Can Feeding Protect a Premature Baby's Eyes? What Research Shows, and What We Still Don't Know

A plain-language guide to a 2024 European expert review and a 2024 study combining eight trials on nutrition, supplements and the eye condition retinopathy of prematurity

Babies born very early can develop retinopathy of prematurity, an eye condition in which the blood vessels at the back of the eye grow abnormally. Two 2024 research reviews looked at whether what these babies are fed can lower that risk. The clearest message is that a mother's own breast milk and steady growth matter most, while one promising fatty-acid supplement has helped in a single Swedish study and still needs to be confirmed.

Why the eyes of very premature babies need special care

The retina is the thin, light-sensing layer at the back of the eye. Its blood vessels are still growing during pregnancy, so when a baby arrives many weeks early, the retina is only partly supplied with vessels and their growth can be interrupted [1]. In some babies the vessels first stall and later grow in a disorganised way. This is retinopathy of prematurity, often shortened to ROP. Severe ROP can damage sight, which is why very premature babies have regular eye checks in the neonatal intensive care unit (NICU).

How doctors came to link growth, a growth hormone and the eyes

ROP is not becoming rarer. In the United States, the share of premature babies diagnosed with it rose from about 4 in every 100 in 2003 to about 8 in every 100 in 2019 [2]. It is a problem of development: when life outside the womb does not match the conditions the retina expects, its vessels and nerve tissue do not grow normally [1]. In the first weeks after birth, swings in oxygen levels, inflammation and not getting enough nutrients all contribute to weight loss and slowed vessel growth [3].

Over twenty years ago, Swedish researchers found a clue. They measured a hormone called insulin-like growth factor 1, or IGF-1, which helps the body and the retinal blood vessels grow. In 84 premature babies, those with low IGF-1 levels were more likely to develop ROP, and the longer levels stayed low, the more severe the ROP tended to be [4]. The same group then showed that tracking a baby's weight gain together with IGF-1 picked out all 6 babies in a group of 79 who later needed eye treatment [5]. Weight-gain rules have since been widely tested as a way to decide which babies need the closest eye checks; one well-studied set of rules almost never misses a baby who needs treatment, although it flags many babies who turn out to be fine [6]. A large Swedish study of more than 11 000 babies also found that those who needed drip feeding (nutrition given into a vein, called parenteral nutrition) for two weeks or longer had roughly twice the odds of needing eye treatment [7].

All of this pointed to an appealing idea: if we feed premature babies better, perhaps they will grow better and get less ROP. But when researchers pulled together the available studies in 2016, they found no safe way of preventing severe ROP that was backed by high-quality evidence [8].

Two reviews that took different approaches

The first new paper is a review written by a group of nutrition experts from the ESPR Nutrition Council, with authors from nine countries in Europe and North America [3]. They reviewed research published up to August 2023. This kind of review explains how things fit together but does not combine numbers from different studies.

The second paper, by doctors in Jeddah, Saudi Arabia, did combine the numbers [9]. They searched for randomised controlled trials — studies in which babies are assigned by chance to receive a treatment or not, which is the fairest way to test whether something works. They found 8 trials involving 1101 babies born before 32 weeks of pregnancy and weighing under 1500 g. Four trials tested vitamin A, three tested propranolol (a beta-blocker medicine [10]) and one tested added fats, which doctors call lipids. Each was compared with a dummy treatment or no supplement.

What the combined trials found

Looking at all three treatments together, there was no clear reduction in ROP of any stage [9]. Among babies included in the analysis, about 41 in every 100 who received a treatment developed some ROP, compared with about 49 in every 100 who did not — a gap small enough that it could have happened by chance.

For severe ROP, the picture looked better: about 12 in every 100 treated babies developed it, compared with about 19 in every 100 untreated babies. But when each treatment was looked at separately, only the fats showed a clear benefit, and that came from a single trial. Vitamin A and propranolol, examined on their own, did not clearly help. There was no clear sign that any of the treatments increased side effects or deaths.

That single fat trial is the same one that the European experts highlighted. It is called the Mega Donna Mega trial (a study of two fatty acids added to the feeds of extremely premature babies), and it took place in three university hospitals in Sweden [11]. It included 206 babies born before 28 weeks. About half received two fatty acids — arachidonic acid (ArA) and docosahexaenoic acid (DHA), which babies normally receive from their mother during pregnancy — given with their feeds from the first days of life until around their original due date; the others received usual care without the supplement. Severe ROP affected 16 of 101 babies who received the supplement and 35 of 105 who did not, roughly halving the risk [11]. That is encouraging, but because both reviews rely on this one trial, they are not two separate confirmations.

