GENERAL PAPERS

CURRENT TRENDS IN FEEDING AND CARING FOR

PREMATURE AND LOW BIRTH WEIGHT INFANTS
Laura Florescu, Oana Temneanu, Dana Mindru
Gr. T. Popa University of Medicine and Pharmacy, Iasi

ABSTRACT
Low weight at birth is an important indicator of infant health due to the tight relationship between birth weight
and infant mortality and morbidity. The diminishing of the mortality and morbidity rate requires information on
the growth characteristics and caring requirements for this category of children. Regardless of the category they
are in prematures, Small for Gestational Age, delay in intrauterine growth these children, due to their low
weight at birth present a high risk to develop malnutrition, a reason why there should be known the energy requirements and the optimum nutrition principles, specific to them. Ensuring an early most favourable diet is the
essential element in their care assistance.
Keywords: low birth weight, premature, small for gestational age, delay in intrauterine
growth, malnutrition

We define an infant with low birth weight (Wb)

any child smaller than 2,500 g. These children form
a heterogenous group of new-born infants: premature infants, born on term but with smaller Wb for
the gestational age (Small for Gestational AgeSGA), both premature as well as low Wb for the
gestational age. The premature infant is the newborn with the gestational age (GA) smaller than 37
weeks, Wb smaller than 2,500 g and the birth height
(Hb) under 47 cm. The newborn with intrauterine
growth retardation (IUGR) is the infant with Wb
under 10 percentile on the standards of intrauterine
growth or smaller than 2 standard deviations (SD)
than the corresponding weight.
It is estimated that approximately 15 million infants are born under the normal gestational age every year. This means more than one in 10 children.
Approximately 1 million children die every year
due to premature birth complications. Many survivors face a real life handicap, including learning
disabilities and visual and hearing problems.(1)
In almost all the countries with fiable data, the
premature birth rate is growing. Worldwide, premature birth is the main cause of death in new born
and a second cause of death after pneumonia in

children under 5. The inequalities as regards the

survival rate in these children differ from one country to another; in the underdeveloped countries,
half of the new born infants with gestational age
under 32 weeks die because of the improper care
conditions and nutrition. More than three thirds of
the premature children can be saved, maintaining
the balance between costs and efficient care, for example antenatal steroids (administered to pregnant
women presenting risks of premature birth, aiming
to help lung development), using the kangaroo
mother care method (the baby is carried by the
mother close to her skin and the baby is breastfed
frequently) and administering antibiotics to treat
neonatal infections even without the possibility to
benefit from intensive neonatal care.(1)
Low birth weight is an important indicator for
the infantile health due to the close relationship between birth weight and infant mortality. There are
two categories of small birth weight: those who are
born as consequence of reduced fetal growth and
those who are born before the term. (2) New-borns
(n.b) with small Wb present a higher risk to have a
precarious health or to die, they need a longer hospitalization period after birth and are more suscep-

Corresponding author:
Oana Temneanu, Gr. T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, Iasi
E-mail: ralucatemneanu@yahoo.com

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tible to develop significant disabilities.(3) Depending on the gestational age and the birth weight there
are three prematurity degrees (Table 1).
TABLE 1. Degrees of prematurity International
Classification of Diseases (ICD)
LBW (low birth weight)
VLBW (very low birth
weight)
ELBW (extremely low
birth weight)

Gestational age
Birth weight
GA < 37 weeks 2,499 g 1,500 g
GA < 32 weeks 1,499 g 1,000 g
GA < 28 weeks

< 1,000 g

The causes for premature birth are numerous:

most of them are spontaneous, but some can be due
to pre-term birth, spontaneous birth or cesarian section. Prematurity is influenced by several social and
economical factors such as unchecked pregnancy,
low level of education of the mother, low income
and precarious life conditions, drug addiction,
smoking and alcohol consumption. To all these we
add the maternal pathology, respectively conditions
prior to the pregnancy (system diseases, TB infections, heart defects); diseases during the pregnancy
(arterial hypertension, diabetes, pneumonia, urinary tract infections and vagina infections); diseases of the female genital apparatus (fibroma, uterus
abnormalities); twin pregnancy (frequently met after in vitro fertilization); short period between
pregnancies and lack of adequate sexual hygiene;
in spite of all these, sometimes no clear cause is
identified. There is also a genetic influence.(4)
Women, especially teenagers should be included in
family planning programs, and also be monitored
before and during the pregnancy. A better understanding of the causes and mechanisms will trigger
advances in finding solutions to prevent premature
birth.
More than 60% of births are in Africa and South
Asia, but premature birth is really a global issue. In
the countries with lower incomes, in average, 12%
of the babies are born too early, in comparison to
9% in the countries with bigger incomes. In all the
countries, poor families present a higher risk.
These babies are born too early, but they do not
come to this world to die, says Dr. Joy Lawn, MD
of Save the Children International.(5) According to
the data provided by Save the Children Romania,
approximately 20,000 children are prematurely
born in Romania. The figure is based on the statistics made by the Romanian Association of Neonatology and it is different from that of the National
Institute of Statistics.
According to a statement made by Save the
Children, even though the infant mortality rate in

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Romania has dropped significantly during 19902010, in percentage as well as in numbers, 8,471
deaths in 1990, 2,250 in 2009 respectively 2,078 in
2010 (the figures show that the level in 2010 is
more than two thirds lower than in 1990), Romania
remains on top in the European Union, with an infant mortality rate of 9,8 in 1,000 babies born alive
in 2010, according to the National Institute of Statistics. (6)
In 2011, the infant mortality rate registered in
Romania (according to the National Institute of
Statistics) was again the highest in Europe, meaning 9,4 in 1,000 babies born alive, the main cause
being premature birth. One third of these deaths
can be prevented by supporting programs for pregnant women and babies, as well as improving the
quality of care assistance for the patients with imminent pre-term birth and equipping the hospitals
and maternity departments. In Romania, more than
20,000 children are born premature and with low
birth weight, prematurity being one of the main
causes of neonatal mortality on national level. The
official data of the National Institute of Statistics
show that in 2009, out of the 222,388 new born infants, 17,383 had less than 2,500 grams and 10,635
children had a gestational age smaller than 36
weeks. (7)
A study made by Save the Children Romania,
part of the program Every Child Matters undertaken during 2010-2015, on a sample of 200 respondents from the counties of Iai, Vaslui,
Botoani, Neam, Suceava, 37% of the mothers
state they did not go to any gynecological check
during the pregnancy and approximately 36% of
the mothers gave birth to the first born before the
age of 18. The average age of the mother at birth is
18, significantly lower than the average of the total
population. (8)
Diminishing the mortality and morbidity rate requires knowledge on the growing demands and
care-assistance characteristics for this category of
children and they start even from the birth ward:
Take measures against breathing deficiency:
lateral decubitus positioning; unblocking the
oropharynx, then the nose using a rubber
tube; vacuum the gastric contents in intestinal stasis to ease the movements of the diaphragm; supply heated humidified discontinuous flow of oxygen, 2 4 l/min, using the
cephalic technique, nose cannula, CPAP
(Continuous Positive Airway Pressure), tracheal intubation;
Take measures against the thermoregulation
deficit: 26C temperature in the birth ward;

