Gaining and Growing: Assuring Nutritional Care of Preterm Infants in the Community


 Hospital to Home
 Transition to the Breast
 Infant's Need for Additional Supplements
 Assessing Breastfeeding Success


Hospital to Home

Expressing Milk

Mothers who plan to breastfeed need to express milk for a prolonged time until the infant is ready to nipple at the breast. Even when the baby starts to go to breast, milk expression should be continued to maintain the milk supply. By the time of discharge it is often recommended that the mother pump enough to build up a milk supply that is 50% greater than her baby will need. Most infants complete the transition to complete nipple feeding after discharge from the hospital. For these infants, it is often the case that the mother needs to continue expressing milk and that the infant continues to receive some supplemental feedings.

Establishing Schedules

The practice of feeding infants on a set schedule in the hospital may not prepare a mother for more typical breastfeeding behavior. If possible, more frequent nursing and/or rooming-in periods before discharge to home should be arranged.

Follow-up plans at discharge

Consultation with the same lactation specialist prior to discharge, and shortly after discharge may facilitate transition to home. It is sometimes recommended that the infant be weighed at the primary care provider's office on the way home and again at 24 to 72 hours after discharge. Frequent weights should be obtained until the weight-gain pattern is satisfactory. Incremental growth assessment will be a useful tool for close monitoring. Plans for test weighing may be appropriate; in which case families may need help obtaining an accurate scale before discharge.

Transition to the Breast

The transition to full breastfeeding involves three major issues:

Maternal Supply

Maternal milk supply depends primarily on regular breast emptying provided by either the breast pump or the infant. If the mother perceives that her milk supply is limited, the solution is to increase the time spent pumping or the number of pumping episodes each day. Double pumps that allow expression of milk from both breasts at the same time may increase prolactin levels and enhance milk production. If the milk supply does not improve within three days, the mother should be referred to a lactation specialist for a more thorough evaluation.

Maternal Let Down

The post discharge period is usually found to be stressful for families of VLBW infants. Anxiety, stress, and fatigue may interfere with maternal let down reflexes. Families may need to implement plans to reduce these factors for the breastfeeding mother as much as possible. Often, lack of let down is also related to the infant's weak and immature suck.

Infant's Feeding Skills and Abilities

There are several reasons that a VLBW infant's feeding skills and abilities may be limited. Assessment of these skills and abilities should be routine in both breastfeeding and bottle feeding infants. Feeding difficulties and skills are covered in the section on assessment of feeding skills.

Infant's Need for Additional Supplements

Vitamins and Minerals

The breastfed VLBW infant will need vitamin and mineral supplements. See section on supplementation recommendations.

Additional Energy, Protein, Carbohydrate, and Fat:

  • When needed? When a mother's milk supply is low, or an infant's feeding skills or endurance for feeding are inadequate to sustain growth, supplements may be needed. Supplementation is a frequent occurrence in this population. The common advice offered to families of full-term infants about avoiding supplements in the first weeks at home is not safe advice for high risk infants.
  • What to offer? Supplements may be expressed breastmilk, expressed breastmilk that has been fortified to increase energy and nutrients, standard infant formula, or concentrated formula. Human milk fortifiers (Enfamil Human Milk Fortifier and Similac Human Milk Fortifier) are designed for gaining and growing premature infants in the hospital. Because these two products contain high levels of vitamins A and D these products should not be continued at the point where the vitamin D intake exceeds recommendations. This will occur at different weights depending on the content of the product. Please see section on increasing formula concentration for more information about energy content of potential additions to breastmilk and concentrating formulas for additional feedings.
  • How to deliver? Supplements may be delivered with additional bottle feedings, offering the bottle after breastfeeding, or a supplemental nursing system. An abstract suggests that Supplemental nursing systems may not work well for feeding preterm infants (Meier P. Pediatric Clinics of North America - Neonatology, #2344, 5/13/1999.) Although cup feeding is used in some settings, this method has not been shown to be an efficient feeding method for preterm infants. The choice of method will vary based on maternal/infant needs, preferences, and the infant's feeding skills.
  • When to deliver? If an infant is unable to sustain prolonged nippling due to respiratory or energy reserve limitations, offering a bottle immediately post feed may not be successful. In planning methods of supplementation it is useful to remember that frequency of nippling at breast enhances milk supply and should be incorporated in the plan.

Assessing Breastfeeding Success


In the long run, growth is the best indicator of breastfeeding success

During an individual feeding

Assessment of feeding effectiveness may be difficult during early breastfeedings in the VLBW infant. In older infants, signs of effective breastfeeding include rhythmic sustained suckling, audible swallow, softening of the maternal breast and maternal signs of milk ejection.

Feeding pattern

The American Academy of Pediatrics has endorsed the WHO/UNICEF Ten Steps to Successful Breastfeeding guidelines (AAP Committee on Breastfeeding, 2012).


Infants should have more than 5 wet diapers a day. Super-absorbant disposable diapers invalidate this method of assessing breastfeeding success.

Test weights for breastfed infants

Short-term weight gain may be a valuable assessment tool. Meier et al. (1994) recommends a program of test weighing in the home for 2 to 3 weeks after discharge for some infants. The basic steps of test weighing are as follows:

  • Before hospital discharge, family obtains an accurate infant scale that can weigh in grams for home.
  • A minimum daily milk intake is prescribed in milliliters at the time of hospital discharge. This is usually determined by an infant's energy intake and growth pattern in the hospital.
  • Family and health care providers make plans for appropriate supplement choice if it is needed.
  • After discharge family keeps records of pre and post test weights for each feeding. If diapers are not changed between weights, a somewhat accurate indication of the amount of liquid that was ingested can be made.
  • At the end of a set period of time, say 6 to 8 hours, the infant's actual intake is compared with the prescribed volume.
  • If the infant consumes less than the prescribed amount, a supplementary bottle feeding, preferably of expressed breast milk, is given as needed to make up the deficit.
  • The plan for weights and supplemental feedings is frequently reviewed by a breastfeeding specialist and or the primary care provider.
  • When the infant has shown that he or she can gain weight steadily, the frequency of test weights may be reduced. Daily weights may be recommended for a few weeks to assure adequate intakes.

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Page reviewed: March 24, 2015