Guidelines for feeding advancement – Newborn infants with birth weight <1000 g

Day of life	Feeding	kcal/oz	Feeding volume (mL/kg/day)	PN (mL/kg/day)	Lipids* (mL/kg/day)	Total fluid^¶ (mL/kg/day)
1	EBM	20	20^Δ	80 to 100	5 to 10^◊	80 to 110
2	EBM	20	20	80 to 100	5 to 10	120 to 130
3	EBM	20	20	80 to 100	10 to 15	120 to 130
4	EBM	20	40^§	80	15	120 to 135
5	EBM	20	60^§	70	15	150
5	Or EBM with donor human milk-derived HMF^¥	26	60^§	70	15	150
6	EBM	20	80^§	50 to 70	15 or off lipids	150
6	Or EBM with donor human milk-derived HMF^¥	26	80^§	50 to 70	15 or off lipids	150
7	EBM	20	100^§	50	0	150
7	Or EBM with donor human milk-derived HMF^¥	26	100^§	50	0	150
8	EBM with bovine HMF^‡	24	100^§	50	0	150
8	Or EBM with donor human milk-derived HMF^¥	26	120^§	Off PN^†	0	120
9	EBM with bovine HMF^‡	24	120^§	Off PN†	0	120
9	Or EBM with donor human milk-derived HMF^¥	26	140^§	0	0	140
10	EBM with bovine HMF^‡	24	140^§	0	0	140
10	Or EBM with donor human milk-derived HMF^¥	26	150 to 160	0	0	150 to 160
11	EBM with bovine HMF^‡	24	150 to 160	0	0	150 to 160
11	Or EBM with donor human milk-derived HMF^¥	26	150 to 160	0	0	150 to 160

This table outlines the protocol used for stable infants in the NICU at Texas Children's Hospital. Protocols used in other NICUs are similar, but the details of timing, composition, and rate of advancement vary. Infants with significant feeding intolerance or other medical problems may progress more slowly. We use mother's own milk whenever possible. For infants <1500 g birth weight, we use donor milk if mother's own milk is not available.

PN: parenteral nutrition; EBM: expressed breast milk; HMF: human milk fortifier; NICU: neonatal intensive care unit.

* Lipid dose refers to 20% emulsion; thus, 10 mL/kg/day = 2 g/kg/day.

¶ Anticipated total fluids include PN, lipids, any other intravenous fluids, medications, and flushes. The volume available for PN may differ depending on volume of medications, flushes, etc. Trophic feeds (20 mL/kg/day) generally do not count towards total fluid.

Δ For infants <1000 g, begin enteral feeds on the first day of life if the infant is medically stable (eg, not requiring pressors except low-dose dopamine). For those >1000 g, begin enteral feeds within 6 to 12 hours of birth if the infant is medically stable.

◊ For infants 751 to 1000 g birth weight, initiate lipids at 5 mL/kg/day.

§ Some institutions may choose to advance more quickly (eg, advancing by 30 mL/kg/day), especially if fortifier is withheld until full feeds are reached.

¥ Donor human milk-derived HMF (Prolacta+6) is preferred for infants <1250 g birth weight (rather than bovine HMF). If this is available, add it to EBM when the feeding volume reaches 60 mL/kg. This increases the caloric density from 20 kcal/oz to 26 kcal/oz.

‡ If donor human milk-derived HMF is not available, then continue on unfortified EBM until feeding volume reaches 100 mL/kg, then begin to fortify feeds with liquid or bovine HMF (eg, Similac HMF, Enfamil HMF, or Nestle products). These bovine HMFs add 4 kcal/oz. The protein and nutrient content varies somewhat among brands.

† After PN is discontinued, add a liquid multivitamin (eg, Poly-vi-sol), unless the HMF includes multivitamins (as examples, Similac HMF contains multivitamins and Prolacta+6 HMF does not). Additional Vitamin D may be required based on brand and vitamin content of HMF used. After 14 days of age, add liquid iron (eg, Fer-in-sol), providing 2 to 3 mg/kg of elemental iron (for infants <1500 g birth weight not on PN).

Adapted with permission from: Guidelines for Acute Care of the Neonate, 26th edition (2018-2019), Fernandes CJ, Pammi M, Katakam L, et al (Eds), Baylor College of Medicine, Houston 2014. Copyright © 2018 Baylor College of Medicine. Updated with information from Guidelines for Acute Care of the Neonate, 27th edition (2019-2020).

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Guidelines for feeding advancement – Newborn infants with birth weight <1000 g