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taking the newborn in sterile napkins, on a

table with radiating heat, 26-28C temperature in wards; premature infants with Wb <
1,800 g will stay in neonatal incubators: for
Wb = 1.000 g t = 34C; for each 250 g
more, the temperature decreases by 1C; for
each 250 g less, it increases by 1C.
Take measures against acidosis: oxygen +
glucose serum 5% + serum bicarbonate for
the mother in labour and then to the premature newborn, during the first days, depending on the Astrup parameter values.
Take measures against intracranial hemorrhage risks: soft manoevres, avoiding the
Trendelemburg position (the risk to intracranial hemorrhage increases); administer capillarotrophic agents (C and E vitamine); administer vitamine K during the first days
(Phytomenadione).
Prevent infections: small wards with their
own reduced circuit; strictly forbidden access
for people outside the family; limit the contact between the sick newborn babies and the
healthy ones; continuous and current decontamination of the wards, beds, incubators; the
humidifier liquid and oxygenator will be
changed daily; prevent the contamination of
the air in the wards; the medical staff will be
periodically checked; the hands will be
washed before each contact with the newborn; the cloths, dishes and instruments will
be sterilized before each use; there will be
taken all the measures to prevent the contamination of the milk.(9)
Criteria to leave the hospital for the newborn:
he receives the full nutrition ratio (breastfed
or bottle);
he presents a constant growth and has reached
2,500 g;
His temperature is stable outside the incubator;
Has not suffered from recent apnea or bradycardia.
Regardless of the category they belong to prematures, SGA, IUGR these infants, due to small
Wb have a risk to malnutrition. In order to properly
assess their development there should be used
graphs/growth curves typical to the age (age in
weeks, since their birthday, out of which the number of weeks the newborn was prematurely born is
taken out). High incidence of malnutrition in these
children requires information on the energy and nutritional maximum needs, in their particular case.
Ensuring an optimum nutritional intake is the key
element in their care.

The digestive system should adapt in the short

postnatal period so as to meet the nutritional and
metabolical needs of the extrauterine life. In intrauterine life, the intestine is somehow adapted to
this function by the daily passage of amniotic liquid which contains immunoglobulins, enzymes,
growth agents, hormones, absorbing a certain quantity of proteins through the digestive mucuous
membrane. The gastrointestinal tract is completely
developed in 20 weeks of gestation; part of the gastrointestinal functions begin to take effect after
birth, regardless of the gestation age (for example,
gastrointestinal permeability), while others seem to
be programmed to function starting from post-conceptional ages (such as the suckling deglution coordination which appears between 33 and 36
weeks). Even if the premature baby presents anatomical and functional immaturity of the digestive
tract which might require parential nutrition in the
first stage, it is recommended to start early and increase gradually the enteral nutrition by special
techniques so as to ensure the calory intake and the
metabolical and hydroelectrolytic equilibrium of
this category of vulnerable infants.(10)
The composition of the premature body grown
in extrauterine environment should be similar to
that of the baby grown in utero. On term, the body
of the newborn contains 75% water (40% extracellular and 35% intracellular) and he loses 5-10% of
the Wb in the first week of life; at 23 weeks GA, the
body of the premature contains 90% water, (60%
extracellular), he might lose 10-15% of the Wb in
the first week of life. SGA premature babies have
more water in their body composition than the AGA
premature infants, 90% versus 84%, in the period
25-30 weeks GA.(11)
A premature infant has increased metabolical
needs (Table 2), inadequate nutritional reserves, organic and functional immaturity, associated multiple
pathology, all these having negative effects on the
proteic, energetic, mineral and vitamin needs, as well
as on the capacity to absorb and digest them.(12)
TABLE 2. Energy needs and the principle of maximum
nutrients for low Wb (13):
Energy needs 110-135 kcal/kg/day
proteins
4-4,5 g/kg/day (G < 1,000 g)
3,5-4 g/kg/day (G = 1,000-1,800 g)
lipids
4,8-6,6 g/kg/day linoleic acid 350-1,400
mg/100 kcal
linolenic acid
50 mg/100 kcal
medium chain
triglycerides up to 40% of
the total quantity of lipids
carbohydrates 11,6-13,2 g/kg/day

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It is initially recommended to ensure the necessary of energy and proteins by parenteral nutrition
to which we can add from the first 24 hours of life
the enteral one (trophic feeding) if the clinical condition allows it. Total parenteral nutrition means
supplying the necessary nutrients for the metabolic
processes and growth through a catheter in the vein,
aiming to provide the necessary energetic requirements and prevent catabolism and also reach a positive nitrogen balance.
Proteins:
from the first 12-24 hours of life, to avoid catabolism
minimum 1,2 g proteins/kg/day, according to
the losses
maximum 4 g proteins/kg/day to ensure a decreasing rhythm similar to the intrauterine
one
minimum intake of 30 kcal/kg/day to maintain proteic homeostasis.
Lipids:
parenteral administration since the first 24
hours of life to provide the essential fat acids
it is temporized in case infections are associated and/or hyperbilirubinemia
minimum intake of 0,5 g/kg/day
depending on tolerance: 1-4 g/kg/day (2,5 g/
kg/day)
lipids emulsions of 20%, administered slowly.
Carbohydrates:
the minimum intake of glucose should supply
the metabolic basic needs and the energy
required for proteic synthesis
a rhythm of 9 mg/kg/min is the minimum
requirement of glucose for the energy needed
by the brain and the proteic synthesis. (14,15)
Prolonged parenteral nutrition increases the risk
of colestasis and hypertriglyceridemia. (16) That is
why it is necessary to assess periodically the hepatic function and the triglycerides. All the solutions of parenteral neonatal nutrition include trace
elements (Zn, Cu, Mn, Cr, Se), but actually there is
suggested an additional quantity of Mo and Co, especially in the children who receive longer parenteral nutrition.(17) Parenteral nutrition in more expensive, it requires technical skills, it has side
effects, it also requires specially trained staff to set
up and maintain the venous lines, there is needed
special equipment in the neonatology department
(such as luminar medical beam to prepare solutions, radiologic scan unit to check the position of
the catheters, perfusion pumps, laboratory). (18)
It is recommended to start the enteral nutrition
as soon as possible after birth (24-48 hours of life),

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in order to prevent intestinal atrophy trophic

nutrition (2,5-20 ml/kg/day, with an average of 10
ml/kg/day). This quantity will be increased gradually, since the 8th day -11th day of life (depending on
the digestive tolerance) by 10-20 ml/kg/day, up to
the complete oral ratio (135-200 ml/kg/day).(13,19)
Among the advantages of the enteral nutrition
we count the physiological stimulation and maintaining the intestinal mucuous membrane, increase
the width of the intestinal mucuous membrane and
stimulate the development of intestinal villi, decrease permeability of the mucous membrane to
foreign antigens, increase the quantity of peptides
and intestinal hormones, decrease complications
due to parenteral feeding, reduced cost. Early enteral feeding allowed the reduction of the necessary
days to reach complete nutrition, the signs of digestive intolerance, hospitalisation period, osteopenia
in the premature infants, the risk of cholestasis associated to parenteral nutrition.(20)
The balanced intake of maximum nutrients is
highly important in early enteral feeding. The studies have shown the existence of a correlation
between the increased intake of carbohydrates during the neonatal period, increased weight gain and
decreased tolerance to glucose in children with Wb
< 1,000 g. Hence, this category of infants presents
an increased risk of metabolic syndrome. (21)
Enteral feeding uses human milk enriched with
fortifiers for Wb < 1,500 g, and in the case of an
inadequate milk secretion/contraindications for
breastfeeding, there will be used special milk formulas for premature infants. The ideal food for enteral feeding is human milk. There are numerous
advantages for feeding premature infants with human milk and they are widely known: antropometric growth and proper development, (22) optimal
absorbtion of nutrients (especially fats, zinc and
iron), decreased osmolarity, proper adjustment of
the thermal, glycemic equilibrium saturation of the
hemoglobin in the oxygen and partial pressure of
oxygen, less variation in the heart and breathing
frequency and less episodes of apnea and bradycardia, it stimulates the increase and postnatal intestinal differentiation due to the presence of several
growth factors (EGF Epidermal Growth Factor,
NGF nerve growth factor, TGF- transforming
growth factor and TGF- transforming growth
factor , insulin, relaxin, insulin-like GF insulinlike growth factor), protection against oxidative
stress by increased content of superoxide dismutase
and glutathione-peroxidase and by the optimal
quantity of vitamins, A and E, with role of antioxidants, (23,24) protection against infections (25)

