ABM Clinical Protocol #12: Transitioning the Breastfeeding Preterm Infant from the Neonatal Intensive Care Unit to Home, Revised 2018

Abstract

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols, free from commercial interest or influence, for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient .

Introduction and Background

THE PRACTICE OF breastfeeding or providing expressed mother’s milk to preterm infants is promoted because of the considerable benefits to their health and well-being. Ideally, preterm infants in the neonatal intensive care unit (NICU) are fed their own mothers’ milk or donor human milk fortified with multiple nutrients and calories to optimize growth and development. Breastfeeding at the breast in the NICU before discharge should be encouraged as it may increase the breastfeeding duration. Near the time of discharge, a decision must be made as to how preterm infants should feed in the postdischarge period.

Growth faltering has been observed in some preterm infants in the NICU and in the postdischarge period if they receive exclusive human milk feedings without nutrient and caloric fortification. Of concern, evidence also suggests that such a nutritional deficit may adversely affect the head circumference, a finding that is associated with poorer neurodevelopmental outcomes. In addition, these infants are at risk for developing metabolic bone disease osteopenia or even rickets.

Unfortunately, there are few systematic studies on the impact of postdischarge fortification for preterm infants. A 2011 Cochrane review of published studies stated that there is not enough evidence to conclude that fortification improves infant growth. In addition, studies suggest that overly rapid early growth may be detrimental for NICU graduates, increasing the risk of long-term health problems such as obesity, diabetes, heart disease, and metabolic syndrome.

As such, the following guidelines are a consensus of best practices that include recommendations for monitoring and providing optimal nutritional support for preterm infants after they are discharged from the hospital. This protocol addresses the care of preterm infants born at a gestational age less than 34 weeks who are discharged home after a stay in the NICU. The American Academy of Pediatrics has recommended that preterm infants be discharged after achieving three physiologic competencies: oral feeding sufficient to support appropriate growth, the ability to maintain normal body temperature in a home environment, and sufficiently mature respiratory control. These competencies are achieved by most preterm infants at a postmenstrual age (PMA) between 36 and 37 weeks, but may take longer. This protocol does not distinguish infants born appropriate for gestational age from small for gestational age, but bases decisions on current nutritional status and body weight. Quality of evidence [levels of evidence IA, IB, IIA, IIB, III, and IV] is based on levels of evidence used for the National Guidelines Clearing House and is noted in parentheses.

General Strategies

• A.

  The goal of the discharge feeding plan recommendations for preterm infants is to enable the mother to exclusively breastfeed or provide as much human milk as possible while protecting and supporting the mothers’ decisions. Specific recommendations on supporting breastfeeding in mothers of premature infants are given in the Support for Breastfeeding Mothers of Premature Infants section.

• B.

  In addition, the feeding plan should correct deficits that arose during the NICU stay and minimize further nutrient deficits after discharge. As the nutritional status of preterm infants varies widely, creating individualized feeding plans is the best approach.

• C.

  All preterm infants should be routinely supplemented with iron, 2–4 mg/kg/day. Vitamin D supplementation of 400 IU per day is recommended by the American Academy of Pediatrics, while 800–1,000 IU/day is recommended by the European Society for Paediatric Gastroenterology Hepatology and Nutrition. Higher doses of iron are recommended, up to 5 mg/kg/day, if hemoglobin is <11 g/dL ( Table 1 ), and higher doses of vitamin D, up to 1,000 IU/day, are recommended in infants with evidence of metabolic bone disease, with an alkaline phosphatase >500 (IIA).

  Table 1

  Biochemical and Growth Monitoring for Premature Infants in the Postdischarge Period

  Modified from Hall and Schanler Conversion factors for biochemical markers: 1. Milligrams/deciliter (mg/dL) to millimoles/liter—divide by 18. 2. Nanograms/milliliter (ng/mL) to nanomoles/liter—multiply by 2.5 (i.e., 1 ng/mL=2.5 nmol/L). 3. International units to micrograms—divide by 40.

  Parameters	Goal	Action values
  A. Growth
  1. Weight gain	20 g/day	<15 g/day
  2. Length increase	0.5–0.8 cm/week	<0.5 cm/week
  3. Head circumference increase a	0.5–0.8 cm/week	<0.5 cm/week or >1 cm/week
  4. Weight/length	>85% c
  B. Biochemical markers
  1. Alkaline phosphatase b	<450 IU/L	>500 IU/L
  2. Blood urea nitrogen	>10 mg/dL	<8 mg/dL
  3. Phosphorus	>5 mg/dL	<5 mg/dL
  4. Vitamin D level	>30 ng/mL	<25 ng/mL
  5. Hemoglobin	>11.5 g/dL	<11 g/dL

  a Changes in head circumference require cranial imaging, such as a cranial ultrasound.

  b High alkaline phosphatase levels may indicate a need for bone imaging, such as a bone x-ray.

  c This is an indication of overnutrition and a cue to stop supplementation.

• D.

  Enriched formula or human milk fortifier is used when fortification is necessary because it provides greater nutrient intake than human milk alone or term infant formula. Although the current published studies on postdischarge supplementation utilized human milk fortifiers, fortifiers are usually not given at home due to lack of availability and expense. The new liquid human milk fortifiers derived from human milk can be tailored more and could potentially be useful in this population; however, they are not readily available and are very expensive. Therefore, enriched formula mixed with expressed human milk generally is a more practical plan to provide fortification in the postdischarge period (IIA).