Introduction and Background
The practice of breastfeeding or providing expressed mother’s milk to premature infants is promoted because of the considerable benefits to their health and well-being. Exclusive breastfeeding has been shown to result in adequate postdischarge weight gain even in very-low-birth-weight infants. The following guidelines include recommendations for monitoring and optimizing nutritional support of premature infants after they are discharged from the hospital. These guidelines represent expert opinions and have not been validated experimentally.
This protocol addresses the care of premature infants less than 37 weeks’ gestation and less than 2500 g at birth, who are being transitioned from the hospital to home. Depending on the unit, these infants often weigh 1750 to 2000 g at discharge or less if a kangaroo mother care (also known as skin-to-skin) program is practiced, which may allow for more rapid development of feeding skills. Many of the infants weighing 2000 to 2500 g are not admitted to NICU; they may be either in a transitional nursery or in the postnatal ward with their mothers. (Please also refer to Protocol #10.) The plan does not distinguish in utero appropriately grown (AGA) from growth-restricted (SGA) infants but bases decisions on current nutritional status and body weight.
For infants less than 1500 g at birth, it is recommended that they be fed their mothers’ milk fortified with nutrients and calories. Infants 1500 g or more may breastfeed ad libitum as they are able, provided they are supplemented with multivitamins and iron. Near the time of discharge, a decision must be made as to the feeding in the postdischarge period (to 1 year corrected age). Many of these infants do well after discharge with full or partial breastfeeding, or receiving mother’s milk by bottle, cup, syringe, nasogastric tube, or supplemental nursing (feeding tube) device. Growth faltering, however, has been observed in some premature infants in the postdischarge period if they receive exclusive human milk feedings without nutrient and caloric fortification.
Most slow growth in these babies, with the exception of the extremely low-birth-weight infant (ELBW is defined as less than 1000 g at birth), is a function of absolute intake rather than milk composition such that every effort to ensure optimal milk volume should be exhausted prior to switching feedings to formula.
Predischarge: Discharge Planning
The clinician should work with the mother to devise a feeding plan well before the actual date of discharge. Rooming-in by the mother for a few days prior to discharge during this transition period is strongly recommended. The baby will preferably be on exclusive breastmilk, either suckling straight from the breast or by use of expressed breastmilk. Less often, the plan may include a combination of breastmilk (directly from the breast or expressed) and formula.
The following aspects of the current feeding plan should be assessed when making postdischarge plans.
“Type” of feeding: Unfortified human milk, fortified human milk, formula, or a combination.
“Amount” of feeding: Milk intake (mL/kg/day): This includes either measuring the mothers’ pumped milk volume or performing daily test weights for infants who feed at the breast. If the baby is already growing adequately, it is not typically necessary to perform test weights.
“Method” of feeding: Oral (breast, bottle, cup, supplemental nursing device, other, or a combination of methods) versus, or in combination with, tube-feeding (nasal or orogastric) or use of a feeding device (e.g., gastrostomy tube).
“Adequacy of growth”: In-hospital growth noted as daily rate of weight gain and weekly rate of length gain calculated or plotted on appropriate growth charts ( Table J-13 ).
< 20 g/day
< 0.5 cm/wk
Head circumference increase
< 0.5 cm/wk
< 4.5 mg/dL
> 450 international units/L
Blood urea nitrogen
< 5 mg/dL
“Adequacy of nutrition”: In-hospital biochemical nutritional status, when feasible ( Table J-13 ).
(Note : It is recognized that biochemical monitoring is not feasible in all settings. In such situations, dietary adequacy is based on optimal growth and absence of clinical rickets.)
Summary of current nutritional assessment: optimal versus suboptimal.
Optimal status (includes all of the following).
Infant can achieve entire intake orally, by breastfeeding or alternate methods.
Volume of intake is approximately 180 mL/kg/day or more. (Rarely, lower volumes will be adequate if both of the following criteria are met.)
Growth (weight and length) is within normal limits or improving.
Biochemical indices (phosphorus, alkaline phosphatase, blood urea nitrogen) are within normal limits (Table J-5) or improving.
Suboptimal (includes any one or more of the following).
Infant’s intake is less than 160 mL/kg/day (with rare exceptions).
Infant cannot consume all feedings orally.
Growth is less than adequate (weight gain less than 20 g/day and/or length gain less than 0.5 cm/week).
Biochemical indices are abnormal and are not improving.
Transition to postdischarge nutrition for infants with “optimal assessment”:
If the infant has been receiving fortified human milk with or without preterm formula, the diet may be changed to unfortified human milk ad libitum, by breastfeeding or alternative feeding methods, at least 1 week before anticipated discharge.
Prior to this transition it is necessary to assure that mother’s milk supply is appropriate for a trial of breastmilk without fortification. This can be done by reviewing the mother’s pumping record. Ideally, the mother has been pumping or expressing breastmilk regularly. It is recommended that the mother continue pumping or expressing milk at least three times per day to have an “oversupply” to facilitate adequate volume consumption by the premature infant at the breast. For some mothers, pumping after each feeding ensures optimal drainage of the breast, optimal milk production, and expression of the highest fat content (hindmilk) for supplemental feedings. This technique of breastfeeding, then feeding previously pumped breastmilk, and then pumping any residual volume from the breast is termed “triple feeding.”
