Gaining and Growing: Assuring Nutritional Care of Preterm Infants in the Community

Bronchopulmonary Dysplasia

 Definitions of BPD and CLD
 Nutrition and Growth
 Oxygen Status
 Guide to Clinical Nutritional Care: Assessment, Intervention, Evaluation


Bronchopulmonary dysplasia (BPD) has been described as a "chronic pulmonary disorder that is the consequence of unresolved or abnormally repaired lung damage," (Farrell, 1997). BPD typically occurs in very low birth weight (VLBW) infants who sustain lung damage as a result of oxygen toxicity and barotrauma from mechanical ventilation early in life. The classic diagnosis of BPD may be assigned at 28 days of life if the following criteria are met (Bureau of Maternal and Child Health, 1989):

(1) Positive pressure ventilation during the first 2 weeks of life for a minimum of 3 days
(2) Clinical signs of abnormal respiratory function
(3) Requirements for supplemental oxygen for longer than 28 days of age to maintain PaO2 above 50 mm Hg
(4) Chest radiograph with diffuse abnormal findings characteristic of BPD

Changes in treatment and survival patterns of VLBW infants have led to some dissatisfaction with the ability of these diagnostic criteria to describe those infants who will require ongoing treatment for lung disease beyond the neonatal period. It has been suggested that the term "chronic lung disease of infancy" (CLD) be used to describe infants who continue to have significant pulmonary dysfunction at 36 weeks corrected age (CA). In current clinical practice, these terms are often not clearly differentiated, but infants with significant pulmonary dysfunction at 36 weeks CA are likely to be those who require ongoing nutritional support after initial hospital discharge.

Nutrition and Growth

The overarching goal for infants with BPD is to promote growth and development. Cornerstones of treatment are pulmonary support to maintain optimal oxygen saturation and prevent complications and nutritional support to promote growth. As infants grow, lung function improves and risk of severe cardiopulmonary sequelae and morbidity and mortality due to respiratory infection declines.

Nutritional care for the infant with bronchopulmonary dysplasia (BPD) must be individualized. Feeding concerns, nutritional needs, and growth outcomes are different for each infant, and are determined by initial severity of BPD, presence of other medical problems, and characteristics the infant and caregiver bring to the feeding relationship. Infants and young children with severe BPD may require ongoing mechanical ventilation and tracheostomy, medications with nutrition implications such as corticosteroids and diuretics, gastrostomy tube feedings, and frequent hospitalization. Infants with milder forms of BPD may require few post discharge medical interventions.

Growth in infants and young children with BPD may be compromised by several factors, which include respiratory limitations, increased energy needs, and feeding difficulties. Respiratory status may limit growth in infants with moderate and severe BPD. Growth of new tissue increases respiratory requirements, and feeding itself may interfere with adequate respiration. The metabolic response to the stress of chronic illness may also inhibit growth. Often, an appropriate goal for these infants is slow and steady growth that continues to follow a low percentile curve. Some infants with moderate BPD will eventually experience catch-up growth when improved pulmonary function supports growth. Infants with mild BPD may have growth expectations similar to those for other VLBW infants.

Many infants with BPD experience increased energy needs. The reasons for this are not entirely clear; increased work of breathing, catecholamine release due to stress, increased energy requirements for feeding, and the effects of medications probably all play a role. It is not unusual for infants with BPD to require 130 or even 160 kcal/kg/day to support adequate growth.

It may be difficult to provide adequate energy (calories) for infants and children with BPD. They may have ongoing fluid restrictions due to concerns about pulmonary edema (See section on fluids). They may experience fatigue with feeding or delayed gastric emptying. Increasing the energy density of formula or breast milk with a balanced proportion of carbohydrate and fat may be helpful (see section on infant formula). A high carbohydrate load increases production of CO2 which may be a concern in infants with respiratory compromise. Excess carbohydrate may also lead to osmotic diarrhea. Excess dietary fat may delay gastric emptying and exacerbate gastroesophageal reflux. Infants with BPD are at risk for more frequent and more serious illnesses in the first months of life. It is important to teach caregivers how to assess hydration status during illness, especially when infants are receiving high calorie formula.

