Your Preemie's Nutrition in the NICU

How a baby receives nutrition in the NICU will depend on gestational age at birth, current gestational age, as well as their medical health, condition, and stability.

Premature babies born after 33 weeks gestation may be ready to begin to feed on a nipple within a matter of days while babies born before this time may have a little bit of a journey until they are developmentally ready to begin this task.

In utero, a baby’s intestines are fully formed by 20 weeks gestation, but the important functions of the intestines do not develop until 28 to 30 weeks gestation. These include peristalsis (contractions of the intestines to move food through them.) as well as the presence of some very important digestive enzymes that help break down the food and digest it.

Your preemie may not be ready to drink from a nipple just yet, but putting nutrients into your baby’s digestive tract will help to stimulate it to develop and mature faster. In the early days of your NICU journey, this is called trophic feeds and you may hear it being referred to as “priming the gut.” These small feeds are given to your preemie and are increased slowly over the first few days while the NICU team keeps an eye on how your baby tolerates these feeds.

Depending on your baby’s gestational age and development, your baby’s nutritional progression through the NICU may consist of the following:

Total Parental Nutrition

Also known as TPN, this form of nutrition bypasses the baby’s digestive system and goes directly into the bloodstream through a vein (IV or central line such as an umbilical vein or a PICC line). This form of nutrition is given to your baby the same way your baby was nourished in the womb. Your baby received all nutrients from you through the placenta, straight into their bloodstream.

TPN contains sugar, vitamins, minerals, trace elements, salts, amino acids, as well as lipids (fats) and has all the nourishment and calories your baby needs in order to live and grow. Premature babies may be given TPN for several days or even several weeks after birth. As your baby’s feedings of milk increase, the amount of TPN will decrease until your baby’s digestive system is able to accept milk fully as their sole form of nutrition.

Gavage or Tube Feedings

Your baby is fed milk through a tube, either in the mouth or nose that goes straight to the stomach. You may hear the tube called an NG or OG tube. NG or nasogastric (nose to stomach) or orogastric (mouth to stomach). Babies are typically fed through a tube while their digestive tract is maturing, while they are working on full volume feeds, or while practicing taking milk through a nipple.

Nipple Feeding

Your baby may be ready to begin working on this important milestone when:

• Your baby has reached 33-34 weeks gestation. (As early as 32 weeks to nuzzle at the breast)
• Your baby is gaining weight on gavage feedings.
• Your baby is off respiratory support.
• Your baby is showing hunger cues and readiness signs such as sucking vigorously on a pacifier and awake and alert at feeding times.
• Your baby’s medical condition is stable.
• Your baby’s vital signs are stable.

Your baby’s healthcare team may refer to this form of feeding as “nippling” — either nursing from the breast or drinking from a bottle.

• First bottle feedings: Premature babies who take their first feeding by the bottle are typically not able to finish their entire volume the first time. It takes a lot of energy and the early attempts at feeding may tire your baby out pretty quickly. It’s important to keep a close eye on your baby’s behavior cues and body language.
• First breastfeedings: Premature babies begin to practice nursing by nuzzling at the breast. Your baby may take a few sucks and then pause or may even quickly fall asleep. This is okay and very normal. Allow your baby to stay close to you, smell your milk, and feel the warmth of your skin. Holding your baby close while being fed through a tube will help create a positive feeding experience for your baby.

Your baby is showing positive feeding cues when:

• Your baby has good muscle tone.
• Your baby is awake and alert.
• Your baby opens their mouth when the lips are stroked with a pacifier, your finger, or the nipple.

Once your baby latches onto the nipple, pay close attention to how your baby is feeding. Is your baby actively engaged in sucking? Is your baby able to coordinate sucking, swallowing, and breathing?

If your baby begins to fall asleep, dribble milk from their mouth, disengage, or shows signs of disorganization such as breathing difficulties, dropping their heart rate, or oxygen saturation, it’s time to stop. These are all cues that your baby has had too much and is ready to rest. Allow your baby this time to recover.

Remember, feeding is supposed to be a positive experience, and you are setting the stage for your baby’s future eating practices.

Feeding is a process, and it takes time. It’s a developmental milestone. Think of it as walking. You can hold your child’s hand, buy push toys and coax your child to take their first steps, but until they are developmentally ready, they won’t do it. It is the same as feeding a premature baby. It is on their time. When your baby is developmentally ready, they will show you, and you will know.

Your baby’s healthcare team is here to help you through these first and important feeding experiences. They will show you what position is most appropriate to hold your baby in, how to hold the bottle and angle the nipple, and how to swaddle and comfort your baby to create a positive and nurturing experience.

Feeding your baby is about much more than nourishment. It is an opportunity to connect with and nurture your baby. It should be a positive and interactive experience.

Being actively involved in your baby’s feeding will not only make you feel more comfortable and confident, but will allow for a positive experience for your baby as they experience their world through taste, touch, smell, sight, and sound.

Breathing, sucking and swallowing simultaneously is very hard work for preterm babies, using up a lot of their energy stores. Because of this, your baby needs you to concentrate all your attention on the feeding experience so that your baby can solely focus on eating without adding distractions that may overwhelm or tire your baby.

Talking, singing, or rocking your baby while feeding can be overstimulating and may cause your baby to shut down from exhaustion. Your baby may turn away from or push out the nipple, gag, spit, fuss, or fall asleep. Stop feeding your baby if they show you these stress cues. Give your baby a break.

Getting to know your baby’s special language and signals will not only help you feel more comfortable and confident but will help your baby be more successful with feeding.

Feeding volumes are important, but it is much more important to keep the experience positive, progressing forward towards a goal at the pace your baby is comfortable with. You are setting the stage for your baby’s future feeding habits. Remember eating should be pleasurable for your baby.

Things you may be able to do for your baby to create a positive and pleasurable feeding experience:

• Hold your baby during feedings, even tube feedings.
• If your baby is receiving feedings by tube, it may be a good opportunity for you to have some skin-to-skin or Kangaroo Care time with your baby. Associating your smell and the sound of your heartbeat with feeding will also help build the foundation for a positive feeding experience.
• Let your baby smell and taste your milk. Place a small drop on the pacifier or place a cloth with your scent in your baby’s incubator.
• Make sure you set the stage for a positive feeding experience for your baby. You can do this by having a dimly lit, quiet space. Limiting this interaction time to just you and your baby will help your baby feel comfortable, content, and organized.
• Offer your baby a pacifier. This will help your baby associate sucking with feeding.
• Positive sensations around the mouth with feeding with help your baby associate eating with pleasure and trust.

Feeding Difficulties

Premature babies who were born before 26 weeks gestation, who have been on a ventilator or respiratory support for a long period of time and have chronic lung disease, or who have had a medically complicated journey, may have a harder time progressing to feeding by mouth.

Medical equipment and supplies such as ventilator tubes, suctioning, tape and tubes on the face may create a negative oral experience for some babies. Because of these medical difficulties some babies may refuse to nipple feed or be very disorganized in their feedings. Your baby may work with a speech therapist through the feeding journey to help create a positive experience and help your baby achieve this milestone.