Preterm Nutrition Discharge Consensus Statement (2023)
Reviewed by Sarvin Ghavam, MD
Preterm Nutrition Consensus Discharge Recommendations
Date of Initial Publication: October 2023
Revision Date:
Contact Author: Sarvin Ghavam
Contributing Authors: Hannah Chalal MD, Noah Cook MD, Gita Jani MD, Michelle Kelly MD, Amy Lembeck DO, Shehla Siddiqui MD, Kristi Spaide MD,RD, CNSC
Abstract
Discharge recommendations for preterm neonates with regard to their nutritional intake has very little consistent research evidence, with few studies and little neurodevelopmental outcomes to support guidelines. Inside the CHOP Division of Neonatology there are no consistent practices. There are limited “gold standard” studies and diverging goals of catch up growth vs. slow and steady growth. Using current practices guidelines and calculated caloric needs of the growing preterm neonate, a guideline is presented to provide appropriate caloric as well as mineral requirements for discharge home based on choice of discharge formula, breastmilk or a combination of both. The finalized discharge algorithm considers current breastmilk supply and caloric requirements for the neonate following discharge. If possible, it is recommended that these high-risk neonates born at less than 32 weeks gestational age and/or less than 1500 grams birth weight be maintained on these regimens until 52 weeks corrected gestational age or up to 1 year.
Consensus Goals
Develop a standardized approach for discharge nutrition for a preterm neonate.
Meet appropriate caloric and mineral needs for a discharged preterm neonate.
Background
Literature search and background studies show that there is no consensus on what diet preterm neonates should be discharged home. There very few RCTs and mostly expert opinions with inconsistency of interventions especially how to mix and what to mix formulas and breastmilk and what comparisons or baseline groups should be used. The two philosophies that exist are allowing premature neonates to have catch up growth versus slow and steady growth without intervention, neither of which touches on neurodevelopmental outcomes. Overall, with all the studies reviewed the conclusion suggests a tailored approach is best.
Previous Consensus Statement or Data from Division of Neonatology (if applicable)
None Available
Literature Search
| Study Type Inclusion | Intervention | Results | |
|---|---|---|---|
| Amissah (2020) LOE I | Cochrane Review; Preterm infants RCT (6 studies) fed HM 204 babies | Adding extra protein to human milk | Adding extra protein may increase short-term growth. Uncertain effects of LOS, intolerance, NEC. No data about later health or development. |
| Nzegwu (2014) LOE V | Review <1500g | Discusses several (BM, fortified BM, Formula only) | Discharge feeds should be started days to weeks before discharge. Paucity of info on long-term growth and developmental outcomes at 12–18 months. Individualize approach. Close monitoring and follow-up required. |
| Teller (2016) LOE V | Review (31 studies); Post-discharge feeding in preterm infants | Nutrient fortification of BM after discharge | Marked heterogeneity, nutrient enriched diets after discharge show no negative effects but frequently improve growth parameters particularly in boys, neurodevelopmental improvements rarely seen |
| Sundseth Ross (2013) LOE V | Review (55 studies); Preterm, feeding | Feeding and growth outcomes post-discharge from the NICU | Established optimal feeding prior to discharge by caregivers—should not just look at what feeding but how feeding and by whom. This impacts growth and neurodevelopmental outcomes. |
| Young (2013) LOE II | Cochrane Review; 2 small trials; 246 infants | Multinutrient fortified breastmilk v unfortified breastmilk after discharge of preterm infants | No evidence at 3–4 months after discharge affected rates of growth during infancy. One trial at 18 months did not find effects on neurodevelopmental outcomes. |
| Study Type Inclusion | Intervention | Outcomes | Results | |
|---|---|---|---|---|
| O’Connor et al. (2008) LOE III | Pilot, randomized cohort; <33 weeks; 750–1800g; 39 babies | Control (unfortified milk) v fortified (half volume feeds with Similac HMF powder to 22 calorie) in predominantly BM fed babies | Weight, length, and Head circumference at discharge, 4, 8, and 12 weeks | Study group was heavier, longer and had larger heads (especially in infants <1250g) |
| Parat et al. (2020) LOE IV | Prospective intervention study; <1500g and fed BM; 36 babies | Target protein fortified human milk v standard fortified human milk while inpatient (Similac liquid HMF + analysis and liquid protein added in intervention group) | Body composition, growth outcomes starting at initiation of feeds to 37 week or discharge (skinfold, HC, weight, length, air placement plethysmography) | Targeted protein intake resulted in higher protein intake and fat-free mass |
| Arslanoglu (2019) LOE IV | Retrospective; Discussed individualized fortification (adjustable v targeted) v standard fortification | Standard (preset mix); Adjustable (change based on BUN); Targeted (based on milk analysis) | Suggests babies adjust volumes based on caloric intake and macronutrients. SF- does not reach desired growth. AF- improves somatic and head growths. TF- needs improvement. No consensus on DC requirements. |
| Study Type Inclusion | Intervention | Outcomes | Results | |
|---|---|---|---|---|
| ESPGHAN (2006) LOE I vV | Consensus/Expert Opinion, some review (7 RCT, 650 babies); Preterm infants <37 weeks or <1850g | Diets | Growth and development to 12 months | Monitor weight, length, HC regularly. Adapt nutritional supplementation to achieve appropriate growth. #1 BM. #2 Formula-preterm. If require catch-up growth- HM with fortification or special post-discharge formula until 52 weeks. |
| Cooke (2011) LOE VII | Expert Opinion | Feeds to achieve “catch-up” growth | Monitor growth until 1–2 months corrected age to make sure “recover” growth occurs with supplementation to achieve this. | |
