Colleagues:
As a neonatologist very interested in appropriate nutrition both in the NICU and post discharge, I am concerned about some of the "breast is best" advice being given.  Of course human milk is the best/necessary, but may not be sufficient for our smallest, most immature and most ill infants.  We use NeoSure 22 or EnfaCare 22 as a post-discharge formula or fortifier sometimes to give patients who were VLBW or very ill the extra protein, calcium and phosphorus needed for optimal growth (see below), not the calories.  Most of use aim for a minimum intake of 150 mL/kg/d as basic full feeds, but increase human milk feeds to 200 mL/kg/d if needed in the hospital (when the amount is under our control - PG).  When infants breastfeed and po ad lib, they sometimes take even more - which is great, but as human milk is so low in protein, calcium on phosphorous, they cannot  physiologically take enough to get adequate amounts of Pro, Ca, Phos.  Our dietician calculates what would be the minimum amount of formula or fortification needed at discharge, and it is discontinued when the infant gets to full direct breastfeeding (which takes several weeks as the majority of patients are discharged well before due date).  The mother decides how it will be given.
 
It is a problem that many neonatologists do not put a discharge nutrition plan in their discharge summaries, along with recommendations for follow-up growth labs.  I always do.
 
We have no idea what "optimal growth" means for very preterm or ill infants in the hospital or post-discharge.  We are balancing brain growth with later cardiovascular/metabolic disease.  We currently use the in utero curves, but we don't know if that is correct - the in utero environment is very different from a premie ex-utero.  We are doing better with immediate TPN and IL and early enteral nutrition with mothers' milk or PDHM, but it is very probable that the optimal growth rate may be different for each individual infant!

 
Nancy E. Wight MD, IBCLC, FABM, FAAP
Attending Neonatologist, Sharp Mary Birch Hospital for Women
Medical Director, Sharp HealthCare Lactation Service
San Diego, CA, USA
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