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and ulcero-necrotic enterocolitis (UNE) due to increased quantity of secretory IgA, (26) lower incidence of acute diarrhea induced by Rotavirus, E.
coli, Shigella, Salmonella, C. difficile, G. lamblia,
Campylobacter, (27) lower incidence of urinary infections and meningitis, protection of premature
infants with family history of atopy against allergies, low incidence of retinopathy of prematurity
(ROP) (28) and improved sight at 2-6 months corrected age, superior neurologic development, more
important as the period of breastfeeding is longer,
the risk to heart diseases in adolescence and maturity is lower, the risk to diabetes type 2 is also lowered and the number of hospitalizations is smaller.
(29)
Digestion and absorbtion of maximum nutrients:
Digestion and absorbtion of milk proteins is
the same as that of newborns.
Digestion and absorbtion of milk lipids is efficient due to the lipases present in this milk.
Digestion and absorbtion of carbohydrates is
satisfactory. The premature baby can use lactose
from the human milk, although it presents a transitory deficit of lactase during the first week of life.
In case the human milk is not produced (agalactia/hypogalactia/associated maternal pathology),
natural feeding should be administered if there are
specialized milk banks to collect and dispence this
milk.(30,31,32,33,34)
Human milk can be collected and administered
immediately, it can be kept in the fridge at 4C for
48 hours, or it can be kept frozen at -20C for 3
months. Freezing the human milk leads to the loss
of 40% of the quantity of Vitamin C, 40% of the
quantity of lysozyme, 30% of the quantity of lactoferrin, 40% of the quantity of secretory IgA decrease by 25% the lipase activity. It is recommended that the doctor indicates freezing the human
milk, not boiling or pasteurize it. During the thermal treatment of the milk, there are more nutrients
than by freezing it. Pasteurization leads to the reduction of IgA and lysozyme percentage, nitrogen
retention, lipids absorbtion and lipase destruction,
decrease in the concentration of water-soluble vitamins and anti-infection factors.(10)
Premature milk contains more proteins, calcium and phosphor than mature milk, but it does
not cover the necessary of calories, proteins, vitamins and minerals in these children, a reason why it
is recommended to increase the quantity of fortifiers. (35)
They will be used for the children with GA < 34
weeks those with Wb < 1,500 g, the moment when

the oral ratio is complete until the baby reaches

2,000 g. By fortifying human milk we obtain: improvement of weight gain, improvement of protein
status, the seric values of calcium, phosphor, alkaline phosphatase are brought to normal, bone minerals are increased.
The potential disadvantages in the use of fortifiers could be the increase of osmolarity, a reason
why it is not recommended for the children suspicious of UNE, the risk of bacterial contamination.
(36)
The special milk formulas for premature and
low weight babies are the best substitute for human
milk; they are used until the baby reaches 2,500 g,
they have a bigger intake of calories (80 kcal/100
ml) and an increased quantity of proteins (2,253,10 g/100 kcal), whey predominant (the whey/
casein ratio is 70/30), they have an increased absorbtion rate. The quantity of lactose is lower than
that in the standard formulas, according to the diminished activity of lactase in these infants. The
lipids are represented by a mixture of mediumchain triglycerides and vegetable oils, rich in long
chain polyunsaturated fatty acids LC-PUFA. The
vitamins, oligelements and minerals are needed in a
greater quantity to cover the increased needs of
these children. (37)
When the babies weigh 2,500 g, there are recommended the transitional formulas, Nutrient-enriched post-discharge formulas NEPDF); (38)
they contain a greater quantity of proteins, calcium,
phosphor, vitamins and minerals in comparison to
the standard formulas, they have a greater caloric
value (70 kcal/100 ml vs 68 kcal/100 ml), they
contribute to an improved growing rhythm and
bone mineralization in comparison to the standard
formulas. If Wb = 1,000-2,000 g, there will be used
transitional formulas up to 9 months of corrected
age, later the standard formulas will be used, should
increased values of calcium and phosphor be noticed or excessive weight gain; when Wb > 2,000 g
there are recommended the standard formulas enriched with iron, up to 1 year of corrected age.
Regardless of the type of feeding (natural or artificial), in the context of an accelerated postnatal
growth during the first year of life (catch-up growth)
it is necessary to supplement the diet with vitamins
until the catch-up growth is reached and the child
receives an equilibrated diet, including solid food.
Vitamin D: 800-1,000 UI/day, during the first months, considering the increased recurrence of pregnant women lacking vitamins. (39, 40)
In order to ensure a proper bone mineralization
and supply an adequate intake of calcium (120-140

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mg/kg/day) and phosphor (60-90 mg/kg/day), it is

recommended to increase the dosage of vitamin A,
700-1500 UI/kg/day until the baby weighs 2,000 g
(there are practically used multivitamin solutions).
Vitamin K is administered in intramuscular injection, at birth, in a dosage of 1mg for the infants of
Wb 1,000 g and 0,3 mg/kg for those with Wb <
1,000 g. (41)
The prophylactic administration of iron supplements as oral solutions (ferrous fumarate or ferrous
gluconate), 2-3 mg/kg/day, starting with the age of
2-6 weeks (LBW and VLBW) and 2-4 weeks
(ELBW), at least up to the age of 6-12 months.(42,
43) The dosage of iron will not be bigger than 5
mg/kg/day due to the risk of premature retinopathy.
Iron will be administered carefully to those who
have been through numerous transfusions.
Premature infants who receive parenteral feeding with high content of folic acid do not risk any
deficit of folic acid during the first two months; the
premature infants with enteral feeding since their
birth with human milk (with or without fortifiers)
or formulas for premature infants with low content
of folic acid might have an increased risk of deficit
of folic acid, especially when the mothers smoke
and/or do not benefit from folic acid supplements
during the pregnancy. (44)
The studies undertaken so far have highlighted
the benefits of improving the standard formulas
with symbiotics (pre and probiotics). The formulas
enriched with probiotics (bifidobacteria, lactobacillus) have a significant effect in preventing acute
and infectious community diarrhea, especially rotavirus diarrhea and significantly reduce the duration
of the condition. (45,46,47)
Also, the formulas enriched with probiotics
have proven the modulation of the immune reaction and reduced incidence of allergies in prema-

