Feeding of lbw infants

for nurses, doctors, postgraduates

1. Feeding of LBW Infants
Dr. L S Deshmukh
DM (Neonatology)

2. Feeding the LBW Infant
Objectives :
•Nutrient requirement
•Formula choices
•Options for feeding regimens
•Adjuncts to feeding

3. “There is no finer
investment for any
community than putting milk
into babies”
- Winston Churchill (1943)

4. LBW Nutrition - Introduction
Improved survival of premies & LBWs
Greater morbidity in preterms
Increased risk of growth deficits and
developmental delay
Increased risk of later adult disease
Recent research, marked difference
between LBW versus term AGA nutrition

5. Goals of LBW Nutrition
Short term :
- Mimic intrauterine growth/composition
Long term :
- Optimize neurodevelopmental outcome
- Impact adult onset disease
Prevent neonatal morbidities :
- Improve feed tolerance
- Reduce NEC
- Minimize infection

6. Problems of Preterm
Physiological Handicaps :
·Poor co-ordination of sucking & swallowing (<33 wks)
·Weak Gag reflex (aspiration)
·Lax esophageal sphincter
·Small gastric capacity
·Gastroparesis & intestinal hypomotility
Biochemical handicaps :
•High energy & micronutrient requirement.
•Higher fluid requirement
•Increase need for proteins, minerals & vitamins
•Relative deficiency of bile acids & lactase
Saili A et al, J Neonatol July-Sept 2002

7. Current Feeding Practices : Problems
•Volume restriction
•Uncertainty about proper conc. of
nutrients
•Global undernutrition of LBWs
•Increased volume of feeds only after
weight plateus (inadequate growth).
•Consequences : ¯ no. of brain cells,
deficit in learning, behavior and memory

8. Glucose
•6 to 10 mg/kg/min, higher than term.
•Higher brain to body ratio
•Avoid higher percentage (adiposity &
­ Co
2
)
•Hypoglycemia redefined as < 45
mg/dl

9. Revised Recommended Protein
Intake for PT Infants
26-30 wks PCA 4.4 g/kg/d
30-36 wks PCA 3.6-4.0 g/kg/d
36-40 wks PCA 3.0-3.4 g/kg/d
(Rigo J,J Pediatr,2006)
positive protein balance requires at least
1.5 g/kg/day – Hay ww et al, Pediatr Neonatol. 2010

11. Lipids
•Vital ingredient
•Provision of 40-50% calories in TPN
•LA & ALA
•Lack of AA & DHA
•0.5 gm/kg/d to prevent EFA deficiency
Controversies :
•Additional LC PUFA to formula/TPN
•Supplemental DHA & AA

12. Role of LCPUFA
*Breast milk has adequate conc.
*Present formulae deficient
*Most important DHA & AA
*Major constituents of nerve cell membranes
*Key role in the structural development of
retinal, neural & synaptic membranes.
*Important for visual & neurodevelopment

13. LBW Nutrition – LCPUFAs
•11 RCTs involving PTs
•Many reported beneficial effects on visual,
neural and developmental outcome.
•Some reports of negative effect on growth
•Cochrane Review, Simmer K, 2004
- Increased early rate of visual maturation
- No effect on growth
- No long term benefit
- Use of fish oil & borage oil in PTs

(Fewtrell MS et al, J Pediatr, 2004)

14. Ca & P Supplementation
• Two- third body mineral content acquired
in 3
rd
trimester
• Fetal accretion rates 105 mg/kg/d and 70
mg/kg/d for Ca & P respectively
• PT born with low skeletal stores
• Very high requirement
• Human milk feeding alone-
- Hypophosphatemia
- Poor bone mineralization
- Elevated Alk. Phospatase
- May lead to # & slow growth

15. Ca & P Supplementation
Osteopenia of prematurity, commoner < 1000 g
Ca & P deficiency, rarely vitamin D deficiency
Ca & P accretion in utero equal to puberty
Rates of bone formation equal to adult
Ca absorption around 60% - 70%
(Hawthorne KM et al, Minerva Pediatr, 2004)

16. Ca & P Supplementation
• Recommended intakes –
• Ca : 200-220 mg/kg/d,
• P : 100-110mg/kg/d
• Ca : P ratio > 16 wks GA 1.8:1
• Supplementation with both essential
for postnatal bone mineralization.
• Supplement till 42-43 wks PNA
•Cochrane Review : No studies which met
selection criteria were identified
(Carl A Kuschel , 2009)

