Feeding: NICU Handbook

Ekhard E. Ziegler, MD
Peer Review Status: Internally Peer Reviewed

Recent years have seen marked changes in the general approach to the nutritional management of preterm infants. The changes reflect a growing awareness of the potential for adverse consequences from starvation and undernutrition during the neonatal period. There can be no doubt that neurodevelopmental processes are susceptible to nutritional insults.

The temporary postnatal growth arrest, which we have come to accept as inevitable, is potentially preventable, if not in its entirety, then at least to a large degree. Somatic growth is a useful indicator of nutritional sufficiency. When somatic growth is near normal, significant nutritional insults to the CNS are unlikely. On the other hand, when somatic growth is abnormal, there is always the possibility of adverse effects on neurodevelopment. Therefore, nutritional efforts aimed at enabling somatic growth as it would have occurred in utero are well justified because they enhance the chance that growth and development of the CNS will continue without interruption.

The trend in recent years has been towards earlier and more aggressive use of parenteral nutrition. This was made possible by expanded use of percutaneously placed central vein catheters. An innovation in enteral feedings has been the use of "trophic" feedings starting very soon after birth. The idea is to prevent intestinal atrophy from occurring, so that, when feedings start in earnest, the gut does not have to go through a lengthy rehabilitation period. Together these two developments have made for greatly improved nutritional management, especially of very small preterm infants.

Ekhard E. Ziegler, MD
Peer Review Status: Internally Peer Reviewed

General concepts

Most neonatologists now embrace the idea that a nutritional insult (starvation) is unlikely to have beneficial effects in an infant already under intense stress. Efforts at minimizing the duration and severity of starvation must, of necessity, rely heavily on the parenteral provision of nutrients. The prevailing hormonal milieu, which accounts, among other things, for glucose intolerance, places limitations on our ability to provide nutritional support. But, within these limitations, nutritional intake should be maximized -- and the earlier, the better. Enteral nutrition should be pursued all the while, but with a view toward nourishing the gut rather than the whole baby.

Indication and time of intiation

The smaller the infant, the greater the need for parenteral nutrition and the greater the urgency to initiate it. Thus, infants with birth weights less than 1500 g should, with few exceptions, receive parenteral nutrition as a matter of routine. These infants should be on TPN by 48 hours of age at the latest. There is no rationale for withholding TPN in these infants for a period longer than is technically required to order and start TPN. Postponing the initiation of TPN simply means that greater nutrient deficits will accrue and that it will take more time later on to make up for the deficits.

On the other hand, larger infants require parenteral nutrition only when enteral feedings are not possible for periods of more than a few days. Because larger infants have greater nutrient reserves, the urgency to start nutrition support is much less than in smaller infants.

Prescribing parenteral nutrition

Three neonatal venous nutrition (NVN) solutions are available. Their main components are listed in Table 1.

¹ All solutions also provide (per liter): 2 mg zinc, 0.4 mg copper, 0.2 mg manganese, 4 µg chromium, 10 µg selenium;
² Trophamine or Aminosyn PF; cysteine is added at 14 mg/g amino acids
³ Higher when potassium is added (e.g., 30 mEq when K is 20 mEq)

The standard and high-amino acid solutions differ only in their amino acid content. We retain the designation "standard" for the solution providing 1.4% amino acids, although high amino acid solutions are now used at least as frequently as the standard solution. The concept behind the standard solution is that in 100 ml/kg/day it provides 1.4 g amino acids per kg/day, the presumed maintenance requirement. If one of the high amino acid solutions is prescribed at 60-70 ml/kg/day, that same amino acid intake is achieved, albeit in a smaller volume. In patients with labile electrolyte and/or blood glucose levels, the remainder of the daily fluid volume can be provided from glucose-electrolyte solutions that can be changed readily in response to changing needs. Potassium, when it is needed after the first few days, has to be prescribed as a separate item. The electrolyte-free solution is free of sodium, potassium and chloride. It is intended for the small preterm infant during the first few days of life and provides maximum flexibility in working around the common fluid-electrolyte problems of small infants. It goes without saying that, once the electrolyte disturbance has been resolved that prompted the use of an electrolyte-free solution, supplemental electrolytes must be provided or an electrolyte-containing solution used.

Vitamins (MVI Pediatric) must be prescribed separately. The dosage is 2.0 ml/kg/day for babies weighing up to 2.5 kg. Babies weighing >2.5 kg receive the maximum dose of 5.0 ml/day.

