Nutrition for premature babies

Babies could be born “too early” aspretermsor “too small” as Low Birth Weight, both have short term as well as long term health consequences. Preterm infants are defined as infants born before the 37th week of pregnancy while Low Birth Weight is defined as birth weight less than 2.5kg.

In India, every year about 13% of babies are born as preterm which accounts to 3.5 million babies. Rate of Low birth weight is even higher (18%) which accounts to 5 million babies every year. Such babies are not fully prepared to live in the outside world – without the protection of their mother’s womb. Moreover, they are at a risk of developing several medical problems and complications since they are not fully-developed.Therefore, special care is required as they get affected by cold easily and may need more help with holding, feeding, bathing, diapering and overall care giving.

With the improvement in health care, in the last few decades, there has been a significant increase in the survival rate of preterm infants. Premature babies have very different nutritional requirements to full term infants as they need to attain the growth that would have occurred in utero, as well as achieve functional development. Meeting the high nutritional needs of these infants is challenging.Human milk is the best feed for preterm infants, but the composition of unsupplemented human milk is not adapted to the increased nutritional requirements of the preterm infant. A mother may not secrete enough milk to meet the nutritional requirements. Therefore, it is common practice to enrich human milk with human milk fortifiers to provide the advantages of human milk to the preterm infant.

Feeding your baby with special care

Holding your baby while feeding:

Hold your baby comfortably with support of your arms and pillows at breast height. Position the baby at your nipple level. Hold baby’s head and back with one hand. Let the other hand guide the areola so that the baby can grasp the nipple. Hold your breast during the entire feeding, due to small mouth of the baby. Avoid and minimize noise, stroking, rocking, and light while feeding. Allow your baby to initiate sucking, gazing, licking, and small sucks normally precede a latching on. You can gently pull down on the chin with a finger if the baby is not opening his/her mouth well. Be patient. The milk ejection reflex takes a minute to several minutes to begin. You should relax especially your arms and shoulders. Gently stroking down the shoulder and arms gives a powerful and effective massage to the baby. Observe your baby for signs that the areola is being drawn into the mouth and that the nipple is not under the tongue. As the milk ejection begins, observe the baby for swallowing, and a slowing of the sucks, as the non-nutritive suck changes to the nutritive suck.

Observe for signs

A mature suck with burst of 10-30 rhythmic sucks of one to one sucking/swallowing and uninterrupted breathing. Immature suck with burst of 3-5 sucks with breathing before or after bursts. Disorganized sucks with bursts of non-rhythmic sucking, irregular respiration and signs of apnea (difficulty in breathing). Offer the baby with second breast after a rest/burping time. Frequently breastfeed your baby.

Duration of breast feeding: Breastfed your baby exclusively until 6 months of age

If you are not able to breastfeed the baby, feed your baby with donor human milk or standard infant formula or preterm infant formula from the time of discharge until 6 months of age.2 Babies who fail to gain weight despite adequate breast-milk feeding should be given human-milk fortifiers, preferably those that are human milk based.

Alternative to breast feeding in premature babies:

If you are not able to breastfed the baby or your baby isn’t sucking well due to prematurity, feed your baby with expressed breast milk.3 Expressing milk means squeezing milk out of your breast so you can store it and feed it to your baby whenever your baby is hungry.

Different feeding methods

If you are not able to breastfed the baby or your baby isn’t sucking well due to prematurity, feed your baby with expressed breast milk.3 Expressing milk means squeezing milk out of your breast so you can store it and feed it to your baby whenever your baby is hungry.

Different feeding methods

Includes cup feeding (or paladai, or bondla which is a cup with a beak) or spoon.

Feed the premature baby based on hunger cues, except when the baby remains asleep beyond 3 hours since the last feed.2 Breastfeeding is the sole source of nutrition for your baby for about 6 months. When you add solid foods to your baby’s diet, continue breastfeeding until at least 12 months. You can continue to breastfeed after 12 months if you and your baby desire.

Warning: Cup feeding should be done under the supervision of a midwife until you feel confident enough to avoid the risk of your baby choking.

Supplementation: It is recommended that premature babies fed with mother’s own milk (breast feeding or expressed milk) or donor human milk should be given extra calcium, phosphorus and iron supplements.2 For further information please consult your doctor.


Young babies naturally fuss and get cranky when they swallow air during feedings. Although this occurs in both breastfed and bottle-fed infants, it’s seen more often with the bottle. When it happens, it may be helpful to stop the feeding rather than letting your infant fuss and nurse at the same time. This continued fussing will cause her to swallow even more air, which will only increase her discomfort and may make her spit up. A much better strategy is to burp her frequently, even if he/she shows no discomfort. The pause and the change of position alone will slow his/her gulping and reduce the amount of air she takes in. Some breastfed babies don’t swallow very much air, and therefore they may not need to burp frequently.


Most babies hiccup from time to time. Usually this bothers parents more than the infant, but if hiccups occur during a feeding, change his position, try to get him/her to burp, or help him/her relax. Wait until the hiccups are gone to resume feeding. If they don’t disappear on their own in five to ten minutes, try to resume feeding for a few minutes. Doing this usually stops them. If your baby gets hiccups often, try to feed him when she/he’s calm and before she/he’s extremely hungry. This will usually reduce the likelihood of hiccups occurring during the feeding.

