Department of Health

Enteral feeding

Key messages

  • Enteral feeds for babies in a Special Care Nursery (SCN) may be breast milk or infant formula
  • Enteral feeds may be at the breast, by orogastric or nasogastric tube, or by bottle or cup
  • If the mother intends to breastfeed, baby's first nutritive sucking should be at the breast wherever possible
  • Skin to skin contact has been shown to promote longer duration of breastfeeding and should be encouraged
  • If a mother chooses to feed her baby expressed breast milk (EBM) or infant formula, her choice should be supported.

Types of food for babies in SCN

Breast milk

  • Breast milk has significant advantages over formula with respect to long-term neurodevelopmental outcomes. It also reduces the  risks of feed intolerance and necrotising enterocolitis.
  • It may be appropriate to delay enteral feeding until the mother’s EBM is available, including when the mother requests to withhold formula. 

Breast milk fortification

  • Breast milk can be supplemented by combining it with a commercial breast milk fortifier, considered in babies with birth weight less than 1500 g or those who were born at earlier than 30 weeks gestation, once receiving 100–150 mL/kg/day enteral feeds
  • Human milk fortifier provides increased protein, energy and minerals for the breast milk fed preterm infant.

Donor milk

  • When the mother’s own milk is not available, pasteurised donor milk is the next best option, particularly for unwell or high-risk infants. In Victoria, pasteurised donor milk is only available in Level 6 neonatal units
  • Informal breast milk sharing arrangements without medical oversight are not recommended for babies in SCN. Unscreened and unpasteurised donor breast milk poses significant risks to infant health, including the transmission of harmful bacteria or communicable diseases. Parents should be educated about the potential harms of sourcing unpasteurised and untested milk for their infants, to ensure they are able to make informed decisions. 

Infant formula

  • Commercial infant formula is the only other suitable and safe alternative to ensure optimal growth and development
  • Ready to feed infant formula that is sterile must be used instead of powdered infant formula where possible and appropriate in SCN because of the risk of bacterial sepsis (for example,  Salmonella species and Enterobacter sakazakii) from non-sterile powdered infant formula
  • Special formulas, designed for infants with gastrointestinal problems or food allergies, should only be prescribed by a medical officer for medically diagnosed conditions
  • A preterm formula (85 kCal/100mL) may be used for infants less than 1500 grams and/or less than 30 weeks gestation and can be used from birth.

Skin-to-skin care

Skin-to-skin care promotes the development and maturation of infant feeding behaviours and enhances breast milk production. The close contact also triggers the enteromammary pathway by which a mother produces antibodies in response to antigens in the infant's environment.

Encourage and facilitate early, frequent and extended skin-to-skin care (also known as 'kangaroo care': the practice of mother holding her baby skin-to-skin between her breasts). Initiation of skin-to-skin care requires individualised assessment of infant readiness, but can be safely initiated for stable infants from 28 weeks' gestation or from birth weight of 600 g. 

Methods of feeding in SCN

Breast

The opportunity for breast contact during skin-to-skin care should be encouraged to promote bonding with the mother and longer duration of breastfeeding.

Gastric tube

  • A dedicated enteral feeding system should be used that does not contain ports or connectors that could accidently be connected to intravenous systems. Neonates with respiratory distress or on CPAP require an orogastric tube. When introducing suck feeds, a nasal tube is preferable.

Gastric tube sizes

 Infant weight Tube size 
 >750g to <1500g feeding only  5G
 >1500g feeding and/or free drainage  6G 
 Surgical cases and/or free drainage  8G 
 Long term feeding tube  6G/8G 

Bottle feeding

  • Bottles should not be introduced to breastfeeding infants or to infants whose mothers intend to exclusively breastfeed, unless the mother explicitly asks for them. For infants in SCN of mothers intending to breastfeed, the first nutritive sucking experiences should be at the breast. Feeding a baby from a bottle with an artificial teat may make it more difficult for the baby to learn to attach well at the breast and establish breastfeeding. 
  • Bottle feeding is associated with lower temperature, lower oxygen saturation, lower transcutaneous pO2, and higher frequency of desaturations in preterm infants and infants with congenital heart disease, compared to cup feeding and breastfeeding. 
  • Partial feeding of infants at 32–36 weeks’ gestational age by cup until full breastfeeding is established may be appropriate.
  • When bottle feeding very premature infants, especially those with ongoing respiratory issues, a semi elevated side-lying position may be adopted.  Studies have shown this position promotes better regulation of breathing during feeding, helping infants to maintain physiological stability.