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ture babies predisposed to atopia, the decrease being significant from the statistical point of view as
regards the incidence of atopic dermatitis.(48)
Feeding methods:
continuous gavage feeding or intermittent
(GA < 34 weeks)
using a bottle/spoon/breastfeeding (GA > 34
weeks), as at this age there is a good coordination between the deglutition, suckling and
breathing mechanisms.
Continuous gavage feeding means using a tube
to administer the whole quantity of milk for 24
hours, distributed in 4-8 syringes; it is used for
ELBW newborn infants (limited gastric volume). It
is indicated in case the intermittent gavage feeding
is not tolerated, or in case of severe respiratory
distress, gatroesophageal reflux, persistent gastric
residuum.
Intermittent gavage feeding means 8-10 meals
in a day, depending on the weight, GA, the clinical
condition; the milk can be administered in free flow
(the recommended method) or using a piston.
(49,50)
The aim of correct and proper nutrition of the
premature infant is to ensure an optimum development, from the weight-height as well as neurological point of view. There is no universal recipe for
feeding the premature infant, it all depends on the
GA, Wb and pathology. Regardless of the type,
method and rhythm of feeding, there should be ensured a similar rhythm to that of a normal last term
of pregnancy.
In conclusion, we consider it is necessary to
continue studying the nutritional needs of the infant
with low birth weight, considering the impact in the
long run of the feeding errors made during the first
months of life.

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2013; 62 Suppl 3:8-14
30. Bertino E., Giuliani F., Baricco M., Di Nicola P., Peila C., Vassia C.,
Chiale F., Pirra A., Cresi F., Martano C., Coscia A. Benefits of donor
milk in the feeding of preterm infants. Early Hum Dev. 2013 Oct; 89
Suppl 2:S3-6.
31. Arslanoglu S., Corpeleijn W., Moro G., Braegger C., Campoy C.,
Colomb V., Decsi T., Domellf M., Fewtrell M., Hojsak I., Mihatsch
W., Mlgaard C., Shamir R., Turck D., van Goudoever J. Donor
human milk for preterm infants: current evidence and research
directions. ESPGHAN Committee on Nutrition, J Pediatr Gastroenterol
Nutr. 2013 Oct;57(4):535-42.
32. Vzquez-Romn S., Bustos-Lozano G., Lpez-Maestro M.,
Rodrguez-Lpez J., Orbea-Gallardo C., Samaniego-Fernndez
M., Palls-Alonso C.R. Clinical impact of opening a human milk bank
in a neonatal unit. An Pediatr (Barc). 2013 Dec 27. pii: S16954033(13)00478-5.

33. Chang F.Y., Cheng S.W., Wu T.Z., Fang L.J. Characteristics of the
first human milk bank in Taiwan. Pediatr Neonatol. 2013 Feb;
54(1):28-33.
34. Delfosse N.M., Ward L., Lagomarcino A.J., Auer C., Smith C.,
Meinzen-Derr J., Valentine C., Schibler K.R., Morrow A.L. Donor
human milk largely replaces formula-feeding of preterm infants in two
urban hospitals. J Perinatol. 2013 Jun; 33(6):446-51.
35. Adamkin D.H., Radmacher P.G. Fortification of Human Milk in Very
Low Birth Weight Infants (VLBW <1500 g BirthWeight). Clin Perinatol.
2014 Jun; 41(2):405-421.
36. Stanger J., Zwicker K., Albersheim S., Murphy J.J. 3rd. Human
milk fortifier: An occult cause of bowel obstruction in extremely
premature neonates. J Pediatr Surg. 2014 May; 49(5):724-6.
37. C. Agostoni et al. Enteral Nutrient Supply for Preterm Infants:
Commentary From the European Society for Paediatric
Gastroenterology, Hepatology, and Nutrition Committee on Nutrition
38. Worrell L.A., Thorp J.W., Tucker R., McKinley L.T., Chen J., Chng
Y.M., Vohr B.R. The effects of the introduction of a high-nutrient
transitional formula on growth and development of very-low-birthweight infants. J Perinatol. 2002 Mar;22(2):112-9.
39. Pereira-da-Silva L., Costa A.B., Pereira. Early High Calcium and
Phosphorus Intake by Parenteral Nutrition Prevents Short-term Bone
Strength Decline in Preterm Infants, Journal of Pediatric
Gastroenterology & Nutrition. February 2011, 52(2):203-209,
40. Van de Lagemaat M., Rotteveel J., Schaafsma A., van
Weissenbruch M.M., Lafeber H.N. Higher vitamin D intake in
preterm infants fed an isocaloric, protein- and mineral-enriched
postdischarge formula is associated with increased bone accretion.
J Nutr. 2013 Sep; 143(9):1439-44.
41. Lippincott Williams & Wilkins. Enteral nutrient supply for preterm
Infants. J Pediatr Gastroenterol Nutr, January 2010, Vol. 50, No. 1
42. Friel J.K., et al. A randomised trial of two levels of iron
supplementation and developmental outcome in low birth weight
infants. J Pediatr 2001; 139:25460.
43. Van de Lagemaat M., Amesz E.M., Schaafsma A., Lafeber H.N.
Iron deficiency and anemia in iron-fortified formula and human
milk-fed preterm infants until 6 months post-term. Eur J Nutr. 2013
Dec 1.
44. Oncel M.Y., Calisici E., Ozdemir R., Yurttutan S., Erdeve O.,
Karahan S., Dilmen U. Is folic Acid supplementation really necessary
in preterm infants 32 weeks of gestation? J Pediatr Gastroenterol
Nutr. 2014 Feb;58(2):190-4.
45. Arboleya S. et al. Assessment of intestinal microbiota modulation
ability of Bifidobacterium strains in in vitro fecal batch cultures from
preterm neonates. Anaerobe. 2013 Feb;19:9-16.
46. Prtty A., Luoto R., Kalliomki M., Salminen S., Isolauri E. Effects
of early prebiotic and probiotic supplementation on development of
gut microbiota and fussing and crying in preterm infants: a
randomized, double-blind, placebo-controlled trial. J Pediatr. 2013
Nov; 163(5):1272-7.
47. Berrington J.E., Stewart C.J., Embleton N.D., Cummings S.P. Gut
microbiota in preterm infants: assessment and relevance to health
and disease. Arch Dis Child Fetal Neonatal Ed. 2013 Jul; 98(4):F28690
48. Srinivasjois R., Rao S., Patole S. Prebiotic supplementation in
preterm neonates: updated systematic review and meta-analysis of
randomised controlled trials. Clin Nutr. 2013 Dec; 32(6):958-65.
49. http://www.who.int/maternal_child_adolescent/topics/newborn/care_
of_preterm/en
50. www.nnfpublication.org Management of Feeding in Low Birth Weight
Infants. NNF Clinical Practice Guidelines

REFERATE GENERALE

TENDINE ACTUALE N ALIMENTAIA I

NGRIJIREA PREMATURULUI I A COPILULUI
CU GREUTATE MIC LA NATERE
Laura Florescu, Oana Temneanu, Dana Mndru
Universitatea de Medicin i Farmacie Gr. T. Popa, Iai

