NICU Breastfeeding Pathway


“Some is better than none, but more is better than some”

(Adapted from Supporting Premature Infant Nutrition –SPIN -

UC San Diego Division of Neonatology)


Step One:

·        Skin-to-Skin Care

      • Should be initiated as early in the baby’s life as possible.
        • After approval by physician
      • No weight or gestational age limitations.
      • Respiratory status stable:
        • Minimal apnea, bradycardia and desaturation events
        • Stable CPAP/Vapotherm/NC
        • Stable ventilated infants on conventional vent
      • Infant does not have a peripheral arterial line, UAC, UVC.
      • Infant does not require vasoactive medications.
      • Infant does not have chest tubes.
      • Parent’s chest is free of rashes or lesions.
      • If the infant is on significant ventilator settings, consult with the attending if you think the infant is stable enough for skin-to-skin contact.
      • Skin-to-skin holding should be done for a time as tolerated by the infant; usually at least one hour and up to 3-4 hours as tolerated

§  Staff role:

·        Remain at bedside during initial trial in order to assess the infant’s tolerance of skin-to-skin holding

·        Encourage Skin-to-Skin and discuss benefits with parents:

          • improved physiologic stability of the infant
          • gained body warmth
          • faster brain maturation
          • conserves infant’s calories
          • stimulation of maternal milk production

·        Discuss and encourage breast feeding and pumping with mom

Step Two:

·        Non-nutritive breastfeeding – Suckling at the breast with little or no secretion of milk

§  Started when:

·        infant displays or shows rooting, suckling, and moving towards the breast (even if minimal) and is at least 30 wk GA

·        Infant stable - Stable VS and RR <60 with no head bobbing, retractions, desaturation/cyanosis with care or during skin-to-skin care.

·        No CPAP; VT flow no higher than 2L

·        Requires discussion with attending physician prior to initiation

§  Pump to empty breast just prior to non-nutritive breastfeeding

§  If infant becomes too sleepy or > 30 minutes, revert to Skin-to-Skin

§  Encourage non-nutritive BF during gavage feedings



Step Three

·        Nutritive Breastfeeding

o   Start when:

§  Infant is active, alert and sucking throughout non-nutritive breastfeeding

      • Stable - Stable VS and RR <60 with no head bobbing, retractions, desaturation/cyanosis with care or during skin-to-skin care.

§  No longer requiring:  CPAP, High Flow Nasal Cannula

§  NC flow 1 lpm or less acceptable

§  Mom to pump following breast feed unless baby empties both sides

§  Initiate breastfeeding when infant shows feeding cues; should relax feeding schedule to meet baby’s signs of hunger

§  Mom may need to pump a few minutes prior to BF attempt if has large volume or brisk let-down

§  No bottle feedings at this time unless requested by Mom

·        Breastfeeding supplement Sliding Scale:

    • A.  Offered the breast, not interested/sleepy
    • B.  Interested in feeding, however does not latch
    • C.  Latches onto the breast, however comes on and off or falls as asleep.
    • D.  Latches, however sucking is uncoordinated or has frequent long pauses.
    • E.  Latches well, long slow rhythmical sucking and swallowing – feed less than 15 min
    • F.  Latches well, long slow rhythmical sucking and swallowing – feed 15 min or more
  • Depending on assessment and scoring:
    • A, B & C requires full supplemental feed.
    • D & E requires ˝ supplemental feed.
    • F requires no supplemental feed.
  • If nasogastric feed is indicated it is preferable to provide the opportunity for infant to have skin-to-skin contact or nuzzling at the breast.
  • Guideline for volume supplementation may be adjusted to meet individual needs – growth, UOP, emesis, etc.

Step Four

·        Breastfeeding and Bottle feeding

§  Bottle feeding will be initiated with Mom’s agreement

§  Feeds to be infant driven by showing hunger cues with feeding interval  no longer than 3-4 hours

§  Breast feed when mom is at bedside; bottle feeding in her absence

§  Oral feeds on demand if no longer requiring NG feeds; feeding interval no longer than 3-4 hrs

o   Signaled by hunger cues

§  Continue feeding q3h if gavage feedings needed

o   Initiate on demand feeding when ready

§  Pump after breastfeeding until exclusive breastfeeding is established



Step Five

·        Discharge planning

·        Confirm that parents have a lactation resource for questions or problems after discharge

·        Develop individualized discharge feeding plan, written for and discussed with family

o   Frequency of feeds and volume if bottle feeding

o   Advancement schedule

o   Recipe instruction for supplementation  if needed

Bridge clinic follow up for feeding/growth assessment if indicated




Niinikoski, 2004: Reduced intestinal blood flow and villous atrophy occurs after 8 hrs of NPO and TPN in term piglet model.

Oste 2005: A period of TPN (2-3 days) before the introduction of enteral diet seemed to be associated with increased lesion scores in preterm piglet model.

Klingerberg et al 2012. Enteral feeding practices in very preterm infants: an international survey

Corpeleijn WE. Feeding VLBW infants: our aspirations versus the reality in practice. Ann Nutr Metab 2011; 58 (1): 20-29

Costa-Orvay et al. The effects of varying protein and energy intakes on the growth abd body composition of very low birth weigh infants. Nutr J 2011; 10: 1-8

Bjornvad CR et al. Preterm birth makes the immature intestine sensitive to feeding-induced intestinal atrophy.  Am J Physiol Regul Integr Comp Physiol 2005; 289: R1212-1222

Sangild PT. Gut responses to enteral nutrition in preterm infants and animals. Experim Biol and Med 2006; 231: 1695-1711

Sisk PM et al. Early human milk feeding is associated with a lower risk of necrotizing enterocolitis in VLBW infants. J Perinatol 2007; 27: 428-433

Ziegler EE. Meeting the nutritional needs of the LBW infant. Ann Nutr Metab 2011; 58 (1) 8-18

Tillman S et al. Evaluation of human milk fortification from the time of the first feeding: effects on infants of less than 31 weeks gestational age. J Perinatol 2012; 32: 525-531

Moya F et al. A new liquid human milk fortifier and linear growth in preterm infants. Pediatrics 2012; Sept 17

Kuschel CA, Harding JE. Multicomponent fortified human milk for promoting growth in preterm infants (review). The Cochrane Library 2009, Issue 1

Quigley M et al. Formula versus donor breast milk for feeding preterm or LBW infants (Review), The Cochrane Library 2008, Issue 4

Henderson G et al. Formula milk versus maternal breast milk for feeding preterm or LBW infants (Review). The Cochrane Library 2008, Issue 4

Mihatsch WA et al. The significance of gastric residuals in early enteral feeding advancement of extremely low birth weight infants. Pediatrics 2002; 109:457-459

Bertino E. et al. Necrotizing enterocolitis: risk factor analysis ad role of gastric residuals in VLBW infants. J Pediatric Gastroenterol Nutr. 2009; 48 (4): 437-442.

Ziegler EE. Meeting the nutritional needs of the LBW infant. Ann Nutr Metab 2011; 58(suppl1): 8-18.

Agostoni et al. Enteral Nutrient supply for preterm infants: commentary from the European Society for Paediatric  Gastroenteraology, Hepatology, and Nutrition Committee on Nutrition.  J Pediatr Gastroenterol Nutr 2010; 50(1): 85-91.