Nutritional Fat requirements for premature infants

Fat provides the major source of energy for growing preterm infants. In human milk, about 50% of the energy is from fat: and, in commercial formulas, fat provides 40% to 50% of the energy.

The preterm infant digests and absorbs the predominantly saturated triglycerides of cow's milk poorly. The recognition of the magnitude of this fat malabsorption led to the use of low-fat formulas for preterm infant feeding in the 1940s and 1950s. By 1960, after unsaturated, long-chain triglycerides from vegetable oils were recognized as being better absorbed than cow's milk fats, vegetable fats were used in commercial infant formulas for feeding of preterm infants. However, medium-chain triglycerides (MCT) are even better absorbed, presumably because their digestion and absorption are not dependent on duodenal intraluminal bile salt levels, which are low in the preterm infant. Thus, the recently developed special formulas for preterm infants contain a mixture of MCT and predominantly unsaturated, long chain triglycerides. The essential fatty acid requirement of at least 3% of total calories in the form of linoleic acid is amply met by this fat mixture. However, the gain in energy through improved absorption of MCT may be offset by an increased frequency of intestinal disturbances (abdominal distension, loose stools, vomiting attributable to the MCT lipid.

The fat of human milk is well absorbed by the preterm infant. One reason for the relatively efficient absorption of human milk fat is the distribution of fatty acids in the triglyceride molecule. Palmitic acid in the beta position, as in human milk fat, leads to better absorption than seen with cow's milk fat, which has stearic acid in the beta position. Ongual lipase, acting in the stomach starts the digestion in the duodenum. These lipase activities substitute for the low pancreatic lipase of preterm infants and appear to precede well in the low intraluminal bile salt concentrations of infants.

Caloric Density and Water requirements
The caloric density of both preterm and term human milk is about 67Kcal/dL at 21 days of lactation. Formulas of this caloric density have been used for feeding preterm infants. However, more concentated milks, 81Kcal/dL (24Kcal/oz), are preferred by many when commercial infant formulas are used. The increased concentration allows feeding volumes to be smaller. an advantages when gastric capacity may be limited. The volume given when formulas of this concentration are fed at the rate of 120Kcal per Kg per day. 150ml/Kg/day, provided sufficient water for most preterm infants for the excretion of protein metabolic products and electrolytes derived from the formula. However, if lower volumes of formula are given, insufficient water may be provided for renal excretion when relatively constant extrarenal losses occur.

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