Infants Born <38 Weeks Gestation or < 6 lbs


Near term or small for gestational age (SGA) infants are at higher risk for hyperbilirubinemia, dehydration and hospital readmission than infants >38 weeks (Sarici, 2004). The threshold for treatment (supplementation and/or phototherapy) should be lower, with a maximum of 8% weight loss or bilirubin levels of > 15 at 72 hours (See AAP guidelines, Bhutani’s curve, for age-appropriate guidelines). Early preventative measures should be initiated within 8 hours to reduce these risks.

Suggested Measures

  1. Advise mothers to breastfeed at least 8-12 times/day. It may be necessary to wake the baby if he/she does not indicate hunger.
  2. Encourage 24 hour rooming-in. Practice skin-to-skin contact from birth and as much as possible, especially during the first days. Benefits of this simple practice include: abbreviation of the learning time to attachment and effective suckling, stimulation of milk production, decreased infant crying, and increased sleeping time (Blaymore-Bier,1996; Kurinij, 1991; Hurst, 1997; Ferber, 2004;Quillin, 2004).
  3. Supplement in addition to breastfeed (See Appendix K).
  4. Within the first 6 hours, teach mothers to manually express colostrum into a teaspoon (see Appendix G) and spoon feed this to the infant, after each breastfeeding, using these volumes (See Appendix K):

Supplementation of SGA or Near Term Infants

After each breastfeed, spoon feed: colostrum, colostrum + formula, donor milk, or formula


Birth - 24 hours

24 - 48 hours

48 - 72 hours

Infants 37-38 weeks AND 6 lbs or more 5 ml (1 tsp) every 2 - 3 hours, at least 8 times in 24 hours 5 ml (1 tsp) every 2 - 3 hours, at least 8 times in 24 hours 5 ml (1 tsp) every 2 - 3 hours, at least 8 times in 24 hours
Infants <37 weeks OR <6 pounds 5 ml (1 tsp) every 2 - 3 hours, at least 8 times in 24 hours 10 ml (2 tsp) every 2 - 3 hours, at least 8 times in 24 hours 15 ml (3 tsp) every 2 - 3 hours, at least 8 times in 24 hours
  1. Add pumping by 24 hours, in addition to hand expression (8 times/24 hrs.) if the infant is too sleepy to attach and nurse effectively.
  2. Begin ad lib supplementation if weight loss exceeds 8%, while encouraging mother to hand express, pump, and breastfeed at least 8 times/24 hrs. Begin with expressed milk and add formula, if needed.
  3. For infants less than 37 weeks or less than 5 pounds, in-home measurement of at-breast intake by test-weighing should be considered, or at least once a day weights. (Meier, 1997) (See Appendix D).
  4. When phototherapy is indicated, consider use of in-room or at-home therapy with a bili-bed, when appropriate, to reduce maternal-infant separation.
  5. Follow-up appt. within 24-48 hours of discharge (See AAP, Management of hyperbilirubinemia, 2004).

Suggested Script

Even though you have exactly the amount of colostrum your baby needs now, for these first couple of days, we have learned that babies born a little early are, in some ways, “too good”. They don’t cry as much, fall asleep quickly, are not as vigorous at the breast, and may not stimulate your breasts to produce as much milk as your baby will need by the 3rd. day. For this reason, we’ve learned that this little “boost” is a very important way of “phoning in your order for Day 3."