Dear colleagues,

I would love to read your thoughts on how you manage moderate/late preterm infants admitted in the NICU who do not have enough mother's milk. How do you feed them? Do you prefer to keep them on IV fluids/PN until MOM is available? Do you have unlimited donor milk to use for every baby? How is your level of concern about cow's milk allergy (CMA)?

I work in a teaching hospital in South Brazil and I'm an enthusiast (aren't we all?) on improving breastfeeding rates in the NICU.

How things work here: we have a limited resource of human donor milk, so we prioritize it to newborns under 32 weeks (when MOM is not available, of course). For babies older than that, when MOM is not available, we are using hydrolyzed formula in the first 24 hours - as an intention to try to avoid early exposure to cow's milk protein.

I am very aware that we don't have good evidence for that. In the ESPGHAN position paper on CMA (https://www.espghan.org/knowledge-center/publications/Gastroenterology/2024-Diagnois-and-Management-of-Cows-Milk-Alergy), it might seem OK to give hydrolyzed formula, and I like the thoughts on how offering this different type of formula might help parents to see it as something temporary.

The thing is sometimes babies keep on receiving hydrolyzed formula for longer than 24 hours, and we also do not have enough of that.

New thoughts on CMA prevention seem to go on a way that probably continue exposure to CMP might help prevent allergies. So, probably, offering hydrolyzed formula to babies who will stay longer in NICU might not be a good idea. Maybe later on I'll start a new topic on CMA in NICU too :)

           Formula Feeding in NICU

Formula feeding in moderate and late preterm infants (32 to <37 weeks gestation) admitted to the NICU is a nuanced topic.

While mother’s own milk remains the gold standard, clinical realities often require consideration of formula.

Here’s a concise overview:

1. Preferred Choice: Mother’s Own Milk (MOM)

   •   Immunological protection, reduced risk of NEC (Necrotizing Enterocolitis).

   •   Enhances gut maturity, promotes neurodevelopment.

   •   Should be prioritized with early lactation support and expression within 6 hours of birth.

2. Donor Human Milk (DHM)

   •   Recommended when MOM is unavailable, especially for infants <34 weeks or <1500g.

   •   Often prioritized in high-risk preterms; in moderate/late preterms, availability may be limited.

3. When Formula is Considered?

Formula becomes a practical choice when:

   •   MOM and DHM are unavailable or insufficient.

   •   There is a delay in milk expression or maternal illness.

   •   Infant is clinically stable and feeding readiness is appropriate.

4. Type of Formula

   •   Preterm formula (higher calories, protein, minerals) is ideal until term corrected age or appropriate growth is achieved.

   •   Transition to term formula or fortified breast milk once growth stabilizes.

5. Risks of Formula in Preterms

   •   Higher risk of feeding intolerance, NEC, and dysbiosis of gut flora,CMPA.

   •   Greater metabolic load on immature kidneys.

6. Feeding Strategy

   •   Minimal enteral nutrition (MEN) with expressed milk is encouraged even if formula is needed later.

   •   Fortification of MOM can be done based on weight and biochemical parameters.

   •   Individualized feeding plan is essential based on growth, tolerance, and comorbidities.

Take-Home Points

   •   Breast milk is best, but formula has a role when human milk is not available.

   •   Use preterm-specific formula when necessary.

   •   Close monitoring of feeding tolerance and growth is vital.

   •   Shared decision-making with parents is key—education about feeding benefits, risks, and plans.

 Dr A Jaleel Ahamed

 Coimbatore

Many thanks @Greice Batista for starting this important topic. While we have good access to donor bank milk, we usually restrict donor milk use to infants <32 weeks or <1500g. The logic is simple pragmatism, we would not have enough if we would universally adopt donor milk to all say <34 weeks.

We do not use IV fluids or TPN unless the infants is unstable and needs intensive care, and I think you share our experience that the majority of those infants ≥32 weeks are just fine. Only nCPAP for transient tachypnea or mild RDS is not a reason to switch from full enteral feeding to IV fluids in our NICU, given reasonable feeding tolerance. We typically aim for 40-60 ml/kg/d enterally the first day of life and then gradually increase to full enteral feeding within 5-6 days (≥150 ml/kg/d).

