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Nancy E. Wight, MD, FAAP, IBCLC Overview. As survival rates for preterm infants and all NICU patients improve, more attention is being focused on improving the quality of survival through optimal nutritional management. Fortification of human milk has been repeatedly demonstrated to have short-term growth advantages for preterm infants born less than approximately 34 weeks gestation or 1800 g birth weight when given both during and after initial hospitalization (Hall 2001, Griffin 2002). VLBW infants grow faster and have higher bone mineral content up to 1 year of age if provided with additional nutrients (especially protein, calcium and phosphorus). Exclusively breastfed former preterm infants tend to "catch-up" if given sufficient time (2-8 yrs). The optimal growth rate (reference target) has not yet been established for post-discharge preterm infants. It is unclear whether the rapid catch-up growth seen with supplementation is of benefit or harm for long term overall health, growth and neurodevelopment (Hall 2001, Griffin 2002).
Although preterm birth does not limit milk production capacity, preterm infants are vulnerable to under consumption until term+ corrected age (Meier 2003). Adequacy of milk supply is a key factor in successful transition to full direct breastfeeding. (Furman 2002) Clinical estimates of milk intake are unreliable (Meier 1994, Scanlon 2002). No alternate feeding method has been shown, as yet, to increase success of direct breastfeeding in preterm infants. At present there are no randomized-controlled trials of methods for transition from bottles or alternate feeding methods to the breast. Discharge planning, started on admission to the NICU, can help assure infants receive appropriate nutrition and mothers reach their breastfeeding goals. Appropriate follow-up is essential (Hall 2001).
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Post-discharge Nutrition. All infants < 34 wks or < 1800 g at birth, and other larger infants with nutritional risk factors (CLD, short gut, neurologic impairment, etc.), should have a complete nutritional assessment prior to discharge which should include both growth parameters (weight, length, head circumference) and biochemical measurements (phosphorus, alkaline phosphatase, urea nitrogen, transthyretin/prealbumin). If the infant is taking 160-80 cc/kg/day and growth parameters are normal or improving (see table) on human milk alone for a week or more prior to discharge, human milk alone should be adequate post-discharge.
If supplementation is deemed necessary, support breastfeeding by having mother directly breastfeed, then substitute from 1-4 feedings per 24 hrs of preterm or post-discharge enhanced formula as needed to reach growth and biochemical goals. Multivitamins with Fe should be added/continued (1 cc/day) for at least 3-6 months, although the exact length of use has yet to be determined. If formula constitutes > 50% of an infant's daily intake, the dose should be 1/2 cc per day.
Transition to Full Breastfeeding at Home. Mothers should continue to pump to maintain milk supply for at least 1 month post-discharge. A common mistake is to advise the pump-dependent mother to stop pumping and just breastfeed. Typically the pump is more effective and efficient than the still preterm infant in maintaining production, and the infant is more capable of accessing and maintaining flow when production exceeds demand.
The mother may need to "triple feed" initially. This involves breastfeeding for a limited amount of time, supplementing liberally with previously pumped breastmilk, or formula, if needed, then pumping. When the infant is growing well, and the volume of supplementation is decreasing, the mother can alternate between limited breastfeeds, followed by supplementation and limited breastfeeds followed by pumping. If the infant continues to grow well, then unlimited demand breastfeeding can be tried, anticipating that the infant may request to feed more frequently. Pumping frequency should be tapered slowly, dropping a session every 2-3 days.
Close monitoring with weights and lactation support are important. Initially breastfeeds should be time-limited to 30-40 minutes. Small infants may fall asleep at the breast due to fatigue, not satiety. As clinical estimates of intake at the breast are unreliable, the use of a home scale and test weighing should be considered. Test weighing has been shown not stressful for mothers, but reassuring, so an appropriate amount of supplement can be given. (Hurst 1999). Continue the method of supplementation initiated in the hospital and agreed upon by mother, physician, nurse and lactation consultant, at home. Although cup feedings have been determined safe in preterm infants, the volumes consumed are significantly smaller and the duration of feedings longer, than with a bottle. (Marinelli 2001)
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