REZUMAT
Greutatea mic la natere este un indicator important al sntii infantile prin prisma relaiei strnse dintre
greutatea la natere i morbiditatea i mortalitatea infantil. Diminuarea ratei de mortalitate i morbiditate
presupune cunoaterea particularitilor de cretere i ngijire la aceste categorii de copii. Indiferent de categoria
din care fac parte prematuri, mici pentru vrsta gestaional, ntrziere n creterea intrauterin aceti copii,
prin greutatea la natere mic, au un risc crescut de a dezvolta malnutriie, motiv pentru care la acetia se
impune cunoaterea necesarului energetic i de principii alimentare maximale, particular lor. Asigurarea unui
suport nutriional optim precoce reprezint elementul esenial al ngrijirii acestora.
Cuvinte cheie: greutate mic la natere, prematuri, mici pentru vrsta gestaional,
ntrziere n creterea intrauterin, malnutriie

Se numete copil cu greutate mic la natere

orice nou-nscut cu greutatea la natere (Gn) mai
mic de 2.500 g. Acetia alctuiesc un grup heterogen de nou-nscui: nscui prematur, nscui la
termen dar cu Gn mic pentru vrsta gestaional
(Small for Gestational Age SGA), att prematuri,
ct i cu Gn mic pentru vrsta gestaional. Prematurul este nou-nscutul cu vrsta gestaional
(VG) mai mic de 37 de sptmni, Gn mai mic de
2.500 g i talia la natere (Tn) sub 47 de cm. Nounscutul cu ntrziere n creterea intrauterin
(IUGR) este copilul care are Gn sub percentilul 10
pe standardele de cretere intrauterin sau mai mic
cu peste 2 deviaii standard (DS) fa de media greutii corespunztoare VG.
Se estimeaz c aproximativ 15 milioane de copii
se nasc sub vrsta gestaional normal n fiecare
an. Aceasta reprezint mai mult de unul din 10
copii. n jur de 1 milion de copii mor n fiecare an
datorit complicaiilor de natere prematur. Muli
supravieuitori se confrunt cu o durat de via de
handicap, inclusiv dizabiliti de nvare i probleme vizuale i auditive. (1)

n aproape toate rile cu date fiabile, rata de

nateri premature este n cretere. La nivel global,
prematuritatea este principala cauz a deceselor la
nou-nscui i a doua cauz de deces dup pneumonie la copii sub vrsta de cinci ani. Inegalitile
n ceea ce privete rata de supravieuire la aceti
copii sunt mari comparativ n diferite ri; n rile
subdezvoltate, jumtate dintre copii nscui sub 32
de sptmni vrsta gestaional, mor datorit condiiilor improprii de ngrijire i nutriie. Mai mult
de trei sferturi dintre copiii prematuri pot fi salvai,
meninnd balana cost-ngrijire eficient, de exemplu administrarea de steroizi antenatal (administrat
femeilor gravide cu risc de natere prematur n
scopul maturrii pulmonare), folosirea metodei
kangaroo mother care (copilul este purtat de mam cu contact piele-pe-piele i alptare frecvent)
i administrarea de antibiotice pentru a trata infeciile neonatale, chiar i fr disponibilitatea de
ngrijire intensiv neonatal. (1)
Greutatea mic la natere este un indicator important al sntii infantile din cauza relaiei

Adresa de coresponden:
Dr. Oana Temneanu, Universitatea de Medicin i Farmacie Gr. T. Popa, Str. Universitii nr. 16, Iai
E-mail: ralucatemneanu@yahoo.com

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REVISTA ROMN DE PEDIATRIE VOLUMUL LXIII, NR. 3, AN 2014

strnse dintre greutatea la natere i morbiditatea i

mortalitatea infantil. Exist dou categorii de copii
cu greutate mic la natere: cei care apar ca urmare
a creterii fetale restrnse i cei rezultai din naterea nainte de termen. (2) Nou-nscuii (n.n) cu
Gn mic au un risc mai mare de sntate precar
sau de deces, necesit o perioad mai lung de spitalizare dup natere i sunt mai susceptibili de a
dezvolta dizabiliti semnificative. (3) n funcie de
vrsta gestaional i greutatea la natere exist trei
grade de prematuritate (Tabelul 1).
TABELUL 1. Gradele prematuritii Clasificarea
Internaional a Bolilor (ICD)
LBW
(low birth weight)
VLBW (very low
birth weight)
ELBW (extremely
low birth weight)

Vrsta gestaional Greutatea la natere

VG < 37 sptmni
2.499-1.500 g
VG < 32 sptmni

1.499-1.000 g

VG < 28 sptmni

< 1.000 g

Cauzele de natere prematur sunt multiple; cele

mai multe sunt spontane, dar unele pot fi datorate
declanrii naterii precoce, spontan sau prin cezarian. Printre cauzele prematuritii pot fi enumerai
factori socio-economici sarcin nedispensarizat,
nivelul educaional redus al mamei, venitul material
i condiiile de via precare, consumul de droguri,
tutun, alcool. La acestea se adaug patologia matern, respectiv suferine preexistente sarcinii (boli
de sistem, infecii TBC, malformaii cardiace); boli
concomitente sarcinii (hipertensiune arterial, diabet zaharat, pneumonii, infecii urinare i vaginale);
boli ale aparatului uro-genital matern (fibrom, malformaii uterine); sarcin multipl (frecven n cazul fertilizrii in vitro); intervalele mici ntre sarcini i lipsa unei igiene sexuale adecvate; cu toate
acestea, de multe ori nici o cauz este identificat.
Exist, de asemenea, o influen genetic. (4). Este
nevoie ca femeile, n special adolescentele, s aib
acces la planning familial, precum i o supraveghere
nainte i pe parcursul sarcinii. O mai bun nelegere a cauzelor i mecanismelor va avansa dezvoltarea de soluii pentru a preveni naterea prematur.
Peste 60% dintre naterile premature au loc n
Africa i Asia de Sud, dar naterea prematur este
cu adevrat o problem global. n rile cu venituri
mai mici, n medie, 12% dintre copii se nasc prea
devreme, comparativ cu 9% n rile cu venituri
mai mari. n toate rile, familiile mai srace au risc
mai mare. Aceti bebelui se nasc prea repede,
ns ei nu vin pe lume pentru a muri, spune dr. Joy
Lawn, MD of Save the Children International. (5)
Potrivit statisticilor organizaiei Salvai Copiii

