Feeding the low birth weight infant.

A true gold standard for assessing the nutritional outcome of preterm infants remains elusive. We are seeing an expansion beyond the traditional intrauterine-based short-term growth and nutrient retention rates toward a broader, and possibly life-long, range of outcomes. As our nutritional end points shift, the suitability of the preterm infants' own mothers' milk may become more apparent. Whether the unique properties of human milk or the use of human milk components for fortification are sufficient to rekindle the use of donor milk from milk banks remains to be seen. Improved formulas designed specifically for preterm infants and the possibility of providing passive immunity in formula have added fuel to the debate over what constitutes an ideal nutrient source. The optimal time to begin to feed our smallest and sickest patients is being reevaluated. A policy of exclusive parenteral nutrition for prolonged periods of time may be replaced with one in which minimal amounts of feeding are used, in conjunction with parenteral support, to prepare and maintain intestinal function until advancements toward full enteral nutrition are possible. Although well-controlled trials are needed to add substance to our decisions on many feeding methods, such as intermittent bolus versus continuous gastric infusion, the use of transpyloric feeding should be discouraged. Finally, we need to determine if there are any tangible nutritional benefits from the use of nonnutritive sucking. It is hoped that resolution of some of the controversies of feeding preterm infants will broaden our clinical view of infant nutrition. The discussion on work rounds will then move away from the current "did the baby get 120 kcal/kg yesterday?" toward an informed discussion of how, what, when, and why to feed the infant. Over a century ago, Abraham Jacopi cautioned pediatricians that "You cannot feed a baby with mathematics; you must feed them with brains."