1. Gomez, Jessica MSN, APRN, NNP-BC, IBCLC
  2. Wardell, Diane PhD, RN, WHNP-BC


Survival rates for extremely low-birth-weight (ELBW) infants are improving as neurodevelopmental impairment (NDI) rates stay stable, thereby increasing the overall number of infants with NDI. Although there are many determinants of NDI in this population, nutritional factors are of interest because they are readily modifiable in the clinical setting. Nurses can influence nutritional factors such as improving access to human milk feeding, using growth monitoring, establishing feeding policies, implementing oral care with colostrum, facilitating kangaroo care, and providing lactation education for the mother. All of these measures assist in leading to a decrease in NDI rates among ELBW infants.


Article Content

Innovations in neonatal care have allowed for improved survival rates for extremely low-birth-weight (ELBW; <1 kg) infants, with the most significant improvement reported in infants 23 to 24 weeks of gestation from 1992 to 2012.1,2 Unfortunately, because neurodevelopmental impairment (NDI) is inversely related to gestational age, more surviving ELBW infants means that the rate of NDI increased during this period.1,3-5


Of all preterm infants, 25% develop moderate to severe NDI by age 2, and up to 50% develop mild NDI; these impairments include movement disorders such as cerebral palsy, learning disabilities, language delays, and/or behavior disorders.5,6 Preterm birth accounts for more than 50% of cerebral palsy diagnoses, 15% to 20% of intellectual or developmental delays, and 10% to 15% of autism spectrum disorders.3 Although there are many determinants of NDI in this population, nutritional factors are of great interest because they are more readily modifiable in a clinical setting.7


To support brain growth in the ELBW infant, adequate nutrition is paramount. Growth at both ends of the spectrum, too slow or too fast, can cause long-term sequelae for the neonate and thus must be carefully regimented and monitored.7-14 To promote ideal infant nutrition, mother's own milk (MOM) is the best diet choice15-17 and can improve brain growth18 and neurodevelopmental outcomes19 in preterm infants. In the absence of MOM, the American Academy of Pediatrics (AAP)15 recommends the use of donor human milk (DHM). DHM is inferior to MOM; however, the alternative of preterm formula (PF) lacks immune support and nonnutritional components of human milk.15 Additionally, the use of PF increases the risk of feeding intolerance, sepsis, and necrotizing enterocolitis (NEC) and therefore is not the first choice of diet.20-22


Nurses are of the upmost importance in promoting evidence-based care.23 To promote growth of neonates in the neonatal intensive care unit (NICU), nurses can provide accurate anthropometric measurements to guide nutritional improvements,10 promote evidence-based feeding policies,24 and support breastfeeding NICU mothers.25 Therefore, the purpose of this article is to summarize current information and provide guidance on many nurse-driven, low-cost methods that can guide nutrition practices and support human milk feeding, thereby working to decrease NDI rates among ELBW infants. A general search of the literature was conducted over time and completed on August 1, 2021, by the first author. The search was conducted using OVID Medline, Google Scholar, and CINAHL databases. Studies related to ELBW growth and neurodevelopmental outcomes as well as nurse-driven interventions that support ELBW growth were reviewed. See the Table 1 for the general topics identified as relevant to nursing care related to supporting growth of ELBW infants.

Table 1 - Click to enlarge in new windowTable 1. Nursing interventions to support ELBW growth and nutrition and decrease NDI


In utero fetal growth rates are the historical standard for ELBW infants' ideal growth trajectories since 1977 but may not be appropriate indicators of successful growth in ELBW infants and are challenging to attain.26-28 Although postnatal growth failure rates are improving, half of ELBW infants at discharge still exhibit postnatal growth failure and do not meet the standards of the 1977 AAP guidelines demonstrating the urgent need for improved nutrition.29


Instead, acknowledging that growth is not constant throughout gestation and using an evidence-based growth chart, such as the Fenton,30 may more accurately guide expectations for growth velocity, or growth measurements over time.31 Once underlying growth expectations and patterns are understood, nutrition can be meaningfully improved using international guidelines for infant growth, weight, length, and occipital frontal circumference (OFC). These measurements should be obtained at least weekly to follow growth velocities and alter diets as needed to improve outcomes.11,32 Growth velocities are a better indicator of each neonate's nutritional accretion than a single measurement in time.11,32


Weight, length, and OFC are all pieces of the nutritional puzzle. Using only a single measure, such as weight, which correlates with brain growth but does not distinguish lean mass from adipose tissue, can lead to a short-stature, heavy infant.7 Importantly, weight gain, in the absence of linear growth, does not improve neurodevelopmental outcomes.14 Length is also an important measurement as it indexes with skeletal growth, lean body mass, and organ growth.9 OFC is a rudimentary approximation for brain growth.9 For the ELBW infant, slow growth in any of these 3 areas of measurement is associated with an increase in NDI.7,9,14


Anthropometric practice

Anthropometric measurement practices in the NICU vary widely and lead to inaccuracies.10 To improve reliability, INTERGROWTH-21st guidelines recommend each measure be done by 2 trained professionals and compared.11 Length measurement guidelines dating back to 193133 support the use of a length board for precise measurements, but a recent study of measurement practices in the NICU found that only 19.4% of nurses used a length board versus a tape measure.10



Providing sufficient nutrition during the first year of life has profound implications for brain growth and neurodevelopment. However, too much growth too fast can also cause long-term harm, as first reported by Barker and associates in 1989.8 The "Barker hypothesis" describes the association between low-birth-weight (LBW) and a higher risk of coronary heart disease, hypertension, and arteriosclerosis in adulthood. LBW infants often have a period of rapid growth (catch-up growth) that may create a potential for insulin resistance, obesity, and cardiovascular diseases.8,12,13,34 This phenomenon has also been described for ELBW infants.35-37 Therefore, close monitoring of excessive growth is essential.


