Nutritional Support of the Very Low Birth Weight Infant – Revised 2008

California Perinatal Quality Care Collaborative, November 2008

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The goals of nutrition are straightforward: achieving a standard of short-term growth; meeting the unique nutritional needs of prematurity; preventing feeding related morbidities; and optimizing long-term outcome. Achieving those goals may not be so simple in the NICU population. The first step is to understand the short-term and life-long importance of nutrition for premature newborns. Only then, with assessment of current practices, outcomes and beliefs, can opportunities for practice improvements be developed and implemented locally.

The CPQCC Nutrition Toolkit 2008, most recently revised in November 2008, has been developed to promote rapid assessment of current practices, outline evidence-based best practices, and enable rapid multidisciplinary improvement cycles to improve nutritional outcomes for premature newborns. This toolkit combines, reorganizes and updates 2 prior CPQCC Toolkits. The first of theseToolkits (“Nutritional Support of the VLBW Infant: Part I; 2004) was designed to provide background information regarding the importance of nutrition and human milk in the VLBW population, and to optimize human milk production and utilization. The second of these Toolkits (“Nutritional Support of the VLBW Infant: Part II; 2005) which focused on practices to optimize parenteral nutrition and the numerous transitions of enteral feedings, from their introduction through discharge and beyond. We hope you find it useful.


  • Section 1: General Principles
    • Best Practice # 1.1: Establish consistent, comprehensive, nutritional monitoring
    • Best Practice # 1.2: Establish standards of nutritional care
    • Best Practice # 1.3: Track nutritional continuous quality improvement data
  • Section 2: Parenteral Nutrition
    • Best Practice # 2.1: Parenteral amino acids within the first 24 hrs
    • Best Practice # 2.2: Parenteral lipid within the first 24 hrs
    • Best Practice # 2.3: Discontinue TPN and central lines appropriately
  • Section 3: Establishing Enteral Nutrition
    • Best Practice # 3.1: Human milk as the feeding of choice
    • Best Practice # 3.2: Start with minimal enteral nutrition
    • Best Practice # 3.3: Standardized feeding management
      • BP # 3.3.1: Standardized definition of feeding intolerance
      • BP # 3.3.2: Minimize fat loss by syringe position
      • BP # 3.3.4: Feeding advancement for optimal growth
    • Best Practice # 3.4: Use fortification appropriately
  • Section 4: Human Milk/Breastfeeding
    • Best Practice # 4.1: Educate and advocate for human milk for NICU infants
      • BP # 4.1.1: Appropriate knowledge, skills and attitudes for all perinatal professionals
      • BP # 4.1.2: Appropriate education for mothers and families
      • BP # 4.1.3: Hospital policies and procedures should support breastfeeding
    • Best Practice # 4.2: Establish and maintain maternal milk supply
    • Best Practice # 4.3: Handle human milk safely and appropriately
    • Best Practice # 4.4: Know when human milk is contraindicated
  • Section 5: Transitioning to oral feedings
    • Best Practice # 5.1: Transition to oral feedings based on physiologic maturity, not gestational age or weight.
    • Best Practice # 5.2: Use methods to support transition to breastfeeding
  • Section 6: Discharge Planning & Post-Discharge Nutrition
    • Best Practice # 6.1: Establish post-discharge nutritional needs and plan
    • Best Practice # 6.2: Facilitate post-discharge transition to direct breastfeeding
  • Section 7: Special/Controversial Issues
    • Best Practice # 7.1: Probiotics and Prebiotics
    • Best Practice # 7.2: Pacifiers
    • Best Practice # 7.3: CMV and Human Milk feeding
    • Best Practice # 7.4: Use of Insulin for Hyperglycemia
    • Best Practice # 7.5: Total Nutrient Admixture

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