Introduction
Do you often wonder what helps to guide care and policies in healthcare? Guidelines for medical care are driven by research and what the evidence has shown, otherwise known as evidence-based practice. And there are organizations, like the World Health Organization (WHO), who review the most up-to-date research findings and develop global guidelines that are meant to help end-users or clinicians make informed decisions on whether, when, and how to undertake specific actions such as clinical interventions, diagnostic tests, or public health measures with the aim to achieve the best possible individual or collective health outcomes. Their goal is that everyone, everywhere can attain the highest level of health.
On November 15th, 2022 the World Health Organization (WHO) released updated recommendations for care of the preterm or low birthweight infant. The recommendations were derived from a group of diverse experts and stakeholders. After they examined the most up-to-date evidence from low- to -high income countries, they developed the updated guidance about the care of preterm or low birthweight infants.
The recommendations are directed at a large target audience and are beneficial for national policy makers, supervisors, managers, NICU clinicians plus more! Not only is the information pertinent to all of the aforementioned, but it is also important for NICU Parents to know what the general recommendations are for care of the preterm or low birthweight infant. So I wanted to provide you with the cliff notes version spotlighting the most pertinent points out of the 137 page document.
The recommendations include guidelines for preventive and promotive care, care of complications, family involvement and support and a good practice statement. Some of the recommendations are new, whereas others are updated based on emerging new evidence.
We started the review in our previous podcast and continue the discussion today! You will want to know all about these new recommendations from the World Health Organization, so start reading or listening now!
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Episode 43
Who is the WHO?
The World Health Organization was founded in 1948. It is the United Nations agency that connects nations, partners and people to promote health, serve the vulnerable, and keep the world safe. Their goal is that everyone, everywhere can attain the highest level of health.
The World Health Organization leads global efforts to promote healthier lives through all stages of life, from newborns to the elderly. Their team consists of over 8000 professionals that include the world’s leading public health experts, physicians, epidemiologists, scientists and managers. Within the World Health Organization, they have different committees. The committees develop global guidelines that ensure the appropriate use of evidence and they contain recommendations for clinical practice.
On our last podcast, we discussed the World Health Organization, who they are and what their goals are in detail. We then started to discuss each of the WHO’s recommendations that they developed and released on November, 15, 2022. If you have not already, I encourage you to go and listen to our 42nd podcast episode: A Review of the WHO Recommendations for the Care of Preterm or Low-Birth-weight Infant
Today we are going to continue our review of the World Health Organization’s recommendations for the care of the preterm or low birthweight infant. The guidelines went through several committees or groups for a thorough review. The final guideline includes 25 recommendations and 1 good practice statement for care of the preterm and low birthweight infant. The recommendations were released on November 15, 2022 and consist of 11 new and 14 updated recommendations. The good practice statement is also new.
We developed a guide so you can follow along easily as we review the recommendations. Grab your FREE PDF of the updated guidelines, so you can easily follow along.
Preventive and Promotive Care
A.6 Early Initiation of Enteral Feeding
Preterm and low birthweight infants, including very preterm infants (<32 weeks’ gestation) and very LBW infants (<1.5 kg) should be fed as early as possible from the first day after birth. Infants who are able to breastfeed should be put to the breast as soon as possible after birth. Infants who are unable to breastfeed should be given expressed mother’s own milk as soon as it becomes available. If mother’s own milk is not available, donor human milk should be given wherever possible.
This recommendation is an updated one that is supported by strong recommendation with moderate-certainty evidence. They do warn that consideration should be given in applying these recommendations to unstable infants and must be based on clinical judgment.
Now, you’re likely thinking, well of course infants should be fed right after birth and this is true, for stable, term infants. But, as the recommendation states, it is still under debate by clinicians when the optimal timing of feeding initiation is for preterm infants. With preterm infants, there is an increased concern for potential health complications including necrotizing enterocolitis (NEC).
Feedings are typically initiated with preterm infants in the first 1-2 days, depending on the infant’s clinical condition. We know that initiation of early minimal enteral feeds with mother’s breast milk or donor breast milk stimulates the development of the intestinal immune system, stimulates motility, enzyme production, GI hormone release, improves digestive tolerance, allows for a faster increase in volume rate, helps infants to achieve full enteral nutrition and limits postnatal weight loss. But as I said, minimal amounts are used to start and slowly advanced based on the institution’s protocols. So, this recommendation will need to be based on each infant’s clinical conditions and guided by clinical judgment of the providers.
