Premature Neonates May Experience Stress Associated with Feeding

Insertion of a nasogastric tube may cause stress to the very premature infant.([FOOTNOTE=Newnham CA, Inder TE, Milgrom J. Measuring preterm cumulative stressors within the NICU: the Neonatal Infant Stressor Scale. Early Hum Dev. 2009;85(9):549-555.],[ANCHOR=],[LINK=]) In addition, more serious feeding-related events can occur. For example, connecting a feeding tube to an I.V. line is a potentially fatal event.([FOOTNOTE=Simmons D, Symes L, Guenter P, Graves K. Tubing misconnections: normalization of deviance. Nutr Clin Pract. 2011;26:286-293.],[ANCHOR=],[LINK=]) In adult, pediatric, and infant patient populations, enteral tube misconnections have resulted in a range of outcomes that have included septicemia/sepsis, respiratory arrest/distress, and neurologic damage.2

The Immature Gut

Premature infants are at increased risk for intestinal injury because their gut motility, digestion, absorption, and circulatory regulation have not matured.([FOOTNOTE=Choi YY. Necrotizing enterocolitis in newborns: update in pathophysiology and newly emerging therapeutic strategies. Korean J Pediatr. 2014;57(12):505-513.],[ANCHOR=],[LINK=]) Moreover, the infant’s immune defenses and the physical barriers that protect the infant’s gut wall are impaired.3

Necrotizing enterocolitis (NEC) is a serious and often fatal inflammatory bowel disease associated with enteral (tube) feeding in premature neonates.3,([FOOTNOTE=Costello JM, McQuillen PS, Claud EC, Steinhorn RH. Prematurity and congenital heart disease. World J Pediatr Congenital Heart Surg. 2011;2(3):457-467.],[ANCHOR=],[LINK=]) What causes NEC is not fully understood, but in combination with the immature gut, "enteral (especially formula) feeding, colonization with pathogenic bacteria and an exaggerated inflammatory response" may result in intestinal injury.4

10% of Premature Infants

About 10% of premature infants <1500 grams at birth experience necrotizing enterocolitis.4

The Vulnerable Brain

Brain growth and development in preterm infants requires adequate nutrition.5 Preterm infants are at increased risk of some nutrient deficiencies, and fetal malnutrition has been linked with long-term consequences such as cognitive impairments and learning disabilities.([FOOTNOTE=Kuenen K, van Elburg RM, van Bel F, Benders MJNL. Impact of nutrition on brain development and its neuroprotective implications following preterm birth. Pediatr Res. 2015;77(1):148-155.],[ANCHOR=],[LINK=])

Premature babies have extreme central nervous system vulnerability and may be susceptible to the long-lasting changes in physical structure and operation of the brain associated with premature birth.1,([FOOTNOTE=Salmaso N, Jablonska B, Scafidi J, Vaccarino FM, Gallo V. Neurobiology of premature brain injury. Nat Neurosci. 2014;17(3):341-346.],[ANCHOR=],[LINK=]) Optimizing protein and energy intake may have neuroprotective benefits for the preterm infant, although the evidence to date is limited and inconsistent.5 Nutritional therapies may help prevent infection and necrotizing enterocolitis.5 They may also decrease inflammation and help minimize injury to the brain’s white matter.5

24 and 40 Weeks

Rapid brain development between 24 and 40 weeks of gestation makes preterm infants extremely susceptible to brain injury.5