Feeding policy

One way to support appropriate anthropometric progression is to standardize nutrition delivery via a feeding policy. A recent systematic review by Jasani and Patoli24 found a significant decrease in NEC, a severe intestinal disease that affects about 10% of ELBW infants, with the use of a standardized feeding policy. The review did not give specific details of the feeding policies but explained that by simply standardizing the progression and fortification of feedings in the NICU, the incidence of NEC decreased, and growth improved. It is important to note that NEC significantly increases the risk of NDI for preterm infants.38 The best practice is to use MOM as much as available, start early, and increase prescriptively as tolerated using bolus feeds, as delays in full oral feeds increase the infant's length of stay.24,39,40 Early enteral feeds have been shown to improve neurodevelopmental outcomes in ELBW infants.41



For preterm infants born at less than 1800 g, feedings should be fortified as the standard of practice to support their growth.42-44 Adding a human milk fortifier (HMF) to MOM or DHM increases macronutrients, especially protein, to improve nutrition delivery to the ELBW infant.42 Recent literature shows enteral feeds can safely be fortified as early as 60 mL/kg/day.45


One option for human milk fortification is a bovine-based HMF. In a systematic review, human milk fortified with bovine-based HMF versus unfortified human milk increased inhospital growth slightly, but did not improve cognitive outcomes.46 Another option is a human milk-based HMF that is made from pasteurized DHM.47 Since human milk is better tolerated and the chosen diet for ELBW infants,15 human milk-based HMF appears ideal. However, currently, evidence of the superiority of human milk-based HMF over bovine-based HMF is insufficient.48 Overall, human milk-based HMF is considered a safe and promising alternative to bovine-based HMF.48 Due to the higher cost of human milk-based HMF, more evidence is needed before it becomes recommended for use. An additional factor to consider is that the volume of human milk-based HMF is greater than that of bovine-based HMF and can displace more MOM than bovine-based HMF, resulting in a decreased amount of MOM fed to the infant.49



The choice of diet also alters the growth trajectory and tolerance of feedings. The choices for enteral feeding in ELBW neonates are MOM, DHM, or PF. Of note, the macronutrients and micronutrients in both MOM and DHM vary, whereas PF is standardized (see the Figure 1).

Figure 1 - Click to enlarge in new windowFigure 1. Macronutrient comparison of diets.

Mother's own milk

As the ELBW infant grows and develops, macronutrients of human milk change over the duration of each mother's lactation. For example, MOM for ELBW infants is higher in fat, protein, and carbohydrates compared to MOM for late preterm and term infants.43,50 MOM also changes in response to stress, maternal diet, and the time of day, among other factors.43,51 The fat content of human milk also varies significantly from the beginning to the end of each milk extraction as well as over the weeks and months of lactation.51 Despite all the variation, MOM is still superior in improving long-term neurodevelopmental outcomes.18,52-56


Human milk has an optimal bioavailability of components, rendering it easier to tolerate and digest.22 Feeding intolerance is a significant iatrogenic contributor to postnatal growth failure for ELBWs, as it often results in frequent starts and stops to enteral feeds57 and postnatal growth failure increases the risk of NDI.40 MOM, in contrast to PF, also contains nonnutritional components that help with the immune system and tolerance of feedings, including anti-infective factors, immunoglobulins, stem cells, enzymes, electrolytes, hormones, pre- and probiotic properties, and antioxidants that can decrease inflammation and its associated conditions.22


Donor human milk

Many benefits of a human milk diet are conferred by DHM. These include being easy to tolerate and digest as well as immunologically protective.58 However, DHM may be lower in calories than MOM or PF, as DHM is often donated near the end of a mother's lactation journey and, therefore, lower in macronutrients, which can lead to poor growth.51,59 For this reason, 2 to 5 DHM samples are pooled before pasteurization to help with the variability of nutrients.51 Because DHM is lower in macronutrients, namely protein, some suggest DHM may need fortification beyond that required for MOM.60,61 Nonetheless, having DHM available in NICUs has been shown to improve breastfeeding rates at discharge by 10% to 13% compared with units where DHM is not available.61,62 The reason for this association is unclear but may be due to NICU staff's acknowledgment of the importance of human milk for ELBW infants and subsequent support of the mother to provide MOM. A systematic review and meta-analysis by Williams et al63 found an overall increase in MOM administration rates at measured time points when DHM was used for supplementation; however, 1 of 10 included studies showed a decrease in the use of MOM when DHM was available. The motive for initiation of DHM availability varied in studies and may explain why one study found a decrease in MOM use at measured time points.