A.7 Responsive and scheduled feeding
Which states in healthcare facilities, scheduled feedings may be considered rather than responsive feeding for preterm infants born before 34 weeks’ gestation, until the infant is discharged.
Just to give you a little background, responsive feeding is simply when you feed the infant in response to their visual and auditory cues, or signals of hunger. Some of these cues include crying, hand-mouth motions, suckling and awakeness.
Scheduled feedings for preterm infants ensure that the infant is fed at a minimum of every 3 hours to allow for the necessary nutritional requirements. This recommendation stems from the fact that in preterm infants, born less than 34 weeks’ gestation, their muscles, nervous system, and other body parts are not mature enough to maintain adequate growth with responsive feeding. At 33 to 34 weeks’ gestation, their coordination to effectively suck, swallow, and breathe with either breast or bottle feeding is just at the beginning stages of development. Infants less than 34 weeks also typically need an enteral feeding tube like an ng or og tube to help them finish their feeding to support their overall growth.
A.8. Fast and slow advancement of feeding
The recommendation states that in preterm and low birthweight infants, including very preterm infants (<32 weeks’ gestation) or very low birthweight infants (<1.5 kg), who need to be fed by an alternative feeding method to breastfeeding (e.g. gastric tube feeding or cup feeding), feed volumes can be increased by up to 30 ml/kg/day.
For this recommendation, it speaks to the matter in how quickly we as providers advance feedings in preterm infants. As I spoke about earlier, for LBW and VLBW infants, feedings are recommended to be introduced early, but with minimal enteral feedings. From that point, feedings are slowly advanced per each institution’s policy which is typically based on gestational age and/or birthweight. Each incremental advancement is also typically calculated based on a set volume times the infant’s weight.
To make the decisions, the WHO reviewed trials that had varying degrees of how quickly they advanced feedings, so based on the findings, the Guideline Development Group (GDG) took the conservative value and they recommend 30 ml/kg/day as the threshold for fast advancement of feedings, which they stated is consistent with many national guidelines.
The Guideline Development Group (GDG) did not make separate recommendations for formula fed infants versus those fed human milk. Additionally, they recommend that the advancement of feedings continue until full maintenance feeding volumes are established, which is institutionally based. The time it takes to get to full-volume feeds will also vary based on the infant’s clinical condition and their tolerance of the advancement.
A.9 Duration of exclusive breastfeeding
The recommendation states preterm or low birthweight infants should be exclusively breastfed until 6 months of age.
The Guideline Development Group (GDG) made a strong recommendation in favor of exclusive breastfeeding until 6 months of age. It is the standard of care for preterm and low birthweight infants across low and high income countries. With this, they also recognize that mothers need encouragement and support before, during, and after birth so they can provide their own breastmilk for their infants. They advise that the support should be done at the facility and community level and integrated within standard national programs.
A.10a Iron supplementation
Which states that enteral iron supplementation is recommended for human milk-fed preterm or low birthweight infants who are not receiving iron from another source.
The Guideline Development Group notes that there was limited data on the dose, timing of initiation, and duration of iron supplementation. But, they ultimately suggest a daily dose of 2-4 mg/kg/day of elemental iron once enteral feedings are well established starting around 2 weeks of age and and should continue until the infant receives iron from another source (at least until 6 months of age). In term and preterm infants, iron deficiency is associated with poor growth and development outcomes.
Due to their low iron stores, catch-up growth, and iatrogenic blood loss, most typically from lab draws, human milk does not typically meet the nutritional requirements needed in preterm and low birthweight infants.
A.10b Zinc supplementation
They recommended that enteral zinc supplementation be considered for human milk-fed preterm or low birthweight infants who are not receiving zinc from another source.
Again, the GDG noted that there was limited data available on the dose, timing, and duration of zinc supplementation, but they suggest a daily dose of 1-3 mg/kg/day of elemental zinc once enteral feeds are well-established, and should be continued until the infant receives zinc from another source.
Zinc is a trace element essential for physiological functions of the human body. Zinc deficiency is associated with dysfunction in epidermal, gastrointestinal, central nervous, immune, skeletal and reproductive systems. Due to low zinc stores and catch-up growth in preterm and low birthweight infants, human milk is not believed to meet their nutritional requirements. A Cochrane review from 2021 reported that zinc supplementation reduced all-cause mortality and was associated with a probable improvement in short-term weight gain and linear growth.
