Aim: ESPGHAN recommends daily phosphate intake of 60-90mg/kg/day in preterm infants to prevent metabolic bone disease (MBD) of prematurity. Our early feeding guideline with routine supplementation of breast milk fortifier (BMF) was introduced in 2015 (Figure 1). We aimed to review daily phosphate intake in our cohort of neonates with this new guideline.

Method: All neonates born in 2015 with birth weight under 1500g were reviewed using electronic medical records.  Data on total daily calcium and phosphate intake through parenteral and enteral nutrition including BMF and additional NaH2PO4 supplementation was collected along with bone profile results.

Results: Table 1 summarises the clinical and nutritional data on 90 neonates from 2015 cohort.  Of this, 100% received mother’s breast milk; 78% received supplemental donor breast milk and 47.8% received formula feeds. 89% (86) neonates received parenteral nutrition and 88% (79) received additional NaH2PO4. MBD was diagnosed biochemically in 0.05% (ALP >900). Only 13% required NaH2PO4 at discharge and two (0.02%) required treatment with cholecalciferol. Subset analysis of 19 neonates with complete medical records until 34 weeks corrected age showed median daily total phosphate intake of 64.3mg/kg (Table 2).

Discussion: We had good compliance with local feeding guideline with lower incidence of MBD. Detailed analysis of daily phosphate intake shows that it is only possible to achieve adequate intake through enteral route with additional NaH2PO4 supplementation. Subsequently, new guideline (Figure 2) on routine phosphate supplementation for high risk infants was introduced for close monitoring for MBD and to consistently meet ESPGHAN recommendations. 

Table 1: Clinical and Nutritional data of the whole cohort of 90 Neonates  


	N=90, median (IQ Range)
Gestational age in weeks	27+5 (26+3-29+6)
Birth weight, grams	952.5 (800-1203.75)
Days of Parenteral nutrition	7.5 (6-11.75)
Days of additional NaH2PO4 supplementation	35 (23.5-56.25)
Bone Profile – Lowest Serum Total Calcium, mmol/L	1.92 (1.71-2.07)
Bone Profile – Lowest Serum Phosphate, mmol/L	1.49 (1.24-1.79)
Bone Profile – Highest Alkaline Phosphatase, mmol/L	489 (391.75-660.75)






Table 2:  Detailed analysis of daily calcium and phosphate intake in a subset of 19 neonates

N=19	Daily Phosphate Intake (average mg/kg/day)	Daily Calcium Intake (Average mg/kg/day)
Parenteral Nutrition	22.4	25.3
Expressed Breast Milk	17.6	30.6
Nutriprem 1	38.5	51.6
Nutriprem 2	26.4	48.9
Breast Milk Fortifier	27.6	46.1




Figure 1: Early Enteral Nutrition Pathway 

 


Figure 2: Prophylactic Phosphate Supplementation for at-risk infants

DAILY PHOSPHATE INTAKE IN PRETERM INFANTS – REALITY VERSUS ESPGHAN RECOMMENDATIONS