Dosage of amino acids

There is no rational basis for intakes less than 1.4 g/kg/day (i.e., maintenance, Table 2) at any time, even on the first day that TPN is given. Whenever energy intakes exceed 40 kcal/kg/day, intakes of amino acids should be increased beyond 1.4 g/kg/day. As a rough guideline, an amino acid/energy ratio of approximately 3.5 g/100 kcal should be maintained. In this way it is ensured that the infant receives sufficient amino acids at all times, especially if and when growth occurs. In larger infants, a lower ratio, e.g., 3.0, should be used.

Special needs

When higher than usual intakes of calcium and phosphorus are desired, e.g., in case of marked osteopenia, or simply to prevent osteopenia, increased concentrations of these minerals can be given. The permissible concentrations depend on the amino acid and glucose concentrations in the TPN solution. Consult the dietitian and/or pharmacist regarding prescribing information.

If additional acetate is desired for the management of metabolic acidosis, it can be added as the Na or K salt. The choice of salt(s) will depend on serum electrolyte levels.

Parenteral lipids

The primary reason for providing parenteral lipds remains the provision of essential fatty acids. That objective is achieved with a lipid intake of 0.5 g/kg/day. There are good reasons for using lipid also as source of fuel, although it appears that a good portion of lipids goes into storage rather than being oxidized as fuel. Intakes of up to 2.5 g/kg/day are commonly used in preterm infants and appear to be safe, as long as they are given slowly. Lipid emulsions are available as 10% and 20% emulsions, with some reports suggesting more favorable metabolic effects with 20% emulsions than 10% emulsions.

Certain rules must be followed. Lipids should be given as slowly as possible, i.e., spread out over 20 hrs each day whenever possible, leaving 4 hrs for administration of intravenous medications. Triglyceride levels should be monitored if rates greater than 150 mg/kg/hr are used. If visible lipemia is noticed, the lipid infusion should be stopped and a serum triglyceride level measured.

Monitoring

Because blood glucose and electrolytes are already being closely monitored in preterm infants, no routine monitoring is required specifically for infants receiving parenteral nutrition, with one exception. Because electrolyte-free TPN is also phosphate-free, serum phosphorus must be monitored if such a solution is used for more than 2 days. Whatever the BUN is, a small rise of it is to be expected when TPN is started or when the amino acid intake is increased.

An important rule in monitoring is never to draw the blood sample from a line that contains the substance to be monitored. No amount of flushing can guarantee that you are not obtaining a falsely high value!

Ekhard E. Ziegler, MD, and Susan J. Carlson, MMSc, RD, CSP, LD, CNSD
Peer Review Status: Internally Peer Reviewed

Feeding the gut (trophic feedings)

The provision of small amounts of feedings starting soon after birth aims at preventing atrophy of the gut. A number of studies in recent years have demonstrated the general feasibility of this approach as well as beneficial clinical effects, with no recognizable increase in the risk of necrotizing enterocolitis. Although we have no formal protocol for the use of trophic feedings, such feedings are being used increasingly and their use is encouraged. Colostrum/human milk should be used whenever available. Otherwise, preemie formula should be used. The use of dilute formula, although practiced widely, has no rational basis and no demonstrated benefits, except that the larger volume may improve gastric emptying. Trophic feedings should be initiated at a volume not to exceed 15 ml/kg/d. These feedings are traditionally given in small boluses of 1 - 3 ml/kg per feeding. Trophic feedings should continue until the infant's respiratory and cardiac status have stabilized. Older preterm infants (i.e. > 27 weeks) and infants with minimal respiratory compromise may bypass trophic feeds and begin feedings using a nutritive feeding regimen.

Feeding the baby (nutritive feedings)

When feedings begin in earnest in the stable baby, feedings should be advanced slowly. The rate of increase should not exceed 20 ml/kg/day except in situations where feedings were held and are being restarted. Feeding volume is increased first by reducing the interval between feeds to q 3 hrs or q 4 hrs and subsequently by increasing the bolus volume. Infants less than 1200 g may tolerate larger volumes with continuous (3 hr on, 1 hr off) feedings than bolus feedings.

Intestinal motility is often impaired in the infant in the Special Care Nursery due to immaturity, sedation, or critical illness and thus feeding aspirates are common. Aspirates should be checked but, as a rule, should be refed, except when they are clearly bilious or when there are other clear signs of bowel obstruction. Aspirates greater than 2 ml, especially if they contain mostly milk or formula rather than gastric juice, should prompt a physical examination of the infant, and subsequent aspirates as well as the infant's medical condition should be monitored closely.

