they will be provided with adequate amounts of protein as well.
Generally, by the time premature infants are discharged from the hospital, their protein needs are equivalent to the full-term infant, and in that case a routine milk, either (unfortified) breast milk or routine infant formula, would be prescribed. However, your infant’s doctor will check the state of protein nutrition of your infant while he is in the hospital, and if deemed necessary, your infant will receive additional parenteral solutions or milk to provide more protein. The infant’s state of protein nutrition is checked by measuring the level of protein-related chemicals in the blood, called albumin, urea, or prealbumin (transthyretin).
I also heard that vitamin E is good for protecting my baby. Should my baby get more vitamin E?
Vitamin E deficiency may occur in the premature infant if he does not receive sufficient amounts of the vitamin. However, breast milk and specially designed formulas for premature infants contain sufficient amounts of vitamin E. Parenteral (through the vein) nutrition solutions also contain adequate amounts of vitamin E. Therefore, your infant will receive a sufficient amount of vitamin E.
There have been a few studies that have shown that a very high dose of vitamin E may protect babies. However, there are some risks to receiving very high doses of vitamin E. Some studies indicate that high doses of vitamin E given the first few days after birth will decrease (but not prevent) the incidence of bleeding in the brain. Long-term use also may decrease some eye problems in the premature infant. Because of the balance between risks and possible benefits, your doctor will decide if very high doses of vitamin E are needed.
I understand that they give vitamin K to all newborn babies. What about my premature baby?
Yes, all newborn infants require vitamin K. Newborn infants are unable to make vitamin K at the time of birth and therefore must receive vitamin K.
Without vitamin K, the newborn premature or full-term infant will experience bleeding and hemorrhage. All infants receive an injection of vitamin K at the time of birth, and premature infants also receive the same injection. Premature infants then receive a sufficient amount of vitamin K in the milk and in the parenteral nutrition solutions that they are fed. Occasionally, your doctor may recommend additional doses of vitamin K for your premature baby.
My baby needs medicines to get rid of water. How much water should my baby be receiving?
We are very cautious about the correct amount of fluid (water) your infant receives. For that reason, the milk that your infant gets is often made more concentrated, so that we cut down on extra water. Your doctor might use 24 kilocalorie-per-ounce formulas and not 20 kilocalorie-per-ounce formulas for this reason. In some situations, if your infant gets too much water, it can affect the lung function (fluid in the lungs), and the body may swell up with fluid, a condition we call edema. The reason your infant responds this way is that the kidneys are immature.
The kidneys will mature during the hospital stay, and the infant will be able to handle more and more fluid as he gets older. This is why your doctor orders fluids, either by vein or in milk, very cautiously, and usually determines the amount of fluid the infant receives, based on the infant’s body weight that day. So, as the infant gains weight, the amount of milk/fluid he receives will be increased.
Does the baby need more sodium?
Premature babies’ kidneys don’t work as well as those of full-term infants. One indication of this is their difficulty in handling water. They don’t get rid of excess water easily. Another indication is that they lose too much sodium in their urine. Their kidneys can’t hold on to sodium. For this reason premature babies require more sodium in their first few weeks as compared to full-term infants.
Because infants may receive diuretics (medicines that get rid of water), they also may lose a lot of sodium. Your doctor may recommend that your infant be tested to determine how much sodium is in the blood. In some circumstances, more sodium will need to be added to the intravenous fluid or milk for the infant. Not only do the diuretic medicines get rid of water and sodium, but they also may affect calcium. This is another reason why premature infants need a greater amount of calcium in their diet.
My baby has lung disease, and my doctors tell me they have to be careful with the amount of fluid. Why is that?
The premature infant’s lungs are weaker and have the ability, unfortunately, to retain a lot of water. If we give too much fluid to the infant, more water will be retained in the lungs and this would affect the infant’s lung function. This is why we are very careful about the amount of fluid the infant receives.
What about the growth of my baby, since he is premature. How does the premature infant grow?
A premature infant is expected to grow at two to three times the growth rate of the full-term infant, because we assume that after the infant is born, he will maintain the same growth rate as he would if he stayed inside the mother. In order to allow this rapid growth rate, the quantity of nutrients we supply must be greater than what we supply to full-term infants. Your doctor will be checking your infant’s daily weight gain and comparing it to his growth throughout hospitalization. In some nurseries, special growth charts are available to see the rate at which your infant is gaining weight.
Premature infants generally lose weight or maintain their body weight for one to two weeks after birth. When their medical problems stabilize, we usually begin to see some weight gain. The smaller the premature infant at birth, the longer it takes for him to regain his birth weight.
Usually, the minimum growth rate for a 2-pound premature infant is 15 grams (1/2 oz.) per day; for a 3-pound infant it is 22 grams (3/4 oz.) per day; for a 4-pound infant, 30 grams (1 oz.) per day.
My premature baby looks so scrawny. Why don’t they fatten him up a little bit?
We would love to fatten up the infant as soon as possible. Premature and growth-retarded infants are born with very little fat stores. It is for this reason that they get cold when they are taken out of their incubators, and this is why they can’t maintain their own body temperature without the use of specially heated environments.
However, there is a risk in fattening them up too quickly. They have difficulty absorbing and digesting sufficient amounts of fat. If we give too much fat in the diet and the infant does not absorb it, it will influence the absorption of other nutrients. Therefore, we are cautious in this regard, but the goal is to provide sufficient amounts of energy, fat, and sugars so the infant can gain weight and put on more fat. We usually give 60 kilocalories per pound of body weight as the average energy intake to achieve good weight gain.
