VLBW: Guideline Overview (2020)

VLBW: Guideline Overview (2020)

Guideline Overview 

Guideline Title 

Very Low Birth Weight Preterm Infant Enteral Nutrition (2020) Evidence-Based Nutrition Practice Guideline

Guideline Narrative Overview 


Each year an estimated 15 million infants are born preterm worldwide. Preterm birth is associated with increased risks for health, growth, and development complications. Adequate nutrition has the potential to minimize risk and perhaps improve health outcomes. The National Institutes for Health (NIH) and the Academy of Nutrition and Dietetics (Academy) initiated a two-phase project, known as the ‘Pre-B Project, ’ to address the lack of evidence-based nutrition practice guidelines based on systematic reviews for preterm infants. The first phase was coordinated by the NIH and involved a collaborative effort to identify research needs and potential topics for systematic reviews. The Academy coordinated the second phase with a multi-disciplinary work group that conducted a scoping review, systematic reviews, and developed evidence-based practice recommendations.

The preterm scoping review identified that the National Institute for Health and Care Excellence (NICE) was in the process of developing Neonatal Parenteral Nutrition guidelines for several patient populations which included preterm infants, therefore, the Pre-B preterm workgroup decided to focus the Pre-B preterm infant systematic reviews on enteral nutrition. After thorough review of articles identified in the scoping review, and deliberation amongst the preterm workgroup, additional criteria was established. Due to heterogeneity in neonatal practice amongst nations, the preterm workgroup decided to limit studies to those conducted in developed nations. Furthermore, the workgroup decided to focus the guideline on the most vulnerable preterm infants, those born less than or equal to 1, 500 grams [which are referred to as very low birthweight (VLBW) infants]. 

The purpose of this guideline is to provide recommendations based on the Pre-B systematic reviews for VLBW preterm infants. The preterm workgroup prioritized the most vulnerable population, and topics that have been found to be confusing or controversial due to discrepancies found in practice and in research. 

VLBW Preterm Infants

VLBW preterm infants are the smallest hospitalized patients. According to the American Academy of Pediatrics, these infants grow very rapidly in their first weeks and months of life and have the highest human nutrient requirements to support this rapid growth rates. These tiny infants have very small nutrient stores, so nutrition is needed in the short term to support ongoing brain and somatic growth. Being born prematurely, these infants have immature organ systems which create challenges to provide nutrition that meets their nutritional needs. At the same time, these infants present challenges to the neonatal health care team to support their respiratory,  and cardiovascular systems, and therefore nutrition may at times not be seen as the highest priority. 

Target Audience 

This guideline is intended for use by health care practitioners, working with VLBW preterm infants in Neonatal Intensive Care Units,  is intended to address gaps in current evidence-based practice guidelines and to address key questions that have arisen in preterm infant nutrition practice and research including, but not limited to, human milk, fortifiers, formula and macronutrient requirements.

Guideline Development 

This guideline is based on systematic reviews conducted by the project workgroup, consisting of RDNs, neonatologists, pharmacist, and physicians, as well as systematic review and guideline methodologists and evidence analysts.  A patient advocate reviewed content and provided feedback. Recommendations were written based on an evidence-to-decision framework that incorporated evidence as well as clinical experience and the values of families and individuals who provide care for VLBW preterm infants. When there was no evidence available for specific research questions, recommendations were based on expert clinical experience and other supporting evidence.

To view specific methods for the development of this guideline,  please see the respective section.  

Topics addressed in this Evidence-based Nutrition Practice Guideline include:

  • Mother's milk and donor milk
  • Human milk fortifiers
  • Formula
  • Enteral
    • Protein amount and type
    • Fat amount and type
    • Amount of energy


Please expand the Guideline and Systematic Review Project Team and Disclosures section from the project landing page for a listing of individuals who contributed to the development of the project, disclosures and funding information.


Academy guidelines are revisited every five years. A scoping review will be conducted to examine the need for new and revised recommendations based on the available science. The process includes:    

  • Literature searches and evidence scoping to identify new research published since the previous searches were completed. Updated inclusion/ and exclusion criteria and search terms may be warranted.
  • Council on Research review to determine if the update will include modification to all, some or no recommendations, compared to the earlier version(s) of the guideline, or development of new recommendations.
  • Creation of a table comparing the new guideline and the older version of the guideline. The document will indicate which recommendations remained unchanged; updated; new; or not reviewed.

Using the Academy's EAL process, an unbiased and transparent systematic review will be completed and the updated guidelines published on the EAL. To learn more about the Academy's guideline development process, download Academy of Nutrition and Dietetics Methodology for Developing Evidence-Based Nutrition Practice Guidelines, JAND May 2017; 117(5):794-804.

Other Guideline Overview Material

For more details on the guideline, please use the links on the left to access:

  • Scope of the Guideline
  • Statement of Intent
  • Guideline Methodology
  • Dissemination and Implementation of the Guideline
  • Benefits and Risks/Harms of Implementing Recommendations


Clinical judgement and individualization are crucial when providing any Medical Nutrition Therapy (MNT), and particularly for high risk VLBW preterm infants. MNT should be guided by the VLBW preterm infant’s family and the multi-disciplinary health care team. 


  • American Academy of Pediatrics, Committee on Nutrition. Nutritional needs of low-birth-weight infants. Pediatrics. 1977;60(4):519-530
  • Excellence NIfHC. Neonatal Parenteral Nutrition. NICE. NICE Guidance Web site. https://www.nice.org.uk/guidance/ng154/chapter/Recommendations. Published 2020. Accessed March 31, 2020.
  • Fenton TR, McMillan DD, Sauve RS. Nutrition and growth analysis of very low birth weight infants. Pediatrics. 1990;86(3):378-383.
  • Moloney L, Rozga M, Fenton TR. Nutrition Assessment, Exposures, and Interventions for Very-Low-Birth-Weight Preterm Infants: A Scoping Review. J Acad Nutr Diet. 2018; 119(2): 323-339.
  • Raiten DJ, Steiber AL, Hand RK. Executive summary: evaluation of the evidence to support practice guidelines for nutritional care of preterm infants-the Pre-B Project. Am J Clin Nutr. 2016;103(2):599S-605S.
  • Raiten DJ, Steiber AL, Carlson SE, et al. Working group reports: evaluation of the evidence to support practice guidelines for nutritional care of preterm infants-the Pre-B Project. Am J Clin Nutr. 2016;103(2):648S-678S.
  • Thureen PJ, Melara D, Fennessey PV, Hay WW, Jr. Effect of low versus high intravenous amino acid intake on very low birth weight infants in the early neonatal period. Pediatr Res. 2003;53(1):24-32.
  • United Nations. World Economic Situation and Prospects. https://www.un.org/en/development/desa/policy/wesp/wesp_current/2012country_class.pdf. Published 2019. Accessed.
  • World Health Organization. Preterm birth. WHO. Newsroom Web site. https://www.who.int/news-room/fact-sheets/detail/preterm-birth. Published 2018. Accessed March 31, 2020.
  • Ziegler EE, O'Ddonnell AM, Nelson SE, Fommon SJ. Body composition of the reference fetus. Growth 1976 Dec; 40(4): 329-41.
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