Human milk

Milk provided by the infant's mother is, of course, the feeding of choice. Fresh milk that has not been frozen is preferred when available. Freezing entails some loss of nutrients, but, with the exception of live neutrophils and lymphocytes, all the protective components of breast milk remain essentially intact. Expressed, stored milk should always be fed in the order in which it was obtained. In this way, the infant receives the colostrum first, which is most protective, followed by transitional and mature milk. If mother's milk is not available, donor milk from the Mother's Milk Bank of Iowa may be substituted. Donor milk is mature human milk and likely contains less protein and sodium than mother's preterm milk but still confers most of the immunological and nutritional benefits of human milk.

¹"Preterm" milk at 2 weeks of lactation

Because human milk does not contain protein and minerals in amounts needed by the growing preterm infant, fortification is necessary. Table 3 indicates the estimated nutrient requirements ("Advisable Intakes") of preterm infants and contrasts these with the composition of unfortified and fortified human milk. It is evident that fortified milk comes close to meeting the needs of larger infants, but that the needs of smaller infants are met only partially. Fortification should be started when milk feeds of approximately 50 - 80 ml/kg/day are achieved. The composition of the Enfamil Human Milk Fortifier is indicated in Table 4. Standard fortification is one envelope per 25 ml of human milk.

Fortified milk has a caloric density of 80 kcal/dl (24 kcal/oz), assuming caloric density of native breast milk to be 67 kcal/dl. Expressed breast milk is frequently low in fat content and thus contains fewer calories than the assumed 67/dl. Use of calories to quantify breast milk is a convenient practice, but we must always remember that the actual intake of calories is likely to be less than the stated value.

In selected cases it may be beneficial to increase fortification by decreasing the volume of milk to which one envelope is added (e.g., to 15 ml). Situations where this might be indicated include very small infants, infants on fluid restrictions, or any infant who fails to gain satisfactorily in spite of receiving what appears to be an adequate intake. The addition of extra fortifier to human milk substantially increases calcium and phosphorus intake, particularly in infants receiving >120 kcal/kg/d from feeds. Routine monitoring of ionized calcium and phosphorus are indicated to prevent the development of hypercalcemia or hyperphosphatemia. The iron content of human milk is negligible. The iron content of Enfamil Human Milk Fortifier will provide a daily iron intake of 2.2 mg/kg/d in infants fed 120 kcal/kg/d. This level of intake is sufficient to meet the iron needs of growing premature infants.

Formula

The composition of a typical premature infant formula is included in Table 3. Premature formula has a caloric density of 80 kcal/dl (24 cal/oz). As Table 3 shows, the formula meets the protein needs of larger infants but not of smaller infants. Infants requiring concentrated feedings will receive premature formula mixed with term formula concentrate. Please contact the dietitian if concentrated feedings are required. The addition of carbohydrate and/or lipid is not a suitable means of increasing caloric density of feedings for premature infants as protein and mineral density of the premature formula is significantly reduced.

Feedings at discharge

Fortified Human Milk and Premature Formula should be used until the infant is feeding ad libitum or a weight of 3000 g has been reached, whichever comes first. Prior to discharge the infant must be transitioned to an appropriate homegoing regimen. Selection of the appropriate feeding for discharge depend on a number of factors including infant weight, degree of growth failure, need for fluid restriction, and oral feeding skills. The use of Preterm Discharge Formulas (e.g. Enfacare, Neosure) as formula, or mixed with breast milk, may enhance growth in preterm infants discharged to home before reaching term size. Preterm Discharge Formulas are routinely prepared at 22 kcal/oz and have a higher protein and mineral content than term formulas. Concentrated term formula (24, 27 kcal/oz) may be indicated for larger infants (e.g. >2500 g) with inadequate oral feeding skills. Vitamin D and iron supplements are indicated for infants breastfeeding at discharge. No additional vitamin or iron supplements are needed for the formulas fed infant. Table 5 lists guidelines for selection of an appropriate discharge feeding regimen.

