Premature Birth is a Global Challenge 

World Prematurity Day, celebrated on 17 November, was established by the European Foundation for the Care of Newborn Infants (EFCNI) along with partnering European organizations to raise awareness of the challenges of preterm birth and how to manage these most effectively.  Premature birth is a common challenge worldwide, with 1 in every 10 babies – or 15 million babies per year – born too early.²  While complications from premature birth are common⁵, advances in medical care and nutrition have improved the outcomes for preterm infants.⁶  

Nutrition plays a critical role in supporting optimal growth and development of premature infants. Promising data suggest that nutrition during pregnancy also plays an important role in pregnancy outcomes, with certain nutrients associated with a reduced risk of premature birth.^2,4,7,8  

Lasting Effects of Nutrition During Pregnancy 

Women experience immense physiological changes during pregnancy, which support optimal growth and development of the fetus.  Meeting the increased needs for key nutrients during pregnancy can be challenging, making pregnant women particularly vulnerable to micronutrient and other deficiencies during this critical period of time. Public health agencies such as the the World Health Organization endorse the use of multiple micronutrients supplements (MMS) as a solution for improving maternal nutrition.  MMS, which include prenatal vitamin and mineral products can help moms bridge gaps in their usual diet.  Included in these products are nutrients which have a positive impact on the duration of pregnancy.⁹  Omega-3 long chain polyunsaturated fatty acids, folate, vitamin D as well as other micronutrients are key during pregnancy, some of which are highlighted here. 

Omega-3 long chain polyunsaturated fatty acids (Omega-3 LCPUFA) 

• DHA, an omega-3 LCPUFA, is preferentially transferred from the placenta to the fetus compared to other fatty acids,¹⁰ especially during the last trimester of pregnancy. This signals the importance of this omega-3 LCPUFA in fetal development. Research suggests DHA is required for optimal brain development and nervous system functioning.⁹ Additionally, maternal supplementation of DHA has been found in some studies to positively impact infant visual attention during the first year of life.¹¹     
• Many pregnant women do not meet the recommended intake of omega-3 LCPUFAs. The 2015-2020 Dietary Guidelines for Americans recommends 250 mg of EPA and DHA per day, yet a recent report revealed that nearly 95% of pregnant women were not meeting these targets.¹² 
• Compelling evidence links omega-3 LCPUFA supplementation during pregnancy with a lower risk of preterm birth. The authors of a recent Cochrane review, that included data from 70 randomized controlled trials, recommend supplementation of omega-3 LCPUFAs from the beginning of the second trimester. They recommend 500–1000 mg of omega-3 LCPUFAs/day, of which at least 500 mg is DHA, due to the important findings of an association with a reduced risk of premature birth.⁸  

Folate

• World wide there are over 300,000 babies born each year with neural tube defects (NTDs).³⁹  These occur very early in pregnancy when the neural tube, which becomes the brain and the spine, does not close properly.   
• NTD’s are linked to a number of factors that include our genetics and low maternal folate intake and status.³⁵ Folate is crucial for normal neural tube development during the first 28 days of conception. It plays an essential role in DNA synthesis and contributes to red blood cell production, which is needed to help increase the mother’s blood volume during pregnancy.⁹  
• The data vary regarding the incidence of folate deficiency in pregnant women. Some studies suggest that the incidence of folate deficiency is quite low at 0.5%, while others suggest about 16% of women consume amounts below the estimated average requirement (EAR). These different findings suggest there may be inconsistent consumption of prenatal vitamins by pregnant women.^14,15     
• In addition, some mothers are genetically predisposed to have a low folate status. The MTHFR gene instructs the body how to make the MTHFR protein, which helps convert synthetic folic acid (the form in most supplements) to the active form of folate. Pregnant women with an MTHFR gene variant have an inefficient conversion to the active form of folate, resulting in low folate stores which are associated with some unfavourable health effects.³⁸ Globally, the frequency of these genetic variants differs, with estimates of up to 20% of the population in the USA and higher in parts of the EU.³⁷  Supplementation with the active form of folate, methylfolate has been reported to support folate status regardless of genetic makeup.^16-18  
• Public health groups such as the World Health Organization recommend strategies to reduce the risk of NTD’s. This includes supplementation with 400 mcg folic acid/day and fortification of staple foods with folic acid.36 The WHO estimates that in doing so the risk of neural tube defects may be reduced by 60–70%.³⁵   

