Ensuring nutrition for the smallest: Why early feeding standards matter for preterm newborns

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Providing optimal nutrition for preterm and low-birth-weight newborns remains one of the greatest challenges in neonatal care. While clinical guidelines exist, actual practices often vary widely depending on local resources and policies. To identify areas where improvements are needed, a descriptive study was conducted in a level 3 neonatal intensive care unit in Portugal, focusing on infants born before 34 weeks of gestation or weighing less than 1500 grams. This study, involving 85 infants, evaluated when and how feeding was initiated and developed over time. It found that although most infants received nutrition early, significant differences existed based on birth weight. The study concluded that access to donor milk and standardised feeding protocols could greatly improve adherence to recommended practices and ultimately support better outcomes for all newborns.

In many parts of the world, nutrition for preterm and low-birth-weight infants is inconsistent, posing risks to their growth and development. While some hospitals follow international standards, others lack the resources, such as human milk banks, to fully implement best practices. This discrepancy affects the timely initiation of feeding and the progression to full nutrition, especially for the most vulnerable infants.

The study looked at how nutrition was managed from birth to hospital discharge in a Portuguese neonatal intensive care unit. All participating infants received parenteral nutrition, with most starting it on the first day of life. However, only 21.5% began enteral (trophic) feeding that early, and 74.7% had started by the third day. Importantly, the type of milk first received was often not human milk due to limited availability, only three infants received donor milk at the start. The study clearly shows how birth weight influenced the timing and progression of feeding.

Weight matters: Feeding milestones differ greatly for preterm infants

Infants with higher birth weights (≥1500 g) consistently began and completed enteral feeding much sooner than those with lower weights. They also had fewer interruptions in feeding and reached breastfeeding and oral feeding milestones earlier. For example, infants weighing less than 1000 g typically began full oral feeding 48 days later than the highest-weight group. Feeding interruptions, often due to diet intolerance or medical complications, delayed progress significantly, particularly for the smallest infants.

Additionally, while most infants (96.5%) received their mother’s breast milk at some point, only a small percentage received pasteurised donor milk, mainly because the hospital’s human milk bank had only recently opened. This lack of donor milk availability led to delays in initiating enteral feeds, especially for extremely low-birth-weight infants. Notably, infants who did receive consistent feeding without interruption reached full enteral nutrition 7 days earlier than those who experienced breaks in their diet.

What this means for parents and hospitals

The findings have direct implications for how neonatal units can improve care. Providing donor milk through human milk banks ensures that preterm infants can begin enteral feeding sooner, reducing complications and supporting growth. Hospitals with access to donor milk can also better follow international feeding guidelines, particularly when mothers’ milk is not immediately available.

This study reinforces the need for standardised feeding protocols and the establishment of human milk banks in every neonatal unit. For parents and caregivers, these improvements translate to better support for breastfeeding, quicker recovery, and earlier discharge from hospital.

By implementing consistent standards and ensuring donor milk availability, healthcare systems can take a significant step forward in protecting and nurturing our most vulnerable newborns.

Paper available at: Wiley Online Library

Full list of authors: de Paula, L.; Silva, D.; Dias, C. C.; Moita, R.; Pissarra, S.

DOI: https://doi.org/10.1002/jpen.2770