Nutrition for the Preterm, VLBW Infant After NICU Discharge

Importance of Human Milk to the VLBW Infant

Mother’s own milk, appropriately fortified, is the optimal nutrition for VLBW infants.

• Every mother should receive information about the critical importance of mother's own milk to the health of a VLBW infant.
• Mother’s own milk has been associated with multiple health benefits for VLBW infants, including lower incidences of
  
  • necrotizing enterocolitis
  • late-onset sepsis
  • chronic lung disease 
  • retinopathy of prematurity
  • neurodevelopmental impairment

The principal goal for infants with very low birth weight is the provision of the mother’s own milk, with donor human milk as a bridge or support while the mother’s milk is made available or increasing in volume.

Donor Milk

Health care providers should discourage families from direct human milk sharing or purchasing human milk from the Internet because of the increased risks of bacterial or viral contamination of nonpasteurized milk and the possibility of exposure to medications, drugs, or other substances, including cow milk protein.

Pasteurized human donor milk is recommended when mother’s own milk is not available or sufficient. However, donor milk is nutritionally suboptimal to a mother’s own milk and should be seen as a bridge until a full supply of mother’s milk is available

• Human milk provision is lowest among non-Hispanic Black and American Indian/Alaska Native populations and within the southern region of the United States 
• pasteurization, freeze-thaw cycles, multiple container changes, and prolonged storage times required for donor milk processing reduce its bioactivity
• When donor milk is provided alone or in combination with mother’s own milk feeding, it is protective against NEC. But donor milk does not appear to confer the additional health benefits that have been reported with mother’s own milk, such as reduction in late-onset sepsis or improvements in neurodevelopment. 
  
  

Feeding the VLBW Infant

Barriers to breastfeeding in the NICU, may make nutrition and feeding more complicated after discharge. These barriers include:

• prolonged immature oromotor coordination,
• mother-infant separation
• the need for fortification of mother’s own milk to optimize growth.

Typically, mothers of babies in the NICU are encouraged to begin oral feeding at the breast as soon as the infant shows physiologic readiness (ie, feeding cues), and the infant’s level of respiratory support allows for oral feeding. Oral feedings at the breast have been studied as early as 31 to 33 weeks’ postmenstrual age. Direct breastfeeding occurs as often as the infant’s condition and mother’s presence allows.

Strategies to provide optimal nutrition after discharge (whether breastmilk, formula or a combination of the two) include:

• Reevaluating the newborn within 24 to 48 hours.
• Arranging post-discharge lactation consultation, if feasible. La Leche League International and Women, Infants, and Children (WIC) are valuable community resources that offer lactation support and peer counseling. Some hospitals offer lactation support clinics.
• Advising the mother to continue to keep a log of the infant’s feedings, any supplementation given, and the infant’s elimination pattern.
• Ensuring that the mother has a clear feeding plan for her late preterm infant at discharge regardless of whether the infant is breast- or formula-feeding.
• Tailoring formula intake recommendations to the individual neonate. Although most formula-fed late preterm infants are fed a 19−20 cal/oz term infant formula, those who are small for gestational age (<2,000 g) or who exhibit excessive weight loss or poor weight gain (<15 g/day) may require higher-calorie full-term or post discharge preterm infant formula.
• Advising the mother that her infant should be breastfed with careful attention to feeding cues and nurse, 8 times in a 24-hour period.
• Transitioning from higher-calorie formula to standard 19−20 cal/oz infant formula when the infant is demonstrating good weight gain (30 to 40 g/day) and growth is above the 10th percentile for postmenstrual age on the World Health Organization Growth Charts for Infants 0 to 24 Months.
• Avoiding soy protein-based formula because of the increased risk of osteopenia.