Before arriving at the ELBW infant's bedside, DHM undergoes many processes that render it less nutritive than MOM. Fat is often lost in DHM, as it is not homogenized, and it undergoes multiple container changes, leaving small amounts of adhered fat in each container.58 During pasteurization, DHM also loses many bioactive components.51,64 To retain the highest fat and biofunctionality of DHM, such as antimicrobial and growth-promoting activity, it should be used within 3 months of expression.65,66 Newer methods of pasteurization show promising results in maintaining more bioactive components of DHM, but further research is needed to evaluate their effectiveness and feasibility on a larger scale.67


Offering DHM as a bridge, an inferior yet safe short-term alternative while the mother establishes her milk supply, can motivate mothers to pump.62,64 Using DHM as a bridge for MOM has been shown to increase the rate of MOM use by 10% and decrease the rate of NEC by 2.6%.62 While using DHM, healthcare providers must account for variations in macronutrients that may require higher amounts of fortification to meet each infant's caloric needs.68 Overall, a DHM diet increases feeding tolerance, decreases the risk of NEC and, therefore, decreases NDI when compared with formula.69


Preterm formula

PF differs from full-term infant formula, as it is higher in protein, minerals, and calories, which are helpful for the ELBW infant's growth.4 PF supports faster growth but does not improve cognitive outcomes.69 PF also increases the risk of NEC, which increases the risk for NDI.1,70 The only confirmed measure for decreasing the risk of NEC is an exclusively human milk diet.15,20,58,65,71 Infants fed formula are at almost twice the risk of developing NEC than those fed human milk.69 For this reason, PF is used with caution in ELBW infants.


COVID-19 influence

The demand for DHM is increasing, but a current concern is that DHM donations may decline owing to the coronavirus disease-2019 (COVID-19) pandemic. Physical distancing restrictions and fewer donations pose unique challenges for collection sites, prompting concern that DHM may not be shipped to banks for timely processing.72 Creative measures, such as home visits to draw donating mothers' blood for testing and pickup options for donated milk, can be taken to ensure mothers may continue to donate human milk safely and in a timely manner. Knowing that DHM remains the best alternative to MOM, many units are revising their feeding policies to only use DHM for infants under 1500 g in anticipation of a potential shortage.72 Furthermore, DHM should still be regarded as safe, as COVID-19 is inactivated with the current pasteurization process.73


Clinical guidelines for mothers during the COVID-19 pandemic have varied.74 However, human milk remains the best choice of diets for all infants75-77 and risk of COVID-19 neonatal infections is low.78 If pumping mothers become infected, they should continue to pump while taking extra precautions to wash their hands before expressing milk, wear a face covering while expressing milk, and clean all pump parts after each use.79 If the mother chooses to receive the COVID-19 vaccine, it is safe to continue breastfeeding.80 Additionally, providing human milk during COVID-19 infection or after vaccination may protect the infant, as anti-SARS-CoV-2 immunoglobulin A had been detected in MOM.81,82



Nutrition during the NICU stay has lasting implications for the ELBW infant, especially during the first 2 weeks of life. Studies have found that higher protein and calorie intake in the first 1 to 2 weeks of life positively correlated with improved neurodevelopmental outcome scores by 2 years of age.83


ELBW infants have many complications, aside from nutrition, that increase NDI. Intraventricular hemorrhage, periventricular leukomalacia, infections, sepsis, meningitis, and posthemorrhagic hydrocephalus are commonly reported conditions in ELBW infants with poor long-term neurodevelopmental outcomes.84-86 The incidence of these disorders increases as gestational age decreases. Even in the absence of a significant brain injury, ELBW infants are at higher risk for NDI.87


Prevention of NEC is of great importance, as it can be deadly to the ELBW infant69 and increases the risk of NDI.70 Feeding with MOM for greater than 50% of total feeds in the first 2 weeks of life significantly decreases the ELBW infant's risk of NEC.58,88 The decrease occurs as the bioactive components in MOM protect the immature ELBW infant's gut by lowering gastric pH,89 decreasing epithelial permeability,90 improving intestinal motility,91 and optimizing the microbiota.92


Supporting mothers

Human milk is vital to decreasing NDI in premature infants. However, many mothers who deliver prematurely have problems achieving an adequate milk supply.93 Some barriers to providing MOM are low milk production, difficulty expressing milk, and separation from the infant.93 Those who care for ELBW infants need to advocate and teach the benefits of breastfeeding, be aware of the risks associated with formula, and develop skills for supporting the breastfeeding dyad.15


The first step in supporting mothers of ELBW infants through their lactation journey is to educate them on the benefits of human milk for their infant shortly after birth and continue, as they navigate the establishment and maintenance of their milk supply. Mothers should be taught to express milk using a hospital-grade, double electric pump every 2 to 3 hours day and night for about 20 minutes each session to promote an adequate supply of 720 to 1050 mL per day by 2 weeks postpartum.94-96 These practices improve the rate of breastfeeding at discharge, which is associated with decreased NDI.97,98


The second step to supporting mothers of ELBW infants is by using their colostrum for their infant's oral care. Expressing human milk for an ELBW infant can be overwhelming, but focusing on such a small volume needed for oral care is more feasible and can empower mothers to, hopefully, set the stage for a positive lactation experience. This practice is safe, and it improves infant outcomes, increases MOM supply, and increases breastfeeding rates at discharge and through 6 weeks of life.99-101 For best absorption of colostrum immune components, 0.1 mL delivered by a needleless, tuberculin syringe in bilateral buccal cavities is recommended.100


The final step that encourages lactation in the NICU is kangaroo care, or skin-to-skin holding. Kangaroo care has been shown to increase milk supply, improve bonding, reduce maternal stress, improve neonatal growth, and decrease neonatal infections.102,103 Once the infant is deemed stable by the medical team, the infant, dressed only in a diaper, should be held directly against the mother's bare skin for continuous, extended periods.103 Contact between a mother and an infant, as achieved with kangaroo care and breastfeeding, allows for MOM leukocytes to change in response to neonatal infection, thereby providing immunity to the infant and perhaps explaining the decreased neonatal infections associated with this practice.104 Kangaroo care is a low-cost, high-impact intervention that can change how parents interact with their ELBW infants.



