Preterm Nutrition Consensus Enteral Feeds 
Population: Neonates <32 weeks and/or <1500 grams 
Date of Initial Publication: March 2022   
Revision Date: October 2024
Contact Author: Sarvin Ghavam
Contributing Authors: Joseph Asaro, Melissa Clegg, Alina Ivashchuk, Purvi Kapadia-Jethva, Catherine Myers, Lauren Slivka, Kristina Spaide, Tami Stuart

Abstract  

The nutrition provided to premature neonates, specifically those most at risk, born less than 32 weeks gestation and/or less than 1500 grams can contribute to a multiple outcome for these neonates. Nutrition impacts weight gain, linear growth, neurodevelopment, as well as outcomes such chronic lung disease and sepsis. The goal of this consensus is to provide a consistent and evidenced based approach toward providing optimal nutritional support for neonates balanced with decreasing risk of necrotizing enterocolitis and feeding intolerance.  

A multidisciplinary team including physicians, dietitians and lactation consultants worked together to formulate a current enteral feeding guideline and unified feeding advance approach. 

Consensus Goals  

• Evidenced based approach to feeding less than 32 wk and/or less than 1500 gram at birth.
• Improve weight gain, linear growth and provide optimal feeding advance and fortification goals.
• Decrease Necrotizing Enterocolitis rates.

Background  

Standardization of feeding protocols has been shown to decreased the incidence of NEC. Early enteral feeds with human milk is beneficial for premature neonates. Exclusive human milk diet had decreased risk of NEC and NEC requiring surgical repair. Research supports early feeding advances up to 30ml/kg/day does not increase the rates of necrotizing enterocolitis and improves time to full enteral feeds with decreased length of time for requiring TPN or intravenous fluids. Rapid enteral advance also decreases extrauterine growth restriction as well as improves short term outcomes. Earlier fortification of feeds improves protein intake of VLBW without deleterious effects, with positive impact on chronic conditions and long term growth. 

Previous Consensus Statement or Data from Division of Neonatology (if applicable) 

None Available 

Literature Review

Literature summary  

• Majority of trials showed safety and improved outcomes with faster feeding advance, especially in the >29 wk and >1000 gram neonates
• Early fortification helps establish improved protein intake, improved growth and decreases chronic issues
• No change in risk of NEC with faster feeding advance and earlier fortification
• Human milk is preferred diet for neonates <32 wks and/or <1500 grams 

Delphi Survey Round Results (if applicable)  

One round of Delphi survey completed across the Division of Neonatology showed agreement trophic feeds at 20ml/kg for neonates <29 wk or <1000 gram at 74%, and trophic feeds for 3 day period at 82%. Feed advancement of 20 ml/kg/day for neonates <29 weeks or <1000 grams at 87% agreement and for neonates >29 weeks or >1000 gram feed advance rate of 30ml/kg/day agreement at 73%. 

Consensus statement and clinical recommendations  

Oral immune therapy  

• Just colostrum
• Start within 6 hr of birth
• Could be q3-q6 based on the volume obtained  

Trophic feeds: Non-advancing feeds  

• Start as soon as possible
  • Use of Donor BM for trophic feeds if available to bridge
  • IF no EBM or DBM, may consider formula feeds by 24 hours of life
  • May delay up 72 hours of life if parents want exclusive EBM
• No benefit to delay beyond 4 days 

<29 weeks or <1000 grams 

• Trophic feeds
  • Volume: 20 ml/kg/day
  • Duration: up to 3 days/72 hours
    • *TO consider smaller volume or prolonged trophic feeds for IUGR neonates or for clinical concern
• Advancing feeds
  • Goal TFL 150-160ml/kg/day
  • Volume: 20ml/kg/day 

29 weeks -32 weeks or 1001 to 1500 grams  

• Trophic feeds
  • Volume: 20ml/kg/day divided q3h
  • Duration: 1-2 days/24- 48 hours
    • *TO consider smaller volume or prolonged trophic feeds for IUGR neonates or for clinical concern
• Advancing feeds
  • Goal TFL of 150-160ml/kg/day
  • Volume: 30ml/kg/day 

Special Circumstances  

• Umbilical Arterial Catheter
  • Trophic feeds based on weight and GA
    • *May use clinical judgement in situations where advance is desired u
• Dopamine (<5mcg/kg/min):
  • Trophic feeds based on weight and GA
• Indomethacin/Tylenol for treatment of PDA
  • Trophic feeds based on weight and GA  

