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In the first year of life, most full-term babies follow a fairly predictable growth pattern. The standard feeding advice given to parents is based on these typical developmental milestones.

However, preterm babies may require special considerations to meet their nutritional needs. Parents should hold off on solid foods before their preemie is ready. When introducing solids to preemies, consider the infant's corrected age rather than their actual age.

“Corrected age” is used because normal development relates to when a baby was due to be born rather than their actual birth date. To calculate it, start with your baby's age in weeks, then subtract the number of weeks the baby was born preterm.

Both the World Health Organization (WHO) and the American Academy of Pediatrics (AAP) recommend that all full-term babies be exclusively breastfed for the first six months of life if possible.

Then, infants can be offered supplementary foods, but should continue breastfeeding or using baby formula through the end of their first year. After the first year, most babies are ready to transition to whole milk and some water.

For preemies, this advice is the same, except you use the corrected age instead of the calendar age. So preemies should be exclusively breastfed until the corrected age of 6 months.

Because preemies are at increased risk of iron and certain vitamin deficiencies, they should receive multivitamin drops starting at 1 month of age. Solid foods will help provide these nutrients later, but the supplemental vitamins should continue until at least 1 year of age.

Developmental Feeding Signs

Keep in mind that every baby is different. Wait until your baby displays signs of readiness for solids before you begin introducing new foods. Here are some indicators that your baby is prepared for the next stage of feeding.

Ready for Pureed Foods or Infant Cereal

• Able to sit upright with support and control head and neck movements
• Begins up and down chewing instead of sucking motion
• Can take food without gagging or choking
• Capable of moving food from the front of the tongue to back and swallowing
• Displays interest in food by leaning forward and opening mouth
• Leans back and turns away when full

Ready for Finger Foods

• Able to sit independently without support
• Can maintain balance while reaching to grasp objects
• Uses a palmar grasp to hold large food items, like a piece of toast

Continued Feeding Progression

Your infant may be ready for the following next steps once they show continued growth and development.

• Cup feeding: Able to control how large of a sip they take, not choking or gagging after swallowing liquid from a cup
• More texture and flavor: Good chewing control and ability to move tongue laterally (from side to side)
• Smaller, softer finger foods: Able to pick up foods between thumb and finger using a pincer grasp
• Softer table foods: Chewing with a more "munching" style, better able to handle large pieces of food without choking

Solid food should never be introduced before 4 months of age. Your baby should be displaying signs of readiness before trying their first bite.

Best Practices for Preemies

When you first bring your preemie home from the hospital, it can be tough to tell if they're hungry or full, as these cues may be more subtle in babies who are born early. Consulting your pediatrician can help you determine whether your baby is eating enough based on their growth pattern and how often they produce a wet diaper.

Common feeding issues for premature infants include when the baby:

• Coughs, gags, or spits up: A feeding therapist can help set up a pacing program for feeding. Smaller, more frequent feedings, using smaller bottle nipples, or putting the baby to the breast after milk letdown has occurred may help.
• Eats less at home: Preemies may sleep more at home, taking in less breastmilk or formula than in the hospital. Families need to work with their doctors to decide whether a baby should be woken up for more frequent feedings or if the reduced intake can be made up for at other times of the day.
• Falls asleep during feeding: Supplemental oxygen might be required to maintain oxygen status while feeding. A small stomach capacity can make it difficult for preemies to get enough nutrition, so a higher concentration formula might be necessary.
• Gets upset during feeding: Preemies should be evaluated for acid reflux with or without aspiration. Once this issue is addressed, it may take time and guidance from a feeding therapist to overcome negative associations with feeding and develop a more positive experience for you and your infant. Keep feeding times quiet and free from distractions to avoid overwhelming your baby.
• Shows preference for bottle: Nursing more frequently or pumping and using a bottle may work better for your baby. Although feeding on the breast is usually ideal, preference must be made to ensure adequate nutrition by whichever means necessary (even when that includes bottles).

Deciding to move to solids should be based on the baby's corrected age and signs of development. Published guidelines for premature infants advise waiting until the baby is able to eat from a spoon and has lost the extrusion reflex (pushing their tongue out in response to feeding) before progressing to solid foods.

It's also commonly recommended that parents wait until their preemie has reached a bodyweight of 5 kilograms (11 pounds) before introducing solids. However, in the case of stalled weight gain, your pediatrician may advise solids prior to hitting the 5-kilogram weight mark. Parents should work together with their child's doctor to decide what's best.

Food Allergies

Regardless of whether your baby is born premature, it's preferable that parents delay the introduction of solid food until six (adjusted) months to avoid food allergies. A good rule of thumb is to introduce new foods to your baby one food at a time.

Adding one new food every couple of days, for example, gives you time to watch for signs of an allergic reaction. Common signs of a food allergy in babies include:

• Rashes or other skin signs like eczema
• Runny nose and sneezing
• Stool changes and other digestive issues

Some babies with food allergies will demonstrate behavioral changes. For example, they might seem fussy, be difficult to soothe, or won't fall or stay asleep well.

If your baby is exhibiting severe symptoms of an allergic reaction, such as difficulty breathing or vomiting that will not stop, seek immediate medical care.

Once your baby is ready for solids, don't wait too long to introduce peanuts, eggs, and other potentially allergenic foods. Giving your baby a variety of solids before the 12-month (corrected age) mark can actually help prevent the development of future food allergies. Although feeding preemies can be stressful in the early stages, keep in mind that most premature infants will catch up in a matter of time.