Many variables that effect neurodevelopmental outcomes in the NICU are not modifiable. However, supporting early nutrition with human milk, prioritizing MOM, to promote growth for ELBW infants is modifiable. As NICU care providers seek to improve nutrition and neurodevelopmental outcomes for ELBW infants, the amount of published literature is overwhelming. The information presented helps to provide guidance on nursing practices that may improve ELBW infant neurodevelopmental outcomes.


Implications for future study

Understanding the extremely complex nature of MOM and its benefits to the ELBW infant in their care may help NICU providers to support lactating mothers further. Also, studies that evaluate storage and administration on the components of MOM will be helpful to improve the process. Does offering fresh MOM confer more immunological benefits over frozen milk? Finally, studies evaluating the changing policies related to human milk use and breastfeeding, as well as shortages in DHM supply during the COVID-19 pandemic, will help the medical community prepare for future crises.



As neonates grow and progress in the NICU, they are subjected to many experiences that can negatively affect the brain's maturation at a critical time, even when a direct insult has not occurred.6 To mitigate the risk for NDI in ELBW infants, ensuring proper growth and nutrition is paramount. Keeping in mind that growth alone may not be enough to ameliorate NDI, the key to improving outcomes may lie in the multiple nonnutritional components of human milk. Following the evidenced-based recommendations provided here can help improve daily practices in a way that ameliorates the neurodevelopmental outcomes of the ELBW infants in our care.




1. Stoll BJ, Hansen NI, Bell EF, et al Trends in care practices, morbidity, and mortality of extremely preterm neonates, 1993-2012. JAMA. 2015;314(10):1039-1051. doi:10.1001/jama.2015.10244. [Context Link]


2. World Health Organization. Preterm Birth. Published 2018. Accessed July 1, 2021. [Context Link]


3. Schieve LA, Tian LH, Rankin K, et al Population impact of preterm birth and low-birth-weight on developmental disabilities in US children. Ann Epidemiol. 2016;26(4):267-274. doi:10.1016/j.annepidem.2016.02.012. [Context Link]


4. Younge N, Goldstein RF, Bann CM, et al Survival and neurodevelopmental outcomes among periviable infants. N Engl J Med. 2017;376(7):617-628. doi:10.1056/NEJMoa1605566. [Context Link]


5. Zablotsky B, Black L, Maenner M, et al Prevalence and trends of developmental disabilities among children in the United States: 2009-2017. Pediatrics. 2019;144(4):e20190811. doi:10.1542/peds.2019-0811. [Context Link]


6. Rogers EE, Hintz SR. Early neurodevelopmental outcomes of extremely preterm infants. Semin Perinatol. 2016;40(8):497-509. doi:10.1053/j.semperi.2016.09.002. [Context Link]


7. Belfort MB, Ramel SE. NICU diet, physical growth and nutrient accretion, and preterm infant brain development. Neoreviews. 2019;20(7):e385. doi:10.1542/neo.20-7-e385. [Context Link]


8. Barker DJP, Osmond C, Winter PD, Margetts B, Simmonds SJ. Weight in infancy and death from ischaemic heart disease. Lancet. 1989;2(8663):577-580. doi:10.1016/S0140-6736(89)90710-1. [Context Link]


9. Cuestas E, Aguilera B, Cerutti M, Rizzotti A. Sustained neonatal inflammation is associated with poor growth in infants born very preterm during the first year of life. J Pediatr. 2019;205:91-97. doi:10.1016/j.jpeds.2018.09.032. [Context Link]


10. Foote JM, Hanrahan K, Mulder PJ, et al Growth measurement practices from a National Survey of Neonatal Nurses. J Pediatr Nurs. 2020;52:10-17. doi:10.1016/j.pedn.2020.02.001. [Context Link]


11. INTERGROWTH-21st Anthropometry Group. INTERGROWTH-21st International Fetal and Newborn Growth Standards for the 21st Century: The International Fetal and Newborn Growth Consortium. Anthropometry Handbook. Published 2012. [Context Link]


12. Kilbride HW, Aylward GP, Carter B. What are we measuring as outcome? Looking beyond neurodevelopmental impairment. Clin Perinatol. 2018;45(3):467-484. doi:10.1016/j.clp.2018.05.008. [Context Link]


13. Lei X, Chen Y, Ye J, Ouyang F, Jiang F, Zhang J. The optimal postnatal growth trajectory for term small for gestational age babies: a prospective cohort study. J Pediatr. 2015;166(1):54-58.e3. doi:10.1016/j.jpeds.2014.09.025. [Context Link]


14. Meyers JM, Tan S, Bell EF, et al Neurodevelopmental outcomes among extremely premature infants with linear growth restriction. J Perinatol. 2019;39(2):193-202. doi:10.1038/s41372-018-0259-8. [Context Link]


15. Section on Breastfeeding. American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-e841. doi:10.1542/peds.2011-3552. [Context Link]


16. Breastfeeding. J Obstet Gynecol Neonatal Nurs. 2015;44(1):145-150. doi:10.1111/1552-6909.12530. [Context Link]


17. World Health Organization. Feeding of low-birth-weight infants in low- and middle-income countries. Published 2011. [Context Link]


18. Ottolini KM, Andescavage N, Keller S, Limperopoulos C. Nutrition and the developing brain: the road to optimizing early neurodevelopment: a systematic review. Pediatr Res. 2020;87(2):194-201. doi:10.1038/s41390-019-0508-3. [Context Link]