A similar trial in Norway, the Immature, Nutrition Therapy (ImNuT) trial, gave the same fatty acids to 120 babies [12]. Severe ROP fell from about 13 in 100 to about 5 in 100, but there were too few cases of severe ROP for researchers to be sure the difference was real [3]. A later review of 11 trials found no clear eye benefit and raised a question about a possible small increase in a lung condition called bronchopulmonary dysplasia when DHA is given [13]. Our article on these fatty acids and the premature brain and eye explores them in detail.

Breast milk, drip feeding and blood sugar

The European experts' strongest message is about breast milk. They describe early feeding with the mother's own milk as the most important nutritional step to lower ROP risk, and say mothers of very premature babies need real support to start and keep up their milk supply [3]. An earlier study of 243 very premature babies compared donor milk with preterm formula for babies whose mothers could not provide enough of their own milk [14]. According to the experts' summary of that study, serious (stage 3) ROP affected about 6 in 100 babies fed their mother's milk, compared with about 19 in 100 fed donor milk and 14 in 100 fed preterm formula [3]. Donor milk is still valuable, but heat treatment to make it safe lowers how much fat the baby absorbs [3].

Other feeding choices are likely to help growth, though their effect on the eyes is less certain. Starting fats in the drip early appears safe and helps babies lose less weight in the first days [15]. Giving more protein in the drip may lower the chance of any ROP but has not been shown to reduce severe ROP [16]. High blood sugar in the first weeks has also been linked with severe ROP [17], although no trial has yet been designed mainly to test whether preventing it protects the eyes [3]. Our article on blood sugar and ROP explains this further.

Approaches that have not yet shown a benefit

Because low IGF-1 is linked to ROP, researchers have also tried giving IGF-1 as a medicine. In one trial in hospitals across Europe and North America, it did not reduce ROP [18]. A 2026 Cochrane review — a type of review known for its careful methods, which we read in its published summary — found only 2 trials with 140 babies and concluded that the evidence was too uncertain to draw any conclusions [19].

What we know and what remains uncertain

What we know with reasonable confidence is that slow weight gain, low IGF-1 and long periods of drip feeding are warning signs for ROP [4][5][7], and that vitamin A, propranolol and fats, taken together, did not clearly prevent ROP of any stage, with no clear sign that they increased side effects or deaths [9]. The experts' view that a mother's own milk matters most is their strongest recommendation, although it comes mainly from observing babies rather than from a trial designed around eye outcomes [3].

What looks promising but is not yet certain is the fatty-acid supplement, which rests on one Swedish trial and a smaller Norwegian trial that did not reach a firm answer. The researchers who combined the trials rated their confidence in the severe-ROP result as "low", because the number of babies was fairly small and the severe-ROP result combined different kinds of severe disease (advanced stages together with ROP needing treatment) [9]. The trials also used different doses and timings.

What we do not yet know includes the best dose of these fatty acids, whether boys and girls need different amounts, and why long drip feeding is linked to ROP [3]. The key fatty-acid trials were done in Sweden and Norway, so results may differ in hospitals elsewhere.

What researchers are working on next, and what this means for your baby

Researchers are now asking: will the fatty-acid supplement work again in a larger trial across many countries, and at what dose? Can better nutrition raise IGF-1 safely, without a medicine? Would shorter drip feeding or avoiding high blood sugar protect the eyes when tested in a trial? They also want to know how well these children see as they grow.

If your baby is in the NICU and you are able to, expressing breast milk is valuable, and the unit's staff can support you. Your baby's team will be watching growth and blood sugar closely, and you can ask how feeding is going and whether a fatty-acid supplement is part of your unit's practice. Whatever your baby is fed, the regular eye checks remain essential, because they are how ROP is found and treated in time.

Bringing it together

These two reviews show that nutrition and premature babies' eyes are closely linked, but proving that a feeding change prevents ROP has been hard. A mother's own milk and steady growth remain the strongest foundations. One fatty-acid supplement looks promising but needs confirming in more babies, and vitamin A, propranolol and IGF-1 treatment have not shown a clear benefit for preventing this eye condition.

References

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  2. Bhatnagar A, Skrehot HC, Bhatt A, Herce H, Weng CY. Epidemiology of Retinopathy of Prematurity in the US From 2003 to 2019. JAMA Ophthalmol. 2023;141(5):479-485. doi:10.1001/jamaophthalmol.2023.0809 ↩
  3. Hellström A, Kermorvant-Duchemin E, Johnson M, Sáenz de Pipaón M, Smith LE, Hård AL. Nutritional interventions to prevent retinopathy of prematurity. Pediatr Res. 2024;96(4):905-911. doi:10.1038/s41390-024-03208-1 ↩
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