• If possible, you should encourage parents to have skin-to-skin contact with their baby whilst tube-feeding and then continue this if the infant is going to be breastfed
• When an infant starts opening or closing their mouth during a tube-feed, this is a sign they are ready to start practising sucking
• It may take several weeks before an infant establishes a mature sucking reflex and is able to feed adequately; this depends on how prematurely they were born and their medical condition.  Also, as with term infants, some infants take longer to learn than others. The important thing is to urge parents to be patient and try not to worry
• Preterm infants are often given dummies (pacifiers) to help develop the sucking reflex.  Research has shown that this non-nutritive sucking helps to promote a more rapid and easier transition from a preterm infant being tube-fed to being able to start feeding normally¹
• Non-nutritive suckling has been linked with the gastric motor functions by stimulating oral nerve fibres, which then go on to stimulate the release of gastrointestinal hormones such as somatostatin, which helps with gastric emptying²
• Non-nutritive suckling has also been shown to help with craniofacial and dental development³

Using low birthweight formula, when breast or donor milk is not available

• In hospital, where the use of expressed breast milk or donor breast-milk is not possible, low birthweight (LBW) infants may be given a specially-designed formula for low birthweight and preterm infants; a low birthweight formula
• This contains the nutrients preterm babies need to help achieve the appropriate growth, including protein, vitamins and minerals, specifically calcium and phosphorus to help with bone mineralisation
• Low birthweight formulas are usually given by naso- or oro-gastric tube-feeding until the baby is mature enough to coordinate sucking, swallowing and breathing then they can begin bottle-feeding
• Once an infant is ready to be discharged from hospital, if they are bottle-feeding, they may be prescribed a post-discharge formula

Bottle-feeding post-discharge

• There is a considerable amount of research which shows that when a preterm infant is ready to leave hospital, their nutrient status has not caught up to normal, even when in-hospital nutrition is managed optimally⁴
• Most LBW/preterm infants have accumulated significant energy, protein, mineral and other nutrient deficits since birth⁵
• Many preterm/LBW infants still weigh less than term infants at time of hospital discharge:
  • Healthy term infants weigh about 3.3 kg on hospital discharge^4,6
  • LBW/preterm infants weigh about 1.8-2.5 kg on hospital discharge^4,6
• Post-discharge formulas (PDFs) are designed to provide a nutritionally sound transition from preterm to term formulas
• PDFs are specially developed to provide extra protein, energy, the key vitamins and minerals required for improved growth and bone mineralization, and all the other vitamins and minerals needed so that no additional fortification/supplementation is required
• There are no established guidelines for when a PDF should be used or when an infant should be transitioned from a PDF to a term formula.  However, most clinical studies have demonstrated the benefits of a post-discharge formula for up to 12 months
• PDFs are recommended by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) for low birthweight/preterm infants. They recommend use in formula-fed infants with a subnormal weight for post-conceptional age at discharge from hospital. They also recommend that they are used at least until a post-conceptual age of 40 weeks, but possibly up to 52 weeks⁷
• The Committee on Nutrition, American Academy of Pediatrics, 2009 states “In general, post-discharge formulas are often continued until 9 to 12 months’ corrected age or until the baby’s weight for length is maintained above the 25th percentile”⁸
• However, the length of time an infant will need to stay on a PDF is dependent on their nutritional status and growth progress
• In general, the smaller the premature infant at birth, the more likely that infant will benefit from a more nutrient-enriched formula when discharged from the hospital
• PDFs should be discontinued in infants whose weight exceeds the 90th percentile of weight for corrected age, or whose weight is disproportionate to the percentiles for length and head circumference
• PDFs offer a nutritionally sound transition from the low birthweight formula to formulas for term babies.