Chapter 7.3 — Enteral Nutrition & Human Milk

Enteral nutrition is the goal for every neonate: it maintains gut integrity, drives normal development, and (with human milk) protects against infection and necrotising enterocolitis. In preterm infants the strategy is to start early trophic feeds, advance steadily to full enteral feeding, use human milk preferentially, and fortify to meet the exceptional growth needs of prematurity — all while remaining alert to NEC.

• All neonates establishing enteral feeds, with emphasis on preterm/VLBW/ELBW infants and those transitioning off parenteral nutrition.
• Infants at NEC risk and those needing fortification or specialised feeds.
• Cross-references: parenteral nutrition (7.2), fluids (7.1), VLBW care (2.1), and NEC.

• Start trophic feeds with MOM/DHM alongside PN within 6–12 hours of birth if stable (consider day 1 for ELBW infants): 20 mL/kg/day at ≤1250 g, held for 3 days at 751–1250 g and 3–5 days at ≤750 g. This promotes gut maturation without increasing NEC.
• Not reasons to withhold: umbilical catheters, dopamine ≤5 mcg/kg/min, or indomethacin/ibuprofen treatment (advance 24 hours after the last dose); individualise for genuinely high-risk infants (e.g., significant growth restriction with absent/reversed end-diastolic flow) using the unit pathway.

• Advance daily by birth weight (Table 14-8a, section 8+): 20 mL/kg/day at ≤1250 g, 30 at 1251–1500 g, 30–40 above 1500 g; cardiac infants may need to stay at 20 for longer.
• Evidence (e.g., SIFT) shows faster advancement does not increase NEC or death versus slower advancement and reaches full feeds sooner — favour the standard, not ultra-slow, rate unless contraindicated.
• Reduce PN in step with rising feeds (lipid off at 80 mL/kg/day; PN off once feeds exceed 100 mL/kg/day — see 7.2). Full feeds: 160 mL/kg/day of fortified human milk below 34 weeks PMA (150 of high-protein preterm formula); 180–200 unfortified from 34 weeks. Then adjust for growth.

• Preterm infants are usually fed by orogastric/nasogastric tube until sucking feeds develop (typically around 32–34 weeks corrected); confirm tube position before feeds.
• Bolus (intermittent) feeding is standard; continuous feeding is used selectively. Support non-nutritive sucking and cue-based oral feeding as maturity allows, with breastfeeding support.

• Start early: within 6–12 hours of birth if stable; for ELBW infants, consider day 1. ≤1250 g: trophic feeds at 20 mL/kg/day, generally not counted toward total fluid intake. Continue trophic feeds for 3 days at 751–1250 g and 3–5 days at ≤750 g; for 22–23 weeks see chapter 2.2.
• Not reasons to withhold trophic feeds: low-dose vasopressors (dopamine ≤5 mcg/kg/min), umbilical catheters, and indomethacin or ibuprofen treatment — but advance only 24 hours after the last dose. Trophic feeds may be prolonged on high-dose vasopressors.
• Method: bolus feeds every 3 hours. With intolerance, run each bolus on a pump over 30 minutes. Avoid continuous feeds except for severe intolerance, because fat is lost in the tubing. Routine residual checks are not supported in most VLBW infants.
• Milk hierarchy in orders: maternal expressed milk first, then donor milk. Formula should not be listed as a backup for infants ≤1800 g or ≤34 weeks PMA; above those limits it is an acceptable backup. Record parental assent before any donor milk.

• Human-milk-based fortifier (≤1250 g): add it to maternal or donor milk once feeds reach 60 mL/kg/day, taking the milk to about 26 kcal/oz. Bovine fortifier: add it after one day at 80 mL/kg/day, to 24 kcal/oz — the same rule applies to infants 1251–2000 g, or <34 weeks PMA.
• PN and lipid come off as feeds rise: lipid stops when feeds reach 80 mL/kg/day and PN once feeds exceed 100 mL/kg/day. Total fluid runs at about 140–150 mL/kg/day, reaching 150–160 mL/kg/day of fortified milk by day 7 (1251–1500 g), day 10 (751–1250 g on human-milk fortifier) or day 12 (≤750 g on human-milk fortifier); the bovine-fortifier schedules run a day or so later. Below 1000 g, total fluid also counts line flushes and drugs (chapter 7.1).
• 1501–2000 g: start with maternal/donor milk (20 kcal/oz) or high-protein preterm formula (24 kcal/oz) at 20 mL/kg/day alongside IV fluid, reaching 160 mL/kg/day by day 7. >2000 g: ad lib up to 30, 60, 90, 120 and then 150 mL/kg/day over days 0–5, with a minimum of 30–40 mL/kg/day if feeding exclusively by mouth (top up with IV fluid otherwise).
• Well infants ≥34 weeks or ≥2000 g really do take little at first: most need no more than 30–40 mL/kg/day in the first 48 hours and 50 mL/kg/day on days 3–4 — write orders to match. Once on full oral feeds they do not need fortification or preterm formula. Transitional formula may be started in healthy infants of 1800–2200 g.
• Below 1500 g, give bolus feeds by gravity, or on a pump over 30–60 minutes when intolerance occurs.