The formula we use is "partly hydrolysed", and we keep using it until there's mother own milk or until discharge, whatever comes first. If the mother does not intend to breastfeed, we commonly switch to regular term baby formula before discharge. My personal advice to parents is to get the basic / cheapest one, there is such a big business of around formula and most more expensive variants of term formula is IMHO not backed by data showing benefits. But there are many variations on this theme, as you probably also experience.

When it comes to cow milk allergy specifically, this is nothing we discuss in the NICU. Back in the days, there were a lot of advice given to parents and also to health care professionals about avoiding "XYZ" to reduce the risk of "ABC", but I agree with you that the trend in the Allergy World is rather that early gradual exposure is beneficial for tolerance.

How do you do in your NICU with IV fluids, formula types, volumes etc?

Thank you for your answer, Dr. Stefan! I specially appreciate you saying "My personal advice to parents is to get the basic / cheapest one, there is such a big business of around formula and most more expensive variants of term formula is IMHO not backed by data showing benefits. But there are many variations on this theme, as you probably also experience", because I do the same and I don't find it very easy to discuss this topic with other colleagues.

In our unit, we are trying a few things:

• a QI project, to start expressing milk from mothers in the first 6 hours. We noticed that most health workers "felt sorry" for the mother and thought they should wait for around 24h to start "asking for milk". We're hoping that sooner we will have to worry less about this topic, since we're going to have more MOM available.

• For preterm infants, we use hydrolyzed formula in the first 24 hours, expecting that hopefully after that period of time, we will have MOM available - of course, that does not happen all the time. After that period, we start regular formula - maybe if we had unlimited resources, we would keep on using hydrolyzed formula for late preterm and term infants, but I am aware that we are not sure it would reduce CPMA.

• For a newborn who does not have risk factors for hypoglycemia, we try to wait for hunger cues to offer formula.

• If the baby is already on IV fluids (i.e., late preterm or term NB), I personally try not to rush with formula if there is some perspective of offering MOM in the next 12-24 hours.

• We also aim for 40-60ml/kg/d, but I'm afraid maybe we, neonatologists, are less tolerant with feeding intolerance! So I believe we do better with the lower range.

Hoping to be reading other units experience around here soon!

Great discussion. We are also in a low resource setting in Odisha ,India. We do not have a human milk bank.

I have also had to use formula feeds even for some newborns in the wards because of documented borderline sugars. This is especially for prime gravidas and post LSCS mothers. The rationale being it is better to prevent hypoglycemia and its consequences and not be very strict about formula especially in the first 24 hrs. We always give formula after checking blood sugars. "Not enough Milk" is the most common complaint during post natal rounds.

Any role of galactagogues and if so which ones in your experience.

Any major difference between preterm formula and term formulas as their are cost implications

No mother is allowed to buy any formula as per the IMS act. It is always hospital supply.

On 5/19/2025 at 8:41 PM, Abdul kasim jaleel ahmed said:

Preferred Choice: Mother’s Own Milk (MOM)

As long as there is no enough evidence about hazards of few formula feedings till the breast milk is available, We use normal formula when there is no enough breast milk.

On 5/25/2025 at 11:15 PM, Mohan said:

Great discussion. We are also in a low resource setting in Odisha ,India. We do not have a human milk bank.

I have also had to use formula feeds even for some newborns in the wards because of documented borderline sugars. This is especially for prime gravidas and post LSCS mothers. The rationale being it is better to prevent hypoglycemia and its consequences and not be very strict about formula especially in the first 24 hrs. We always give formula after checking blood sugars. "Not enough Milk" is the most common complaint during post natal rounds.

Any role of galactagogues and if so which ones in your experience.

Any major difference between preterm formula and term formulas as their are cost implications

No mother is allowed to buy any formula as per the IMS act. It is always hospital supply.