17. LBW Nutrition - Iron
•Total body iron low at birth
•Further decrease in iron, phlebotomy
losses / Epo
•Early iron deficiency – Late cognitive
effects
•Dose 2-4 mg/kg/d started between 2 wks
to 2 mo PNA
•6 mg/kg/d for Epo / IDA
(Rao R et al, Semin Neonatol. Oct. 2001)

18. Zinc Supplementation
*Preterm HM has less conc. & LBW may be zinc
deficient
*Better weight gain
*May improve immune function
*Improves mental development & behaviour ?
(Lira PI et al, Eur J Clin Nutr, 1998)
Sazwal et al, Indian StudySazwal et al, Indian Study, Pediatr 2001, Pediatr 2001
- Decreased risk of death due to diarrhea- Decreased risk of death due to diarrhea
- Zinc deficiency more in SGA babies- Zinc deficiency more in SGA babies
Effect on growthEffect on growth
- Better weight & height gain - Better weight & height gain
- Dose : 2 mg/kg/d x 6 wks- Dose : 2 mg/kg/d x 6 wks
Islam MN et al. indian pediatr, 2010Islam MN et al. indian pediatr, 2010

19. Vit.A Supplementation
Regulates & promotes growth of many cells
Maintains integrity of respiratory epithelial tract
Important for visual pigment, human function and as
antioxidant.
 1000 IU / kg/d for all VLBW
Theraupeutic use
¯ O
2
requirement & BPD
¯ ROP
¯ Nosocomial sepsis
Dose : 5000 IU IM 3 times a wk x 4 wks.
Oral - 4000 IU/kg/d
( Darlow BA, Cochrane Review, 2002)

20. Vitamin E in LBW Nutrition
·Routine supplementation, ­ses Hb marginally
·¯ risk of IVH,
·¯ risk of severe ROP
·RD for LBW - 0.7 IU/100 kcal + 1 IU/gm
PUFA
·Recommended 10 mg/d (Oral)
IM 20 mg/kg/d x 3 d
·Side effects : sepsis, NEC, thrombocytosis

((Brian LP, Cochrane Review, 2006)Brian LP, Cochrane Review, 2006)

21. Enteral feeding - Early Gut Development
•Int. mucosal development by II
nd

trimester.
•Organize motility develops till 28-30
wks.
•Motility – rate limiting
•Poor esophageal motility – GER
•Gastric emptying slower
•Only 50% <28 wks. pass mec. within
3 d.

22. Maturation of oral feeding skills in LBW infants
GA Maturation of feeding skillsInitial feeding
method
< 28 wksNo proper sucking efforts
No propulsive motility in the gut
Intravenous fluid
28-31 wksSucking bursts develop
No coordination between
suck/swallow and breathing
Oro-gastric (or naso-
gastric) tube feeding
with occasional
spoon/paladai feeding
32-34 wksSlightly mature sucking pattern
Coordination between breathing &
swallowing begins
Feeding by
spoon/paladai/cup
>34 wksMature sucking pattern
More coordination between breathing
and swallowing
Breast feeding

23. Enteral feeding - issues
•what milk to feed
•what nutritional supplements
•how to feed
•how much and how frequently
•what support
•how to monitor

24. What to feed
•Nutritional sources for LBW infants
Human milk
Breastmilk substitutes
Locally prepared animal milks

25. Nutrient guidelines Milk Selections (Per100
Kcal)
Nutrient Am Acad Pediatr Consen. Recomm.
Protein (g) 2.9-3.3 2.5-3.2
Calcium (mg) 175 100-192
Phos. (mg) 92 52-117
Sodium (mEq) 2.1-2.9 1.7-2.5
Vit. D (IU) 270 125-133
Iron (mg) 1.7-2.5 1.7
Zinc (mg) >500 833

