Dr. Pinki Barui

The goal during the first year is not simply to promote weight gain, but to support healthy growth, brain development, adequate nutrition and a strong foundation for lifelong health and well-being

Preterm or premature infants, who are born before 37 completed weeks of pregnancy, require careful monitoring for growth and development, particularly during the first year. Parents often have anxiety about whether their premature baby is growing adequately and how soon she will catch up with those born at term.

Although many preterm infants achieve substantial catch-up growth, their development should be assessed using appropriate measures and corrected age rather than compared directly with term-born babies. Adequate nutrition and regular monitoring during the first year are important to support optimal growth and development.

Corrected age

One of the most important concepts for parents of a preterm infant to understand is corrected age, which helps assess the baby’s growth and development in relation to the expected due date.

A baby born at 32 weeks arrives about eight weeks earlier than the expected 40 weeks. Therefore, when the infant is four months old according to the calendar, the corrected age is approximately two months.

Corrected age = chronological age minus weeks born early.

For gauging developmental milestones, corrected age is generally used during early infancy rather than expecting a preterm baby to achieve every milestone as per chronological age. This prevents unnecessary parental anxiety.

0-12 months: What should parents monitor

Growth is much more than simply checking weight. Parents should follow three important growth parameters: weight, length and head circumference. A baby who is on a reasonably consistent growth trajectory may be doing well even if she is smaller than a term-born child of the same chronological age.

Parents should maintain a growth record and ensure weight, length and head circumference are measured accurately during scheduled pediatric visits. Growth charts appropriate for preterm infants and corrected age may be used during early follow-up, followed by appropriate standard growth charts as advised by the pediatrician.

A one-time low weight reading should not automatically be interpreted as poor growth. Similarly, rapid weight gain doesn’t always mean healthy catch-up growth. Quality and proportionality of growth matter.

Developmental milestones

Here are important developmental milestones parents should watch out for:

0-3 months corrected age. Increasing alertness; looking at faces; responding to sound; improving head control and beginning to smile socially

3-6 months corrected age. Better head and trunk control; reaching for objects; bringing hands to mouth; responding to familiar people; increasing interaction and vocalization

6-9 months corrected age. Sitting with progressively better control; reaching and transferring objects; babbling; responding to familiar voices; increasing interest in the environment

9-12 months corrected age. Sitting independently; moving around in different ways; attempting to stand; using gestures; babbling with increasing variety; responding to simple interactions and familiar commands

These are broad developmental windows, not examination dates. A preterm infant may achieve individual milestones at different times.

If you notice loss of a previously acquired skill, marked asymmetry of movement, poor interaction, feeding difficulties, or persistent concerns about development, discuss them promptly with your pediatrician.

Nutrition: Does every preterm baby need extra calories?

No. This is one of the most important messages for parents. A preterm baby may have higher nutritional requirements than a term infant, particularly during the early period, but nutritional needs vary according to gestational age, birth weight, whether the baby was appropriate or small for gestational age, current weight and growth trajectory, medical problems, feeding ability, and whether the baby is breastfed or formula-fed.

Therefore, “catch-up growth” should not mean simply feeding more. The aim is healthy, proportionate growth, rather than rapid weight gain at any cost.

Breastmilk remains the foundation

WHO recommends breastmilk as the preferred milk for low-birth-weight infants whenever possible. When mother’s own milk is unavailable, donor human milk may be considered where safe and available. Formula is an alternative only when human milk is unavailable. Breast milk provides not only nutrients but also important protective and developmental benefits.

However, some very small or very preterm babies may require additional nutritional support.

When is nutritional adjustment necessary?

Additional nutritional support is considered when a baby has very low birth weight, was born very preterm, has persistent growth faltering, is not gaining weight adequately despite appropriate feeding, or has additional nutritional requirements because of a medical condition.

For selected very-low-birth-weight infants, WHO recommendations include consideration of human-milk fortification when adequate breast-milk feeding does not result in appropriate weight gain. Consult a pediatrician/neonatologist to individualise fortification, formula concentration and supplements.

Don’t forget micronutrients

Depending on birth weight, gestational age, feeding pattern and clinical condition, pediatricians recommend supplements such as iron and vitamin D, among others.

WHO specifically recommends vitamin D supplementation of 400–-000 IU/day until six months of age for VLBW (Very Low Birth Weight) infants, while calcium and phosphorus supplementation is prescribed in VLBW infants receiving human milk during the early months.

However, supplementation should be individualized. More is not necessarily better, and parents should not start multiple supplements without medical advice.

Starting complementary foods

Around six months of age, complementary feeding generally becomes necessary because breast milk or formula can no longer meet all nutritional requirements. For a preterm baby, however, the decision involves monitoring developmental readiness and corrected age, rather than relying only on the calendar age.

Signs of readiness include good head and neck control, ability to sit with support, reduced tongue-thrusting, interest in food, ability to bring objects toward the mouth, and capability to safely swallow food.

WHO recommends complementary feeding from around six months while continuing breastfeeding. However, for a preterm infant with growth problems, complementary feeding should focus on nutrient density rather than simply increasing volume. Protein-rich and nutrient-rich foods such as appropriately prepared egg, fish, meat, pulses, dairy products and other locally available nutritious foods can be introduced according to developmental readiness, family dietary practices and allergy considerations.

Catch-up growth does not mean “the faster, the better”. This is perhaps the most important message for parents. Catch-up growth is desirable when a preterm baby has fallen behind because of prematurity or early growth restriction. But excessive or disproportionately rapid weight gain is not the goal.

The objective is to achieve healthy weight, appropriate head growth and overall development rather than rapid weight gain. Therefore, parents should avoid force-feeding, adding extra cereal, unnecessarily concentrating formula or using calorie-dense foods/supplements without professional medical guidance.

When should parents seek medical advice?

Parents should contact their pediatrician if they notice poor or stagnant weight gain; repeated feeding difficulties; frequent choking, coughing or tiring during feeds; persistent vomiting; significant feeding refusal; reduced urine output; loss of developmental skills; marked stiffness or floppiness; significant asymmetry of movements; poor interaction or reduced alertness.

Early diagnosis allows nutritional or developmental problems to be addressed before they become more difficult to correct. The goal during the first year is not simply to promote weight gain, but to support healthy growth, brain development, adequate nutrition and a strong foundation for lifelong health and well-being. Every preterm baby has a different pathway. Regular follow-up with a pediatrician/neonatologist ensures that the journey stays on the right track.

Growth Monitoring Checklist

During every doctor’s visit/follow-up, ask:

• Is my baby’s weight increasing appropriately?
• Is length increasing?
• Is head circumference increasing appropriately?
• Is the growth trajectory proportionate?
• Is my baby feeding effectively?
• Are developmental milestones progressing according to corrected age?
• Is my baby receiving the recommended supplements?
• Is complementary feeding developmentally appropriate?
• Does my baby need any nutritional adjustment?