What is the best course of action for a premature infant with impaired feeding (not eating)?

Management of Premature Infant with Feeding Impairment

For a premature infant not eating, initiate parenteral nutrition immediately while introducing minimal enteral feeding as soon as clinically tolerated, using breast milk as the first-line enteral feed, and advance feeding volumes cautiously under multidisciplinary nutrition team supervision. 1

Immediate Nutritional Support Strategy

Parenteral Nutrition Initiation

• Start parenteral nutrition (PN) within 8 hours of birth to prevent nutritional deficits that rapidly accumulate in premature infants 2
• Begin amino acids on the first postnatal day at minimum 1.5 g/kg/day, advancing to 2.5-3.5 g/kg/day from postnatal day 2 onwards 2
• Target energy delivery of 90-120 kcal/kg/day parenterally, with most practitioners aiming for at least 120 kcal/kg/day to facilitate catch-up growth 2
• Ensure non-protein energy exceeds 65 kcal/kg/day when providing high protein doses to optimize nitrogen retention 2
• Start intravenous lipid emulsions immediately after birth or no later than postnatal day 2, advancing to 3-4 g/kg/day 2

Critical Principle: Avoid Complete Enteral Starvation

• Never maintain complete enteral starvation (total PN) when any amount of enteral feed can be tolerated 1
• Introduce minimal enteral feeding even if only small volumes are tolerated, as this promotes gut maturation and reduces complications 1
• This recommendation is particularly important because complete reliance on PN increases infection risk and prolongs hospital stay 1

Enteral Feeding Introduction and Advancement

First-Line Enteral Feed Selection

• Breast milk is the enteral feed of first choice for premature infants 1
• If breast milk is unavailable, start with elemental formula in early infancy and severe illness, then switch to extensively hydrolyzed formula, and finally to polymeric feeds based on clinical condition 1
• Feed may be given at normal concentrations (not diluted) 1

Feeding Delivery Method

• Introduce enteral feeding as liquid feed infused continuously by tube over 4-24 hour periods using a volumetric pump 1
• Bolus liquid feed via feeding tube or by mouth may be attempted if tolerated 1
• For infants with severe reflux, vomiting, or aspiration risk, consider nasojejunal feeding 1

Advancement Protocol

• Make only one change at a time when increasing enteral feed to properly assess tolerance 1
• In severe intestinal failure or feeding intolerance, increase feed volumes slowly according to digestive tolerance 1
• Reduce PN in proportion to, or slightly more than, the increase in enteral nutrition 1
• If a chosen weaning strategy fails, retry more slowly 1

Recognizing and Managing Feeding Intolerance

Warning Signs Requiring Attention

• Gastric residuals alone are likely benign consequences of delayed gut maturation and should not immediately prompt feeding cessation 3
• More concerning signs include: bilious vomiting, abdominal distension, abdominal wall erythema or ecchymosis, blood in stool (gross or occult), apnea, bradycardia, and temperature instability 3
• When gastric residuals occur with these additional warning signs, feeding advancement should be paused and clinical reassessment performed 3

Pharmacologic Intervention for Feeding Intolerance

• Metoclopramide may promote enteral feeding in premature infants with documented feeding intolerance who have failed enteral feeding on multiple occasions 4
• This intervention improved feeding tolerance from 11.7 cm³/kg/day to 134 cm³/kg/day over 29 days in one study, with significant reduction in gastric residual volumes 4

Multidisciplinary Team Involvement

Essential Team Composition

• Supervision of nutritional support must be provided by a multidisciplinary nutrition support team including doctor, nurse, dietitian/nutritionist, and pharmacist 1
• For high-risk infants with persistent feeding problems, intensive multidisciplinary feeding intervention (IMFI) involving psychology, medicine, nutrition, and feeding skill expertise represents the standard of care 5
• Accurate anthropometrics and thorough clinical evaluation should be undertaken by a skilled practitioner 1

Monitoring and Growth Targets

Laboratory and Clinical Monitoring

• Frequency of laboratory assessment should be based on clinical condition, ranging from once daily to 2-3 times per week 1
• Monitor electrolytes closely: sodium 4-7 mEq/kg/day, potassium 2-4 mEq/kg/day 1, 2
• Ensure calcium intake of 2-3 mmol/kg/day (80-120 mg/kg/day) with calcium:phosphorus ratio of 0.8-1.2 2

Growth Expectations

• Target weight gain of 17-20 g/kg/day after initial postnatal weight loss to prevent dropping across weight centiles 2
• Weight gain below 9 g/kg/day requires immediate intervention to prevent impaired neurodevelopment 2
• Birth weight should usually be regained by 7-10 days of life 1
• Weight, length, and head circumference should be measured serially to determine adequacy of nutritional support 1, 2

Critical Pitfalls to Avoid

• Do not delay PN initiation: premature infants rapidly develop nutritional deficits without early support 2, 6
• Do not withhold all enteral feeding: even minimal amounts promote gut maturation and reduce complications 1
• Do not make multiple feeding changes simultaneously: this prevents accurate assessment of tolerance 1
• Do not ignore isolated gastric residuals without other warning signs: these are often benign in premature infants 3
• Do not provide inadequate protein: underestimating protein needs in premature infants leads to growth failure and poor neurodevelopmental outcomes 2, 6

Special Considerations for Discharge Planning

Home Feeding Support

• Gavage feeding at home has limited role and should only be considered when feeding is the last issue requiring hospitalization 1
• Not all parents are capable of safely managing home gavage feedings 1
• When long-term tube feeding seems inevitable with little oral feeding progress, placement of gastrostomy tube provides an alternative 1
• Oral feeding should continue alongside tube feeding unless precluded by neurologic deficits threatening airway defense 1

Transition to Full Oral Feeding

• Maintain some degree of oral feeding or oral stimulation during enteral tube feeding to support oral development and reduce risk of oral aversion 1
• Children who rapidly recover intestinal function may be weaned straight onto normal food 1