Vitamin D 

• Vitamin D plays an important role in several areas of fetal growth and development: supporting formation of the skeletal system and tooth enamel, aiding in calcium regulation, and evidence suggests vitamin D is involved in modulating inflammation and immune development and functioning.⁹  
• It is estimated that at least 40%-60% of pregnant women in the US are vitamin D deficient (defined as serum 25(OH)D levels <50 nmol/L), and global estimates are 54%. Rates of deficiency can be considerably higher in African American women.^19-21  
• Observational studies have demonstrated a correlation between low serum vitamin D (25(OH)D) levels in pregnant women and preeclampsia, small for gestational age infants, and preterm birth.22 Further, evidence exists for a relationship between maternal vitamin D deficiency and suboptimal infant neurodevelopmental outcomes.²³ 
• The established role of vitamin D in health combined with expert concerns regarding vitamin D deficiencies reported around the world have resulted in most experts recommend supplementation of 600 IU/day of vitamin D during pregnancy (EFSA 201733, IOM 201034).    
• Collectively, the data suggest supplementation may be necessary for many pregnant women to achieve recommended intakes of key nutrients. A variety of dietary supplements can bridge the gap between required and actual nutrient intake.  
  

Nutrition is Essential for Premature Infants’ Growth and Development   

Preterm infants – who are born before 37 weeks gestation – have higher nutrient requirements relative to full-term infants. The third trimester of pregnancy is a time of rapid nutrient accumulation and growth, and infants born during this time are vulnerable to nutrient deficiencies^.1,24 At the same time, they often struggle to tolerate adequate volumes of enteral feedings required to deliver the nutrients they need.²⁵ Suboptimal nutrition in the neonatal period leads to cumulative protein and energy deficits, which can affect short term growth trends, limit brain growth, and result in poor developmental outcomes.^24,26 

In a recent randomized, controlled trial that included mothers intending to provide human mik and delivering at <28 weeks gestation and their infants, mothers were randomized to receive supplemental DHA at either 200 mg/day or 1000 mg/day. DHA levels were measured in maternal breast milk and in both maternal and infant red blood cells (RBCs), and markers of inflammation were measured in both mothers and infants. Breast milk levels of DHA correlated to the supplemented amount, with greater levels seen in the group receiving 1000 mg/day. Additionally, decreases in inflammatory markers in infants were found regardless of maternal supplementation amount. The anti-inflammatory impact of DHA in premature infants may promote an environment more suitable to growth and development.²⁷ Other data suggest that DHA may have a positive role in reducing the risk of the retinopathy of prematurity, one of the consequences of premature birth.^9,28  

Tailored nutrition support strategies help clinicians meet the nutrient requirements of premature infants and positively influence long-term neurodevelopmental outcomes. Strategies include early parenteral nutrition, ensuring protein requirements are met, providing sufficient LCPUFAs like DHA and ARA, and prioritizing human milk for enteral feedings.^1,24,29 The superiority of human milk for premature infants has been well-established based on expert recommendations, as well as improved clinical outcomes in premature infants fed exclusive human milk diets.^30-32 Human milk contains many protective enzymes, hormones, and bioactive and growth factors that play important roles in immune function and organ system development and maturation. Whenever possible, human milk – either mother’s own milk or donor milk – should be provided to all premature infants.³⁰ 

EFCNI Helps Guide Clinicians Caring for Premature Infants  

Meeting the nutrient requirements of premature infants often necessitates a personalized approach, yet standards of care are also needed to guide clinical decisions and ensure evidence-based practices are being utilized. Nutritional care practices can vary widely between physicians and hospitals; as such, written standards and protocols are quite valuable in helping caregivers ensure optimum feeding practices – both in the hospital and at home. EFCNI helps to meet this need by providing multiple standards of care for optimizing nutrition

Help Set Preterm Infants on a Path to a Long, Healthy Life 

World Prematurity Day brings together parents, healthcare professionals, experts in neonatology, and scientists who have the common goal of improving the long-term health of infants born prematurely. These groups advocate for the best possible prevention, treatment, support, and care for preterm and newborn children through specific focus on both dietary and medical angles. World Prematurity Day is celebrated with national and local events, educational campaigns, marches, and a call to take action for moms and babies. Participants are asked to commit to helping address preterm birth and working towards improving outcomes for preterm babies and their families. For more information, visit www.efcni.org.  

Join the World Prematurity Day movement and conversations online. 

#WorldPrematurityDay 

DSM prioritizes educating and building awareness around nutritional solutions to help reduce the risk of preterm birth and supports optimal nutrition for preterm and newborn care. For more information about how DSM supports infant nutrition, visit: https://www.dsm.com/markets/human-nutrition/en/early-life-nutrition.html