Oxygen Status

Persistent hypoxemia is recognized as a cause of poor growth as well as feeding problems in BPD. Inappropriate discontinuation of oxygen therapy for children with BPD has been reported to cause an abrupt drop in growth rates (Groothuis, 1987). Infants with BPD who are not on oxygen therapy may experience oxygen desaturation with feeding after hospital discharge (Singer et al, 1992). Oxygen saturation should be assessed when growth falters or when fatigue and aversive behaviors are observed during feeding. Pulse oximetry readings should be at or above 92% during sleep and during and after feeding (Singer et al., 1992). If this goal is not being met, instigation of home oxygen therapy or increased flow rate should be considered.


Feeding problems are common in infants with moderate or severe BPD. These infants benefit from a multidisciplinary team approach to assessing and treating feeding issues. Problems found in infants with BPD include poor coordination of sucking, swallowing, and breathing, swallowing dysfunction with silent microaspiration, oral-tactile hypersensitivity, and "learned" behavior problems (Pridham et al, 1989). The assessment of feeding problems through feeding observations, swallowing studies, and measurements of oxygen saturation during feeding may be helpful. Infants with BPD may also experience gastroesophageal reflux and/or delayed gastric emptying. The feeding situation may show significant improvement if these conditions are diagnosed and treated with changes in feeding patterns, positioning, or medications.


Growth and development of infants with BPD are influenced by family characteristics (Singer, 1996). Taking care of these infants can present many challenges. Feeding issues may contribute to the stress of caring for an infant with BPD. Feeding infants with moderate and severe BPD may require several hours each day. Nighttime feedings may last for several months. Health care professionals and the families themselves may put excessive emphasis on weight gain increments and establish problematic feeding behavior patterns. Infants with BPD are often re-hospitalized. They are at high risk of serious illness during the respiratory syncytial virus (RSV) season from November through March, and families are usually told to keep their babies at home. Many caregivers report a sense of social isolation. Assuring that family needs for social, emotional and financial support are met is an essential component of good care for these infants and young children. For more information, see sections on "what parents say about feeding preterm infants" and the caregiver/infant feeding relationship.

Guide to Clinical Nutritional Care







Measure and plot on appropriate growth chart using correction for gestational age:

  • Length for age
  • Weight for age
  • Weight for length
  • Head Circumference

For infants and children with mild and moderate BPD these values should be obtained monthly for the first 4 months after hospital discharge and every 3 months thereafter for the first year of life, more often if weight gain is less than 15 g/day. For infants with severe BPD measure length bimonthly, weight weekly (use incremental growth standards), and head circumference monthly.

Further assessment is required to determine potential causes of inadequate growth. Intervention may be a combination of dietary, feeding, behavioral and medical interventions.

Maintain established growth pattern for weight and length for age.

For older toddlers and children with moderate to severe BPD, especially those on corticosteroid therapy mid-arm circumference, mid-arm muscle circumference and triceps skinfold every two months can be useful to assess fat stores and protein status.

Very inactive children and those dependent on steroids or mechanical ventilation may develop excessive fat stores and energy intake may need to be reduced.

Excessively thin or wasted children will require interventions as described above.

Fat and muscle stores within normal parameters for age, gender, and medical condition.







Iron status

Measure hematocrit, hemoglobin or erythrocyte protoporphyrin at least every 3 months. Samples taken when child is sick may give false positive readings for iron deficiency and should be repeated.


If lab values indicate possible iron deficiency anemia, assess dietary and supplemental iron intake and apply dietary methods to increase iron intake and absorption and/or consider trial dose of increased iron supplement.


Indicators of iron status are within normal limits.

Bone Mineralization

For infants at high risk of osteopenia of prematurity (those on long-term diuretics or corticosteroid therapy and those fed term formula, soy formula, or unfortified human milk before achieving infant weights of 2000 g) measure alkaline phosphatase, calcium, and phosphorus every two months.