Janet F. Geyer, RN, ARNP, CPNP and Ekhard E. Ziegler, MD
Peer Review Status: Internally Peer Reviewed - 2/24/12

1. It is the responsibility of the healthcare team to promote breastfeeding as best for infant feeding based on scientific knowledge and research.  All mothers should be offered the right to breastfeed.
2. The healthcare team recognizes that breastfeeding success or failure is a personally defined experience based on a woman’s individual perceptions.
3. Information regarding the use of donor milk from the Mother’s Milk Bank of Iowa will be presented to families.
4. Expressed milk is precious to the mother and the baby and should be treated as a valuable commodity. It should be discarded only for a good reason.
5. Breastfeeding is contraindicated in a small number of rare conditions or circumstances:
   1. Infant with galactosemia.
   2. Mothers with active untreated TB.
   3. Mother who is HIV or HTLV Type I or II positive.
   4. Mothers receiving antimetabolites or chemotherapeutic agents until they clear the milk.  For additional medications refer to LIP or Lactation Specialist, to clear the milk for feeding.
   5. Mothers receiving diagnostic or therapeutic radioactive materials (for as long as milk is radioactive).
   6. Mothers that test positive for using drugs of abuse during this pregnancy.
   7. Mothers with active herpes simplex lesions on a breast (infant can feed from the other breast if no lesions are present).
6. Milk may be expressed by hand, manual pump or electric pump. The most effective are the electric breast pumps. Electric breast pumps are located in each NICU room, available at Ronald McDonald House, in the Mother Baby Unit (MBCU) and are available for rent from drugstores and medical supply businesses across Iowa. University of Iowa’s Children’s Hospital has a lending service available. Some insurance companies will pay for the rental of an electric breast pump with a prescription for breast milk.
7. Instructions given to the mother regarding pumping should be specific and complete, with emphasis on cleanliness. Before expression, hands should be washed with soap and water. Breast cleansing routines are unnecessary and can be damaging to nipple skin.  Mothers should be instructed to empty breasts as completely as possible to include end milk with high caloric content (high fat content).
8. Containers for storage of expressed milk should be small in size (4 oz. or less). If milk is to be frozen it should be stored in airtight containers (polycarbonate of polypropylene)
9. The collection container and pumping parts need to be washed in hot soapy water and rinsed in hot water between uses and allowed to air dry in the designated clean area.
10. Breast milk requires proper identification to assure expressed milk is fed only to the infant whose mother provided the milk.  All patient supplied breast milk will need to be labeled with the following: 1) Patient’s name and hospital number – use Zebra printer labels 2) Date and time pumped – use blank labels for mom to add this information
11. Expressed milk should be refrigerated within 1 hour. If it was never frozen, it may be kept for up to 5 days.
12. Mothers should be encouraged to store fresh expressed milk in feeding-size portions that will be consumed in 24 hours due to smaller volumes consumed.
13. Human milk, to which fortifiers have been added, should be used within 24 hours of fortification.
14. Thawed milk that has not been warmed for use or fed to the infant should be stored in the refrigerator and used within 24 hours.
15. All transported human milk should be packed tightly in a cooler with freezer gel pads.  Do not use ice during transport to the hospital.

References: N-CWS-PEDS-13.010 Breastfeeding: Promotion, Support and Protection SOP

1. Alade, R. L. (1992). Sucking technique and its effects on success of breastfeeding. Birth. 19(4), 185-189.
2. American Academy of Breastfeeding Medicine. #7 Model Breastfeeding Policy.
3. American Academy of Pediatrics. Policy Statement, Breastfeeding and the Use of Human Milk. Pediatrics, 115(2) (February 2005), 496-506.
4. Dix, D. (1991). Why women decide not to breastfeed. Birth:  Issues in Perinatal Care and Education. 18(4), 222-225.
5. Glass, P. (1994). The Vulnerable Neonate and the Intensive Care Environment. Neonatology, Pathophysiology, and Management of the Newborn (4th ed.). J. B. Lippincott.
6. Hubbard, Deborah, Lactation Specialist, Children’s and Women’s Services, UIH.C
7. International Lactation Consultants Association (ILCA). Clinical Guidelines for Establishment of Exclusive Breastfeeding (June, 2005).
8. Isaccson, Laura J. (2006). Steps to Successfully Breastfeed the Premature Infant. Neonatal Network, 25(2), 77-86.
9. Mohrbacher, N., Stock, J. (Eds.) (2003). The Breastfeeding Answer Book. LaLeche League International (3rd ed.). Schaumburg, IL, 542-545.
10. Morris, S. E., Klein, M. D. (1987). Pre-Feeding Skills. Therapy Skill Builders (pub.).
11. Palmer, M. M., Vandenberg, K. A. (1998). A Closer Look at Neonatal Sucking. Neonatal Network, 17 (2), 77-79.
12. Riordan, J., Auerbach, K. (Eds.) (2005). Breastfeeding and Human Lactation (3rd ed.). Jones and Bartlett pub., Boston, MA, 449-481.
13. Zaichkin, J. (2002). Newborn Intensive Care: What Every Parent Needs to Know. NICU Ink, Petaluma, CA.

