Daria Renata Borakowska, Rafał Podgórski, Edyta Łuszczki

The Significance of Clinical Nutrition in Prevention of Osteopenia of Prematurity — A Narrative Review

 

2026-04-09

The Significance of Clinical Nutrition in Prevention of Osteopenia of Prematurity — A Narrative Review

Background. Nutritional therapy is an essential aspect of patient care that provides nutritional treatment for those who are unable to consume sufficient food by the oral route. There are two types of nutritional treatment: enteral nutrition, which is administered through a syringe into a nasogastric tube (with a size of Ch-5 for neonates 500–1500 g or Ch–6 for preterms above 1500 g) into the stomach, and parenteral nutrition, which is given via a central vein. The correct size of the feeding tube prevents serious complications that could preclude the continuation of enteral feeding. Preterm infants are highly susceptible to osteopenia of prematurity (OOP) due to interrupted mineral accrual during the third trimester and early postnatal deficiencies.

Aim. To synthesize recent evidence on the significance of clinical nutrition—especially the timely introduction of enteral feeding—to prevent OOP. To synthesize recent evidence on nutritional strategies—especially the timely introduction of enteral feeding—to prevent OOP, with emphasis on fortified breast milk given via feeding tube.

Material and methods. We conducted a narrative review using a structured and reproducible search on PubMed and Google Scholar for publications from 2016 to 2025. Priority was given to human neonatal data. The authors focused on reviews that mainly addressed the interactions between nutrients in human milk fortifiers and those found in breast milk. Additionally, we reviewed recommendations regarding the safety of enteral nutrition in English, as well as textbooks discussing the effects of medications on nutritional status in Polish.

Findings. Human milk fortification, characterized by a typical calcium-to-phosphorus ratio of approximately 1.6 to 1.8, along with adequate protein and vitamin D, correlates with improved biochemical markers and a lower incidence of osteopenia of prematurity compared to unfortified feeds. Prolonged parenteral nutrition (PN) and delays in advancing to enteral feeding are associated with an increased risk of OOP. Unit-level protocols that optimize calcium and phosphorus delivery from the first day, along with the routine use of human milk fortifier, reduce the incidence of metabolic bone disease. The nutrients in breast milk (e.g., phospholipids) enhance the bioavailability of vitamins (i.e., A, D, K) and minerals (e.g., phosphorus) from human milk fortifier, components essential for bone development.

Conclusions. Timely initiation of enteral feeding with adequate mineral supplementation (especially calcium and phosphorus)/vitamin D and protein supplementation and the positive effect of macronutrients (whey and casein proteins) and oligosaccharides present in human milk on mineral absorption from breast milk fortifiers are central to OOP prevention. Further multicenter studies and protocols are needed to clarify the long-term health benefits of clinical nutrition on the skeletal system.

Keywords: phosphorus, bioavailability, parenteral nutrition, enteral nutrition, preterm infants, clinical nutrition, human milk, calcium-to-phosphorus ratio, human milk fortifier, osteopenia of prematurity.

© Farm Pol, 2025, 81(8): 509–520