1. Feeding of preterm infants should start when they are hemodynamically stable and have signs of feeding readiness like presence of bowel sounds and lack of abdominal distension. 2. Feeding can be started with trophic or minimal enteral feeds for extremely preterm infants or those recovering from conditions like NEC. 3. Standard feeding advancement involves slow increases in milk volume based on weight and gestational age, checking for signs of feeding intolerance, with the goal of meeting caloric needs. Breast milk is preferred but preterm formulas can be used.

1. By
Dr Magdy Shafik Ramadan
Ph. D Pediatrics
Pediatric Consultant

2. When to start
How to start
Signs of feeding intolerance
Supplemants
General Rules
Objectives

3. The baby is not distressed:
>80: no oral feeding
60-80: trophic feeding ( orogastric – 0.5 – 1 ml / hour
infusion or bolus )
Neurologically intact

4. 1-Significant hypoxic/asphyxic event or
acidosis
2-Symptomatic sepsis.
3- Suspected or confirmed NEC.
4- Evidence of intestinal obstruction/perforation or
paralytic ileus.
5-Presence of symptomatic PDA.
6- Treatment with indomethacin for PDA

5. 1-Presence of bowel sounds
2- Lack of abdominal distension
3- Stable blood pressure
4- Stable electrolytes (as electrolyte
abnormalities affect gastric motility)
5- Stable respiratory status

6. Type of milk:
breast milk is the ideal
Formula is the alternative
NB. start with glucose was removed from protocol since
several years
Amount: 2-5 cc milk with suction after 2 hours.
Route:
<32-34 weeks → orogastric feeding (suckling swallowing
coordination is not well developed)
>34 weeks→ breast feeding if available or bottle feeding

7. 1-Trophic feeding (non-nutritive feeding)
also known as minimal enteral nutrition
(MEN), gut-priming or hypo caloric
feeding,
2-Standard feeding advancement (nutritive
feeding)

8. Trophic feeding
Indications
Premature infants with extremely low birth weights (<1,000
gm).
Infants recovering from NEC.
Infants who have been NPO for an extended period of time.
N.B.: Mechanical ventilation or the presence of UAC (per se)
is not a contraindication for initiation of trophic
.feedings
.

9. Strategy
Use colostrum/breast milk or full strength term or
pretermformulas (20 kcal/oz);begin at a volume of one ml
every 6 hrs for 2 days, then one ml every 4 hrs for another 2
days, and then advance slowly to reach 10-20 ml/kg/day
divided intoequal aliquotsand administered by gavage
feeding every 3-6 hrs as slow bolus feeds.
Trophic feeds should be used until the infant becomes
clinically stable enough for feeding advancement.
The transition to nutritive enteral feedings then can
proceed slowly, with continuous assessment of feeding
tolerance (see later) to avoid complications such as NEC.

10. N.B.: Expressed breast milk (EBM) is the preferred milk
for MEN.
Advantages
Improve GI motility
Promote GI hormones and enzyme secretion
Improve feeding tolerance
Allow earlier progression to full enteral feedings

11. 2-Standard feeding advancement (nutritive
feeding)
Caloric requirements:
healthy term infant average 110 (100-120)
kcal/kg/day.
Preterm infants 120-130kcal/kg/day
Infants with severe and/or prolonged illness (up to 130-
150 kcal/kg/day)

12. :Strategy
Weight-specific guidelines are based on birth weight
and gestational age (GA):
► Weight: <1,200 gm; GA <30 weeks.
□ Volume: 1-2 ml/ kg every 2 hrs, and advance by 10-20 ml/kg/day.
full □ Type: EBM, term or preterm formulas (20 kcal/oz). Once
feedings of 20kcal/oz are tolerated, consider preterm formulas (24
kcal/oz), or adding human milk fortifier (HMF) to breast milk (if
available
► Weight: 1,200-1,500 gm; GA <32 weeks
□ Volume: 1-2 ml/kg every 3 hrs, and advance by 10-20 ml/kg/day.
□ Type: EBM, term or preterm formulas (20 kcal/oz). Once full
feedings of 20kcal/oz are tolerated, consider preterm formulas (24
kcal/oz) or adding HMF to
breast milk (if available

13. ► Weight: 1,500-2,000 gm; GA 32-36 weeks
□ Volume: 2.5-5 ml/kg every 3 hrs, and advance by 10-20 ml/kg/day
as tolerated.
□ Type: breast milk or preterm formulas.
► Weight: 2,000-2,500 gm; GA >36 weeks.
□ Volume: 5 ml/kg every 3 hrs, and advance by 10-20 ml/kg/day as
tolerated.
□ Type: breast milk or term formula.
Another suggested enteral feeding strategy for stable, growing
preterm infants is presented in(Table 20-1); this should be
individualized based on the infant’s clinical status/severity.

