Postnatal growth trajectories and extrauterine growth restriction in very low birth weight infants managed without routine parenteral nutrition in a resource-limited south African neonatal unit

BACKGROUND: Optimal nutritional management of very low birth weight infants (VLBWIs) remains challenging in resource-limited settings where parenteral nutrition is often unavailable. Data describing growth outcomes among infants managed with predominantly enteral strategies are limited. OBJECTIVE: To evaluate nutritional intake, postnatal growth trajectories, and extrauterine growth restriction (EUGR) in VLBWIs managed with predominantly enteral feeding in a tertiary neonatal unit in South Africa. METHODS: A retrospective cohort study was conducted at a tertiary unit between January 2021 and December 2022. Nutritional practices prioritised mothers' own milk. Anthropometric measurements were assessed using the Intergrowth-21st (IG-21ST) standards. EUGR was defined as a decline in weight Z-score > 1.28 from birth to discharge. Receiver operating characteristic (ROC) analysis was used to assess the predictive value of early feeding variables for EUGR. RESULTS: Of 1235 VLBWIs admitted, 511 (41.3%) met inclusion criteria. Mean gestational age was 28.6 ± 1.7 weeks, and mean birth weight was 1061.2 ± 204.3 g. Median birth weight Z-score was -0.2 (IQR -0.9 to 0.5). Mean weight growth velocity (WGV) was 13.4 ± 6.6 g/kg/d. Median discharge weight Z-score was -0.7 (IQR -2.0 to 1.9). At discharge or transfer, 166 infants (32.4%) met the ΔZ > 1.28 definition of EUGR, while 196 infants (38.4%) had a discharge/transfer weight Z-score below -1.28. EUGR was associated with lower birth weight, IUGR, late-onset sepsis, and longer time to regain birth weight. CONCLUSIONS: Despite successful early advancement of enteral feeding, suboptimal growth and declining Z-scores remained common. Achieving enteral feed volumes alone was insufficient to prevent EUGR, highlighting the importance of early protein and energy optimisation, timely advancement to full fortification, and routine growth monitoring in resource-limited settings.