Assure adequate dietary intake of calcium, phosphorus, and vitamin D. If lab values indicate risk of osteopenia, consider dietary supplementation. Discuss possibility of changing dosing patterns (i.e., every other day) or methods of delivery (i.e., inhaled vs. systemic) of corticosteroids with primary care provider. See nutritional impact of medications.


Indicators of bone mineralization are within normal limits.


For infants and children on diuretics measure electrolytes, calcium, phosphorus, magnesium every two months.


Consider supplementing with electrolytes or minerals. Discuss possibility of changing type or dose of diuretics with primary care provider. See nutritional impact of medications.


Indicators of mineral and electrolyte status are within normal limits.

Poor Growth

If long term growth is poor consider monitoring for protein-energy nutrition with measures of serum albumin or transthyretin (prealbumin).


Assess dietary intake, feeding skills, and feeding interactions. Plan interventions based on assessment. Possibilities include increased energy density of formula and foods (see infant formulas), initiation of tube feeding (see enteral feeding), referral for caregiver counseling and support, and referral for therapies and treatment of problems such as reflux and aspiration.


Growth and laboratory values improve in response to intervention.







Oxygen status

Periods of hypoxemia or marginal hypoxemia should be suspected whenever infants with BPD fail to grow. Previously undetected hypoxemia has been reported during sleep and during and after feeding.

Oxygen status should be assessed with pulse oximetry during feeding, sleeping, and crying (Moyer-Mileur et al, 1996).

SaO2 > 92% during feeding, sleeping, and crying is recommended. Values in the range of 95% have been reported to increase growth.


Provide oxygen therapy as needed. This may include oxygen support only at feeding and sleeping or increased flow rates at these times.


Growth is appropriate. SaO2 remains > 92%.

Fluid restriction

Fluid restriction may be prescribed for infants with severe BPD in first months of life.


Plan diet that provides adequate energy and nutrients with limited fluid intake without exceeding renal solute load beyond infant's abilities. May need to concentrate formula. See infant formulas.


Growth is appropriate.

Gastroesophageal reflux

Symptoms: regurgitation with gagging/coughing/repeated swallowing between meals, red and teary eyes, excessive vomiting, esophagitis (postprandial pain, anemia), respiratory symptoms (pneumonia, wheezing), neurobehavioral symptoms (irritability, crying, feeding refusal, seizure-like attack)

If these symptoms indicate need for further assessment, refer to primary care provider for arrangements for diagnostic tests.

Diagnosis: pH probe or technicium scan


Medication: H2 blockers, proton pump inhibitors, motility enhancers, coating agents for esophagus.

Positioning: make sure trunk is erect and not slumped during and after feeds, position head above trunk in wedge seat or other device after feeds.

Dietary: smaller more frequent feeds

Surgical: fundoplication - reserved for most severe


Meal times and postprandial period are pleasant and pain free. Respiratory symptoms improve.

Growth is appropriate










For infants: assess intake of energy, protein, carbohydrate, vitamins, minerals.

In infancy protein intake may be compromised if intakes of infant cereal, high carbohydrate baby food, or glucose polymers are excessive. Protein should provide 8-12% of energy for infants.

Excessive protein with high renal solute load may be provided if formula is concentrated greater than 24 kcal/ounce without the use of modulars.

For infants with mild BPD, appropriate growth and good feeding skills, provide standard infant formula.

For infants with moderate or severe BPD, ongoing fluid restriction, or feeding problems that interfere with adequate intakes, a 22 kcal/ounce formula may be used or formula may be concentrated to 24 to 30 kcal/ounce.

Guidelines for tube fed infants may be found in section on enteral feeding.

Small infants with limited energy needs may require additional supplements to meet DRI requirements for vitamins and minerals if sufficient formula is not taken. See nutrition supplement recommendations.

Attention should be paid to iron, calcium and phosphorous intakes of all VLBW infants.

