Infant Feeding

Aka: Infant Feeding, Infant Nutrition, Neonatal Feeding, Neonatal Nutrition

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II. Monitoring

  1. Adequate newborn weight gain
    1. Anticipate up to 10% weight loss after delivery and regain to birth weight by 2 weeks
    2. Weight gain (1 gram = 0.0352 oz)
      1. Daily: 20-30 grams per day
      2. Weekly: 150-200 grams (5 to 7 ounces) per week
    3. Infant doubles birth weight in 6 months
  2. Adequate hydration
    1. Expect clear Urine Output 6-8 times daily

III. Protocol: Term Newborn

  1. Indications to delay start of enteral feeding
    1. Prolonged asphyxia with 5 minute APGAR less than 6
    2. Respiratory distress
    3. Neurologic depression
    4. Abdominal Distention
    5. No stool passage by 24 hours
    6. Severe Sepsis suspected
  2. First feeding with sterile water
    1. Tracheoesophageal fistula (risk of aspiration)
  3. Vitamin Supplementation
    1. See Preterm Infant information below regarding supplementation
    2. Vitamin D 200 IU daily
      1. Started at 2 months of age for Breast-fed infants with <500 ml formula/day
      2. Indicated in Breast-fed Premature Infants (see below)
      3. Consider for darker skinned ethnicity during winter (less sunlight exposure)
  4. Term Infant
    1. Human Breast Milk preferrred
    2. Cow's milk Infant Formula
    3. Soy-based Infant formula
      1. Not recommended (except in vegan families who are Bottle Feeding)
      2. No advantage in milk allergy (30% cross-reactivity with milk Proteins)
      3. Attempt to switch to cow's milk Infant Formula
    4. Elemental formula
      1. Indicated in Cow's Milk Allergy

IV. Protocol: Preterm Infant (especially < 1500 grams)

  1. Premature Infants with >10 percentile weight and adequate catch-up growth may use standard term feeding protocols
  2. Indications for preterm feeding protocol
    1. Inadequate catch-up growth or <10 percentile or
    2. Discharge weight less than reference growth chart despite birth at appropriate weight for Gestational age or
    3. Birth weight Small for Gestational Age and still below reference growth chart weight at NICU discharge
  3. Consultation
    1. Neonatal dietician or
    2. Neonatologist
  4. Goals
    1. Infant feeds on demand every 2-4 hours
    2. Goal intake 120-150 ml/kg/day
    3. Ongoing growth approaches 50th percentile
  5. Premature Infant formula
    1. Inpatient (NICU): 24 calories/ounce used until weight >1800 grams
    2. Outpatient:
      1. Use 22 calories/ounce until one year of adjusted age or growth caught-up >25th percentile
      2. Use 20 calories/ounce after catch-up growth achieved up until one year (then transition to whole milk)
    3. Supplements
      1. Iron Supplementation 2 mg/kg/day (up to 15 mg/day)
        1. Not indicated if infant takes 150 ml/kg/day iron fortified formula (contains 2 mg/kg/day iron)
        2. Indicated as addition to formula if <150 ml/kg/day of formula taken daily
  6. Human Breast Milk (preferred for at least the first 6 months of life)
    1. Feed on demand every 2-4 hours
    2. Milk fortifier or Premature Infant formula
      1. Use until catch-up weight achieved >25th percentile or >6 months of age
      2. Adjust calorie density to achieve weight gain of 15-20 g/kg/day
        1. Option 1: Alternate Breast Feedings (1/2 to 2/3 of feedings) with Enriched Formula
          1. Give 22-24 cal/oz Enriched Formula feedings (1/3 to 1/2 of feedings)
        2. Option 2: Fortify Breast Milk with 22-24 cal/oz powdered Enriched Formula
          1. Kcal/oz 22: For each 50 ml Breast Milk add 1/4 tsp powdered Enriched Formula
          2. Kcal/oz 24: For each 50 ml Breast Milk add 1/2 tsp powdered Enriched Formula
      3. References
        1. Koo (2006) Am J Clin Nutr 84:1357-64 [PubMed]
    3. Other Supplements
      1. See Lactation Vitamin Supplementation
      2. Multivitamins 0.5 to 1 ml per day
        1. Use until weight >11 pounds (5 kg)
      3. Iron Supplementation 2 mg/kg/day (up to 15 mg/day)
      4. Vitamin D 200-400 IU per day
        1. Start at 2 months old if exclusively Breast fed

V. Protocol: Birth to 4 months

  1. Avoid honey and unpasteurized dairy, cheese or juice until over 1 year of age
    1. Risk of neonatal Botulism
  2. Avoid water supplementation
    1. Risk of Hyponatremia
  3. Avoid semi-solid food until age 4-6 months
    1. Infants do not accept semi-solid food
    2. Tongues protrude when spoon in mouth
    3. Unable to transfer food to back of mouth
    4. Risk of Choking

VI. Protocol: Age 4 to 6 months

  1. Iron-fortified infant cereal (4-8 Tablespoons per day)
    1. Source of Iron and B Vitamins
    2. Begin with rice
    3. Avoid other grains until older than 6 months
      1. Barley
      2. Oats
      3. Wheat
  2. Unsweetened fruit juices (2-4 ounces per day)
    1. Source of Vitamin C
    2. Plain Vitamin C fortified juice
      1. Dilute juice with water 1:1
    3. Avoid other juices until older than 6 months
      1. Orange
      2. Pineapple
      3. Grapefruit
      4. Tomato

VII. Protocol: Older than 6 months (Infant able to transfer semisolid food to swallow)

  1. See Solid Food Introduction in Infants
  2. Continue to avoid honey and unpasteurized dairy, cheese or juice until over 1 year of age
  3. Encourage foods with iron and zinc (esp. Breast fed infants)
  4. Avoid foods and beverages with added sugar for the first 2 years of life
  5. Avoid food and beverages with high Sodium content
  6. Fluoride Supplementation if indicated
  7. Water intake may begin
    1. Confirm that fluoride concentration is not too high
  8. Initiate dental care
    1. Wipe teeth and baby's gums with soft damp cloth

VIII. References

  1. Gauer (2014) Am Fam Physician 90(4): 244-51 [PubMed]
  2. Pierre (2022) Am Fam Physician 106(4): 427-38 [PubMed]

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