Research references:

1. Alade, R. L. (1990). Effect of delivery room routines on the success of first breastfeed. Lancet. 336, 1105-1107.
2. Arafat, I., Allen, D., Fox, J. (1981). Maternal practice and attitudes towards breastfeeding. JOGNN. 10, 91-95.
3. Baranowski, T., Bee D. E., Rassin, D. L., et al. (1983). Social support, social influence, ethnicity and the breastfeeding decision. Social Science Medicine. 17, 1599-1611.
4. Meier, P. & Mangurten, H. (1993). Breastfeeding the preterm infant. In:  Riordan, J. & Auerbach, K.G. (Eds). Breastfeeding and Human Lactation. Boston:  Jones & Bartlett Publishers, Inc.
5. Ludington-Hoe, S. & others (1994). Kangaroo Care:  Research results and practice implications and guidelines. Neonatal Network, 13, 19-27.
6. Lawrence, R. (2005). Breastfeeding:  A Guide for the Medical Profession, (6th ed.). St. Louis: Mosby.
7. Shrago, L. & Bocar, D. (1990). The Infant’s Contribution to Breastfeeding. JOGNN, 19(3), 209-215.
8. Stine, M. (1990). Breastfeeding the Premature Newborn:  A Protocol Without Bottles. Journal of Human Lactation, 6(4), 167-170.
9. Byzak, Susan (1990). Factors Associated with the Transition to Oral Feeding in Infants Fed by Nasogastric Tubes. The American Journal of Occupational Therapy, 44 (12), 1070-1078.
10. Human Milk Bank Association of North America (2005). Best Practice for Expressing, Storage, and Handling Human Milk in Hospitals, Homes, and Child Care Settings.

Susan Carlson RD, CSP, LD, Beth Wojcik RD, LD, Anne Barker MS, RD, LD and Jonathan Klein MD - 08/11/11
Peer Review Status: Internally Peer Reviewed

Background

Human milk is the ideal feeding for all infants.  While the nutrient composition of human milk is ideal for term infants; protein and mineral content of human milk is insufficient to meet the needs of the growing preterm infant.  These deficits are particularly of concern in the smallest infants (ELBW < 1000 g and VLBW < 1500 g) who have the highest protein and mineral needs for growth.  While TPN will provide supplemental amino acids, protein intake may be limited if unfortified breast milk comprises > 50% of total fluid intake.  As the mineral content of TPN is limited, preterm infants will accrue a mineral deficit until fortification of human milk is initiated.  Fortification of Human Milk is indicated in order to supply the nutrients required and support the rapid rate of growth and bone mineralization in the preterm infant. 

Commercial human milk fortifiers are predominantly a protein and mineral supplement.  They also typically contain additional calories, electrolytes and vitamins. 

Studies have shown that the addition of human milk fortifier is associated with short-term improvements in weight, length, and head circumference growth.  Other studies suggest human milk fortifier may improve bone mineralization and neurologic outcome.  (1 – 5)

The addition of human milk fortifier is well tolerated.  An early study by Lucas et al showed an increase in infections (43% versus 31%) and NEC (5.8% versus 2.2%) in infants fed fortified versus unfortified human milk; however the infants in the study received > 50% of their feeds from formula (6).  Other studies with human milk fortifiers showed an increase in osmolality of the breast milk feeding after initiation of the supplement (7).  Recent changes in fortifier composition have minimized this effect by adding fat and reducing the carbohydrate content of the supplement.

The addition of human milk fortifier appears to have no effect on the IgA content of human milk or on the concentrations of natural killer cell subsets in preterm infants fed the fortified milk (8, 9).  While the addition of human milk fortifier has been found in some studies to temporarily delay gastric emptying and cause a short term increase in gastric residuals and emesis, fortification is not associated with an increase in number of held feedings, incidence of blood in stools, incidence in apnea and bradycardia, or a delay in advancement to full enteral feeds (5, 10 – 12).