19. Rahman A, Kase JS, Murray YL, Parvez B. Neurodevelopmental outcome of extremely low-birth-weight infants fed an exclusive human milk diet is not affected by growth velocity. Breastfeed Med. 2020;15(6):362-369. doi:10.1089/bfm.2019.0214. [Context Link]


20. Cortez J, Makker K, Kraemer DF, Neu J, Sharma R, Hudak ML. Maternal milk feedings reduce sepsis, necrotizing enterocolitis and improve outcomes of premature infants. J Perinatol. 2018;38(1):71-74. doi:10.1038/jp.2017.149. [Context Link]


21. Madore LS, Bora S, Erdei C, Jumani T, Dengos AR, Sen S. Effects of donor breastmilk feeding on growth and early neurodevelopmental outcomes in preterm infants: an observational study. Clin Ther. 2017;39(6):1210-1220. [Context Link]


22. Spiegler J, Preu[latin sharp s] M, Gebauer C, et al Does breastmilk influence the development of bronchopulmonary dysplasia? J Pediatr. 2016;169:76-80.e4. doi:10.1016/j.jpeds.2015.10.080. [Context Link]


23. White KM, Dudley-Brown S, Terhaar MF. Translation of Evidence Into Nursing and Healthcare. New York, NY: Springer Publishing Company; 2019. [Context Link]


24. Jasani B, Patole S. Standardized feeding regimen for reducing necrotizing enterocolitis in preterm infants: an updated systematic review. J Perinatol. 2017;37(7):827-833. doi:10.1038/jp.2017.37. [Context Link]


25. Shattnawi KK. Healthcare professionals' attitudes and practices in supporting and promoting the breastfeeding of preterm infants in NICUs. Adv Neonatal Care. 2017;17(5):390-399. [Context Link]


26. American Academy of Pediatrics, Committee on Nutrition. Nutritional needs of low-birth-weight infants. Pediatrics. 1977;60(4):519-530. [Context Link]


27. Villar J, Ochieng R, Staines-Urias E, et al Late weaning and maternal closeness, associated with advanced motor and visual maturation, reinforce autonomy in healthy, 2-year-old children. Sci Rep. 2020;10(1):5251. doi:10.1038/s41598-020-61917-z. [Context Link]


28. Papageorghiou AT, Ohuma EO, Altman DG, et al International standards for fetal growth based on serial ultrasound measurements: the Fetal Growth Longitudinal Study of the INTERGROWTH-21st Project. Lancet Lond Engl. 2014;384(9946):869-879. [Context Link]


29. Horbar JD, Ehrenkranz RA, Badger GJ, et al Weight growth velocity and postnatal growth failure in infants 501 to 1500 grams: 2000-2013. Pediatrics. 2015;136(1):e84. doi:10.1542/peds.2015-0129. [Context Link]


30. Fenton TR, Kim JH. A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants. BMC Pediatr. 2013;13:59. [Context Link]


31. Fenton TR, Anderson D, Groh-Wargo S, Hoyos A, Ehrenkranz RA, Senterre T. An attempt to standardize the calculation of growth velocity of preterm infants-evaluation of practical bedside methods. J Pediatr. 2018;196:77-83. [Context Link]


32. World Health Organization Multicentre Growth Reference Study Group. WHO Child Growth Standards: Growth velocity based on weight, length and head circumference: Methods and development. Published 2009. [Context Link]


33. Bakwin H, Bakwin RM. Body build in infants: I. The technique of measuring the external dimensions of the body in infants. J Clin Invest. 1931;10(2):369-375. doi:10.1172/JCl100357. [Context Link]


34. Kunz SN, Bell K, Belfort MB. Early nutrition in preterm infants: effects on neurodevelopment and cardiometabolic health. Neoreviews. 2016;17(7):e386-e393. doi:10.1542/neo.17-7-e386. [Context Link]


35. Morrison KM, Ramsingh L, Gunn E, et al Cardiometabolic health in adults born premature with extremely low-birth-weight. Pediatrics. 2016;138(4):e20160515. [Context Link]


36. Mhanna M, Iqbal A, Kaelber D. Weight gain and hypertension at three years of age and older in extremely low-birth-weight infants. J Neonatal Perinat Med. 2015;8(4):363-369. [Context Link]


37. Bassareo P, Fanos V, Puddu M, Marras S, Mercuro G. Epicardial fat thickness, an emerging cardiometabolic risk factor, is increased in young adults born preterm. J Dev Orig Health Dis. 2016;7(4):369-373. [Context Link]


38. Matei A, Montalva L, Goodbaum A, Lauriti G, Zani A. Neurodevelopmental impairment in necrotising enterocolitis survivors: systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed. 2020;105(4):432-439. [Context Link]


39. Chan S, Johnson MJ, Leaf AA, Vollmer B. Nutrition and neurodevelopmental outcomes in preterm infants: a systematic review. Acta Paediatr. 2016;105(6):587-599. doi:10.1111/apa.13344. [Context Link]


40. Patra K, Greene MM. Impact of feeding difficulties in the NICU on neurodevelopmental outcomes at 8 and 20 months corrected age in extremely low gestational age infants. J Perinatol. 2019;39(9):1241-1248. doi:10.1038/s41372-019-0428-4. [Context Link]


41. Hiltunen H, Loyttyniemi E, Isolauri E, Rautava S. Early nutrition and growth until the corrected age of 2 years in extremely preterm infants. Neonatology. 2018;113(2):100-107. doi:10.1159/000480633. [Context Link]


