by Anne Eglash MD, IBCLC, FABM
What are current recommendations for feeding the premature NICU graduate? The Academy of Breastfeeding Medicine recently updated their Clinical Protocol #12: Transitioning the Breastfeeding Preterm Infant from the Neonatal Intensive Care Unit to Home, Revised 2018
For many premature infants in the USA, post-discharge care is done by physicians or other providers who do not work in the neonatal intensive care unit. These outpatient providers, as well as lactation consultants who care for premature NICU graduates need guidance on how to help mom gradually transition the infant to either fully nursing or taking 100% unfortified breastmilk. Many families are instructed at the time of NICU discharge to either fortify their breastmilk with high calorie formula, or to supplement their premature infant with formula, but the parameters for stopping fortification/supplementation is often unclear. Having to continue calories from formula keeps these NICU grads from feeding 100% at the breast, and may lead to early weaning, due to the maternal stress of needing to incorporate some combination of pumping, supplementing at the breast, and bottle feeding.
This protocol reviews what the parameters are for adequate growth. These include a weight gain of at least 20g/day, a length increase of 0.5-0.8cm/week, head circumference increase of 0.5-0.8cm/week, an alkaline phosphatase of less than 450 IU/L, blood urea nitrogen greater than 10mg/dl, a phosphorus level of greater than 5ml/dl, a vitamin D level of greater than 30ng/ml, and a hemoglobin greater than 11.5g/dl.
The authors do state that if a premature infant is growing well in the NICU according to the above parameters it is reasonable to transition the infant to 100% unfortified breastmilk prior to discharge, or at the time of discharge, with close follow-up of the growth measurements. It is recommended to use the Intergrowth-21st Postnatal Growth of Preterm Infants growth charts until 50 weeks postmenstrual age.
What do you think are true statements based on the Academy of Breastfeeding Medicine’s updated protocol? (choose 1 or more)
- Infants who are breastfeeding at the time of discharge have longer breastfeeding durations.
- A weight/length measurement over the 85% indicates over-nutrition.
- All premature infants should receive 2-4mg/kg/day of iron.
- Premature infants who are gaining at least 20 grams a day post NICU discharge do not need blood testing for adequate nutrition.
See the Answer
A,B,C are correct, D is not correct.
Read the Article
(the updated protocol will eventually be available free of charge at www.bfmed.org/protocols)
Milk Mob Comment by Anne Eglash MD, IBCLC, FABM
The authors recommend biochemical screening for growth at 1 month post discharge and at 4 months corrected age in addition to monitoring infant weight gain as measures of adequate nutrition.
As a physician who often cares for premature NICU grads, I rarely if ever see a premature infant in my community who was prescribed unfortified breastmilk ad lib at the time of NICU discharge. This may be just our regional health practice, since medical practice trends differ geographically. This protocol is important because it provides indications to stop supplementation, rather than assuming that fortification needs to go on for a prescribed time such as 3-4 months. However, providers in my community are not conducting routine blood testing on premature NICU grads as recommended by this protocol. In addition, we use EPIC electronic medical software, and in our medical group, the Fenton growth chart is available for use, not the Intergrowth-21 charts. The Fenton does not provide weight/length measurement. Regarding growth, I typically consider adequate weight gain to be 30g/day, not 20g/day for outpatient infants in the first 3 months of life, unless they are petite and staying on their growth curve.
This protocol is a good start, and now we need change in outpatient practices to further support infant transition to full breastfeeding.