Romnia, circa 20.000 de copii se nasc prematur n

Romnia. Cifra are la baz statistica Asociaiei Romne de Neonatologie i este diferit de cea a Institutului Naional de Statistic.
Potrivit unui comunicat al organizaiei Salvai
Copiii, dei rata mortalitii infantile din Romnia
a sczut semnificativ n perioada 1990-2010, att ca
procent, ct i ca cifre absolute, 8.471 de decese n
1990, 2.250 n 2009 i respectiv 2.078 n 2010 (n
cifre absolute se observ c nivelul din 2010 este cu
mai mult de dou treimi mai mic dect n 1990),
Romnia se menine pe primul loc n Uniunea
European, cu o rat a mortalitii infantile de 9,8
la 1.000 de copii nscui vii n 2010, conform Institutului Naional de Statistic. (6)
n 2011, rata mortalitii infantile nregistrat n
Romnia (conform Institutului Naional de Statistic) a fost din nou cea mai ridicat din Europa,
fiind de 9,4 la 1.000 de copii nscui vii, cauza principal fiind naterile premature. O treime din aceste
decese pot fi prevenite prin dezvoltarea de programe
suport pentru gravide i copii, precum i prin mbuntirea calitii asistenei medicale la pacientele
cu iminen de natere prematur i dotarea maternitilor i seciilor. n Romnia peste 20.000 de
copii se nasc anual prematur i cu greutate mic,
prematuritatea fiind una din principalele cauze de
mortalitate neonatal la nivel naional. Datele oficiale ale Institutului Naional de Statistic arat c,
n 2009, dintre cei 222.388 de copii nscui, 17.383
au avut sub 2.500 de grame, iar 10.635 de copii au
avut o vrst gestaional mai mic de 36 de sptmni. (7)
Conform unui studiu efectuat de Salvai Copiii
Romnia, n cadrul programului Fiecare copil
conteaz ce se desfoar pe perioada 2010-2015,
pe un eantion de 200 de respondeni din cadrul judeelor Iai, Vaslui, Botoani, Neam, Suceava,
37% dintre mame afirm c nu au fost la nici un
control ginecologic n timpul sarcinii, iar aproximativ 36% dintre mame au nscut primul copil
nainte s mplineasc 18 ani. Vrsta medie a mamei la natere este de 18 ani, cu mult sub media din
populaia general. (8)
Diminuarea ratei de mortalitate i morbiditate
presupune cunoaterea particularitilor de cretere
i ngrijire la aceste categorii de copii care ncep
nc din sala de natere:
Combaterea deficitului respirator: aezarea n
decubit lateral; dezobstruarea orofaringelui,
apoi a nasului cu ajutorul unei sonde/par de
cauciuc; aspirarea coninutului gastric n staz pentru uurarea micrilor diafragmului;
administrare de oxigen nclzit, umidificat,

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discontinuu, 2-4 l/min, prin cort cefalic, canul nazal, CPAP (Continuous Positive
Airway Pressure), intubaie traheal;
Combaterea deficitului de termoreglare: temperatura de 26C n sala de natere; preluarea
n.n. n cmpuri/scutece sterile, pe mas cu
cldur radiant, temperatura de 26-28C n
saloane; prematurii cu Gn < 1.800 g vor fi
pui n incubatoare: la Gn = 1.000 g
t = 34C; pentru fiecare 250 g n plus se scade
t cu 1C; pentru fiecare 250 g n minus se
crete t cu 1C.
Combaterea acidozei: oxigen + ser glucozat
5% + bicarbonat de sodiu la mam, n travaliu, i apoi la prematur, n primele zile, n
funcie de valorile parametrilor Astrup.
Combaterea tendinei la hemoragii: manevrri
blnde, evitarea poziiei Trendelemburg (crete
riscul hemoragiei intracraniene); administrare
de capilarotrofice (vitamina C i E); administrare de vitamina K n primele zile (Fitomenadion).
Prevenirea infeciilor: saloane mici cu circuit
propriu; accesul persoanelor strine strict interzis; limitarea contactului ntre n.n. bolnavi
i cei sntoi; decontaminarea ciclic i curent a saloanelor, paturilor, incubatoarelor;
lichidul din umidificatoare i barbotoarele de
oxigen se va schimba zilnic; prevenirea contaminrii aerului din saloane; personalul din
secie va fi verificat periodic clinic i bacteriologic; splarea riguroas a minilor nainte
de manevrarea fiecrui n.n.; lenjeria, vesela
i instrumentarul utilizate se vor steriliza naintea fiecrei ntrebuinri; luarea tuturor msurilor necesare pentru a preveni contaminarea laptelui. (9)
Criterii de externare a nou-nscutului:
primete ntreaga raie alimentar (la biberon/la sn);
prezint o cretere constant n greutate i a
ajuns la 2.500 g;
este stabil termic n afara incubatorului;
nu prezint crize de apnee sau bradicardie recente.
Indiferent de categoria din care fac parte prematuri, SGA, IUGR aceti copii, prin Gn mic, au
un risc crescut de a dezvolta malnutriie. Pentru
aprecierea corect a dezvoltrii lor este necesar
utilizarea graficelor/curbelor de cretere corespunztoare vrstei corectate (vrsta n sptmni, de la
data naterii, din care se scade numrul de sptmni
cu care s-a nscut nainte de termen acel copil). Incidena crescut a malnutriiei la aceti copii

305

impune cunoaterea necesarului energetic i de

principii alimentare maximale, particular lor. Asigurarea unui suport nutriional optim precoce reprezint elementul esenial al ngrijirii acestora.
Tractul digestiv trebuie s se adapteze n perioada postnatal imediat pentru a satisface nevoile
nutritive i metabolice ale vieii extrauterine. Intrauterin, intestinul este adaptat ntr-o anumit masur
pentru aceasta funcie prin pasajul zilnic de lichid
amniotic care conine imunoglobuline, enzime,
factori de cretere, hormoni, absorbind o cantitate
de proteine prin mucoasa digestiv. Tractul gastrointestinal este complet dezvoltat la 20 de sptmni
de gestaie; o parte din funciile gastro-intestinale
sunt iniiate dup natere, indiferent de vrsta de
gestaie (de exemplu permeabilitatea gastro-intestinal), altele par s fie programate s intre n
funcie la anumite vrste postconcepionale (de
exemplu cordonarea supt deglutiie apare ntre 33
i 36 de sptmni). Chiar dac prematurul prezint
imaturitate anatomo- funcional a tractului digestiv
care poate necesita ntr-o prima faz nutriie parenteral, se recomand iniierea precoce i creterea
treptat a alimentaiei enterale prin tehnici speciale
pentru asigurarea aportului caloric i a echilibrului
metabolic i hidro-electrolitic al acestei categorii
vulnerabile de nou-nscui. (10)
Compoziia corpului prematurului crescut n
mediu extrauterin trebuie s fie similar cu cea a
copilului dezvoltat in utero. La termen corpul nounscutului conine 75% ap (40% extracelular i
35% intracelular) i pierde 5-10% din Gn n prima
sptmn de via; la 23 sptmni VG, corpul
prematurului conine 90% ap (60% extracelular),
poate pierde 10-15% din Gn n prima sptmn de
via. Prematurii SGA au n compoziia corpului
mai mult ap dect prematurii AGA, 90% versus
84%, n intervalul 25-30 de sptmni VG. (11)
Prematurul este un copil cu nevoi metabolice
crescute (Tabelul 2), rezerve nutriionale inadecvate,
imaturitate organic i funcional, patologie multipl asociat, toate acestea avnd efecte negative
asupra necesarului energetic, proteic, mineral i de
vitamine, precum i asupra capacitii de absorbie
i de digestie a acestora. (12)
Se recomand iniial asigurarea necesarului
energetic i proteic prin nutriie parenteral, la care
se poate asocia din primele 24 de ore de via i cea
enteral (nutriie trofic), dac starea clinic permite. Nutriia parenteral total reprezint furnizarea alimentaiei necesare proceselor metabolice i
creterii, pe cale intravenoas, obiectivul fiind asigurarea de energie pentru a preveni catabolismul i
pentru a atinge o balan nitrogen pozitiv.

