Are You Maximizing Nutrition for Bigger NICU Infants?

Kim Flanagan, MSN, CRNP / October 2016


It is well established in the literature that human milk in the Neonatal ICU serves as a critical intervention to improve clinical outcomes for extremely low birth weight and very low birth weight infants. Numerous researchers have studied the positive role human milk plays in necrotizing enterocolitis, sepsis, retinopathy of prematurity and bronchopulmonary dysplasia.

However, when we begin to discuss the method in which we administer enteral feeds to premature patients, the water can begin to get a little muddy. Bolus, gravity, continuous? When to start? How quickly to advance? When to fortify?

Numerous institutions have worked very hard to look at the evidence and create feeding protocols to best serve their patients. Because, although the details are still getting worked out, we know that having a feeding protocol is better than no protocol at all.

A deeper dive into these protocols reveals a greater emphasis on the smaller NICU baby verses the larger or more mature NICU/PICU patient. So when caring for our ELBW and VLBW, we follow this standard:

We have an established feeding protocol. Check.

We have our feeding order. Check.

We have our human milk supply ready. Check.

The next step is to draw up the feed into a syringe and administer, either via gravity, or from an enteral-only feeding pump for those patients too premature to feed orally. In addition, it is ideal to point the syringe vertically to maximize fat delivery.

These recommendations are supported by four separate regulatory agencies: The Joint Commission, the American Society of Parenteral and Enteral Nutrition, the American Dietetic Association and the Human Milk Banking Association of North America:

Joint Commission:

Use tubing and related equipment only as they are intended to be used. Do not use IV tubing or IV pumps for enteral feedings.1

American Dietetic Association (ADA):

  • In general, intravenous pumps should not be used for enteral feeding when enteral feeding pumps designed for infants or pediatrics are available.
  • When human milk is continuously infused, large amounts of fat may be lost with separation and layering of fat in the delivery system. Tilting the delivery system so that the exit point of the feedings is elevated to minimize the loss of fat.2

American Society of Parenteral and Enteral Nutrition (ASPEN):

  • When syringe pumps are used in neonatal ICUs for human milk or other feedings, they should be clearly distinct from syringe pumps used for IV or other medical purposes. Ideally, they should be a different model, color, or as different in appearance from IV pumps as possible. The enteral feeding pumps should be clearly labeled as enteral feeding pumps.
  • Recommendation: HBM infused at low rates should be administered via syringe pump with the syringe tip elevated. “Continuous drip feedings using HBM is often indicated for neonates and infants. This can result in loss of fat and protein along with separation of a fat layer within the bag. To prevent this from occurring, a syringe pump is often used because it is accurate. Tilting of the pump to at an angle with the syringe tip elevated will prevent loss of fat.3

Human Milk Banking Association of North America (HMBANA):

The fat portion of the milk rises to the top when the milk is sitting. Use of a feeding pump system with the syringe tip pointed up reduces fat loss from 48% to less than 8%.4

Clearly the optimal method of delivery for human milk feeds is in a syringe for accuracy, nutrition optimization, and cost benefit. Seems pretty straight forward, doesn’t it?

No matter how you choose to feed the NICU infant, the products used to deliver feeds are consistent: feeding tube, extension set, syringe, and (when needed) a pump. Put the syringe in place either hanging via gravity, or on the pump and voila! Dinner is served!

But what about the bigger babies we care for? The ones who are able to benefit from human milk, but are receiving a feeding too large to accommodate the use of a 60 cc syringe? What do we do with those patients? How do we feed them utilizing the best practice of our regulatory agencies and nutritional standards?

Once we begin to move to discussing larger babies in the NICU or the pediatric unit, practice changes. If you have a 4 kg patient that receives full enteral human milk feeds at 150-160cc/kg/day, using a 60 mL syringe can be a challenging way to administer the feed and here’s why:

4kg (8.8lbs)=640cc/day=26cc/hr

Amount required in syringe:
If baby is fed q3 hours = 80 mL
If baby is fed q4 hours = 106 mL
If baby is fed continuously = 106 mL

None of these amounts allow us to utilize a 60 mL syringe.

Even a 100 mL syringe only works for q3 hour feeder. And if the baby is over 5 kg, the nurse would not be doing much else besides changing syringes that shift. In order to allow for nursing efficiency, and not change a syringe every 45 minutes, an enteral feeding bag and pump is used. Herein lies the problem.

Once we utilize a bag to feed human milk, we have possibly decreased the nutritional benefit and increased the cost. The bags have large priming volumes, potential fat loss, and can be expensive.

The NICU has always had unique needs surrounding many therapies, and feeding this population brings many challenges. Luckily, manufacturers like Medela are constantly researching and exploring feeding options to meet the nutritional needs of NICU patients and the efficiency needs of busy clinicians who care for them. I am confident that we will soon see more effective solutions that provide maximum nutrition for bigger infants in neonatal intensive care.


1. The Joint Commission. Sentinel Event Alert, Issue 53, August 20, 2014, Page: 4 #9

2. American Dietetic Association: Infant Feedings: Guidelines for preparation of human milk and formula in health care facilities. (2011), Page: 99-101

3. ASPEN Enteral Nutrition Practice Recommendations. Journal of Parenteral and Enteral Nutrition. (2009), Page: 152,157 #9

4. HMBANA Guidelines (2011) Best Practices for Storing and Handling Human Milk in Hospitals, Homes, and Child Care Settings. p. 4


About the Author

Kim Flanagan, MSN, CRNP, has worked as a NICU nurse and Neonatal Nurse Practitioner for 20 years. She currently serves as the Clinical NICU Specialist for Medela, Inc. In this role, she works with NICUs across the country to maximize their use of human milk in the neonatal population to improve patient outcomes, patient safety and best practices.