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Clinical Findings


The protocols in this chapter are for neonates with very low birth weight (VLBW) (≤1500 g) who are clinically stable for initiation of enteral feedings. The goal is to initiate enteral feedings by day of life 3.


There should be no congenital gastrointestinal defects precluding enteral feedings.




  1. Hemodynamic instability requiring volume resuscitation, dopamine > 5 μg/kg/min, or initiation of hydrocortisone

    1. Feeding should be delayed until hemodynamically stable for 24–48 hours.

    2. Patient may be started on feedings while on hydrocortisone (ie, weaning course of treatment) if the patient is hemodynamically stable.

  2. Hemodynamically significant patent ductus arteriosus (PDA) requiring indomethacin treatment or surgical closure: Feeding should be delayed until 24–48 hours after indomethacin course is completed or surgery is completed.

  3. Abdominal distension, signs of obstruction, abdominal discoloration consistent with peritonitis, or surgical abdomen

  4. Large-volume gastric fluid, discolored (eg, bilious) gastric fluid

  5. Sepsis, severe metabolic acidosis, hypoxia-asphyxia: Feeding should be delayed based on clinical evaluation.






Per individual units’ policies, parental assent or informed consent may need to be obtained for use of banked donor breast milk if maternal breast milk (MBM) is not available.


Monitoring During Treatment


  1. Cardiorespiratory and oxygen saturation monitoring is necessary during treatment.

  2. Gastric residuals may be measured prior to each feeding per unit policy.





Colostrum Administration

  1. The change from colostrum to transitional milk is individual. However, as a working definition, milk obtained from mothers during the first 7 days will be considered colostrum. During this time, fresh colostrum (not previously frozen) may be used.

  2. If the infant is ready to begin enteral feedings, colostrum may be administered in trophic feedings given via gavage tube (see the sample feeding volume and advancement schedule).

  3. If colostrum is available but the infant is not ready for enteral feedings, colostrum may be administered in the following fashion: Colostrum, 0.5 – 1 mL every 6 hours, may be delivered via syringe into the buccal pouch of the mouth or may be delivered via sterile cotton swab to the buccal cavity.

Enteral Feeding Choice

Maternal breast milk is the enteral feeding of choice unless contraindications for its use exist.


  1. Possible contraindications for MBM use (individual units will have their own policies) are the following:

    1. Infant with galactosemia

    2. Mother with active untreated tuberculosis

    3. Mother receiving diagnostic or therapeutic radioactive isotopes or with exposure to radioactive materials

    4. Mother receiving antimetabolites or chemotherapeutic agents

    5. Mother positive for human immunodeficiency virus (HIV)

    6. Mother with active herpes lesion on breast(s). Milk may be used from unaffected breast.

    7. Mother with varicella determined to be potentially infectious to infant

    8. Mother ...

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