If on fortified EBM with protein supplements total fluid volume should not exceed 150ml/kg/day due to a theoretical risk of protein toxicity. We believe that breastfeeding is the ideal nutritional start for babies and we fully support the World Health Organization’s recommendation of exclusive breastfeeding for the first six months of life followed by the introduction of adequate nutritious complementary foods along with continued breastfeeding up to two years of age. Increased preterm nutritional requirements persist beyond the time when early milk composition changes to that of mature milk. This often coincides with a slowing of weight gain and a sequential reduction in serum urea, where a level <1.6mmol/l is indicative of a protein intake of <3g/kg (65).

Moro GE et al(1991) Growth and Metabolic Responses in Low-Birth-Weight Infants Fed Human Milk Fortified with Human Milk Protein or with a Bovine Milk Protein Preparation. Journal of Pediatric Gastroenterology and Nutrition; 13(2):150-54. Lucas A, Fewtrell M, Morley R, Lucas P, Baker B, Lister G, et al. Randomized outcome trial of human milk fortification and developmental outcome in preterm infants. Am J Clin Nutr 1996;64(2):142-51. Lucas A et al. Randomised controlled trial of a synthetic triglyceride milk formula for preterm infants. Archives of Disease in Childhood 1997; 77: F178–F184. Andersen C, Hart J, Vemgal P, Harrison C, Prospective evaluation of a multi-factorial prevention strategy on the impact of nosocomial infection in very-low-birthweight infants. J Hosp Infect . 2005 Oct;61(2):162-7.Breast milk is fortified without knowing the nutritional composition of an individual mother's EBM. As the composition of breast milk, particularly protein concentration, varies from one mother to the next and from expression to expression in the same mother, individual analysis prior to fortification would appear to be of value. Such analysis is at present impractical in day to day practice. The most recent evidence from the SIFT study showed that slow advancement of feeding in very low birthweight infants did not reduce the risk of NEC showing no advantage in increasing at 18ml/kg/day versus 30ml/kg/day. (14) http://www.unicef.org.uk/Documents/Baby_Friendly/Research/Liz_Jones_article_full.pdf?epslanguage=en Where maternal EBM is not available preterm formulas are to be used for babies born <34/40 and <2000g who have none of the risk factors outlined above. Advance to an initial volume of 150ml/kg/day increasing to 165-180ml/kg/day as indicated by weight gain and volume tolerance.

Bolus fed infants may experience less feed intolerance and have a greater rate of weight gain. (27) R W I Cooke, L Foulder-Hughes, Growth impairment in the very preterm and cognitive and motor performance at 7 years, Arch Dis Child 2003 ; 88 : 482 - 487 Current UK practice strongly advocates the use of donor milk as a supplement to mother's milk or to establish enteral feeds. Likewise the recent AAP publication on use of DBM recommends use for those infants <30 weeks gestation and/or <1500g. Bellander. M. et al(2003) Tolerance to early human milk feeding is not compromised by Indomethacin in preterms with PDA. ActaPaediatrica: 921074-8 Koenig W.J et al (1995) Manometrics for preterm and term infants: a new tool for old questions. Pediatrics, 95,203-206

SMA® Gold Prem 2

There is no good evidence that slow advancement of feeding in very low birth weight infants reduces the risk of NEC (17,18,19). Reaching full enteral feeds faster results in earlier removal of vascular catheters, less sepsis and fewer other catheter-related complications. (18) The SIFT trial concluded there is no evidence that slower advancement in feeds reduces risk of NEC, even in those infants thought to be at “high risk” (20). Specialised formulas should only be used where absolutely necessary and ideally under the direction of a Paediatric and Neonatal Dietician. If feeding contraindicated/feeding intolerance, colostrum should be used buccally as mouth care (see below).

Gastric residual volume and colour of aspirate may indicate level of gut maturity rather than gut dysfunction and as volumes vary in the early stages of feeding significant increases should not be used in isolation when deciding to limit advancement of feeds. Wang Q, Dong J, Zhu Y. (2012) Probiotic supplement reduces risk of necrotizing enterocolitis and mortality in preterm very low-birth-weight infants: an updated meta-analysis of 20 randomized, controlled trials. J Pediatr Surg; 47(1):241-8. During establishment of feeds it is common to find small quantities of bile in the gastric residuals. Factors contributing to nutrient deficits are numerous, though fluid restriction is often the greatest contributor. The majority of infants will meet their nutritional requirements with between 150 and 180ml/kg of an appropriate feed, therefore interruption and reductions in feeds to below 150ml/kg should be minimised. Where prolonged fluid restrictions are unavoidable in the older formula fed infant eg cardiac disease, consideration should be given to the use of nutrient dense term formulas such as SMA High Energy or Infatrini.Amber Level 3- Specialist Initiation with ongoing monitoring requirements (Full Amber Drug Guidance required) Assess the infant’s feed tolerance at least twice daily, before making each increment in feed volumes. However, some infants with feed intolerance may have significant intra-abdominal or other problems. On specialist/secondary care recommendation only: for cows’ milk protein allergy or intolerance in infants with liver, gastro or cardiac disease