Optimizing Nutrition in Extremely Low Gestational Age Neonates: An Evidence-Based Protocol

Understanding the principles of enteral and parenteral nutrition practices is critical for improving the short- and long-term outcomes of extremely low gestational age neonates (ELGANs). An immature intestinal epithelium predisposes ELGANs to a significantly higher incidence of feed intolerance and necrotizing enterocolitis (NEC). While evidence-based guidelines for nutritional management in preterm neonates are available, their extrapolation to ELGANs may not be appropriate, given the lack of robust evidence in this latter group. This review discusses the evidence for parenteral nutrition practices, feeding initiation and advancement, monitoring for feed intolerance, NEC prevention strategies, probiotics, multi-nutrient fortification, and growth monitoring of ELGANs. The authors suggest starting minimal enteral feeds on day 1, advancing by 20–30 mL/kg/d, and adding multi-nutrient fortification once 100 mL/kg/d is tolerated. When enteral feeds are not possible, parenteral nutrition should be initiated early. The routine use of abdominal girth, gastric residuals, and glycerine enemas during feed advancement is not recommended. The authors suggest using probiotics cautiously only in growth-restricted ELGANs with antenatal Doppler abnormalities. Growth monitoring in ELGANs is critical, and an individualized approach is recommended depending on the intrauterine growth status, co-morbidities, and growth potential of a neonate, to prevent the consequences of undernutrition and excessive growth.