What is the best course of action for a premature (premie) infant who is not eating?

Management of Premature Infant Not Eating

For a premature infant who is not eating, immediately assess feeding readiness and oral-motor coordination, initiate or optimize nutritional support through gavage or parenteral nutrition to prevent growth failure, and systematically evaluate for gastroesophageal reflux as a treatable cause of feeding refusal. 1

Immediate Assessment and Stabilization

Evaluate Feeding Readiness

• Assess postconceptional age: Most preterm infants develop coordinated suck-swallow-breathe patterns between 32-34 weeks postconceptional age, though individual variation exists 2
• Check for physiologic stability: Evaluate respiratory rate, oxygen saturation, heart rate stability, and ability to maintain body temperature during feeding attempts 2
• Observe behavioral cues: Look for signs of feeding readiness including alertness, rooting reflex, hand-to-mouth movements, and ability to remain engaged during feeding 2

Rule Out Pathologic Causes

• Gastroesophageal reflux is a significant and often overlooked cause of feeding refusal in premature infants 1, 3
• Symptoms include arching/hyperextension of the torso, excessive crying during or after feeds, and active refusal of oral feeding 3
• Consider that reflux may be "silent" without visible emesis, making diagnosis challenging 3
• Evaluate for esophagitis through endoscopy and biopsy if feeding refusal persists despite conservative management 3
• Perform intraesophageal pH monitoring to quantitate acid exposure and correlate symptoms with reflux episodes 3

Nutritional Support Strategy

Prevent Nutritional Deficits

Growth failure from inadequate nutrition produces irreversible neuronal deficits, organ growth failure, and poor cognitive outcomes—making aggressive nutritional support non-negotiable 4, 5

Parenteral Nutrition (if oral feeding insufficient)

• Start within 8 hours of birth for preterm infants to prevent catabolism 6
• Protein: Begin amino acids at 1.5 g/kg/day on day 1, advance to 2.5-3.5 g/kg/day by day 2 6
• Energy: Target 90-120 kcal/kg/day parenterally, with most practitioners aiming for at least 120 kcal/kg/day 6
• Ensure non-protein energy exceeds 65 kcal/kg/day when providing high protein doses to optimize nitrogen retention 6
• Lipids: Start immediately or by day 2, advance to 3-4 g/kg/day 6
• Electrolytes: Sodium 4-7 mEq/kg/day, potassium 2-4 mEq/kg/day 1, 6
• Minerals: Calcium 2-3 mmol/kg/day, phosphorus calculated based on calcium intake and protein accretion, magnesium 0.12-0.20 mmol/kg/day 6

Enteral Feeding Approach

• Always initiate minimal enteral feeding ("trophic feeds") even when primarily on parenteral nutrition 4
• Trophic feeds promote intestinal maturation and feeding capacity while reducing necrotizing enterocolitis risk compared to aggressive enteral advancement 4
• Use human milk preferentially over formula to reduce necrotizing enterocolitis risk 4
• For infants receiving human milk, provide iron supplementation of 2-3 mg/kg/day 1, 6

Gavage Feeding When Oral Skills Insufficient

• Consider gavage feeding only when feeding is the last barrier to discharge and parents are capable of safely managing home gavage feeds 1
• Gavage feeding has a limited role and should not delay development of oral feeding skills 1
• Continue oral feeding attempts alongside gavage feeds to promote skill development 1
• Paradoxically, tube feedings increase gastroesophageal reflux episodes, so monitor closely for reflux symptoms 3

Growth Monitoring and Targets

Critical Growth Parameters

• Target weight gain of 17-20 g/kg/day after initial postnatal weight loss to prevent dropping across weight centiles 6
• Weight gain below 9 g/kg/day requires immediate intervention to prevent impaired neurodevelopment 6
• Monitor weight, length, and head circumference serially 1, 6
• Provide parents with realistic expectations about slow weight gain and common setbacks 1

Expected Postnatal Weight Loss

• Normal term breastfed infants lose 6-7% of birth weight by days 2-3, regaining birth weight by 8-9 days 1
• Premature infants, especially extremely low birth weight infants, may lose 7-10% of birth weight when receiving enhanced nutritional support 1
• Weight loss exceeding 10% warrants investigation for inadequate fluid, sodium, protein, or energy intake 1

Management of Gastroesophageal Reflux

Treatment Algorithm

When reflux is diagnosed as the cause of feeding refusal:

• Medical management first: Use antacids, H2-receptor antagonists, or proton pump inhibitors and/or prokinetic agents 1
• Positional therapy: Maintain upright posture after meals 3
• Feed modification: Consider thickened feeds 3
• Fundoplication is indicated only when symptoms are life-threatening or persistent despite medical management 1

Pain Management Approach

• The goal is removing pain associated with eating and making eating pleasurable 3
• Infants may develop learned food refusal if eating causes pain from odynophagia or heartburn 3
• Some infants have visceral hyperalgesia where previously innocuous stimuli (luminal distension, acid reflux) are perceived as painful even without tissue damage 3

Developmental Feeding Support

Optimize Feeding Environment

• Coordinate all procedures (bathing, venipuncture, suctioning) to prevent overstimulation and excessive energy consumption 1
• Plan procedures when infant shows behavioral readiness to interact 1
• Limit unnecessary stimulation including stroking, talking, and position shifts 1
• Protect sleep cycles and prevent interruption of deep sleep whenever possible 1
• Maintain calm environment with gradual transitions to preserve energy for feeding 1

Feeding Technique

• Use immersion bathing rather than sponge bathing to avoid tactile overload 1
• Provide opportunities for non-nutritive sucking and holding caregiver's finger during procedures 1
• Ensure consistent caregivers from shift to shift to enhance development and family support 1
• Modulate social interchange carefully—avoid overly animated facial expressions 1

Discharge Planning Considerations

Readiness Criteria

• Most preterm infants should learn oral feeding in the hospital under expert care before discharge 1
• Ensure physiologic stability in appropriate car seat or car bed before discharge 1
• Complete metabolic screening, hearing assessment, and retinopathy of prematurity examination 1
• Assess hematologic status as anemia is highly prevalent after neonatal intensive care 1

Home Care Preparation

• Identify at least 2 responsible caregivers who can learn necessary care 1
• Young mothers without a co-parent are especially vulnerable to home care strain and need additional support 1
• Avoid overstating infant fragility, which can lead to excessive protectiveness and later behavioral problems 1
• Arrange close follow-up, as late-preterm infants (34-37 weeks) are at increased risk for feeding problems after discharge 1

Common Pitfalls to Avoid

• Never delay nutrition "until the infant is stable"—without immediate nutrition, the infant enters catabolism which impairs development 4
• Do not underestimate protein needs: 3.5-4.0 g/kg/day are necessary for normal protein balance and growth in very preterm infants 4
• Avoid overfeeding with excessive carbohydrate and lipid relative to protein, which produces organ and adipose fat deposition without growth benefit 4
• Do not ignore "silent" gastroesophageal reflux as a cause of feeding refusal—absence of visible emesis does not exclude reflux 3
• Never use divided or reduced vaccine doses in premature infants—use full recommended doses at chronological age regardless of birth weight 1