Post discharge nutrition for preterm infants – the role of pediatric and neonatal dietitians in Sweden

THE IMPORTANCE OF POST DISCHARGE NUTRITION

Nutrition plays a key role in the health and development of preterm infants. During the NICU stay, babies are fed breast milk fortifiers added to the breastmilk or preterm formula. If possible, the goal is always to discontinue breastmilk fortifiers before discharge, and ideally, babies should be fully breastfed.

However, optimizing nutrition and facilitating growth is not always possible before discharge as the babies experience various morbidities and complications affecting growth. Furthermore, studies have shown higher prevalence of growth retardation in preterm infants later in life compared to term born infants, as well as higher prevalence of feeding problems. Therefore, prolonged nutritional treatment and parental support after discharge is sometimes necessary.

The recent position paper from the ESPGHAN Nutrition Committee on “assessment of growth status and nutritional management of prematurely born infants after hospital discharge” strongly recommended that all extremely and very preterm infants undergo close nutritional and growth monitoring after discharge. Furthermore, the committee recommends that if an infant is two or more SDs below the norm in either weight and/or length and/or weight for‐length z‐score at discharge, fortified human milk or a protein and energy -⁠ -enriched formula should be provided until catch‐up growth is achieved.

SWEDISH NEONATAL DIETITIANS –⁠ HOW ARE WE ORGANIZED?

The dietitian’s role at the NICUs in Sweden can vary between counties and hospitals. However, generally, the dietitian is an active part of the nutrition team at an early stage of the NICU stay and primarily involved in the enteral nutrition and target fortification. On a national level, the Swedish Association of Registered Dietitians have a working group for neonatal nutrition arranging recurring seminars and workshops as well as development of national guidelines. The group also cooperates with the Swedish Neonatal Societies working group for nutrition. Furthermore, dietitians have an important role in post discharge nutrition.

THE MANAGEMENT OF POST DISCHARGE NUTRITION AT KAROLINSKA UNIVERSITY HOSPITAL

Karolinska University Hospital in Stockholm has the biggest children’s hospital in Sweden and the largest resources of neonatal dietitians. If the baby requires feeding support after discharge the baby will be referred to a dietitian. The family will attend growth monitoring at the hospital or local Well-baby clinic, often 1–3 times per month during the first weeks and then gradually reduced. If the baby experiences serious feeding issues or growth failure, a multidisciplinary team visit is often arranged.

Karolinska University Hospital NICUs has around 40 inpatient beds divided between 3 hospitals. In total, the neonatal dietitian resources are three full-time positions, of which 0.7 full-time equivalents are assigned to follow-up after discharge. Very and extremely preterm infants are followed up according to a national follow-up program until 2 or 5,5 years of age depending on level of prematurity, and by a neonatal dietitian up to 2 years of age. If there is continued need for nutritional treatment the child will be referred to a dietitian in primary care or another in-hospital dietitian if there is a need for follow-up within other specialties.

STRATEGIES FOR OPTIMIZING POST DISCHARGE NUTRITION

There is a limited number of studies that have investigated preterm post discharge nutrition. The resent position paper by ESPGHAN on post discharge nutrition for preterm infants concludes that there is a lack of evidence for the optimal strategy for post discharge nutrition but that the nutrition therapy should ideally be individualized both regarding type and duration. The nutritional treatment may include continued fortification, prescription of preterm infant formula or high-energy enteral nutrition product for children or continued enteral feeding if oral feeding is insufficient or not feasible for the child.

Generally, the goal of the nutritional treatment at the NICU or after hospital discharge is to maintain steady growth along their individual growth curves within the normal range of −2 to +2 standard deviations. Given adequate knowledge, time and resources, the management of nutritional treatment and growth monitoring is an ideal task for a pediatric/neonatal dietitian.

RECOMMENDATIONS FOR STRATEGIC INVOLVEMENT OF PEDIATRIC DIETITIANS IN THE NICU NUTRITION TEAM

• To enhance learning and contribute expertise in feeding support, pediatric dietitians should be involved in nutritional care from the outset of the NICU stay.

• Dietitians should be involved in the production of local nutritional guidelines and recommendations.

• Team follow-up visits for patients born preterm with growth, feeding and/or gastrointestinal complications should be facilitated. The team should be multidisciplinary and include at least one pediatrician, nurse, and dietitian. Ideally, other resources, including speech therapists and psychologists, should also be available for consultation.

• Pediatric dietitians interested in neonatal nutrition should organize themselves nationally. A national working group could help broaden the knowledge of neonatal nutrition amongst dietitians and facilitate the organization of courses, seminars, creating national guidelines and mentorship.

• Lectures, seminars, and exams on neonatal nutrition should be included in the dietitian bachelor program. Furthermore, pediatric dietitians should be given the opportunity to pursue continuing education and professional development by attending advanced neonatal nutritional courses and international conferences.