The optimal dose of Zinc and timing of initiation are unclear, but the dose used in most of the studies was 3-5 mg/day.
A.10c Vitamin D supplementation
Which states that enteral Vitamin D supplementation may be considered for human milk-fed preterm or low birthweight infants who are not receiving Vitamin D from another source.
Vitamin D increases intestinal absorption of calcium and phosphorus. It also plays an important role in skeletal health and enhances bone mineralization. Low Vitamin D levels are associated with seizures, irritability, rickets, bone fractures, osteopenia, and metabolic bone disease. Human milk is not thought to meet the nutritional requirements of preterm or low birthweight infants due to their low Vitamin D stores, their need for catch-up growth, and the additional risk factors they face including long-term parenteral nutrition use, intolerance to human milk fortifiers and formula, and neonatal cholestasis.
Although the Guideline Development Group (GDG) notes that there was limited data in the research they reviewed regarding the dose, timing of initiation, and duration of supplementation, they suggested a daily dose of 400-800 IU once enteral feeds are well-established and should be continued until the infant receives Vitamin D from another source. In 2011, WHO recommended continuing Vitamin D supplementation until 6 months of age. The American Academy of Pediatrics (AAP) recommends 400 IU/day of Vitamin D for all infants who are human milk-fed or receiving less than 32 ounces of formula per day. But, the dose will vary based upon each institution’s guidelines.
A.10d Vitamin A supplementation
Enteral Vitamin A supplementation may be considered for human milk-fed very preterm infants (<32 weeks’ gestation) or very low birthweight infants (<1.5 kg) who are not receiving vitamin A from another source.
Vitamin A regulates cell growth and helps to maintain the integrity of the mucosa and epithelium of the respiratory and gastrointestinal tracts. It may also boost immune function and has been reported to reduce bronchopulmonary dysplasia (BPD) in studies of preterm infants born less than 32 weeks’ gestation.
The evidence was derived from a systematic review of random control trials (RCT) that only included infants less than 32 weeks’ gestation and therefore the recommendations provided are recommended for preterm or low birthweight infants. The GDG suggests a daily dose of 1000-1500 IU to be initiated once enteral feeds are well established and should continue until the infant receives Vitamin A from another source.
Closing
I hope you found some value in hearing these global recommendations developed by the World Health Organization. As I mentioned, all of the recommendations are evidence-based and they have been reviewed by several committees through several stages to ensure the validity of each one.
Whether you are a policy maker, supervisor, NICU parent or a NICU clinician, I think it is important to know what the global recommendations are for the care of the preterm and low birthweight infant. The recommendations are meant to help guide clinicians so the most optimal care for preterm and low birthweight infants is provided globally. And since NICU Parents are often thrown into a world without any basis of knowledge, we hope this review is beneficial. We at Empowering NICU Parents want to help provide you with appropriate, evidence-based education so you feel more confident in caring for and advocating for your infant.
Next time, we will complete our review of the recommendations from the World Health Organization so you can stay up-to-date on what is best for the preterm and low birthweight neonatal population.
Remember to grab your free PDF of these recommendations if you have not already!
References
Gardner, S., Carter, B., Enzman-Hines, M., & Niermeyer, S. (2021). Merenstein & Garner’s Handbook of Neonatal Intensive Care Nursing: An Interprofessional Approach, Ninth Edition. Elsevier.
Gomella, T., Eyal, F., & Bany-Mohammed, F. (2020). Gomella’s Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs, 8th Edition. McGraw-Hill.
Kolodziejczk-Nowatarska, A., Bokiniec, R., & Seliga-Siewecka, S. (2021). Monitored supplementation of Vitamin D in preterm infants: A Randomized Controlled Trial. Nutrients. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8537871/pdf/nutrients-13-03442.pdf
Manea, A., Marioara, B., Lacob, D., Dima, M., & Emil Lacob, R. (2016). Benefits of early enteral nutrition in extremely low birth weight infants. Singapore Medical Journal, 57(11), 616–618.
World Health Organization. (2022, November). WHO recommendations for care of the preterm or low-birth-weight infant. World Health Organization. https://apps.who.int/iris/bitstream/handle/10665/363697/9789240058262-eng.pdf