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TABELUL 2. Necesarul energetic i de principii alimentare

maximale al copiilor cu Gn mic (13)
necesar 110-135 kcal/kg/zi
energetic
proteine 4-4,5 g/kg/zi (G < 1.000 g)
3,5-4 g/kg/zi (G = 1.000-1.800 g)
lipide
4,8-6,6 g/kg/zi acid linoleic 350-1.400 mg/100 kcal
acid linolenic 50 mg/100 kcal
trigliceride cu lan mediu pn la
40% din cantitatea total de lipide
glucide
11,6-13,2 g/kg/zi

Proteinele:
din primele 12-24 de ore de via pentru a
evita catabolismul lor
minim 1,2 g proteine/kg/zi, corespunztor
pierderilor
maxim 4 g proteine/kg/zi pentru asigurarea
unui ritm decretere similar celui intrauterin
aport minim de 30 kcal/kg/zi pentru meninerea homeostaziei proteice.
Lipidele:
administrare parenteral nceput n primele
24 de ore de via pentru a asigura acizii grai
eseniali
se temporizeaz n cazul asocierii infeciei i/
sau hiperbilirubinemiei
aport minim de 0,5 g/kg/zi
n funcie de toleran: 1-4 g/kg/zi (2,5 g/kg/zi)
emulsii de lipide 20%, administrate lent.
Glucidele:
aportul minim de glucoz trebuie s furnizeze
necesarul metabolic bazal i energia necesar
pentru sinteza proteic
un ritm de 9 mg/kg/min reprezint necesarul
minim de glucoz pentru asigurarea suportului energetic al creierului i pentru sinteza
proteic. (14,15)
Nutriia parenteral prelungit crete riscul apariiei colestazei i hipertrigliceridemiei. (16) Din
acest motiv se impune evaluarea periodic a funciei
hepatice i a trigliceridelor. Toate soluiile de nutriie parenteral neonatal conin oligoelemente (Zn,
Cu, Mn, Cr, Se), dar actualmente se sugereaz necesitatea suplimentrii acestora cu Mo i Co, ndeosebi la copiii care primesc nutriie parenteral mai
ndelungat. (17) Nutriia parenteral este scump,
necesit abiliti tehnice, nu este lipsit de efecte
secundare, necesit personal special pregtit pentru
montarea i ngrijirea liniilor venoase, necesit dotri speciale ale seciei de neonatologie (ex. flux
laminar pentru prepararea soluiilor, serviciu de radiologie pentru verificarea poziiei cateterelor,
pompe de perfuzie, laborator). (18)

Se recomand iniierea nutriiei enterale ct mai

curnd dup natere (24-48 de ore de via), pentru
a preveni apariia atrofiei intestinale nutriie trofic (2,5-20 ml/kg/zi, cu o medie de 10 ml/kg/zi).
Aceast cantitate va fi crescut progresiv, din a 8-a
a 11-a zi de via (n funcie de tolerana digestiv)
cu cte 10-20 ml/kg/zi, pn la raia oral complet
(135-200 ml/kg/zi). (13,19)
Printre avantajele alimentaiei enterale se numar stimularea fiziologic i pstrarea integritii
mucoasei intestinale, creterea grosimii mucoasei
intestinale i stimularea dezvoltrii vilozitilor intestinale, scderea permeabilitii mucoasei la antigenele strine, creterea cantitii de peptide i hormoni intestinali, scderea complicaiilor datorate
alimentaiei parenterale, costul redus. Alimentaia
enteral precoce a permis reducerea: numrului de
zile necesare pentru atingerea alimentaiei complete
per os, semnelor de intoleran digestiv, duratei
spitalizrii, osteopeniei prematurului, riscului colestazei asociate nutriiei parenterale. (20)
Aportul echilibrat de principii alimentare maximale este deosebit de important n alimentaia enteral precoce. Studiile efectuate au subliniat existena unei corelaii ntre aportul crescut de glucide
n perioada neonatal, creterea excesiv n greutate
i scderea toleranei la glucoz la copiii cu Gn <
1.000 g. Astfel, aceast categorie de copii are un
risc crescut de a dezvolta ulterior sindrom metabolic.
(21)
Nutriia enteral se face cu lapte uman, la G >
1.500 grame, lapte matern mbogit cu fortifiani
la G < 1.500 g, iar n cazul unei secreii lactate inadecvat/contraindicaii pentru alptare se vor utiliza
formule de lapte speciale pentru prematuri. Alimentul ideal n nutriia enteral este laptele uman.
Avantajele administrrii laptelui uman la prematuri
sunt multiple i unanim recunoscute: cretere antropometric i dezvoltare corespunztoare, (22) absorbie optim a nutrienilor (ndeosebi a grsimilor,
zincului i fierului), osmolaritate sczut, reglare
corespunztoare a echilibrului termic, glicemic, a
saturaiei hemoglobinei n oxigen i a presiunii pariale a oxigenului, mai puine variaii ale frecvenei
cardiace i respiratorii i mai puine episoade de
apnee i bradicardie, stimuleaz creterea i diferenierea intestinal postnatal prin prezena a numeroi factori de cretere (EGF Epidermal Growth
Factor, NGF nerve growth factor, TGF- transforming growth factor i TGF- transforming
growth factor , insulin, relaxin, insulin-like
GF insulin-like growth factor), protecie mpotriva
stresului oxidativ prin coninutul crescut de superoxid-dismutaz i glutation-peroxidaz i prin can-

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titatea optim de vitamine A i E, cu rol antioxidant,

(23,24) protecie mpotriva infeciilor, (25) i enterocolitei ulcero-necrotice (EUN) prin cantitatea
crescut de IgA secretorie, (26) inciden sczut a
bolii diareice acute determinate de Rotavirus, E.
coli, Shigella, Salmonella, C. difficile, G. lamblia,
Campylobacter, (27) inciden sczut a infeciilor
de tract urinar i a meningitelor, protecia prematurilor cu istoric familial de atopie mpotriva alergiilor, inciden sczut a retinopatiei prematuritii
(ROP) (28) i acuitate vizual mbuntit la 2-6
luni vrst corectat, dezvoltare neurologic superioar, cu att mai important cu ct durata alptrii
este mai mare, scderea riscului de boli cardiovasculare n adolescen i la vrsta adult, scderea
riscului de diabet zaharat tip 2, rat sczut a respitalizrilor. (29)
Digestia i absorbia principiilor alimentare maximale:
Digestia i absorbia proteinelor din lapte este
la fel cu cea a n.n. la termen.
Digestia i absorbia lipidelor din laptele uman
se realizeaz eficient datorit lipazelor existente n acest lapte.
Digestia i absorbia glucidelor este satisfctoare. Prematurul poate utiliza lactoza din
laptele matern, dei prezint un deficit tranzitor de lactaz n prima sptmn de via.
n situaia n care laptele uman nu este disponibil
(agalactie/hipogalactie/patologie matern asociat),
alimentaia natural poate fi administrat, acolo unde
exist bnci specializate pentru depozitarea acestui lapte. (30-34)
Laptele uman colectat poate fi administrat imediat, poate fi refrigerat la 4C timp de 48 de ore, sau
poate fi congelat la -20C timp de 3 luni. Refrigerarea laptelui uman determin pierderea a 40% din
cantitatea de vitamina C, 40% din cantitatea de lizozim, 30% din cantitatea de lactoferin, 40% din
cantitatea de IgA secretorie i scderea cu 25% a
activitii lipazei. Se recomand ca medicul s indice congelarea laptelui matern i nu fierberea sau
pasteurizarea acestuia. n timpul tratrii termice a
laptelui, se pierd mai multe substane nutritive dect
n timpul congelrii. Pasteurizarea determin reducerea concentraiei de IgA i lizozim, a reteniei
azotului, absorbiei lipidelor prin distrugerea lipazei, scderea concentraiei de vitamine hidrosolubile
i factori antiinfeciosi. (10)
Laptele prematur conine mai multe proteine,
calciu i fosfor dect laptele matur, dar nu acoper necesarul de calorii, proteine, vitamine i minerale la aceti copii, motiv pentru care se recomand suplimentarea cu fortifiani. (35)

