Human milk, fortification and preterm nutrition

Question 1 (10 marks)

a) What is this infant's nutritional status, and what target is being missed? (3 marks) This infant is failing to meet the intrauterine growth rate. The target weight gain for a preterm infant is 15 to 20 g/kg per day, and this infant is gaining only 8 g/kg/day, placing him on a trajectory toward extrauterine growth restriction. His current intake of unfortified mother's milk at 20 kcal/oz delivers only approximately 93 kcal/kg/day and 1.4 g/kg/day protein, well below the ESPGHAN targets of 110 to 135 kcal/kg/day and 3.5 to 4 g/kg/day [1].

b) Describe the fortification strategy you would implement. (4 marks) Multicomponent human milk fortifier should be introduced now. Since this infant is already receiving 140 mL/kg/day, the enteral volume threshold of 80 to 100 mL/kg/day for fortification has been exceeded. Standard fortification raises the caloric density from 20 to 24 kcal/oz, increasing energy to approximately 112 kcal/kg/day and protein toward the 3.5 to 4 g/kg/day target. The Cochrane review confirms that multicomponent fortification improves short-term weight gain, length, and head circumference without increasing NEC risk [2].

c) What monitoring would you put in place to assess adequacy? (3 marks) Daily weight should be plotted on a Fenton chart, targeting 15 to 20 g/kg/day. Weekly head circumference should track at 0.9 to 1.0 cm per week. Blood urea nitrogen should be checked weekly and maintained above 1.5 mmol/L to confirm protein adequacy. Alkaline phosphatase, calcium, and phosphate should be monitored weekly to screen for metabolic bone disease, which affects up to 30 percent of very preterm infants [1].

Question 2 (10 marks)

a) Why is extrauterine growth restriction a concern beyond cosmetic appearance? (4 marks) Extrauterine growth restriction — weight below the tenth centile at 36 weeks postmenstrual age or discharge — is a preventable cause of neurodevelopmental impairment. Cohort data demonstrate that infants with EUGR have higher rates of cerebral palsy, lower mental development index scores, and increased neurodevelopmental disability at 18 to 22 month follow-up. The seminal study showed that the magnitude of growth faltering during the NICU stay correlates directly with adverse cognitive and motor outcomes, establishing growth failure as a clinical priority [3].

b) If standard fortification at 24 kcal/oz fails to achieve target growth, how would you escalate? (3 marks) The strategy would intensify in a stepwise manner. First, increase caloric density to 26 or 30 kcal/oz using additional fortifier or fat modules. Second, use adjustable fortification, titrating the protein dose by blood urea nitrogen and adding more protein when BUN falls below 1.5 mmol/L. Third, consider targeted or individualised fortification, in which the actual macronutrient content of each mother's milk batch is analysed and individualised protein, carbohydrate, and fat modules are added to hit exact targets [2].

c) Name three advantages of mother's own milk over preterm formula for this infant. (3 marks) First, human milk provides immunological protection through immunoglobulins, lactoferrin, and oligosaccharides that reduce the incidence of necrotising enterocolitis. Second, human milk contains growth factors and stem cells that promote gut maturation and repair. Third, human milk is associated with improved long-term neurodevelopmental outcomes compared with formula, reflecting both its bioactive components and its role in healthy microbial colonisation [1].