Spitting Up

Spitting up is another common occurrence during infancy. Sometimes spitting up means the baby has eaten more than her stomach can hold; sometimes he/she spits up while burping or drooling. Although it may be a bit messy, it’s usually no cause for concern. It almost never involves choking, coughing, discomfort, or danger to your child, even if it occurs while she’s sleeping. Some babies spit up more than others, but most are out of this phase by the time they are sitting. A few “heavy spitters” will continue until they start to walk or are weaned to a cup. Some may continue throughout their first year.

It is important to know the difference between normal spitting up and true vomiting. Unlike spitting up, which most babies don’t even seem to notice, vomiting is forceful and usually causes great distress and discomfort for your child. It generally occurs soon after a meal and produces a much greater volume than spitting up.

While it is practically impossible to prevent all spitting up, the following steps will help you decrease the frequency of these episodes and the amount spit up.

Make each feeding calm, quiet, and leisurely. Avoid interruptions, sudden noises, bright lights, and other distractions during feedings. Burp your baby at least every three to five minutes during feedings. Avoid feeding while your baby is lying down. Hold the baby in an upright position for 20 to 30 minutes after each feeding. Do not jostle or play vigorously with the baby immediately after feeding. Try to feed her before she gets frantically hungry. Elevate the head of the entire crib with blocks (don’t use a pillow) and put her to sleep on her back. This keeps her head higher than her stomach and prevents her from choking in case she spits up while sleeping.

Breast milk or formula should be your child’s sole nutritional source for about the first six months, and the major source of nutrition throughout the first twelve months. During this time, you and your pediatrician will need to pay attention to her pattern of feedings and make sure that she’s getting enough for growth.

Care guide for babies

Care guide for babies who are born too soon and too early

A premature baby is one that is born prior to the completion of 37 weeks of pregnancy. Such babies are not fully prepared to live in the outside world – without the protection of their mother’s womb. Moreover – they are at a risk of developing several problems and complications since they are not fully-developed.1 Therefore, special care is required as they get affected by cold easily and may need more help with holding, feeding, bathing, diapering and overall care giving.


Premature babies are supposed to be held and tended to – using the kangaroo care technique. Kangaroo care involves early, continuous and prolonged skin-to-skin contact between low birth weight infant/premature baby and the mother.

Benefits of kangaroo care for the premature babies include:

  • Warmth
  • Stability of heartbeat and breathing
  • Increased time spent in the ‘deep sleep’ and ‘quiet alert’ states
  • Decreased crying
  • Increased weight gain
  • Increased breastfeeding

These benefits start showing up even when only a few minutes of kangaroo care is given to the baby – each day.


Premature babies need to have their diapers changed – several times each day.

Changing Diaper of premature infant

  • Gently cradle the baby’s head and feet
  • If the newborn is younger than 33 weeks’ gestation, place ‘boundaries’ – such as rolled blankets – around the baby
  • Gently remove the clothes and diaper on the lower part of baby’s body
  • Carefully clean the skin around the diaper area and slide the new diaper under your baby
  • Try not to lift your baby’s hips or bottom off the table or put pressure on his/her stomach
  • Some premature babies need to rest during a diaper change – to help them stay calm
  • Always remember to wash your hands before and after a diaper change to protect both – the mother and the baby


Premature babies have delicate skin that requires gentle bathing styles, namely ‘spot’ and ‘swaddled’ bathing.

Spot Bathing

In this technique, the premature baby needs cleaning only in certain ‘spots’, such as the mouth, diaper area and around tubes.

Clean the aforementioned spots using a wet cloth (of smooth material); subsequently, dab them using a dry cloth

Swaddled Bathing

This technique is used at a later stage, when the premature baby grows stronger and is ready for a swaddled bath.

  • Wrap your baby in a blanket/cloth and place him/her in a tub of warm water in such a way that the water touches the baby’s shoulders
  • Use a wet cloth (without soap) of smooth material to wash your baby’s face; wipe it from nose to ears and then pat it dry
  • Add cleansing lotion to your wet cloth
  • Remove one part of the blanket at a time to wash the body; cover each area after you have washed it
  • Use the soapy, wet cloth to wash the hair, then rinse the soap from your baby’s hair with clean water
  • Remove your baby from the wet blanket and wrap him/her in a warm, dry towel; cover his/her head to keep him/her warm and pat him/her dry.