Energy comes in the form of fat, sugar, and protein. We not only have to ensure that the infant puts on fat, but also builds muscle from protein. Therefore, we have to balance all the forms of energy we give to the premature infant.
Why do they keep giving fluids by vein to my baby? Why don’t they just test the intestine? Shouldn’t the intestine work?
Initially, right after birth, your premature infant has many adjustments to make to being born. His circulation may be abnormal and this may take a day or two to adjust. He may also have difficulty with kidney function, and therefore, the amount of fluids we give the infant needs to be regulated very carefully. While your infant is adjusting to being born, and while circulation and kidney function begin to improve, we can provide more nutrients by vein (paren-teral nutrition). The intestines of the premature infant are also immature. Because of this immaturity, milk feedings usually are not begun on the first day after birth.
We try to provide small amounts of milk early because we believe that this practice will provide stimulation for the intestines to develop. We try small amounts of milk feeding as soon as possible in the first week after birth. Each day we check the function of the intestines and note whether the milk is being accepted by the infant. As soon as it is, we can reduce and eventually stop the solutions by vein.
How do you know if my infant is tolerating her milk feedings?
The physicians and nurses closely check the infant’s “feeding tolerance,” especially when he is fed by tube. Before each feeding, the stomach contents are checked for leftover milk from the previous feeding (gastric residual volume). If it is excessive, your infant’s doctor will be notified. Feeding tolerance is also checked by noting if the infant has too many or too few bowel movements, if his abdomen appears enlarged (distended) or tender, and if he has vomiting.
These conditions may be worrisome, and your infant’s doctor will check him to determine if he is really not tolerating his milk. Usually, if these conditions occur, the milk feeding is stopped for a few hours or a few days. If the infant’s physical examination becomes more normal, then the feedings are resumed.
Sometimes feedings are stopped for a few hours or days and restarted again. At other times, feedings are continued. In all these cases your infant’s tolerance of milk is being observed closely.
The doctors give my baby this yellow liquid through the vein and they say there is some danger to it. What is it and what is the danger?
Parenteral (intravenous or through-the-vein) nutrition is given to nearly all small premature infants in the first few days after birth. The yellow color comes from the multivitamin preparation. The parenteral nutrition (TPN) solutions also contain amino acids (the building blocks of protein), glucose (sugar), and minerals.
There are several risks resulting from the use of TPN. Since so many different nutrients are added each day, there is a small risk that an excess or insufficient quantity will be added. Even though the mixtures are prepared carefully, this is an occasional concern. There may be some damage to the infant’s liver from the chemicals in the solution. Sometimes TPN is associated with a higher possibility of infection. These risks, however, are minimal.
Newer techniques are always emerging, and your doctor will be weighing the risks and the benefits from the use of the TPN. Most of the risks of TPN can be anticipated by routinely checking the chemicals in the blood and frequently examining the infant.
What about vitamins by vein? Is that safe?
The multivitamin preparation that is available for use in premature infants has been tested and it is considered to provide safe quantities of the vitamin. Individually, however, when extremely high doses of specific vitamins have been given by vein, they can be dangerous. When multivitamins are used and the amounts given are checked daily, they are not toxic.
How much protein can they give by vein?
Parenteral (intravenous) nutrition solutions contain amino acids. These are the building blocks for protein. In the usual circumstance, your doctor will specify the amount to be given to your baby. If the solutions are needed for long periods, or if your infant develops conditions in which more protein is needed, the amount of the amino acids can be increased to provide more building blocks for protein. Your infant’s doctor also will check blood tests that tell whether he is receiving enough or too much protein. These tests include measurements of albumin, blood urea nitrogen (BUN), or prealbumin (transthyretin).
My doctor is also going to give some “fat” through the vein. What kind of problems can that cause?
Intravenous fat is the white substance that runs in the parenteral nutrition solution. In controlled quantities, the risk to the infant is very low. However, high quantities over prolonged periods may cause problems. Because problems can occur, your doctor will monitor your baby’s blood level of fat (triglycerides).
Usually if the blood level is maintained in a normal range, the risks are low. Some risks include bleeding abnormalities, liver abnormalities, and lung abnormalities. These risks would only be seen if high doses of fat are given intravenously, leading to very high blood levels of fat that are not lowered.
The nurses say they use sugar in the veins. How do they know if there is too much sugar? Can that be a problem?
The first intravenous fluid your infant will receive is sugar, or what we call glucose or dextrose. Generally, this is well tolerated, but very premature infants may have difficulty accepting even small amounts of sugar. Your doctor will know this because the blood can be tested easily. The infant’s urine can also be tested because, if there is too much sugar in the blood, it will spill over into the urine.
In all of these cases, when infants are receiving too much sugar for their needs, the amount of sugar can be reduced. In some circumstances, the very premature infant may even require insulin for a few days to help manage the sugar problem. Insulin decreases the blood sugar level. This condition is not permanent. As the infant matures, he can handle sugar better. After several days, the amount of insulin can be reduced and stopped, and the infant can handle the sugar by vein.
If the amount of sugar is too great and it is not treated enough, hyperglycemia (high blood sugar) may result. This can be harmful to the infant’s brain and also can result in a large amount of sugar being lost in the urine. In that case, the large amounts of sugar would pull water and minerals with it, and therefore cause dehydration and loss of minerals such as sodium. These problems can be anticipated and prevented by proper checking of blood and/or urine for the amount of sugar.
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