Guidelines for the use of human milk fortifier

1. Human Milk Fortifier (24 kcal/oz) is indicated for all breast milk fed infants weighing less than 2000 g.  Infants weighing 2000 – 2500 g may also benefit from the addition of HMF, particularly if they are SGA or demonstrated poor intake and/or growth.
2. Human Milk Fortifier (24 kcal/oz) should be initiated when the infant is tolerating breast milk feeds of > 25 ml/day.  Infants receiving 25 ml of breast milk on the first day of feeds should wait until day of life 3 or 4 before starting HMF.
3. Infants who have been tolerating breast milk + HMF feeds and are made NPO should be restarted on breast milk + HMF feeds.
4. Indications for using concentrated breast milk feeds (27 kcal/oz or 30 kcal/oz high protein) in infants include:
5. 1. Fluid restriction < 140 ml/kg
   2. Poor weight gain (< 10 – 15 g/kg/d) on 120 kcal/kg of 24 kcal/oz Breast Milk + HMF
   3. Metabolic bone disease (alkaline phosphatase > 600 U/L) with poor bone mineralization on x-ray requiring increased intakes of calcium and phosphorus

Note: Infant must be tolerating full feeds with HMF (24 kcal/oz) prior to further advance in nutrient density

5. Infants > 3000 g who require concentrated breast milk feeds should receive breast milk mixed with Term Formula Concentrate.
6. Infants on breast milk concentrated with HMF (27 kcal/oz or 30 kcal/oz) who develop hypercalcemia (ionized calcium > 6.5 mg/dl) or hyperphosphatemia (phosphorus > 7.5 mg/dl) should receive a Nutrition Consult and be switched to the reduced mineral recipe to decrease mineral content (see specific recipe below).

Monitoring guidelines for infants on breast milk + HMF:

Preterm infants fed breast milk + HMF are at risk for hyponatremia due to the limited sodium content of these feeds and increased urinary sodium losses.  Infants fed concentrated breast milk feeds (> 27 kcal/oz) are at risk for hypercalcemia and hyperphosphatemia secondary to the increased mineral content of these feeds.

24 kcal/oz breast milk + HMF

• Check electrolytes weekly until the electrolytes are stable (within normal limits) and the patient is no longer receiving IV fluids or oral electrolyte supplements.

27 kcal/oz breast milk + HMF

• Check electrolytes weekly until the electrolytes are stable (within normal limits) and the patient is no longer receiving IV fluids or oral electrolyte supplements.
• Check ionized calcium and phosphorus weekly while patient is on concentrated breast milk + HMF.  Contact NICU RD if ionized calcium is > 6.5 mg/dl or phosphorus is > 7.5 mg/dl for recommendations to reduce mineral intake with the use of term formula concentrate.

30 kcal/oz breast milk + HMF

• Check electrolytes weekly until the electrolytes are stable (within normal limits) and the patient is no longer receiving IV fluids or oral electrolyte supplements.
• Check ionized calcium and phosphorus weekly while the patient is on concentrated breast milk + HMF.  Contact NICU Dietician if ionized calcium is > 6.5 mg/dl or phosphorus is > 7.5 mg/dl for recommendations to reduce mineral intake with the use of term formula concentrate.

References:

1. Faerk J, Petersen S, Peitersen B, Michaelsen KF.  Diet and bone mineral content at term in premature infants.  Pediatr Res. 2000 Jan;47(1):148-56.
2. Gross SJ.  Bone mineralization in preterm infants fed human milk with and without mineral supplementation.  J Pediatr. 1987 Sep:111(3):450-8.
3. Nicholl RM, Gamsu HR.  Changes in growth and metabolism in very low birthweight infants fed with fortified breast milk.  Acta Paediatr. 1999 Oct;88(10):1056-61.
4. Pettifor JM, Rajah R, Venter A, Moodley GP, Opperman L, Cavaleros M, Ross FP.  Bone mineralization and mineral homeostasis in very low-birth-weight infants fed either human milk or fortified human milk.  J Pediatr Gastroenterol Nutr. 1989 Feb:8(2):217-24.
5. Martins EC, Krebs VLJ.  Effects of the use of fortified raw maternal milk on very low birth weight infants. J Pediatr (Rio J). 2009;85(2):157-162.
6. Lucas A, Fewtrell MS, Morley R, Lucas PJ, Baker BA, Lister G, Bishop NJ.  Randomized outcome trial of human milk fortification and developmental outcome in preterm infants.  Am J Clin Nutr. 1996 Aug;64(2):142-51.
7. DeCurtis M, Candusso M, Pieltain C, Rigo J> Effect of fortification on the osmolality of human milk. Arch Dis Child Fetal neonatal Ed. 1999;81:F141-F143.
8. Jocson MA, Mason EO, Schanler RJ.  The effects of nutrient fortification and varying storage conditions on host defense properties of human milk.  Pediatrics. 1997 Aug;100(2 Pt 1):240-3.
9. Tarcan A, Gurakan B, Tiker F, Ozbek N.  Influence of feeding formula and breast milk fortifier on lymphocyte subsets in very low birth weight premature newborns.  Biol Neonate. 2004;86(1):22-8.  Epub 2004 Feb 20.
10. Ewer AK, Yu VY.  Gastric emptying in pre-term infants:  the effect of breast milk fortifier.  Acta Paediatr. 1996 Sep;85(9):1112-5.
11. McClure RJ, Newell SJ.  Effect of fortifying breast milk on gastric emptying.  Arch Dis Child Fetal Neonatal Ed. 1996 Jan;74(1):F60-2.
12. Moody GJ, Schanler RJ, Lau C, Shulman RJ.  Feeding tolerance in premature infants fed fortified human milk.  J Pediatr Gastroenterol Nutr. 2000 Apr;30(4):408-12.