Routine care

  • Includes medication, treatment of minor illnesses and injuries,
    observation of behavior and giving out parenting advice.
  • However, your pediatrician may not be able to answer your queries without seeing your child first

Urgent care

If the newborn experiences any of the following symptoms, you must call the doctor to find out if your baby needs to be treated;

  • Vomiting, rash, diarrhea and stomach/abdomen pain
  • Prolonged/worsening cough and cold accompanied by fever
  • Sharp/persistent pain in the abdomen/stomach
  • Continuous vomiting
  • Blood in the urine

Emergency care

Call the doctor immediately if your baby is severely ill or injured

Tips before and during your call to the doctor

Before calling your doctor, keep a pen and paper ready to jot down any instructions and questions – as you should not miss out of anything that the doctor says to you


Check your baby’s body temperature before calling the doctor; also make note of the time of the temperature measurement

Medical problems

Remind the doctor about past medical problems (such as asthma, seizures or any other conditions)


Do inform your doctor if the baby is already undergoing medication; including prescription and non-prescription drugs, inhalers, supplements, vitamins, herbal products or home remedies


Keep immunization records at hand; they are especially helpful if the baby has; an injury that may require a tetanus shot or pertussis (whooping cough).

How babies grow up?

At 13 to 18 months

I. Motor Skill

  • Is able to feed himself/herself
  • Tries using spoon for feeding
  • Is able to scribble with a large crayon
  • Walks alone with his/her heels – flat on the floor
  • Coordinates while using both his hands – well

II. Language Skills

  • Uses a vocabulary of four to ten words
  • Follows simple verbal instructions

III. Activity Skills

  • Uses his/her thumb and first finger easily to pick up very small objects

IV. Social/Emotional Skill

  • Responds to his/her name
  • Tries holding conversations

All babies will eventually walk, all babies will eventually talk but each baby follows her own pattern of reaching such milestones and developmental stages. While this guide will help you to understand the developmental milestones you could expect in your little ones at different points, it is important to understand that development is not a race. Every baby develops at her own pace. Some children do not reach every milestone at the same time. This is especially true if they were born early. Do visit your doctor regularly as per schedule and discuss your concerns, if any. All you have to ensure is that your baby is growing progressively.

The information below shows how young children typically develop. It is important to use your child’s adjusted age when tracking his development.1 • So, if your baby is 21 weeks old, but was born 5 weeks early, his/her adjusted age is 16 weeks (or 4 months). This means you should refer to the milestones listed under “at 4 months (16 weeks)” to see what your child should be doing at this age.

At 2 months

I. Motor Skill

  • Shows active movement of hands and legs
  • Lifts head and chest when lying on the stomach
  • Requires parents’ support to control his/her head
  • Holds objects in hands

II. Language Skills

  • Responds to the sounds of toys and the voices of family members
  • Makes cooing noises like ‘aaaah’ and ‘ooooh’
  • Cries when he/she needs something

III. Activity Skills

  • Fixes eyes on person/object (for example: mother/toy) and follows their movement
  • Cries out in different ways for different needs

IV. Social/Emotional Skill

  • Makes eye contact
  • Smiles
  • Recognizes the mother and family members

At 4 months

I. Motor Skill

  • Brings hands together, and/or covers his/her mouth
  • Lifts head and pushes on arms when lying on the
  • stomach
  • Reaches out for objects
  • Turns and twirls/makes crawling movement when lying on the stomach

II. Language Skills

  • Follows/recognizes and turns head to familiar voices
  • Laughs and squeals
  • Makes a combination of sounds

III. Activity Skills

  • Grasps objects
  • Brings objects to mouth
  • Gets excited upon seeing a toy

IV. Social/Emotional Skill

  • Shows interest in surroundings
  • Becomes more playful and interactive
  • Gets comfortable with parents and family members

At 6 months

I. Motor Skill

  • Pushes objects using his/her feet
  • Stands up with support
  • Sits comfortably on his/her own
  • Holds/rattles/bangs objects
  • Transfers objects from one hand to another
  • Holds two objects at a time – one in each hand
  • Rolls over from stomach to back

II. Language Skills

  • Responds to his/her name
  • Turns around and gives a look
  • Babbles monosyllables

III. Activity Skills

  • Enjoys staring at toys, listening to music and glaring at light

IV. Social/Emotional Skill

  • Recognizes parents and reacts to their calling
  • Reacts differently to strangers
  • Expresses signs of happiness/sadness

At 9 months

I. Motor Skill

  • Picks up small objects with thumb and fingers
  • Crawls and moves with the support of furniture
  • Walks with others’ hand support
  • Pulls to a stand

II. Language Skills

  • Recognizes familiar words (for example: names of his/her favorite food/activity)
  • Babbles different sounds and repeats movements

III. Activity Skills

  • Explores objects – carefully (turns them upside down, puts hands inside openings)
  • Becomes more involved in feedings (tries to hold bottle, picks up finger food)

IV. Social/Emotional Skill

  • Enjoys interactions with family members
  • Becomes anxious around strangers

At 12 months (one year)

I. Motor Skill

  • Manages to stand independently/without support
  • Takes first steps while attempting to walk
  • Turns pages (few at a time) of books
  • Puts small objects in container

II. Language Skills

  • Combines movements with sounds (for example: pointing at an object and demanding it)
  • Follows simple instructions
  • Associates words with objects/people
  • Repeats the same word again and again

III. Activity Skills

  • Tries to feed himself/herself (attempts to drink from cup)
  • Helps with dressing

IV. Social/Emotional Skill

  • Prefers to be with parents and family members
  • Plays with other children