( Note : In many areas manual expression is the norm or only available method for milk expression. Preliminary evidence suggests that greater volumes may be obtained with electric, hospital-grade pumps. Therefore, whenever possible, use of the latter is recommended.)
For infants receiving formula supplements, a trial without formula is appropriate while increasing human milk intake to approximately 180 mL/kg/day, if possible. Use of hindmilk to increase caloric intake for some feedings may be appropriate.
Add iron, 2 mg/kg/day. If enriched postdischarge formula is used, a decrease in the quantity of iron and multivitamin supplementation is indicated. Generally, if formula constitutes about 50% of the diet, the dose for iron is 1 mg/kg/day and multivitamin preparation is half the doses listed below.
Add a complete multivitamin preparation. (Dosed to receive at least the following amounts of vitamin A [1500 IU/day], C [20 to 70 mg/day], and D [400 IU/day]; vitamin C requirements of preterm infants are poorly studied. B vitamins are also necessary for the former preemie receiving unfortified human milk. Typically, appropriate amounts of all vitamins will be provided by infant multivitamin [MVI] preparations at 1 mL/day.) See note under iron above C1 (c) if providing enriched post-discharge formula supplements.
Monitor milk intake and growth (weight and length) during this week. Volumes of pumped or expressed milk and daily test weights (for infants fed at the breast) should be recorded during this period.
If intake and growth are adequate, continue this diet after discharge.
If intake and growth are suboptimal, follow D (d) below.
If the infant has been receiving unfortified human milk:
Continue iron (2 mg/kg/day).
Continue multivitamin preparation [see dosing above, C,1 (c)].
Continue this diet after discharge.
Transition to postdischarge nutrition for infants with “suboptimal assessment”:
If the infant has been receiving fortified human milk:
Change the diet to unfortified human milk, with or without preterm formula, ad libitum (by breastfeeding and/or alternative feeding methods) plus a minimum of two to three feedings of enriched postdischarge formula prepared per manufacturer instructions (≈ 22 kcal/oz) at least 1 week before anticipated discharge.
( Note : Many neonatologists and institutions add powdered discharge premature formula to expressed breastmilk to provide enriched feeds while still providing the advantages of breastmilk. There is no evidence to recommend for or against this practice. This use of powdered premature formula is off-label and the potential for error is great, so be advised to be extremely cautious if using this approach.)
Recommend that the mother continue pumping or expressing milk at least three times/per day [see C,1 (a) above].
Monitor milk intake and growth during this week.
Assess adequacy of breastfeeding and address problems or potential problems.
Milk transfer/milk volume. If lactation has been suppressed or the baby is not adequately draining the breast, it may be necessary to intervene to increase volume (i.e., increased pumping after feeds or pumping at some feeds and feeding the expressed milk in lieu of or in addition to feeding at the breast.) (Please also see Protocol #9.)
Maternal milk content. Consider the use of hindmilk for some feedings to increase caloric content. This must be considered in conjunction with milk transfer and volume as it may be particularly important if the baby is getting only foremilk and leaving hindmilk.
Frequency of feeds at breast (please note that with “sleepy preemies” subtle feeding cues may be missed).
Optimize milk transfer. Suggested techniques may include pumping or expressing to let down before putting baby to breast or using breast compression during feedings.
Maternal satisfaction. Mothers may have preferences regarding timing of feeds, feeding devices, and so on that fit best with the family’s needs and can be accommodated without compromising the infant’s nutrition.
Consider use of a feeding device.
Nipple shield to improve milk transfer.
( Note : Any mother who is discharged using a nipple shield must be closely monitored by a competent lactation professional to watch for potential associated complications.)
Supplemental nursing (feeding tube) device while at breast.
May be able to use nipple shield and supplemental nursing device together effectively (e.g., by placing tube inside nipple shield so when baby suckles, the volume of milk available for transfer is increased).
Monitor milk intake and growth (weight and length) during this week. Record volumes of pumped or expressed milk and daily test weights (for infants fed at the breast) during this period.
If intake and growth are adequate during this week after switching:
Add iron (1 to 2 mg/kg/day), depending on how much formula is fed.
Add multivitamin preparation (half to full dose described above C,1 [c]), depending upon how much formula is fed.
Continue this diet after discharge.
If the infant has been receiving unfortified human milk, assess the adequacy of breastfeeding and address problems or potential problems as above, D,1 (d).
If addressing any existing breastfeeding problems does not result in “optimal assessment,” add two to three feedings of enriched postdischarge formula prepared per manufacturer instructions (≈ 22 kcal/oz) [see note under D,1 (a) above]. Ensure that the mother is expressing milk to maintain and optimize her milk production. Anticipate at least 1 more week of continued hospitalization before discharge.
Monitor milk intake and growth during this week.
Continue iron and multivitamin supplement.
If the feeding assessment continues to be suboptimal after 1 week, increase the number of feedings of enriched postdischarge formula or increase the concentration of enriched formula to 24 to 30 kcal/oz.