Recipes for fortified human milk - hospital use

breast milk + human milk fortifier for preterm infants

24 kcal/oz Breast Milk + HMF
      25 mL breast milk
      1 packet Human Milk Fortifier

27 kcal/oz Breast Milk + HMF
      100 mL breast milk
      6 packets Human Milk Fortifier

30 kcal/oz Breast Milk + HMF
      100 mL breast milk
      6 packets Human Milk Fortifier
      30 mL High ProteinTerm Formula Concentrate
(Note - Formula room will prepare high protein concentrate which is made by mixing 1 pkt beneprotein with 150 ml Term Formula Concentrate) 

Reduced calcium/phosphorus breast milk + HMF

27 kcal/oz Reduced Mineral Breast Milk + HMF
      100 mL breast milk
      5 packets Human Milk Fortifier
      20 mL Term Formula Concentrate

30 kcal/oz Reduced Mineral Breast Milk + HMF
      100 mL breast milk
      5 packets Human Milk Fortifier
      50 mL High ProteinTerm Formula Concentrate
(Note - Formula room will prepare high protein concentrate which is made by mixing 1 pkt beneprotein with 150 ml Term Formula Concentrate) 

Concentrated breast milk feeds for term infants

24 kcal/oz Breast Milk
      100 mL breast milk
      25 mL Term Formula Concentrate

27 kcal/oz Breast Milk
      100 mL Breast Milk
        50 mL Term Formula Concentrate

30 kcal/oz Breast Milk
      50 mL Breast Milk
      50 mL Term Formula Concentrate

Written:     5/31/05, Susan Carlson MMSc, RD, CSP, LD, Beth Wojcik RD, LD, and Jonathan Klein MD
Reviewed:     8/11/11; Susan Carlson MMSc, RD, CSP, LD, CNSC, Anne Barker MS, RD, LD and Jonathan Klein MD

Janet F. Geyer, RN, ARNP, C.P.N.P.
Peer Review Status: Internally Peer Reviewed - 2/27/12

Advocating for breast-feeding of ill or preterm infants

For inpatient mothers, the nurse or LIP will:

• Discuss feeding options with mother
• Provide breastfeeding handouts
• Instruct the mother on pumping and storage of breast milk
• Assure that pumping is initiated within the first 6 hours after delivery

For mothers of transported infants, the transport nurses will:

• Give breastfeeding handout to mother
• Ask the local maternity nurse to assure that pumping begins within 6 hours

Initiating non-nutritive "time at the breast"

Baby meets these criteria:

• Corrected gestational age about 32 weeks
• Has ability to swallow own secretions
• Temperature stability
• Tolerates kangaroo care

Nursing interventions:

• Discuss goals of non-nutritive "time at the breast" with mother
• Help position the baby at the breast
• Review pumping techniques with mother and assess her ability to pump
• Arrange housing for the mother close to the nurseries

Progress toward non-nutritive sucking

Baby displays these signs:

• Mouth is at breast, but may not latch on or suck
• May swallow once or twice
• May fall asleep at the breast

Nursing interventions:

• Avoid feeding with a bottle; continue with orogastric or nasogastric gavage
• Time feedings with infant hunger cues if possible
• Teach mother infant feeding cues
• Begin using the SAIB (Systematic Assessment of Infant at Breast) scale to assess progress toward nutritive sucking
• Review with mother the importance of pumping at least 8-10 times a day

Progress toward nutritive sucking

Baby displays these signs:

• Consistently latches on
• Feeds for about 5 minutes
• Shows progress on the SAIB scale

Nursing interventions:

• Communicate infant's feeding progress with physicians and/or nurse practitioners
• Continue supplements as ordered
  • If infant breast feeds < 5 minutes, provide the entire ordered feeding volume by gavage
  • If infant breast feeds 5-10 minutes, provide 1/2 of the ordered feeding by gavage
  • If infant breast feeds > 10 minutes, no supplementation is needed
   
