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Recommendations Summary

VLBW: Type of Fat (2020)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.

  • Recommendation(s)

    VLBW: Type of Fat

    Health care practitioners should not routinely supplement additional enteral long chain fatty acids [docosahexaenoic acid (DHA), eicosapantaenoic acid (EPA), and arachidonic acid (AA]) for very low birthweight (less than or equal to 1, 500g at birth) preterm infants. If health care practitioners choose to supplement additional omega-3, then AA should also be provided. Current evidence does not suggest consistent benefits with enteral long chain fatty acid supplementation. 

    Rating: Fair

    • Risks/Harms of Implementing This Recommendation

      Routine supplementation of long chain omega-3 fatty acids (i.e. DHA and EPA) via enteral nutrition without supplementation of arachidonic acid may impair growth in exclusively formula-fed very low birth weight preterm infants. 

    • Conditions of Application

      This recommendation applies to very low birth weight (less than or equal to 1, 500g birth weight) preterm infants. Healthcare practitioners should use professional expertise and individual assessment prior to prescribing enteral long chain omega-3 supplementation. Formula-fed preterm infants receiving docosahexaenoic acid (DHA) supplementation should also be supplemented with arachidonic acid (AA).

    • Potential Costs Associated with Application

      Enteral supplementation of long chain omega-3 fatty acids or formula fortified with long chain omega-3 fatty acids may increase formulary cost.

      Implementation Considerations

      When considering a DHA supplement, clinicians should also consider the AA content and the presence of other ingredients, such as vitamin A and vitamin D. Avoid use of cod liver oil as a source of DHA, as it is prone to heavy metal and environmental toxin contamination.

    • Recommendation Narrative

      Clinicians and parents question the type and amount of fat a preterm infant should receive. Observational research indicates that changes in the fatty acid profile of preterm infants from fetal or birth levels have been associated with neonatal morbidity and subsequent negative cardiometabolic and neurodevelopmental outcomes (Martin et al., 2011; Panagos et al., 2016) . It is accepted by most clinicians and parents that preterm infants would benefit from enteral fat sources that are rich in long chain omega-3 fatty acids.

      A systematic review was conducted to determine the effect of type of fat intake on preterm infant outcomes. A total of 14 randomized controlled trials were included in the review.  All included studies evaluated the impact of DHA and EPA intake amongst human milk-fed and formula-fed infants. There is high-certainty evidence that the long chain omega-3 fatty acid intake does not have an effect on mortality, bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, or gastrointestinal health. There is moderate certainty that long chain omega-3 fatty acids does not have an effect on mental development or IQ by seven years of age. There is low certainty that long chain omega-3 fatty acids does not have an effect on anthropometrics, visual acuity, or adverse events. There was low-certainty evidence that long chain omega-3 supplementation in formula -fed infants for four months to five months may have lower weight compared to usual care. These infants were formula fed and not supplemented with arachidonic acid. 

      Results of the systematic review failed to demonstrate substantial health benefits for supplementation of long chain omega-3 fatty acids.  Lack of effect may be due to ineffective delivery strategies rather than the importance of the type of fat. Studies were heterogenous and spanned a long period of time, during  which health care interventions changed.  

    • Recommendation Strength Rationale

      • High certainty evidence (Grade I) for mortality, necrotizing enterocolities, retinopathy of prematurity, feeding tolerance and sepsis.
      • Moderate certainty evidence (Grade II) for bronchopulmonary disease and neurodevelopment.
      • Low certainty evidence (Grade III) for atopy (hay fever), visual acuity, weight gain, lenght gain, head circumference and adverse effects.

    • Minority Opinions

      Consensus reached.