 

Semi elevated side lying feeding
Semi elevated side lying feeding figure 2

Figures provided by Dr Jennifer Dawson: Semi elevated side lying feeding 

Enteral feeding volumes for neonates > 1500 g on full enteral feeds

 Age

 Term (mL/kg/day)

 Preterm (mL/kg/day)    Small for gestational age (mL/kg/day)
 < 24 hours  30  60  30-60 **
 24–48 hours  60  60   60
 48–72 hours  80  80  90
 72–96 hours  100  100  120
 96–120 hours  120  120  140
 120–144 hours  150  150  160
 6–14 + days    180

 180

(180 mL/kg at doctor's discretion)

**consideration taken for Total Fluid Intake (TFI) when oral feeds given in combination with intravenous fluids.

Notes:

  • If the infant is on intravenous fluids, do not increase above TFI 120 - 140 mL/kg/day.
  • Parenteral nutrition (TPN) may need to be considered in Level 5 or 6 neonatal units or discuss with PIPER on 1300 137 650.
  • Caution is required in grading feeding volumes for extremely growth - restricted babies (<5th centile), those with respiratory distress or those with low Apgar scores. For these babies, consider an intravenous infusion and introduce breast milk slowly as available.

Frequency of feeding for babies in SCN

Enteral feeds are commenced when the infant’s respiratory status and condition has stabilised.  The preference is for all feeds to be commenced as bolus feeds unless otherwise indicated and ordered by a medical officer.

Feeding frequency

 Weight  Frequency 
 < 1000 g  1 - 2 Hourly 
 1000 - 1500 g  2 - hourly
 > 1500 g  3 - hourly

Signs of readiness to feed

The following are signs that the infant is ready to feed:

  • rooting reflex, mouthing, swallowing saliva
  • sucking on feeding tube, fingers, dummy
  • fighting feeding tube
  • alert and looking for feed.

Note:

  • Crying is a late sign of hunger and may result in an uncoordinated sucking pattern

Introducing enteral feeds after IVT

  • Start at 30 mL/kg/d; reduce IV infusion rate to maintain ordered and calculated total daily fluid intake
  • Increase enteral intake as tolerated, maintaining total daily fluid intake
  • IV infusion can usually cease when > 90 mL/kg/d enteral intake is tolerated. Thereafter enteral intake is gradually increased to 150 mL/kg/d total.

Feed intolerance in low birth weight and premature infants

Signs of feed intolerance can include:

  • positing
  • vomiting
  • abdominal distension
  • abdominal discolouration
  • increased respiratory effort
  • apnoea and/or bradycardia.

Absolute indications to withhold feeds, aspirate gastric tube and notify medical officer:

  • suspected or diagnosed NEC (link to necrotising enterocolitis)
  • significant abdominal distension
  • significant abdominal discoloration
  • other suspected or diagnosed bowel pathology
  • blood in stool
  • blood or bile stained vomitus or aspirate
  • large gastric residuals or vomiting (greater than 50 per cent of 6 - hour feed volume).

References

AMA 2017, Position statement. Infant feeding and parental health, Australia
Australia New Zealand Food Standards Code – Standard 2.9.1 – Infant formula products

International lactation consultant association 2015, Neo-BFHI: The baby-friendly hospital initiative for neonatal wards. Three Guiding Principles and Ten Steps to protect, promote and support breastfeeding. Core document with recommended standards and criteria

King Edward Memorial Hospital 2015, Neonatology clinical care unit: Section 6: Nutrition: Enteral and parenteral. Retrieved January 12, 2016 from 

Park, J Thoyre, , Knafl, GJ  Hodges, EA.& Nix, WB 2014,. Efficacy of semi elevated side-lying positioning during bottle-feeding of very preterm infants: A pilot study. Journal of Perinatal and Neonatal Nursing, 28(1), 69–79

The Women’s Hospital, Melbourne 2016, Infant feeding: baby led feeding to support the transition from tube to breastfeeding, Retrieved 2017

Wheat, JC, Nutritional management of children with congenital heart disease. Nutrition Bytes, 8(2), Article 5 (2002)

World Health Organization 2009, Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals, WHO, France 

Reviewed 08 March 2018

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