• Prepare early: non-nutritive sucking on a pacifier during tube feeds as soon as the infant is stable; frequent skin-to-skin; non-nutritive breastfeeding from 32 weeks PMA if stable (CPAP is not a contraindication). Put the breast before the bottle, and invite parents to be present for the first oral feed.
• Supply for the pumping mother: stimulate the breasts every 2–3 hours (8–10 times a day) in the first weeks. For mothers aiming to breastfeed exclusively, consider delaying bottles until the infant manages two successful breastfeeds a day.
• When to start: consider oral feeds at 32–34 weeks PMA when stable on minimal support (high-flow cannula under 2 L/min or low-flow). Bovine-fortified milk is not a barrier. On CPAP or high flow above 2 L/min, limited oral feeds may build skills in stable infants with chronic lung disease — the goal is skill, not full oral feeds. Before any oral feed on CPAP, the infant must be >37 weeks PMA, on FiO₂ below 40%, showing cues, able to protect the airway, and formally assessed by OT or speech therapy. Evidence on the safety of oral feeds above 2 L/min is inconclusive.
• Cue-based feeding: nurses score readiness at every care time from 32 weeks PMA. Start oral attempts once 4 of the last 8 scores are A or B; after that, each attempt needs an A or B. Discuss scores on rounds. Never push a feed to completion — gavage the remainder, since good skills matter more than finishing a bottle.
• Test weighing for early breastfeeds: weigh the clothed infant on the same electronic scale before and after (1 g = 1 mL transferred). Limit to once or twice a day; the result guides supplements.
• Pulling the tube: once the infant takes 75% of feeds orally, consider removing the tube to watch intake and weight — 75% covers only minimal hydration needs. If intake or gain has not improved within 3–4 days, replace the tube and consider discharge on partial tube feeds (chapter 2.5) or delay discharge.
• Refer for feeding difficulty: desaturation, apnoea, bradycardia, cough or choke, colour change, stress cues, poor tone. Aspiration risk is higher with long intubation, severe hypotonia, neurological or craniofacial disorders, and tracheostomy or ventilator dependence. OT handles oral-motor therapy and feeding progression; speech pathology assesses dysphagia and arranges VFSS or FEES when swallow dysfunction is suspected.

• The AAP recommends exclusive breastfeeding for 6 months and continued breastfeeding through 2 years. Formula-fed infants have more respiratory, ear and gastrointestinal infections, more allergic and autoimmune disease, and a higher SIDS incidence.
• Skin-to-skin as soon after delivery as possible, with the first breastfeed within the first hour — after caesarean as well as vaginal birth. Feed to hunger cues, 8–12 times a day, usually at least 10–15 minutes on each breast. No water supplements. Avoid pacifiers and other artificial nipples until breastfeeding is established — about the first 4 weeks.
• Signs that feeding is effective: a sustained deep latch, long jaw movements, swallowing heard or seen, and little or no maternal discomfort.

• Infant indications beyond those above: signs of inadequate intake on day 5 or later (continued weight loss or meconium stools); loss above the 75th nomogram percentile; poor milk transfer despite adequate supply and skilled lactation help (expressed milk may be used).
• Maternal indications: Sheehan syndrome (postpartum haemorrhage followed by failed lactogenesis), primary glandular insufficiency, breast pathology or surgery limiting production, and hypolactation of unknown cause despite appropriate management.
• What to give: mother's expressed milk or colostrum and/or donor milk first, then formula. How: a tube-at-breast supplementer is the most physiological; syringe, spoon, cup or bottle are alternatives, chosen with the mother — bottles are the most likely to disturb latch.