26. Recommended dietary allowance in preterm VLBW
infants and the estimated intakes with
fortified/unfortified human milk
RDA
(Units/kg/d)
At daily intake of 180 ml/kg
Only expressed
Breast milk
EBM fortified
with lactodex-
HMF
(4g/100mL)
EBM fortified
with preterm
formula
(4g/100mL)
Energy (kcal)
Protein (g)
Carbohydrates (g)
Fat (g)
Calcium (mg)
Phosphorus (mg)
Vit. A (IU)
Vit. D (IU/d)
Vit.E (IU)
Vit B1 (mcg)
Vit B2 (mcg)
Bit. B6 (mcg)
Folic acid (mcg)
Zinc (mg)
105-130
305-4.0
10-14
5.4-7.2
210
110
90-270
400
>1.3
>48
>72
>42
39.6
>0.6
117
2.46
11.6
6.8
43.2
22.2
680
3.5
1.9
36.2
84.2
25.7
6
0.6
144
3.2
16.84
7.1
223
112
3308
903
6.3
79.4
156.2
115.7
150
0.96
153
3.4
15.58
9.06
103
52
980
40
3.6
231
564.2
221
36
0.96

27. Recommended and Actual Intake of

Various Nutrients
Nutrient P-RNI Intake from FHM
kg/d Mother’ milk
Energy (Kcal) 105-13588-145 104-174
Sodium (mmol) 2.5-4.01.3-2.2 1.7-2.8
Zinc (µmol) 17.0 7.7-12.3 20.6-34.3
Vit. D (IU/d) 400 4.8-8.0 257-428
Proteins (g) 3-3.5 2.0-3.4 2.9-4.8
Calcium (mg) 160-24036-60 144-240
Phosph. (mmol) 2.5-3.80.5-0.9 2.3-3.8
Iron (mg) 2.0-3.00.04-0.060.04-0.06

28. Human milk
•Mother’s own milk and donor milk
•Fore milk and hind milk
•Drip milk and expressed milk
Storage of human milk
HUMAN MILK SUPPLEMENTS

29. Prevents Infection
& Inflammation
sIgA, Lactoferrin,
Lysozyme,
Cytokines,
oligosaccharides
Promotes int.
adoptation
sIgA, Growth factor,
hormones,
oligosaccharides
Enhance function
poorly expressed
in the infants
Lipids, cytokines,
hormones
Promotes
establishment of
beneficial microbiota
sIgA, Lactoferrin, a-LA,
Oligosaccharides
Compensate for
immaturity of the
intestine
Neocleotides, PAF-
AH, cytokines
growth factors
Beneficial
effects of
bioactive
agents in
HM

30. Human milk supplementation
• Individual vitamins or minerals
— Vitamin A
— Vitamin D
— Vitamin K
— Iron
— Zinc
— Calcium and phosphorus
• Multivitamins
• Multicomponent fortifiers

31. Multicomponent Fortifier
•facilitate more rapid catch-up
growth
•May improve neurodevelopmental
outcomes.
•logistically difficult for infants
fed directly
McCormick FM et al, 2010

32. Fortified Breast Milk : Safety
•HM – sterile product
•EBM contamination at various points.
- Pumping
- Storage
- Transportation
- Addition of fortifier
- Setup & administration of feed
•Effect of iron content on bacterial growth
(Dalidowitz C, J Am Diet Asso, Oct, 2005)

33. Breastmilk substitutes
•Pre-term infant formulas
•Standard infant formulas
•Nutrient enriched “post-discharge”
formulas
•Soy-based formulas

34. ENTERAL FEEDING – Time of initiation
•Early Vs Delayed feeding
•Early feeding < 4 d
•Delayed > 5-7 d
•Feeds delayed to dec. NEC
•No evidence that delayed introduction
of progressive enteral feeds prevents
NEC (Morgan J et al , cochrane, 2011 )

35. Delayed Feeding : Consequences
•Fewer mucosal antibody cells.
•Reduction in the local immune response.
•Decreased enzyme levels.
•Damage to mucosal barriers.
•Increased susceptibility to infections.
•Morphologic injury.
•Decreased secretion of IgA.
•Bacterial overgrowth.

