• Adapted from the Oxford NICU guideline - for use at Wexham Park Hospital only.
• Applicable to infants born <32 weeks gestation OR <1500g.
• Preterm infants born >32 weeks and 1500g should be started on maternal milk at 60mL/kg on the first day of life with 30mL/kg/day increments thereafter.
• Maternal breast milk is the milk of choice in all infants.
• All preterm infants receiving breast milk should receive breast milk fortifier as standard.
• Adherence to standardised feeding regimes reduces the incidence of NEC and improves growth.
• Milk should routinely be started by the attending nursing staff – this decision does not need to wait until the next ward round.

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition.

Print copies must be destroyed after use.

Abbreviations

• Mother’s own breast milk is the best milk for all babies with measurable benefits for preterm and term infants, and mothers.

• Preterm babies who receive donor breast milk are less than half as likely to develop necrotising enterocolitis (NEC) compared to those who receive formula milk. The benefits of receiving mothers’ own breast milk are likely to be greater.

• Adherence to standardised feeding regimens reduces the incidence of NEC and improves growth.

• Achieving early full enteral feeding improves growth and reduces cholestatic jaundice.

• Greater growth velocity before term is associated with improved neurodevelopmental outcome.

• Breast milk alone will not meet the growth requirements of preterm infants and should be fortified when intake reaches 96mL/kg/day.

• Babies born <32 weeks gestation.

• Babies with birthweight <1500g.

• Infants 34-36 weeks with abnormal dopplers and IUGR <2^nd centile to be discussed with consultant.

Preterm infants born >32 weeks and >1500g should be started on maternal milk at 60mL/kg/day on the first day of life with 30mL/kg/day increments thereafter.

1. Maternal breast milk

2. Donated breast milk

3. Preterm formula

For guidance on choice of formula for infants born between 32 and 36+6 weeks please see appendix 2.

• Fortifier should be routinely added to breast milk for all babies who are:

  • born <34 weeks gestation OR,

  • born weighing <1500g.

• Fortifier should be considered in babies <37 weeks with a birthweight of 1500 – 2000g where:

  • volumes 150-180mL/kg unlikely to be tolerated OR,

  • serum urea <4mmol/L and falling OR,

  • weight gain is <15g/kg/day on maximum volumes tolerated OR,

  • IUGR with birth weight <9^th centile.

• Fortifier should be added when baby has tolerated 96mL/kg/day of milk feeds (>50% breast milk) for 24 hours:

  • For babies >1000g, fortifier should be introduced at half strength for 24-48 hours before grading up to full strength.

  • For babies <1000g, fortifier should be introduced at quarter strength, increasing by a further quarter every 24 hours.

• Milk should routinely be started by the attending nursing staff – this decision does not need to wait until the next ward round.

• All babies should receive colostrum on the first day of life, preferably within first 6 hours

1. Standard Regime for Advancing feeds

Increasing in increments of 24mL/kg/day every 24 hours

Day 0: Colostrum as available to max volume 12mL/kg/day (0.5mL/kg/hr)

Day 1: 24mL/kg/day (1mL/kg/hr)

Day 2: 48mL/kg/day (2mL/kg/hr)

Day 3: 72mL/kg/day (3mL/kg/hr)

Day 4: 96mL/kg/day (4mL/kg/hr)

Day 5: 120mL/kg/day (5mL/kg/hr) – start fortifier

Day 6: 144mL/kg/day (6mL/kg/hr) – stop TPN

Continue to advance feeds until reached volume of 165mL/kg/day

2. High risk regime for advancing feeds

For infants <32 weeks with AREDF AND birthweight <2^nd centile.

If birthweight >2^nd centile, follow standard regime

Increasing in increments of 12mL/kg/day every 24 hours

Day 0: Colostrum mouthcare

Day 1: 12mL/kg/day (0.5mL/kg/hr)

Day 2: 24mL/kg/day (1mL/kg/hr)

Day 3: 36mL/kg/hr (1.5mL/kg/hr)

Day 4: 48mL/kg/day (2mL/kg/hr)

Day 5: 60mL/kg/day (2.5mL/kg/hr)

Day 6: 72mL/kg/day (3mL/kg/hr)

Day 7: 84mL/kg/hr (3.5mL/kg/hr)

Day 8: 96mL/kg/day (4mL/kg/hr)

Day 9: 108mL/kg/day (4.5mL/kg/hr) – start fortifier

Day 10: 120mL/kg/day (5mL/kg/hr)

Day 11: 132mL/kg/day (5.5mL/kg/hr)

Day 12: 144mL/kg/day (6mLkg/hr) – stop TPN

Continue to advance feeds until reached volume of 165mL/kg/day

• This guideline has been adapted directly from the Oxford Neonatal Unit guideline. Please read in conjunction with the original and the Oxford fortifier guideline. Both can be accessed following the link on the neonatal guideline page.

• Please note: we do not follow the Oxford supplement guideline, so please adhere to our local guidance.

• Milk feeding in Preterm Infants, Oxford Neonatal Unit guideline, March 2024.

1. Standard Risk Feeding Regime

For infants <32 weeks and/or <1500g.

2. High Risk Feeding Regime

For infants <32 weeks with AREDF AND birthweight <2^nd centile. If birthweight >2^nd centile, follow standard regime.

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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