• Use cue-based feedings when possible
• Use finger feeding when the mother is unavailable to breastfeed
• Teach mother to continue to pump between or after feedings if needed
• Minimize pacifier use until breast-feeding proficiency is achieved

Successful transition to breast-feeding

• Baby wakes up for feedings
• Mother identifies nutritive suck and swallow
• Baby feeds well based on SAIB scale
• Baby shows adequate hydration and weight gain without supplementation
• Mother is confident in her ability to breast-feed baby at home

Nursing interventions:

• When mother is not available for breastfeeding, provide milk or formula by gavage or by bottle
• Provide information for local breastfeeding support (Primary care provider, La Leche League, WIC consutant, lactation specialist)
• Complete discharge teaching, document in electronic medical record

Originally written by the Pediatric Nursing Research Committee

References: N-CWS-PEDS-13.010 Breastfeeding: Promotion, Support and Protection SOP

1. Alade, R. L. (1992). Sucking technique and its effects on success of breastfeeding. Birth. 19(4), 185-189.
2. American Academy of Breastfeeding Medicine. #7 Model Breastfeeding Policy.
3. American Academy of Pediatrics. Policy Statement, Breastfeeding and the Use of Human Milk. Pediatrics, 115(2) (February 2005), 496-506.
4. Dix, D. (1991). Why women decide not to breastfeed. Birth:  Issues in Perinatal Care and Education. 18(4), 222-225.
5. Glass, P. (1994). The Vulnerable Neonate and the Intensive Care Environment. Neonatology, Pathophysiology, and Management of the Newborn (4th ed.). J. B. Lippincott.
6. Hubbard, Deborah, Lactation Specialist, Children’s and Women’s Services, UIHC.
7. International Lactation Consultants Association (ILCA). Clinical Guidelines for Establishment of Exclusive Breastfeeding (June, 2005).
8. Isaccson, Laura J. (2006). Steps to Successfully Breastfeed the Premature Infant. Neonatal Network, 25(2), 77-86.
9. Mohrbacher, N., Stock, J. (Eds.) (2003). The Breastfeeding Answer Book. LaLeche League International (3rd ed.). Schaumburg, IL, 542-545.
10. Morris, S. E., Klein, M. D. (1987). Pre-Feeding Skills. Therapy Skill Builders (pub.).
11. Palmer, M. M., Vandenberg, K. A. (1998). A Closer Look at Neonatal Sucking. Neonatal Network, 17 (2), 77-79.
12. Riordan, J., Auerbach, K. (Eds.) (2005). Breastfeeding and Human Lactation (3rd ed.). Jones and Bartlett pub., Boston, MA, 449-481.
13. Zaichkin, J. (2002). Newborn Intensive Care: What Every Parent Needs to Know. NICU Ink, Petaluma, CA.

Research References

1. Alade, R. L. (1990). Effect of delivery room routines on the success of first breastfeed. Lancet. 336, 1105-1107.
2. Arafat, I., Allen, D., Fox, J. (1981). Maternal practice and attitudes towards breastfeeding. JOGNN. 10, 91-95.
3. Baranowski, T., Bee D. E., Rassin, D. L., et al. (1983). Social support, social influence, ethnicity and the breastfeeding decision. Social Science Medicine. 17, 1599-1611.
4. Meier, P. & Mangurten, H. (1993). Breastfeeding the preterm infant. In:  Riordan, J. & Auerbach, K.G. (Eds). Breastfeeding and Human Lactation. Boston:  Jones & Bartlett Publishers, Inc.
5. Ludington-Hoe, S. & others (1994). Kangaroo Care:  Research results and practice implications and guidelines. Neonatal Network, 13, 19-27.
6. Lawrence, R. (2005). Breastfeeding:  A Guide for the Medical Profession, (6th ed.). St. Louis: Mosby.
7. Shrago, L. & Bocar, D. (1990). The Infant’s Contribution to Breastfeeding. JOGNN, 19(3), 209-215.
8. Stine, M. (1990). Breastfeeding the Premature Newborn:  A Protocol Without Bottles. Journal of Human Lactation, 6(4), 167-170.
9. Byzak, Susan (1990). Factors Associated with the Transition to Oral Feeding in Infants Fed by Nasogastric Tubes. The American Journal of Occupational Therapy, 44 (12), 1070-1078.
10. Human Milk Bank Association of North America (2005). Best Practice for Expressing, Storage, and Handling Human Milk in Hospitals, Homes, and Child Care Settings.