36. Minimal Enteral Nutrition
(MEN) Benefits
- Stimulates secretion of GI hormones
- Improved glucose tolerance
(enteroinsular axis)
- Stimulates motor activity
- Stimulation of bile flow & ¯ cholestasis
AIIMS- NICU protocols 2008

37. Minimal Enteral Nutrition (MEN)
·Dilute / full strength feeds < 10 to 15mL/Kg/day
or no enteral nutrient intake (water only)
·“Trophic” feedings
·¯ feed intolerance
·? ¯ NEC
·¯ hospital stay
Tyson JE, Cochrane Review, 2006,

38. * Can be started on ventilator and /or
receiving TPN
* In severe birth asphyxia, after 48-72
hours
* VLBW infants born with antenatal
diagnosis of altered umbilical arterial
blood flow delayed for 2 to 3 days.
MEN - essentials

39. Initiation of Enteral Feeding : Issues
NG V/s OG Feeding :
Nasogastric feeding
-Pulmonary compromise
-Higher A & B
Orogastric Feeding :
-Grooved palate
-Sialadenitis
No large RCTs available, insufficient
data
(Cochrane Review, 2006)

40. Initiation of Enteral Feeding : Issues
Feeding tube placement :
Size of feeding tube : Problems with larger
tube
•Nasal inflammation
•Throat irritation
•Pressure necrosis
•Pulmonary compromise
•GER
•Apnea & bradycardia
Use smaller feeding tubes

41. Initiation of Enteral Feeding : Issues
Intermittent Bolus Feed
Benefits :
-Promotes cyclical surge of gut
hormones
-Promotes gut development
Risk :
-Feeding intolerance
-Delayed gastric empty / intestinal
transit
-Difficult metabolic homeostasis

42. Initiation of Enteral Feeding : Issues
Continuous Feeding :
Benefits :
-Energy efficient
-Improved nutrient absorption
-Reduced feed intolerance
-Improved growth
Risk :
-Alters cyclical pattern of release of
hormones
-Potential to affect metabolic homeostasis
-­ GER

43. Continuous vs. intermittent feeding
•There is no difference in time to
achieve full feedings
(Premji SS et al, Cochrane,2008 )

44. Enteral feeding - interval
•ad libitum or demand/semi demand
Vs Scheduled
•Some evidence - earlier hospital
discharge
(McCormick FM, Cochrane, 2010 )

45. Feeding volumes and frequency
Birth
weight
(g)
Starting
volume
(ml/kg/d)
Volume
increment
each day
(ml/kg/d)
Maximum
volume
(ml/kg/d)
Frequency
of feeds
<1200 10-20 20 180 2 hrly
1200-
1600
60 30 180 2 hrly
>1600 60 30 150 3 hrly

46. Cup feeding versus Bottle / spoon
•cup fed more likely to be exclusively
breastfed at hospital discharge
•no difference at 3 / 6 mo
•one study feed by cup spent ten days
longer in hospital
•cannot recommend cup feeding.
Flint A et al , Cochrane , 2008

47. Initiation of Enteral Feeding : Issues
Enteral Feeding with Umbilical Lines :
•Fear of feeding problems & NEC
•A prospective, RCT of 60 PT infants
with low UAC – no feeding problems
•Monitor infants for signs of feeding
problems.

48. Breast Feeding LBW - Challenges
•Fortification of preterm HM
•Establishing a milk supply
•Maintaining milk supply
•Transition from gavages to
breast feed
•Incidence and duration of BF
•Barrier to BF in PT

49. Initiation of Breast Feeding : When ?
•Traditional Criteria :
•Physiologic stability
•Ability to tolerate bolus feeds
•GA > 34 wks & BW > 1500 g
•Behaviorally based criteria :
•Mother – Caregiver observations
•Infant sucks on pacifier / tube
•Makes rooting motions
•Has brief periods of active / quiet alert state

50. feeding intolerance

•Significant abdominal

distension or
discoloration

•Signs of perforation

•Obvious

blood in stool

•Gastric residuals  25% to 50% of interval
volume

for 2 to 3 feedings

•Bilious gastric residual or emesis

•Significant

apnea/bradycardia

•Significant cardiopulmonary instability

(The Vermont Oxford Network "Got Milk" focus group ,2003)

51. Gastric residuals
•Prefeed aspirate, milky & > 50%, omit
feeds & evaluate
•25-50%, omit feed & monitor (AC)
•< 25% aspirate, push back, monitor &
continue feeding.
(Saili A, J Neonatol, 2002)

52. Non-nutritive Sucking (NNS)
·Different from nutritive sucking
·During gavage feeds
·Pacifier (thumb size) / empty breast
·Facilitates development of sucking.
·Improves digestion
·Decreased hospital stay
(Source : Pinelli J. Chochrane Review, 2010)
·Calming as well as analgesic effect
(Source : Symington A, Chochrane Review, 1998)