42. Agostoni C, Buonocore G, Carnielli VP, et al Enteral nutrient supply for preterm infants: commentary from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition. J Pediatr Gastroenterol Nutr. 2010;50(1):85-91. doi:10.1097/MPG.0b013e3181adaee0. [Context Link]


43. Leke A, Grognet S, Deforceville M, et al Macronutrient composition in human milk from mothers of preterm and term neonates is highly variable during the lactation period. Clin Nutr Exp. 2019;26:59-72. [Context Link]


44. Moro GE, Arslanoglu S, Bertino E, et al XII. Human milk in feeding premature infants: consensus statement. J Pediatr Gastroenterol Nutr. 2015;61(suppl 1):S16-S19. doi:10.1097/01.mpg.0000471460.08792.4d. [Context Link]


45. Shah SD, Dereddy N, Jones TL, Dhanireddy R, Talati AJ. Early versus delayed human milk fortification in very low-birth-weight infants-a randomized controlled trial. J Pediatr. 2016;174:126-131.e1. [Context Link]


46. Brown JVE, Lin L, Embleton ND, Harding JE, McGuire W. Multi-nutrient fortification of human milk for preterm infants. Cochrane Database Syst Rev. 2020;6(6):CD000343. [Context Link]


47. Ganapathy V, Hay JW, Kim JH. Costs of necrotizing enterocolitis and cost-effectiveness of exclusively human milk-based products in feeding extremely premature infants. Breastfeed Med. 2012;7(1):29-37. doi:10.1089/bfm.2011.0002. [Context Link]


48. Premkumar MH, Pammi M, Suresh G. Human milk-derived fortifier versus bovine milk-derived fortifier for prevention of mortality and morbidity in preterm neonates. Cochrane Database Syst Rev. 2019;2019(11):CD013145. doi:10.1002/14651858.CD013145.pub2. [Context Link]


49. Meier P, Patel A, Esquerra-Zwiers A. Donor human milk update: evidence, mechanisms, and priorities for research and practice. J Pediatr. 2017;180:15-21. doi:10.1016/j.jpeds.2016.09.027. [Context Link]


50. Bauer J, Gerss J. Longitudinal analysis of macronutrients and minerals in human milk produced by mothers of preterm infants. Clin Nutr. 2011;30(2):215-220. doi:10.1016/j.clnu.2010.08.003. [Context Link]


51. John A, Sun R, Maillart L, Schaefer A, Hamilton Spence E, Perrin MT. Macronutrient variability in human milk from donors to a milk bank: implications for feeding preterm infants. PLoS One. 2019;14(1):e0210610. doi:10.1371/journal.pone.0210610. [Context Link]


52. Blesa M, Sullivan G, Anblagan D, et al Early breast milk exposure modifies brain connectivity in preterm infants. Neuroimage. 2019;184:431-439. doi:10.1016/j.neuroimage.2018.09.045. [Context Link]


53. Horta BL, Loret de Mola C, Victora CG. Breastfeeding and intelligence: a systematic review and meta-analysis. Acta Paediatr. 2015;104:14-19. doi:10.1111/apa.13139. [Context Link]


54. Lenehan SM, Boylan GB, Livingstone V, et al The impact of short-term predominate breastfeeding on cognitive outcome at 5 years. Acta Paediatr. 2020;109(5):982-988. doi:10.1111/apa.15014. [Context Link]


55. Villar J, Giuliani F, Barros F, et al Monitoring the postnatal growth of preterm infants: a paradigm change. Pediatrics. 2018;141(2):e20172467. doi:10.1542/peds.2017-2467. [Context Link]


56. Zhu Z, Cheng Y, Qi Q, et al Association of infant and young child feeding practices with cognitive development at 10-12 years: a birth cohort in rural Western China. Br J Nutr. 2020;123(7):768-779. doi:10.1017/S0007114519003271. [Context Link]


57. Flidel-Rimon O, Branski D, Shinwell ES. The fear of necrotizing enterocolitis versus achieving optimal growth in preterm infants-an opinion. Acta Paediatr. 2006;95(11):1341-1344. [Context Link]


58. Maffei D, Schanler RJ. Human milk is the feeding strategy to prevent necrotizing enterocolitis! Semin Perinatol. 2017;41(1):36-40. doi:10.1053/j.semperi.2016.09.016. [Context Link]


59. McGee M, Unger S, Hamilton J, et al Adiposity and fat-free mass of children born with very low-birth-weight do not differ in children fed supplemental donor milk compared with those fed preterm formula. J Nutr. 2019;150(2):331-339. doi:10.1093/jn/nxz234. [Context Link]


60. de Halleux V, Pieltain C, Senterre T, Rigo J. Use of donor milk in the neonatal intensive care unit. Semin Fetal Neonatal Med Adv Nutr. 2017;22(1):23-29. doi:10.1016/j.siny.2016.08.003. [Context Link]


61. Arslanoglu S, Corpeleijn W, Moro G, et al Donor human milk for preterm infants: current evidence and research directions. J Pediatr Gastroenterol Nutr. 2013;57(4):535-542. doi:10.1097/MPG.0b013e3182a3af0a. [Context Link]


62. Kantorowska A, Wei JC, Cohen RS, Lawrence RA, Gould JB, Lee HC. Impact of donor milk availability on breast milk use and necrotizing enterocolitis rates. Pediatrics. 2016;137(3):e20153123. doi:10.1542/peds.2015-3123. [Context Link]


63. Williams T, Nair H, Simpson J, Embleton N. Use of donor human milk and maternal breastfeeding rates: a systematic review. J Hum Lact. 2016;32(2):212-220. [Context Link]


