Nutritional management of newborn infants: Practical guidelines

Table 1 Evidence-based enteral nutrition in preterm newborns

	Evidence-based enteral nutrition
Human milk	Human milk from the preterm infant's own mother is the first choice. Human milk can be stored at room temperature for up to 24 h after expression in colostrum and up to 6 h for mature milk. Beyond that, it should be stored at 3-4°C before use. If not used for more than 5 d, it should be frozen
Human milk fortifier	Human milk fortifier is indicated in preterm infants < 31 wk and/or < 1500 g. Human milk (100 mL/kg) is given per day and discontinued when the infant has established full breast-feeding
Formula milk	If human milk from the preterm infant's own mother is not available, the only acceptable alternative is a preterm formula. A concentration of about 60 kcal/100 mL or 20 kcal/oz is recommended, but should be increased to 80 kcal/100 mL or 24 kcal/oz when the infant has achieved full enteral feeds
Feeding methods	Gavage feeding is given via an indwelling nasogastric tube during mechanical ventilation. An indwelling orogastric tube is used after endotracheal extubation. Intermittent intragastric feeding is the first choice method, but continuous transpyloric feeding can be tried in selected preterm infants with extremely poor gastric emptying and symptomatic gastro-esophageal reflux
Commencement of feeds	Hourly feeds of 1 mL are generally used in infants weighing less than 1000 g, 2-h 2 mL for infants weighing 1000-1500 g, 3-h 3 mL for infants weighing 1500-2000 g, and 4-h 4 mL for infants weighing more than 2000 g, unless there is significant respiratory distress, when the infant remains on 1-2-h feeds. If this might not be tolerated, milk may be commenced at 1 mL every 2 h, even less than 1 mL every 4-6 h. Such trophic feeding should begin as soon as possible after birth, and definitely within the first 3-4 d
Progression of feeds	Daily increment in the range of 10-30 mL/kg of milk feeds is safe. Demand feeding is started after infants have established full milk feeds on a 4 h regimen. Non-nutritive sucking is beneficial without side effects
Supplements	Multivitamin supplement is started when the infant has established full enteral feeds, and iron is started when the infant has doubled their birth weight (usually at 2 mo). Medium-chain triglycerides can be used as an energy supplement for preterm infants who fail to thrive