53. Kangaroo Mother Care (KMC)
Possible Benefits:
• Promotes & Prolongs Breastfeeding
• Physiologic stability ( A&B, quiet sleep)
• Maternal confidence & Bonding
• Decreased Infection
• Cost Savings
(Kirsten GF, PCNA,2001)

54. Oil Application / Massage
•Greater weight gain
•? Greater length gain
•Better neurobehavior
•Better thermoregulation
(Ramji S et al, 2005; Modkar JA et al, 2005)
•Better skin barrier function
"¯ sepsis (use of sunflower seed oil)
(Darmstadt GL et al, 2005)

55. Feed Intolerance : Oral Erythromycin
•Potent prokinetic activity
•Acts through motilin receptors
•Improves feed tolerance
•Cochrane review, 2008- not enough evidence
to show any benefit
•high-dose erythromycin probably justifiable
(Lam HS et al, Curr Opin Pediatr. 2011 Apr;23(2):156-60 )

56. Lactase Treated Feeds
•Last of the disaccharidases to develop in PT.
•first detectable in the fetal intestine by 10
weeks' gestation
•At 28 to 34 weeks, lactase activity is only ~30%
•often managed with soy protein, protein
hydrolysate, low lactose, or lactose-free formulas
•Lactase to hydrolyse lactose for promotion of
growth & feed intolerance.
•greater rate of weight gain and higher serum
albumin- indicative of improved nutritional status
(J Pediatr, Oct. 2002)
•Single RCT, no significant benefit.
(Ohlsson A et al, cochrane 2006),

57. Feed Intolerance : Adjuncts
•Enteral insulin- accelerates GI develop.
- stimulates intestinal activity
- increases lactate activity
Pilot study, Shulman RJ, 2002
Limitation : Historic controls, need RCT
•Enteral solution (like human amniotic fluid)
- Phase I trial, significant increase in milk
feeding.
- May be related to growth factors
(Barney CK et al, Adv Neo Care, April, 2006)
•Cisapride : RCT, Kohl M et al, Biol Neonate, 2005
- No benefit (only in ELBW)
- More vulnerable to side effects
•Metoclopramide : No role, adverse effects

58. Role of Glutamine
•Increased feed tolerance
•Decreased sepsis
•Decreased nosocomial infections
•Better short term outcome
•Dose – 0.3 gm/kg/d
Van Den Berg et al, Am J Clin Nutr, 2005
• No effect on mortality, serious
infection, gut complications or long term
development.Tubman TRJ et al, Cochrane Review,
2006
•may lead to significant improvements
in growth Korkmaz A, Turk J Pediatr. 2007

59. Role of Arginine
•RCT
•152 PT infants
•L-arginine (1.5 mmol/kg/d)
•Significant decrease in all
stage of NEC
(Amin HJ et al, J Pediatr 2002)

60. Role of probiotics
•Two Meta-analyses
•reduced the risk of death due to
all causes
•Significant decrease in NEC
•No effect on sepsis
•No significant adverse effects
•strain specific
Szajewska H, Early Hum Dev. 2010

61. Prebiotic supplementation
• galacto-oligosaccharides
• fructo-oligosaccharides
• supplementation appears safe
• may benefit enteral tolerance in the
most immature infants.
Modi N et al, Pediatr Res. 2010 Nov;

62. Antenatal corticosteroids –
Role in PT nutrition.
•Early introduction of enteral feeding
•Enhanced intestinal motility, integrity
and growth
•Maturation of intestinal arginine
synthesis
•Shortened hospital stay
Wu G et al, J Nutr Biochem Aug. 2004.

63. Feeding of LBW : Poor Weight Gain
Diet Considerations :
•Incorrect calculations of actual
intakes
•Milk prepared incorrectly
•Volume intakes not advanced for
weight gain.
•Increased nutrient demands
•Feed intolerance

64. Feeding of LBW : Poor Weight Gain
Use of Human Milk Consideration :
•Greater vol. production than intake
(foremilk V/s hindmilk)
•Incorrect proportion of HMF
•Need for sodium supplementation
•Need for increased vol. or protein
supple.

