Dear colleagues, 

I'm a neonatologist in South Brazil and we're writing a new feeding protocol... we frequently disagree about the amount of milk we should start for late preterm/term infants, who cannot breastfeed right away, but can be enterally fed. They are babies that are not so sick that need to be NPO, but still have to be in neonatal ward. 

Some people calculate same volume as It would be parenterally, some tend to wait to see if baby will be able to breastfeed in the next hours, some tend to start with 10ml...

In my opinions and in my readings, it is not very easy to get an agreement... so I would love to read some opinions around the world to check how everybody else is doing.

Best regards,

Greice

Thanks for raising this question, I think this is a more common patient than those needing iv fluids / TPN!

For a term infant we typical start with 40 ml/kg/d and a late preterm (say 34-36w) we usually go for 40-60 depending on fetal growth, clinical situation etc. We increase feeding volume w 20-30 ml/kg/d. 

We feed every 3 hours, so a 3 kg term would have 120 ml first 24 hours. We would probably feed some thing like 10 ml x 1-2, 15 ml x 5-6 and then 20ml per feed.

it is common we do not go up to ”full feeding”which at our NICU is 170-185 ml/kg/d. If the infant is starting breastfeeding practise early (for example, term infant with TTN) we usually stop at 125~150 to promote a quicker full breastfeeding.

Of course, we do take b-glucose, weight development, nutritional needs due to clinical symptoms and everything like that into account, so all infants have their own path too  

 

Thank you for sharing, dr. Stefan! 

I think this strategy of starting with less and increasing in the next feedings seems very reasonable. 

As you said, all infants have their own path, so even though they are "easier" patients, they might require more thinking and more individualized approach (don't we all? 😁). Once again, there's probably no one size fits all. 

I too tend to start with less and, when it is feasible, tend to wait a little to offer, trying to mimic what would happen if baby and mom would be together. 

Fully agree, also the "easy patients" deserve an individualized strategy, similarly to the TLC that we otherwise dedicate to the tiny preterm infants.

I agree with Stefan, we have very similar feeding practice at my NICU.

Hi, @Greice Batista

I'm also a Neonatologist from south Brazil, and we are reviewing our feeding protocols.

About late preterm infants, we start with 30-40 ml/kg/d enteral feedings, and if the baby tolerates well, we progress the volume twice in one day (to 60 and then 80 ml/kg/day).

We increase twice daily until they are on 150-160 ml/kg/day.

We also stimulate breastfeeding, and they usually progress very well.

Let me know if you want to share other practics and ideas...

On 1/23/2025 at 9:23 PM, Greice Batista said:

Dear colleagues, 

I'm a neonatologist in South Brazil and we're writing a new feeding protocol... we frequently disagree about the amount of milk we should start for late preterm/term infants, who cannot breastfeed right away, but can be enterally fed. They are babies that are not so sick that need to be NPO, but still have to be in neonatal ward. 

Some people calculate same volume as It would be parenterally, some tend to wait to see if baby will be able to breastfeed in the next hours, some tend to start with 10ml...

In my opinions and in my readings, it is not very easy to get an agreement... so I would love to read some opinions around the world to check how everybody else is doing.

Best regards,

Greice

This is our schedule for enteral feeds, the columns is as follows:

Gestational age at birth, Bolus starting amount (ml/kg/feed), Bolus daily increase (ml/kg/feed), days until full eneteral nutrition.

There was a post about this on bluesky regarding a recently published study.

Where we also got a suggestion from how they do in Aarhus in Denmark. https://bsky.app/profile/padkaer.bsky.social/post/3lhgbmxkyis2y

thank you @Padkaer for sharing

Thank you Stefan

My experience is that most of neonatology are following the old figures of 60 mls/kg day one, 90 mls/kg day2 and 120 mls/kg day 3. with higher figure in Prems.

My practice since i worked with late prof. Cliff Roberton is to keep premature babies crisp ! , so agree with your suggested figures.

Regards.

Manual nutricão v1.2024.docx

I’d like to translate it to English…

I think this approach is a little conservative, bur after inquire the team, I saw that there were too many concerns about progressing too fast. Let’s see how it goes.

Practice change can be a challenge, even if it’s evidence based! Good luck, and thank you for sharing!

Nice feeding plan from different NICU but the most important gain is avoiding needless starvation as practised in the past for fear of different outcomes. Buccal colostrum is typically now also started from delivery room.