Enteral Diet/Fortification  

• Early fortification is considered safe and may have a positive impact on long-term growth and chronic conditions
• For all infants <32wks and/or <1500g:
  • After a minimum of 2 feeds of tolerance at 60mL/kg/d, fortify feeds:
  • Prolact+6 (if available at your facility)
  • HMF 24 kcal/oz (1pk per 25mL)

  • Premature formula 24kcal/oz*

    *For facilities without DBM, MBM is not available or the use of DBM has not being consented  *Must already be tolerating preterm formula 20kcal/oz u Resume a feed advance after a minimum of 2 feeds of tolerance

• Feeding calculator
  • Developed by using the previous recommendations from the feed advance group
  • Enter the weight for calculation and each feed volume will be provided
  • May be for use with units using nurse driven feeds
  • Use birthweight until 7 days and/or birthweight surpassed 

Table Representation of Recommended Feeding Advance and Fortification For Preterm Neonates <32 weeks and/or <1500 grams 

Considerations for High Risk patients and need to deviate from Feeding Advance Recommendations 

• Medically unstable patients
• Intrauterine Growth Restriction/Small for Gestational Age
• Significant resuscitation needs at time of delivery
• Taking Gestational Age into account when choosing feed advance
  • Small baby who is LGA
  • Consider longer trophic feeds and possible slower advance
• <24-week gestational age consider a more cautious approach
  • Consideration for longer trophic feed period (up tp 5 days, use clinical judgement)
  • Consideration for 10ml/kg/day trophic feed volumes
  • Consideration for slower feed advance  

Vitamin D and iron supplementation for preterm infants  

VITAMIN D  

For All Babies, please supplement with 400IU (10mcg) of Cholecalciferol daily Once feed volumes are at (or approaching) below levels, at which time vitamin D supplementation may not be necessary 

*Please consult Registered Dietitian for vitamin D supplementation needs with other caloric densities or feedings  

1 All Enfamil liquid HMFs (acidified, standard protein, high protein) have the same vitamin and mineral content  

2 All Similac liquid HMFs (hydrolyzed, extensively hydrolyzed CL) have the same vitamin and mineral content 

SPECIAL CONSIDERATION FOR INFANTS RECEIVING PROLACTA  

Given the recognized variability of human milk, exclusive human milk diets will require nutritional supplementation. Thus, Prolacta fortification requires additional vitamin and mineral supplementation. If receiving Prolacta, regardless of volume, supplement 0.5mL twice daily multivitamin solution (poly-vi-sol without Fe). 

Note: 1 mL of Poly Vi Sol provides 400 IU(10mcg) of Vitamin D.  

IRON  

Iron intake recommendations for preterm infants: elemental iron 2 to 4 mg/kg daily, maximum 15 mg total from diet and supplementation (if receiving rh-Epo, provide 6mg/kg/d) 

1 EXCEPT: Similac PM 60/40 will require additional iron supplementation due to its very low iron content  

2 Supplementation required until appropriate (providing 2mg/kg/d) iron-containing complementary foods have been introduced  

3 Consider supplementation for IDM, SGA, and VLBW neonates at 10 to 14 days if they are feeding >100 mL/kg/day  

4 An exception to this practice may be infants who have received an iron load from multiple transfusions of packed red blood cells, who might not need any iron supplementation. However, transfusion-acquired iron overload occurs primarily in neonates with hemolytic disorders 

Methods of Supplementation 

Note: PVS+Fe may provide excessively high iron supplementation, depending on the weight of the infant. For infants <2.5 kg, consider ordering specific mg/kg/d FeSO4 dosing. 

Further Goals  

• Continue to add evidence based recommendations with evolving evidence
• Review of integration of feeding advance into Divisional practice  

QI Metrics  

• Review NEC rates pre and post Preterm Nutrition Consensus 

Disclaimer  

©2025 by Children's Hospital of Philadelphia, all rights reserved.  

Use of this site is subject to the Terms of Use.  

The Neonatology Consensus Statements (“Statements”) are based on a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These Statements are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.  

Accordingly, these Statements are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among CHOP, its physicians and the individual patients in question. CHOP does not represent or warrant that the Statements are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the Statements, or for any outcomes a patient might experience where a clinician consulted one or more such Statements in connection with providing care for that patient. If you use a printed version of a Statement, please ensure that you are using the most current version.