| Marino (2019) LOE VI | Quality Improvement; BF; ≤1800g; 39 babies | BMF “shots” (sachet of BMF mixed with small volume of BM at regular intervals, 4–6× day) from discharge until 48 weeks | Questionnaires to assess feasibility, safety and attitudes; growth at 1 year; change in SD or weight, length and HC at "various time points" | Compared to baseline, improved growth of weight, HC and length at discharge and at 1 year for head and length. Showed feasible and safe. |
| Groh-Wargo (2014) LOE V | Expert Opinion, Review | Discusses various articles with addition of fortification | HM does not meet needs of VLBW at discharge. Enriched HM (PTDF to 24 cal) adds little nutrition. HM alternated with PTDF or FHM gets closer to recommendations. FHM is BEST option. |
| Study Type Inclusion | Intervention | Outcomes | Results | |
|---|---|---|---|---|
| Kleinman (2019) LOE VII | Text | Paucity of information on what to feed. Unsure about how fast to grow a preterm infant. Preferred feeding in HM. Variability in HM puts preterm infants at risk for nutritional deficits. Reports mixed outcomes on review of fortification of BM on long term outcomes of growth and neurodevelopment. Recommends fortification of HM or formula if born <1000g and discharge <2000g for at least 12 weeks. | ||
| Heird (2008) LOEVII | Text | No universally accepted approach. AAP endorsed post-discharge formula but provides no recommendations. "Most authors recommend that the post-discharge formulas be used routine or that breast-fed infants receive a nutrient supplement, which of course is problematical and may interfere with normal lactation and breastfeeding." | ||
| Taylor (2022) LOEVII | NeoReviews | Some evidence- length gain proportional to weight gain relate to higher neurodevelopmental scores. Strong evidence from full term population- maternal milk should be prioritized at discharge. Some evidence- specific formula or maternal milk supplementation has not been identified as superior. Some evidence plus consensus- many require nutrient supplementation to sustain acceptable growth for at least a few weeks to months. Some recommend 12-16 weeks corrected age. Consensus- likely requires personalized approach that considers deficits, history, milk supply and lactation goals. |
Literature summary
The literature varies in recommendations for discharge nutritional needs of the preterm neonate. There are no standardization of goals and assumptions are made for the final recommendations, which remain vague. There are limited “gold standard” studies and consistency and perseverance is lacking.
Using recommendations discussed in the Groh-Wargo article as well as recommendations from the Best Practices Recommendations of the CPQCC 2018, a joint algorithm was developed to help guide the discharge <32 weeks and/or <1500 grams neonates.
Delphi Survey Round Results (if applicable)
Practice survey conducted throughout the Network. Overview of the results below:
What criteria do you use to switch to a home feeding regimen?
- 42% - 100% PO and no other criteria
- 7% - 60% PO and no other criteria
- 7% 80% PO, ~35 weeks, and 1800-2000g
- 14% 3500-4000g or prior to discharge
- 7% 34wks CGA
- 14% no response
Consensus statement and clinical recommendations
Discharge Feeding Algorithm Babies <32 wk or <1500 gm
Risk Factors Include
- Anthropometric: ≤1500 g BW GA and/or ≤32 weeks at birth; history of suboptimal weight gain with declining weight percentile or Z-score 1-2 weeks prior to discharge. At ≤37 weeks and/or ≤2 kg at dc
- Biochemical: alkaline phosphatase ≥600 U/L, serum phosphorus ≤5.5 mg/dL
- Nutritional: Total parenteral nutrition ≥4 weeks; total volume intake <130 mL/kg per day; history of intolerance or use of low nutrient density nutrition (e.g., soy, protein hydrolysate, amino acid-based formulas, or unfortified human milk).
- Miscellaneous: Osteopenia of prematurity, radiological evidence of bone demineralization and/or fracture(s); chronic use of mineral-wasting medications (e.g. furosemide)
Tips for After Discharge
- Consider continuing until at least ~52 wk corrected GA and up to 1 year for neonates born <32 wk GA, or at the discretion of your pediatrician
- Always use CORRECTED GESTATIONAL AGE for growth charts until at least 2 years of age (even for late preterm neonates) If weight gain is suboptimal (declining weight percentile or Z score), increase caloric concentration Lactation support as available
- May need a letter of medical necessity for WIC
Abbreviations
- PTP24 - Preterm 24 calorie formula * (Enfamil Premature)
- PTDF - Preterm Discharge Formula (Neosure or Enfacare)
- PT30 - Preterm 30 Calorie Formula*
- EBM - Expressed Breast Milk
- BF - Breastfeeding
*Formula representative will need to be contacted to obtain products for post discharge by hospital representative
Further Goals
Education and dissemination of recommendations to local pediatricians. Monitoring and comparison of growth following discharge, especially growth failures
QI Metrics
Implementation survey of neonatology and pediatric partners following dissemination Post discharge/Follow Up clinic analysis of growth parameters
WIC Supplemental Letter Template
To Whom It May Concern,
My patient, @NAME@, DOB @DOB@, was seen in the Neonatal Neurodevelopmental Follow-up program today. As you know, *** was born at the premature age of *** weeks. It is vital to *** as @HE@ grows that @HE@ receives optimal nutrition. To this end, @HE@ should not be switched to whole milk when @HE@ reaches @HIS@ first birthday. *** should remain on infant formula until at least @HIS@ due date of ***
Thank you for your understanding in this matter. If you require any further information on this matter, please call the neonatology office at ***.
Sincerely,
Nutrition Discharge Planning Information
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.