Breastfeeding Of High-Risk Infants After Discharge From The NICU: A Nutritional Perspective

December 6, 2011

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Up to 10% of all newborns will spend some time in a neonatal intensive care unit. They will often just spend a few days there due to jaundice or being born as “late preterms” at 34-36 weeks gestation. However, they may have much longer hospital stays due to being very low birth weight (VLBW, <1500 g at birth) or having congenital health problems. The vast majority of these babies will go home and do well, but they may have unexpected feeding problems.

In addition to occasional breastfeeding difficulties, the medical team must consider the nutritional aspects of breastfeeding high-risk infants after they go home. I’d like to help guide parents in understanding what goes into the medical team’s decisions about nutrition as they prepare to send an infant home from the NICU.

First, it is important to remember that virtually all infants benefit from being fed human milk. Babies who have spent time in the NICU may particularly benefit after they go home from the immunological and growth factors that are unique to human milk. Fighting off infections and developing a healthy intestine are critical for many infants who have required an NICU stay.

However, most VLBW babies benefit from getting higher levels of some nutrients, like calcium, than are found in human milk. Human milk is critically important for these babies, but it does not, over the course of their hospitalization, provide enough protein and minerals to support the fast growth rate of the smallest preterm infants. Therefore, while they are hospitalized, we provide extra protein and minerals through the use of specialized products added to human milk. Some of these are derived from human milk while others are derived from infant formulas.

When ready to go home, most VLBW infants have not reached the weight of a full-term infant and also have not reached the same bone mineralization as a full-term infant. They will often benefit from a small amount of extra protein and minerals, usually for at least a couple months after hospital discharge. This is most commonly done by having the infant be breastfed (or fed a bottle of mother’s milk) most of the time, but receive 1 to 3 bottles per day of an infant formula designed for use by preterm infants after they go home. This small amount of specialized formula helps with growth and bone mineralization and can often be discontinued by the pediatrician after a few months, although for very tiny infants, it is sometimes needed for most of the first year of life.

Some families wish to avoid using any infant formula after hospital discharge or have infants who don’t tolerate formula well. In this case, I encourage pediatricians to work with the family and carefully monitor the infant’s body and bone growth carefully. If all is well, then there is no need to intervene and the baby can be exclusively breastfed. If growth, especially carefully measured increases in length, slows down considerably, then an individualized approach to nutrition is needed that may include nutritional supplements.  A consultation with a pediatric gastroenterologist may be helpful in these cases.

Above all, mothers should be strongly encouraged to breastfeed or provide their milk as the primary nutritional source for their infant, rather than switching entirely to an infant formula due to fears of slow growth. Adding a small amount of formula should not be seen as a sign of breastfeeding failure, but instead as a way to support the growth of small infants to provide the best possible long-term outcome.

Infants who go home from the NICU, regardless of feeding type, often need additional vitamins and iron. Again, this is expected and reflects the rapid growth of these infants and the loss of some of the iron they would have gotten during pregnancy had they been born full-term.

In addition to VLBW infants, infants with other health problems, such as congenital heart disease, may need specialized feedings after they go home. The principles described here are the same. Focus on the importance of human milk, but families should understand that a small formula supplement is sometimes needed.

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