64. O'Connor DL, Ewaschuk JB, Unger S. Human milk pasteurization: benefits and risks. Curr Opin Clin Nutr Metab Care. 2015;18(3):269-275. doi:10.1097/MCO.0000000000000160. [Context Link]


65. Kanaprach P, Pongsakul N, Apiwattanakul N, et al Evaluation of fetal intestinal cell growth and antimicrobial biofunctionalities of donor human milk after preparative processes. Breastfeed Med. 2018;13(3):215-220. doi:10.1089/bfm.2017.0208. [Context Link]


66. Vazquez-Roman S, Alonso-Diaz C, Garcia-Lara NR, Escuder-Vieco D, Pallas-Alonso CR. Effect of freezing on the "creamatocrit" measurement of the lipid content of human donor milk. An Pediatria Engl Ed. 2014;81(3):185-188. doi:10.1016/j.anpede.2013.09.004. [Context Link]


67. Pitino MA, Unger S, Doyen A, et al High hydrostatic pressure processing better preserves the nutrient and bioactive compound composition of human donor milk. J Nutr. 2019;149(3):497-504. doi:10.1093/jn/nxy302. [Context Link]


68. Boyce C, Watson M, Lazidis G, et al Preterm human milk composition: a systematic literature review. Br J Nutr. 2016;116(6):1033-1045. doi:10.1017/S0007114516003007. [Context Link]


69. Quigley M, Embleton ND, McGuire W. Formula versus donor breast milk for feeding preterm or low-birth-weight infants. Cochrane Database Syst Rev. 2019;7(7):CD002971. doi:10.1002/14651858.CD002971.pub5. [Context Link]


70. Hickey M, Georgieff M, Ramel S. Neurodevelopmental outcomes following necrotizing enterocolitis. Semin Fetal Neonatal Med. 2018;23(6):426-432. doi:10.1016/j.siny.2018.08.005. [Context Link]


71. Tosh K. Feeding preterm infants with formula rather than donor breast milk is associated with faster rates of short-term growth, but increased risk of developing necrotising enterocolitis. Evid Based Nurs. 2019;22(1):18. doi:10.1136/eb-2018-102988. [Context Link]


72. Furlow B. US NICUs and donor milk banks brace for COVID-19. Lancet Child Adolesc Health. 2020;4(5):355. doi:10.1016/S2352-4642(20)30103-6. [Context Link]


73. Conzelmann C, Gro[latin sharp s] R, Meister TL, et al Pasteurization inactivates SARS-CoV-2-spiked breast milk. Pediatrics. 2021;147(1):e2020031690. [Context Link]


74. Pavlidis P, Eddy K, Phung L, et al Clinical guidelines for caring for women with COVID-19 during pregnancy, childbirth and the immediate postpartum period. Women Birth. 2021;34(5):455-464. [Context Link]


75. American Academy of Pediatrics. AAP issues guidance on infants born to mothers with suspected or confirmed COVID-19. AAP News. April 2, 2020. [Context Link]


76. Centers for Disease Control and Prevention. Coronavirus Disease (COVID-19) and Breastfeeding. Published 2020. [Context Link]


77. World Health Organization. Breastfeeding and COVID-19. Published 2020. [Context Link]


78. Capobianco G, Saderi L, Aliberti S, et al COVID-19 in pregnant women: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2020;252:543-558. [Context Link]


79. American Academy of Pediatrics. FAQs: Management of Infants Born to Mothers with Suspected or Confirmed COVID-19. Published 2021. Accessed November 19, 2021. [Context Link]


80. World Health Organization. Frequently asked questions: COVID-19 vaccines and breastfeeding based on WHO interim recommendations, 12 August 2021. Published 2021. Accessed November 19, 2021. [Context Link]


81. Lebrao CW, Cruz MN, Silva MHD, et al Early identification of IgA anti-SARSCoV-2 in milk of mother with COVID-19 infection. J Hum Lact. 2020;36(4):609-613. doi:10.1177/0890334420960433. [Context Link]


82. Perl SH, Uzan-Yulzari A, Klainer H, et al SARS-CoV-2-specific antibodies in breast milk after COVID-19 vaccination of breastfeeding women. JAMA. 2021;325(19):2013-2014. [Context Link]


83. Barreault S, Bellanger A, Berneau P, de La Pintiere A, Lallemant C, Beuchee A. Impact of early protein and energy intakes on neurodevelopment at 2 years of corrected age in very low-birth-weight infants: a single-center observational study. PLoS One. 2019;14(6):e0218887. doi:10.1371/journal.pone.0218887. [Context Link]


84. Gordon S, Srinivasan L, Harris M. Neonatal meningitis: overcoming challenges in diagnosis, prognosis, and treatment with omics. Front Pediatr. 2017;5:139. doi:10.3389/fped.2017.00139. [Context Link]


85. Konikkara KP, Manjiyil IJ, Narayanan VA, Kannambra PN. Seroprevalence of TORCH infections in pregnant women attending antenatal clinic in a tertiary care hospital. J Evol Med Dent Sci. 2019;8(39):2958-2965. doi:10.14260/jemds/2019/643. [Context Link]


86. Patel RM. Short- and long-term outcomes for extremely preterm infants. Am J Perinatol. 2016;33(03):318-328. doi:10.1055/s-0035-1571202. [Context Link]


