For premature babies, getting the right amount of nutrition at each feeding is crucial for growth and development. Premature infants, also known as preemies, often have difficulty coordinating sucking, swallowing and breathing while feeding. As a result, preemies may need specialized support and care when it comes to feeding.
What is a preemie?
A preemie is a baby born before 37 weeks of pregnancy. Full term pregnancy is considered to be 39 to 40 weeks. Preemies may be:
- Late preterm – born between 34 and 37 weeks
- Moderately preterm – born between 32 and 34 weeks
- Very preterm – born at less than 32 weeks
The earlier a baby is born, the higher the risk for medical problems and complications. Preemies often have difficulty feeding because their organs, including the brain, lungs and gastrointestinal system, are still developing.
Why is getting proper nutrition important for preemies?
Proper nutrition is essential to help preemies:
- Achieve appropriate growth and development
- Develop a strong immune system
- Heal and recover from medical issues related to prematurity
- Prepare for discharge from the neonatal intensive care unit (NICU)
Because preemies are growing and developing so rapidly, they need more calories and nutrients than full term babies. Getting adequate nutrition during the first weeks and months of life lays the foundation for long-term health and development.
What are some feeding challenges for preemies?
Some of the common feeding issues preemies may face include:
- Poor sucking reflex – Preemies may have an uncoordinated or weak suck that makes it hard to breastfeed or bottle feed.
- Difficulty coordinating suck-swallow-breathe pattern – Preemies may forget to breathe while eating, take breaths during swallowing, or have apnea episodes.
- Feeding fatigue – Eating takes a lot of energy for preemies and they may tire quickly while feeding.
- Gastroesophageal reflux – Preemies have an increased risk of spitting up or reflux after eating.
- Slow gastric emptying – Food may remain in a preemie’s stomach for longer periods of time.
These issues can lead to inadequate nutrient intake and poor growth. Preemies often need specialized support, such as tube feeding or thickened feeds, to get the nutrition they need.
How are preemies fed in the NICU?
Feeding methods for preemies may include:
- IV nutrition – Preemies receive fluid, calories, protein, fat, vitamins and minerals through an intravenous line (IV).
- Tube feeding – Breastmilk or formula is delivered through a small tube passed through the nose or mouth into the stomach.
- Bottle feeding – Preemies are given expressed breastmilk or formula by bottle when they demonstrate readiness.
- Breastfeeding – Mothers can provide breastmilk via tube feeding or nurse directly at the breast when the preemie has a mature suck-swallow-breathe pattern.
The NICU team works closely with parents to support feeding development and transition preemies to full oral feeds when they are medically stable and demonstrate feeding readiness.
How do doctors determine how much a preemie should eat?
The recommended intake for preemies is based on the baby’s:
- Gestational age at birth
- Birth weight
- Current weight
- Medical condition and complications
In general, preemies need between 120 to 150 calories per kilogram per day to support growth and development. The calorie level is often higher for extremely preterm or very low birth weight babies.
The NICU team, including neonatologists, nurses and dietitians, calculates the right amount of milk or formula needed to help the preemie gain weight and grow appropriately. Intake is tailored to the individual baby and adjusted as the preemie’s needs change.
Feeding volumes based on preemie size
As a general guideline, preemies usually start at lower feeding volumes and advance as tolerated. Here are typical feeding ranges based on size:
| Preemie Size | Feeding Volume Range |
|---|---|
| Less than 1,500 g (3.3 lbs) | 2 to 10 mL per feed |
| 1,500 – 2,500 g (3.3 – 5.5 lbs) | 15 to 30 mL per feed |
| Greater than 2,500 g (5.5 lbs) | 30 to 60 mL per feed |
Feedings are usually started slowly at lower volumes and advanced in a stepwise manner based on the preemie’s tolerance and clinical status. Preemies are fed at least 8 to 12 times per day to provide adequate calories and nutrition.
Factors affecting feeding volumes for preemies
There are many factors that impact how much milk or formula a preemie can take at each feeding, including:
- Birth gestational age and weight – Younger, smaller babies start at lower volumes.
- Tolerance – Signs of feeding intolerance like apnea, bradycardia, desaturation or reflux require slower advancement.
- Medical conditions – Issues like sepsis, pneumonia or heart conditions affect feeding tolerance.
- Growth trajectory – Preemies who need extra calories for catch-up growth may require more volume.
- Transition to breastfeeding – Direct breastfeeding may involve smaller volumes until stamina improves.
The NICU team monitors how the baby handles each feeding and makes adjustments to ensure optimal nutrition without overwhelming the preemie.
Strategies for increasing feeding volumes
Some strategies used in the NICU to safely increase a preemie’s feeding volumes include:
- Advancing by 10-30 mL/kg per day as tolerated
- Fortifying breastmilk or using higher calorie formula
- Adding nutrient powders or oils to increase calorie density
- Adjusting feeding frequency – 8 to 12 times per day
- Pacing feeds with breaks to improve tolerance
- Using feeding tubes or specialty bottles/nipples if needed
Careful assessment guides how quickly volumes are increased to ensure preemies are developing appropriate oral feeding skills.
Transitioning from tube to bottle feeding
The transition from tube to full bottle feeding usually happens gradually, often over weeks or months. This process allows the preemie to develop coordination of suck-swallow-breathe.
Here are some tips that can help preemies transition to bottle feeds:
- Start with 1-2 bottle feeds per day, alternating with tube feeds
- Choose times when baby is alert and demonstrates hunger cues
- Utilize pacifiers and non-nutritive sucking to develop skills
- Offer small volumes (5-30 mL) at first, then advance slowly as tolerated
- Use specialized bottles/nipples designed for preemies
- Frequently monitor oxygen levels, heart rate, respiration during oral feeds
- Provide supportive comfort measures like swaddling or positioning
The NICU team works closely with parents/caregivers to know when to progress bottle feeds and ensure the transition is successful.
Tracking growth and adjusting intake
NICUs closely monitor a preemie’s growth with frequent weight checks, head circumference and length measurements. Growth velocity helps determine if feeding volumes and calories need adjustment.
- Preemies should gain 15-20 g (0.5-0.7 oz) per day or 110-150 g (4-5 oz) per week.
- Poor weight gain may necessitate increased calorie or volume intake.
- Excessive weight gain could indicate overfeeding or fluid retention issues.
Growth that falls above or below expected rates prompts nutrition adjustments under medical guidance. Preemies are weighed daily at first and then weekly closer to discharge as growth rates stabilize.
Discharge from the NICU
Most preemies are discharged from the NICU once they:
- Weigh close to their expected birth weight
- Maintain body temperature outside the isolette
- Take all feeds by breast and/or bottle without difficulty
- Show appropriate weight gain and growth
Prior to discharge, the medical team makes sure parents are comfortable and confident with all aspects of feeding and infant care. Ongoing support from the baby’s pediatrician is recommended after NICU discharge to ensure continued proper growth and development.
Takeaway points
Key points to remember about feeding volumes for preemies:
- Start with lower volumes based on size, then advance slowly as tolerated
- Frequent small feeds (8-12x/day) provides optimal nutrition
- Monitor tolerance and watch for signs of reflux, apnea, fatigue
- Fortify breastmilk or use higher calorie formula if extra calories are needed
- Weigh frequently and adjust volumes to achieve appropriate growth
- Work closely with medical team for safe transition to full bottle feeds
With specialized support and care, most preemies can achieve successful feedings and continue to thrive after discharge from the NICU.
