Preterm Neonatal Nutrition: Evolution Over the Course of 50 Years and Contemporary Challenges

Advances in neonatal nutrition have markedly improved preterm survival, but achieving optimal growth and neurodevelopment remain a challenge. Modern fluid guidelines favor individualized, weight-guided fluid management based on gestational age, shifting away from historic liberal strategies to avoid patent ductus arteriosus and necrotizing enterocolitis (NEC). Inadequate intake causes extrauterine growth restriction, negatively impacting neurodevelopment and long-term cardiometabolic risks. Human milk strongly reduces NEC risk but requires fortification to meet these high protein and mineral targets safely. Lipids supply critical fatty acids for brain development. Carbohydrates are the primary immediate energy substrate, and both macronutrients require careful titration to prevent complications, such as hypertriglyceridemia and hyperglycemia. High calcium and phosphorus intake are critical to prevent metabolic bone disease. Since unfortified milk is insufficient, targeted fortification guided by alkaline phosphatase monitoring is recommended.