Growth is adequate. Intakes of vitamins and minerals meet the DRI for age and size. For infants, iron intakes are those recommended by the American Academy of Pediatrics for former VLBW infants (See AAP guidelines for preterm infants).

Assess introduction of non-milk feedings (solids)

Foods are sometimes introduced to the infant with BPD according to chronological age since birth. This is not nutritionally nor developmentally appropriate.

Foods should be introduced to as the infant is developmentally ready. See developmental aspects of feeding.

Foods are introduced to the child when developmentally appropriate

For young children: assess intake of energy, protein, vitamins, and minerals.

If energy needs remain high past early infancy, foods should be chosen to provide optimal energy and other nutrients. Suggestions include:

  • Yogurt
  • Pudding
  • Cottage cheese
  • Pancakes
  • Hot cereals
  • Tuna or meat salad
  • Scrambled egg
  • Cheese
  • Mashed avocado

High fat foods such as butter, margarine, mayonnaise, cream cheese, and cream can be added to other foods to increase energy content.

Homemade milkshakes, fruit smoothies, and instant breakfast products can be used as an energy-dense snack or bedtime beverage. Commercial pediatric enteral feeding products may also be used for this purpose.

Meals and snacks should be offered at regular times 5 or 6 times each day in a pleasant, non-coercive environment.

Young children are growing adequately and achieving DRI levels of vitamin and mineral intake.

Tube feedings are sometimes required for infants with BPD, especially those who continue to depend on mechanical ventilators. The type of enteral feeding is usually changed at about 1 year of age. Tube fed infants should continue to receive oral stimulation and to have social interactions at feeding times.








Feeding problems are common in infants with BPD. Feeding should be assessed through feeding observations and careful questioning of caregivers. See section on feeding assessment. A team approach to feeding problems and referral for additional assessment and therapy may be indicated. See section on resources.




Consider fatigue with feeding an issue if infant stops feedings before ingesting an adequate amount. Family may be spending several hours each day feeding infant, and may feel inadequate in light of meeting energy requirements.


Check with primary care provider about provision of additional oxygen at feeding times and/or use of bronchodilators before feeds.

Increase energy concentration of breast milk, formula or other foods. See concentration of infant formula.

Manipulate the feeding schedule to increase efficiency. Shorten feeding times and end when feeding becomes less efficient. Try smaller, more frequent feeds.

Consider gastrostomy tube placement. See enteral feeding.


Child ingests adequate amount to support growth. Family is able to enjoy feeding interactions with child.


Poor coordination: Feeding observation may show abnormal sucking patterns with short irregular sucking burst with long pauses and rapid breathing.


See sections on assessing feeding and oral-motor feeding problems.

Help infant to "pace" feeding.

Consider interventions listed above under fatigue section.

Refer for feeding therapy. See section on resources.


Infant feeds without distress and demonstrates coordination of suck-swallow-breathe.


Dysfunction due to aspiration: Infants with BPD are at risk of aspiration due to airway damage caused by intubation as well as reduced ability to use pulmonary air to clear the larynx. Suspect aspiration with episodes of respiratory deterioration or wheezing with feedings, and refer for testing and intervention.

Aspiration can be assessed with videofluoroscopic swallowing study (VFSS).


Dependent on findings of specialist. May include changes in texture or temperature of foods and beverages. In severe cases it may not be safe to feed orally.


Feeding is not associated with adverse pulmonary consequences.

Oral-Tactile Hypersensitivity

Infant becomes agitated, pulls back, gags or vomits when oral feeding is attempted. Infants and young children with BPD are at increased risk due to aversive oral experiences early in life. This situation often requires the intervention of specialists in pediatric feeding therapies. See section on resources for referral sources.


See section on oral motor feeding problems.

Avoid aversive oral experiences as much as possible.

Gradually introduce pleasant oral-tactile experiences into daily care routines.

Encourage oral exploration.


Child displays pleasure with feeding and oral exploration.


Infants and children with BPD are at risk for developing inappropriate feeding behaviors and interactions.


See section on behavior problems related to feeding.



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Page reviewed: March 24, 2015