65. Approximate Daily Weight Gain for Infants
Gestational age g/kg/d
24-28 wk 15-20
29-32 wk 17-21
33-36 wk 14-15
37-40 wk 7-9
Corrected age g/d
40 wk – 3 mo 30
3-6 mo 20
6-9 mo 15
9-12 mo 10
12-24mo 6
Care of high-risk infant, Klaus,2000

67. LBW Daily Weight Chart
Ehrenkranez RA et al, Pediatrics 1999

68. MCT oil for wt gain
• primarily of energy
• Increased weight-length ratio
• producing obesity
• RCT, PE Vs MCT oil’
• Significantly higher protein intake
• better growth
Brumberg HL et al, J Perinatol. 2010

69. Postdischarge Nutrition
•Often neglected
•Mostly only breast fed
•More attention beneficial
Important for :
Who can’t consume ad libitum quantities
Poor growth
Abnormal biochemical screen of nutritional
status
Important – monitor just before and at least one
month after discharge and consider
fortification
Lucas A et al, Pediatr 2001.

70. Weaning Preterm Infants
•Early onset of weaning
•Use of foods with higher energy and
protein
•Foods rich in iron and zinc
•Beneficial effect on length & iron
status
Marriott LD et al, Arch Dis Child Fetal Neonatal ed.
Nov. 2003

71. Feeding Options for PTs
During stable growth phase
First Choice : preterm human milk +
Lactodex – HMF (if affordable) + Fe
supplements from 2 wks.
OR
Preterm human milk + Ca/P +
multivitamins, Zinc + Fe supplement.
Second Choice : LBW formula milk +
multivitamins, Zinc + Fe supplements.
Third Choice : Undiluted cow’s milk +
mltivitamins, Zinc + Fe supplement.

72. Potentially Better Practices
•Monitoring of growth & nutrition
•Early initiation of enteral nutrition
•Consistent systematic advancement of feeds.
•Uniformity & clarity as to withholding feeds.
•HM is the preferred nutrient for PT
•Use of appropriate enteral products
•Early initiation of TPN, when feasible
(The Vermont Oxford Network "Got Milk" focus group ,2003)

73. Thank You

74. Developmental signs that show readiness for feeding
Behaviour at
the breast
Response when
offered
expressed
breat mild by
cup
Range of
gestational or
post-menstrual
age (wks)
Feeding
readiness
Range of birth
weight
No definite
mouthing
No extrusion of
tongue, no
licking
< 28 No readiness
IV feeding
needed
Intragastric tube
may be possible
< 1000 g

75. Developmental signs that show readiness
for feeding
Behaviour at
the breast
Response when
offered
expressed
breast milk by
cup
Range of
gestational
or post-
menstrual
age (wks)
Feeding readinessRange of birth
weight
Occasional,
ineffective
suckling
attempts
Opning mouth,
tongue out of
the mouth,
licking milk.
Not able to
coordinate
breathing and
swallowing well
28-31 First signs of oral
readiness.
Intragastric feeding
appropriate Can try
small amount of
direct expression or
cup feeding to gain
oral experience
1000-1500g

76. Developmental signs that show readiness
for feeding
Behaviour at
the breast
Response when
offered
expressed breast
mild by cup
Range of
gestational
or post-
menstrual
age (wks)
Feeding readinessRange of birth
weight
May root and
attach to
breast. Weak
suckling
attempts
Opening mouth,
tongue forward,
licking milk
Able to
coordinate
breathing and
swallowing well
32-34 Can now use cup or
other alternative
feeding method for
most feeds.
Allow baby to
attach to breast for
part of feed or for
some feeds
1300-1800g

77. Developmental signs that show readiness
for feeding
Behaviour at
the breast
Response when
offered expressed
breast mild by cup
Range of
gestational or
post-
menstrual
age (wks)
Feeding
readiness
Range of birth
weight
Able to root
and attach to
the breast
May have
periods of
organized
suckling with
long pauses
Opening mouth,
tongue forward,
licking milk,
coordinating
breasting and
swallowing
Coordinating
breathing and
swallowing well
An now able to
suck at the milk
from the cup and
other alternatives
33-35 Breast feed for
part of feedor
some complete
feeds
Cup or
alternative
supplement
most feeds to
ensure
adequate intake
1600-2000g

78. Developmental signs that show readiness
for feeding
Behaviour at
the breast
Response when
offered expressed
breast mild by cup
Range of
gestational or
post-
menstrual
age (wks)
Feeding
readiness
Range of birth
weight
Able to suckle
effectively at
the breast
Able to suck at milk
from the cup and
other alternative
feeding methods
34-36 Breastfeed, and
may need some
supplements by
cup or other
alternative
1800-2200g