87. Bolisetty S, Dhawan A, Abdel-Latif M, et al Intraventricular hemorrhage and neurodevelopmental outcomes in extreme preterm infants. Pediatrics. 2014;133(1):55-62. doi:10.1542/peds.2013-0372. [Context Link]


88. Corpeleijn WE, de Waard M, Christmann V, et al Effect of donor milk on severe infections and mortality in very low-birth-weight infants: the early nutrition study randomized clinical trial. JAMA Pediatr. 2016;170(7):654-661. doi:10.1001/jamapediatrics.2016.0183. [Context Link]


89. Guillet R, Stoll BJ, Cotten CM, et al Association of H2-blocker therapy and higher incidence of necrotizing enterocolitis in very low-birth-weight infants. Pediatrics. 2006;117(2):e137-e142. [Context Link]


90. Nair RR, Warner BB, Warner BW. Role of epidermal growth factor and other growth factors in the prevention of necrotizing enterocolitis. Semin Perinatol. 2008;32(2):107-113. [Context Link]


91. Hunter CJ, Upperman JS, Ford HR, Camerini V. Understanding the susceptibility of the premature infant to necrotizing enterocolitis (NEC). Pediatr Res. 2008;63(2):117-123. [Context Link]


92. Underwood MA, Gaerlan S, De Leoz MLA, et al Human milk oligosaccharides in premature infants: absorption, excretion, and influence on the intestinal microbiota. Pediatr Res. 2015;78(6):670-677. [Context Link]


93. Alves E, Magano R, Amorim M, Nogueira C, Silva S. Factors influencing parent reports of facilitators and barriers to human milk supply in neonatal intensive care units. J Hum Lact. 2016;32(4):695-703. doi:10.1177/0890334416664071. [Context Link]


94. Fewtrell MS, Kennedy K, Ahluwalia JS, Nicholl R, Lucas A, Burton P. Predictors of expressed breast milk volume in mothers expressing milk for their preterm infant. Arch Child Fetal Neonatal Ed. 2016;101(6):F502. doi:10.1136/archdischild-2015-308321. [Context Link]


95. Mohrbacher N. How to Build a Full Milk Supply with a Breast Pump. Published 2007. [Context Link]


96. Spatz DL, Edwards TM. The use of human milk and breastfeeding in the neonatal intensive care unit: Position Statement 3065. Adv Neonatal Care. 2016;16(4):254. doi:10.1097/ANC.0000000000000313. [Context Link]


97. Gharib S, Fletcher M, Tucker R, Vohr B, Lechner BE. Effect of dedicated lactation support services on breastfeeding outcomes in extremely low-birth-weight neonates. J Hum Lact. 2018;34(4):728-736. doi:10.1177/0890334417741304. [Context Link]


98. Johnson S, Evans TA, Draper ES, et al Neurodevelopmental outcomes following late and moderate prematurity: a population-based cohort study. Arch Child Fetal Neonatal Ed. 2015;100(4):F301-F308. doi:10.1136/archdischild-2014-307684. [Context Link]


99. Nasuf A, Ojha S, Dorling J. Oropharyngeal colostrum in preventing mortality and morbidity in preterm infants. Cochrane Database Syst Rev. 2018;9(9):CD011921. doi:10.1002/14651858.CD011921.pub2. [Context Link]


100. Maffei D, Brewer M, Codipilly C, Weinberger B, Schanler RJ. Early oral colostrum administration in preterm infants. J Perinatol. 2020;40(2):284-287. doi:10.1038/s41372-019-0556-x. [Context Link]


101. Snyder R, Herdt A, Mejias-Cepeda N, Ladino J, Crowley K, Levy P. Early provision of oropharyngeal colostrum leads to sustained breast milk feedings in preterm infants. Pediatr Neonatol. 2017;58(6):534-540. doi:10.1016/j.pedneo.2017.04.003. [Context Link]


102. Conde-Agudelo A, Diaz-Rossello JL. Kangaroo mother care to reduce morbidity and mortality in low-birth-weight infants. Cochrane Database Syst Rev. 2016;2016(8):CD002771. doi:10.1002/14651858.CD002771.pub4. [Context Link]


103. Sharma D, Farahbakhsh N, Sharma S, Sharma P, Sharma A. Role of kangaroo mother care in growth and breastfeeding rates in very low-birth-weight (VLBW) neonates: a systematic review. J Matern Fetal Neonatal Med. 2019;32(1):129-142. doi:10.1080/14767058.2017.1304535. [Context Link]


104. Hassiotou F, Geddes DT. Immune cell-mediated protection of the mammary gland and the infant during breastfeeding. Adv Nutr. 2015;6(3):267-275. doi:10.3945/an.114.007377. [Context Link]


105. Shulhan J, Dicken B, Hartling L, Larsen BM. Current knowledge of necrotizing enterocolitis in preterm infants and the impact of different types of enteral nutrition products. Adv Nutr. 2017;8(1):80-91. doi:10.3945/an.116.013193. [Context Link]


106. Abbott Nutrition. Similac(R) Special Care(R) 20 for premature infants. [Context Link]


107. Czosnykowska-Lukacka M, Krolak-Olejnik B, Orczyk-Pawilowicz M. Breast milk macronutrient components in prolonged lactation. Nutrients. 2018;10(12):1893. doi:10.3390/nu10121893. [Context Link]


The NCPD test for this article is available online only. Log onto the journal website,, or to to access the test. For more than 56 additional nursing continuing professional development activities related to Perinatal topics, go to


extremely premature infant; growth and development; human milk; infant nutrition disorders; neonatal intensive care unit; neonatal nurses; neurodevelopmental disorders