e-Library of Evidence for Nutrition Actions (eLENA)

Feeding of low-birth-weight infants in low- and middle-income countries

Full set of recommendations*

WHO recommendations

None of the recommendations below address sick infants or infants with birth weight less than 1.0 kg.

What to feed

Choice of milk

1. Low-birth-weight (LBW) infants, including those with very low birth weight (VLBW), should be fed mother’s own milk.

2. LBW infants, including those with VLBW, who cannot be fed mother's own milk should be fed donor human milk (recommendation relevant for settings where safe and affordable milk-banking facilities are available or can be set up).

3. LBW infants, including those with VLBW, who cannot be fed mother's own milk or donor human milk should be fed standard infant formula (recommendation relevant for resource-limited settings).

VLBW infants who cannot be fed mother's own milk or donor human milk should be given preterm infant formula if they fail to gain weight despite adequate feeding with standard infant formula.

4. LBW infants, including those with VLBW, who cannot be fed mother's own milk or donor human milk should be fed standard infant formula from the time of discharge until 6 months of age (recommendation relevant for resource-limited settings).

5. VLBW infants who are fed mother’s own milk or donor human milk should not routinely be given bovine milk-based human milk fortifier (recommendation relevant for resource-limited settings).**

VLBW infants who fail to gain weight despite adequate breast milk feeding should be given human-milk fortifiers, preferably those that are human milk based.**

Supplements

6. VLBW infants should be given vitamin D supplements at a dose ranging from 400 IU to 1000 IU per day until 6 months of age.**

7. VLBW infants who are fed mother’s own milk or donor human milk should be given daily calcium (120-140 mg/kg per day) and phosphorus (60-90 mg/kg per day) supplementation during the first months of life.**

8. VLBW infants fed mother’s own milk or donor human milk should be given 2-4 mg/kg per day iron supplementation starting at 2 weeks until 6 months of age.**

9. Daily oral vitamin A supplementation for LBW infants who are fed mother's own milk or donor human milk is not recommended at the present time, because there is not enough evidence of benefits to support such a recommendation.

10. Routine zinc supplementation for LBW infants who are fed mother's own milk or donor human milk is not recommended at the present time, because there is not enough evidence of benefits to support such a recommendation.

When and how to initiate feeding

11. LBW infants who are able to breastfeed should be put to the breast as soon as possible after birth when they are clinically stable.

12. VLBW infants should be given 10 ml/kg per day of enteral feeds, preferably expressed breast milk, starting from the first day of life, with the remaining fluid requirement met by intravenous fluids (recommendation relevant for resource-limited settings).**

Optimal duration of exclusive breastfeeding

13. LBW infants should be exclusively breastfed until 6 months of age.

How to feed

14. LBW infants who need to be fed by an alternative oral feeding method should be fed by cup (or palladai, which is a cup with a beak) or spoon.

15. VLBW infants requiring intragastric tube feeding should be given bolus intermittent feeds.**

16. In VLBW infants who need to be given intragastric tube feeding, the intragastric tube may be placed either by oral or nasal route, depending upon the preferences of health-care providers.**

Frequency of feeding and how to increase the daily feed volumes

17. LBW infants who are fully or mostly fed by an alternative oral feeding method should be fed based on infants’ hunger cues, except when the infant remains asleep beyond 3 hours since the last feed (recommendation relevant to settings with an adequate number of health-care providers).

18. In VLBW infants who need to be fed by an alternative oral feeding method or given intragastric tube feeds, feed volumes can be increased by up to 30 ml/kg per day with careful monitoring for feed intolerance.**

IU = international unit
* This is an extract from the relevant guideline (1). Additional guidance information can be found in this document.
** These recommendations specifically address infants with birth weight between 1.0 and 1.5 kg.


References

1. WHO. Guidelines on optimal feeding of low birth-weight infants in low- and middle-income countries. Geneva, World Health Organization; 2011 (http://www.who.int/maternal_child_adolescent/documents/infant_feeding_low_bw/en/).