14. Type of milk:
breast milk is the ideal
Formula is the alternative
Breast milk:
1-the mother’s own preterm breast milk is the milk of
choice for her preterm infant. Compared with term
breast milk, preterm breast milk has higher
levels of energy, lipids, protein, nitrogen, fatty acids,
some vitamins, and minerals(such as sodium,
chloride, and magnesium). In addition, preterm breast
milk has higher levels of immune factors

15. 2-Hindmilk feeding; the lipid and caloric content of
hindmilk is greater than that of foremilk. Some researchers
recommend that the hindmilk fraction of expressed breast
milk to be predominantly used for feeding of preterm VLBW
infant
3-Human milk fortifier (HMF):
is added to the breast milk to increase energy, protein, and essential
minerals (calcium, phosphorus, zinc, and cupper) to a level that is more
appropriate for preterm infants
► HMF is used in premature infants with birth weights <1,500 gm and
should be considered in those with birth weights <2,000 gm

16. ► The addition of HMF is started once preterm infants are
tolerating 100 ml/kg/day of breast milk and continued for
up to the time of discharge or at a weight of 2,000 gm.
► Example:
□ Fortify with 1 packet HMF, to each 50 ml breast milk when baby
receives 100ml/kg (22 kcal/oz)
□ Fortify with 1 packet HMF, to each 25 ml breast milk when baby
receives 150ml/kg (24 kcal/oz)

17. Formula KCAL
density
Volume to =
108 kcal/kg/day120 kcal/kg/day
20 cal/oz (67.6 cal/100
ml)
160 ml/kg/day180 ml/kg/day
22 cal/oz (74 cal/100
ml)
145 ml/kg/day160 ml/kg/day
24 cal/oz (81 cal/100
ml)
135 ml/kg/day150 ml/kg/day
27 cal/oz (91 cal/100
ml)
120 ml/kg/day130 ml/kg/day
30 cal/oz (100 cal/100
ml)
110 ml/kg/day120 ml/kg/day
Fluids to meet nutritional needs-
enteral nutrition

19. Formulas:
► Term formulas (20 kcal/oz) :are adequate to meet the needs
of term infants
► Preterm formulas
□ they contain a higher calcium and phosphorus ratio,
increased protein, vitamins, electrolytes and caloric content
sufficient for the growth of the premature infant.
□ Preterm formulas are available in 2 preparations:
- 20 kcal/oz formulas; and
- 24 kcal/oz formulas
□ They are indicated in preterm infants <1,800-2,000 gm.

20. □ Start with preterm formula (20 kcal/oz) and advance to
preterm formula (24cal/oz), as tolerated, at 100 ml/kg of
volume. This volume is then maintained for approximately 24
hrs before the advanced schedule is resumed.
□ Preterm formulas are given until the infants weigh 2,000-
2,500 gm.

21. Transition to breast/bottle feedings
1-Infants who are 34 weeks' gestation and who have
coordinated suck-swallow-breathe patterns and
respiratory rate <60/minute are candidates for
breast/bottle feeds
Oral feedings should begin slowly at one feeding per day,
then increase as tolerated to once every 8 hrs, then once
every third feeding, then every other feeding

23. Shift to full oral:
When reach 1/2 requirements, IVF could be stopped
with more rapid advancement
With preterm specially VLBW: slow advancement is
the rule

24. Supplemants:
Full term: no supplements.
Preterm:
Folic acid 500 microgram tab:1/2 tab twice weekly till 2 kg weight is
reached
Poly vitamins:5drops with feeding once or twice /day for 2 month
Iron supplements: 2-3 mg/kg starting after 3 weeks for 2 months
Corn oil: 0.13 ml/30 ml milk for caloric increase without amount increase

25. Gastric residue:
50 %: stop and try again after 2 hours
≥20% but less than 50 % push it again with prolonged
interval (/3hours)
Brownish gastric aspirate: stop oral feeding – assessment
for NEC
Abdominal distension : stop oral feeding – assessment
for NEC
Bloody stools : : stop oral feeding – assessment for NEC

26. General Rules
Caloric requirements 110 -140 Kcal/kg/day
Every 100 ml cc milk contain about 67 kcal
The target increase in weight is 15gm/kg/day (10-
25gm/kg/day)
Start with only 2-5 cc milk /feed
Suction after 2 hours
Abdominal circumference before every feeding
Increments very slowly with preterm specially VLBW
Start Dompridone 1ml/kg /day before feeding
Weight record everyday for full term and twice daily for
preterm