307

Acetia vor fi utilizai la copiii cu VG < 34 de

sptmni i la cei cu G < 1.500 g, din momentul n
care s-a ajuns la raia oral complet pn la atingerea greutii de 2.000 g. Prin fortifierea laptelui
uman se obine: mbuntirea creterii ponderale,
mbuntirea statusului proteic, normalizarea valorilor serice ale calciului, fosforului, fosfatazei alcaline, creterea mineralizrii osoase.
Potenialele dezavantaje ale utilizrii fortifianilor ar fi creterea osmolaritii, motiv pentru care
nu se recomand la copiii la care se suspicioneaz
EUN, riscul contaminrii bacteriene. (36)
Formulele de lapte speciale pentru prematuri i
copii cu greutate mic la natere reprezint cel mai
bun substitut n absena laptelui matern; se folosesc
pn la atingerea greutii de 2.500 g, au un aport
mai mare de calorii (80 kcal/100 ml) i cantitate
crescut de proteine (2,25-3,10 g/100 kcal), cu predominana celor din zer (raport zer/cazein de
70/30), acestea avnd o rat de absorbie crescut.
Cantitatea de lactoz este mai sczut comparativ
cu cea din formulele standard, n concordan cu
activitatea mai sczut a lactazei la aceti copii. Lipidele sunt reprezentate de un amestec de trigliceride cu lan mediu i uleiuri vegetale, bogate n
acizi grai polinesaturai (long chain polyunsaturated fatty acids LC-PUFA). Vitaminele, oligoelementele i mineralele ntr-o cantitate mai mare, pentru a acoperi nevoile crescute ale acestor copii. (37)
Dup atingerea greutii de 2.500 g, se recomanda formulele de tranziie (Transitional Formulas, Nutrient-enriched post-discharge formulas
NEPDF); (38) acestea conin o cantitate mai mare
de proteine, calciu, fosfor, vitamine i minerale comparativ cu formulele standard, au valoare caloric
mai mare (70 kcal/100 ml vs 68 kcal/100 ml), contribuie la mbuntirea ritmului de cretere i a
mineralizrii osoase comparativ cu formulele standard. n situaia cnd Gn = 1.000-2.000 g, vor fi
utilizate formule de tranziie pn la 9 luni vrst
corectat, ulterior se va trece la formulele standard
dac se constat valori crescute ale calciului i fosforului i/sau o cretere ponderal excesiv; cnd
Gn > 2.000 g se recomand administrarea formulelor standard mbogite cu fier pn la 1 an vrst
corectat.
Indiferent de tipul de alimentaie (natural sau
artificial), n contextul unei creteri postnatale accelerate n primul an de via (catch-up growth)
este necesar suplimentarea cu vitamine pn n
momentul n care catch-up growth este obinut i
copilul primete o alimentaie echilibrat, care include solide. Vitamina D: 800-1.000 UI/zi, n primele luni de via, avnd n vedere prevalena cres-

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cut a deficitului acestei vitamine la femeile nsrcinate. (39,40)

Pentru asigurarea unei bune mineralizri osoase
este necesar i furnizarea unui aport zilnic adecvat
de calciu (120-140 mg/kg/zi) i fosfor (60-90 mg/
kg/zi). Se recomand suplimentarea cu vitamina A,
700-1.500 UI/kg/zi pn ce copilul atinge greutatea
de 2.000 g (n practic se utilizeaz preparate de
multivitamine). Vitamina K se administreaz intramuscular, la natere, n doz de 1 mg la cei cu Gn
1.000 g i 0,3 mg/kg la cei cu Gn < 1.000 g. (41)
Administrarea profilactic a preparatelor orale
de fier (fumarat feros sau gluconat feros), 2-3 mg/
kg/zi, ncepnd cu vrsta de 2-6 sptmni (LBW i
VLBW) i 2-4 sptmni (ELBW), cel puin pn
la vrsta de 6-12 luni. (42,43)
Nu se va depi doza de 5 mg fier/kg/zi din
cauza riscului de apariie a retinopatiei prematuritii. Administrarea fierului va fi temporizat la
cei care au primit multiple transfuzii.
Sugarii premature care primesc nutriie parenteral cu coninut ridicat de acid folic nu au nici un
risc de deficit de acid folic n timpul primelor dou
luni de via; prematurii cu nutriie enteral de la
natere cu lapte uman (cu sau fr fortifiani) sau
formule pentru premature cu un coninut sczut de
acid folic ar putea avea risc crescut pentru deficit de
acid folic, mai ales atunci cnd mamele sunt fumtore i/sau nu beneficiaz de suplimentarea cu acid
folic n timpul sarcinii. (44)
Studiile efectuate pn n prezent au evideniat
beneficiile suplimentrii formulelor standard cu
simbiotice (pre i probiotice). Formulele mbogite
cu probiotice (bifidobacterii, lactobacili) au efect
semnificativ de prevenire a diareilor comunitare
acute infecioase, n special rotavirale i reduc semnificativ durata episoadelor diareice. (45,46,47)
De asemenea, formulele mbogite cu probiotice
au demonstrat modularea rspunsului imun i redu-

cerea incidenei alergiilor n cazul prematurilor

predispui la atopii, scderea fiind semnificativ
statistic n ceea ce privete incidena dermatitei atopice. (48)
Modaliti de administrare a alimentaiei:
prin gavaj continuu (gastrocliz) sau gavaj
intermitent (VG < 34 sptmni)
cu linguria/biberonul/direct la sn (VG > 34
de sptmni), deoarece la aceast vrst putem vorbi de o bun coordonare ntre mecanismele de deglutiie, supt i respiraie.
Gavajul gastric continuu (gastrocliz) reprezint
administrarea, cu ajutorul unei pompe, a ntregii
cantiti de lapte pentru 24 ore, distribuit n 4-8
seringi; se instituie la nou-nscuii ELBW (volum
gastric limitat). Este indicat n intoleran la gavajul
gastric intermitent, detres respiratorie sever, reflux gastro-esofagian, reziduu gastric persistent.
Gavajul intermitent reprezint administrarea a
8-10 prnzuri pe zi, individualizat nfuncie de greutate, VG, starea clinic; administrarea se poate realiza prin cdere liber (cea mai indicat metod)
sau mpingerea cantitii de lapte cu pistonul. (49,
50)
Scopul nutriiei corecte a prematurului este de a
asigura o dezvoltare optim, att staturo-ponderal,
ct i neurologic. Nu exist o reet universal valabil pentru alimentarea nou-nscutului prematur,
aceasta realizndu-se n funcie de VG, Gn i patologie. Indiferent de tipul, modul i ritmul de administrare al alimentaiei trebuie asigurat un ritm
de cretere similar celui din ultimul trimestru de
sarcin.
n concluzie, considerm necesar continuarea
studierii nevoilor nutriionale ale copilului cu greutate mic la natere, avnd n vedere impactul pe
termen lung al erorilor alimentare n primele luni
de via.