Here in our nursery, we use dextrose in the first 24 hours when we identify asymptomatic newborns with low blood sugar (we always try to breastfeed and "harvest" colostrum first). After that period, if there is not enough breast milk, we use formula too. We have a form to fill when we prescribe formula. When we look at the data, we see not enough milk and excessive weight loss as the main causes for supplementation.

We don't use galactogogues routinely here. If we do, I believe domperidone is the first choice.

Hi @Greice Batista , I work in a surgical nicu in UK and we have a very protective approach to feeding, similar to yours for preterm babies 30-33 weeks, especially IUGR with documented poor Antenatal Doppler flows. We stratify these babies into high risk, moderate risk and low risk depending on their background and occasionally preterm IUGR babies <1.2-1.4 kg would receive IV fluids/ TPN while we slowly increase enteral Maternal/Donor EBM feeds over 7-10 days. While I agree with @Stefan Johansson that there’s no strong evidence to support this practice, practically we have struggled with poor growth and abdominal concerns in the smaller IUGR babies, when we tried to push feeds in the past.

I’m awaiting the results of the FEED1 trial RCT which compared rapid vs normal rate of feeding in 30+0 -32 week babies to find out more.

Hi @Greice Batista

I work in a private hospital unit that does not have a human milk bank, but we do have a lactation center. Despite this, we have achieved excellent breastfeeding outcomes in our NICU. We begin with the most extremely premature infants, implementing a routine of prolonged oral immunotherapy as soon as the mother begins expressing milk, and we continue this practice until the infant transitions to full oral feeding. We have trained personnel to start early support for breastfeeding initiation for preterm mothers, and even when they start a little bit later (second or third day postpartum), most of them are successful in coming to volume. For these youngest babies (<30 weeks and/or under 1500 grams), we initiate an amino acid and glucose solution immediately upon their admission to the NICU. We wait for expressed breast milk to become available before starting enteral nutrition—typically within the first 72 hours. Our breastfeeding rate at discharge in this group (not exclusive, but predominant) is approximately 95%.

For moderate to late preterm infants, we aim to initiate enteral feeding with breast milk within the first 48 hours of life. On average, these babies achieve full enteral feeds between 7 and 10 days of life, always prioritizing their own mother’s milk. When breast milk is unavailable, we begin with preterm infant formula. In this group, we rarely observe cow's milk protein allergy. We are more tolerant of frequent vomiting episodes (always monitoring weight gain) and continue encouraging mothers to express milk. The breastfeeding rate at discharge in this population is slightly lower, around 80%.

I believe the most impactful change was the creation of a multidisciplinary team and the implementation of weekly breastfeeding-focused rounds. Through this initiative, we began daily monitoring of breastfeeding rates at discharge, stratifying infants by gestational age (<30 weeks vs. ≥30 weeks). This helped us identify lower breastfeeding rates at discharge, particularly among the more mature preterm infants. We then constructed a Dashboard, making this data available for everyone in the NICU.

We are aware that certain characteristics of our population also facilitate our results: most mothers have private health insurance or are hospitalized as private patients, which means they are generally entitled to formal maternity leave and have easier access to the NICU. Their increased presence in the unit allows our team to provide ongoing guidance and support for breastfeeding. I recognize that this scenario may not always be feasible for patients in the public healthcare system (SUS)...

On 6/24/2025 at 5:45 PM, Mariana Oliveira said:

I believe the most impactful change was the creation of a multidisciplinary team and the implementation of weekly breastfeeding-focused rounds. Through this initiative, we began daily monitoring of breastfeeding rates at discharge, stratifying infants by gestational age (<30 weeks vs. ≥30 weeks). This helped us identify lower breastfeeding rates at discharge, particularly among the more mature preterm infants. We then constructed a Dashboard, making this data available for everyone in the NICU.

I really liked this idea, Mariana! I'll definetely try to put this in practice here. We have rounds and I do believe they talk about it, but the idea of focusing "only" in breastfeeding and breastmilk might enhance the importance of it. Thank you for sharing!