A mother’s own milk provides the strongest short- and long-term health benefits for infants hospitalized with very low birth weight, according to an updated clinical report from the American Academy of Pediatrics (AAP). The guidance emphasizes fortified maternal milk as the preferred nutritional source for very low birth weight infants in the neonatal intensive care unit (NICU), supported by extensive observational data and randomized clinical trials.1,2
The revised report, Promoting Human Milk and Breastfeeding for the Very Low Birth Weight Infant, was developed by the AAP Committee on Fetus and Newborn, the Section on Breastfeeding, and the Committee on Nutrition.
Human milk feeding is associated with lower risk of necrotizing enterocolitis and infection
Very low birth weight infants—defined as those weighing 1500 g or less at birth—face increased risks of serious complications, including necrotizing enterocolitis (NEC), late-onset sepsis, chronic lung disease, retinopathy of prematurity, and adverse neurodevelopmental outcomes. The clinical report summarizes evidence showing that use of mother’s own milk as the base diet, when appropriately fortified, is associated with lower rates of NEC and other complications compared with preterm infant formula.
“A mother’s own milk, when fortified properly, gives very low birth weight babies powerful health benefits both right now and in the future,” said Margaret G. Parker, MD, FAAP, a lead author of the report and member of the Committee on Fetus and Newborn. “No formula can fully match the unique makeup and protective qualities of human milk. In addition, breastfeeding has been associated with many health benefits for mothers, including a reduction in cardiovascular disease and cancer.”
Dose–response evidence supports prioritizing maternal milk supply
The report highlights a consistent dose–response relationship between exposure to mother’s own milk and improved neonatal outcomes. Higher volumes and longer duration of maternal milk feeding are associated with reduced risk of NEC, late-onset sepsis, and neurodevelopmental impairment across multiple observational studies and meta-analyses.
Although feeding very low birth weight infants a human milk–based diet does not eliminate the risk of NEC, rates are consistently lowest when human milk—rather than preterm infant formula—is used as the primary source of nutrition.
Pasteurized donor human milk is recommended when mother’s milk is unavailable
When a mother’s own milk is not available, insufficient in volume, or contraindicated, the AAP recommends pasteurized donor human milk obtained from screened and approved donors. Randomized controlled trials summarized in the report demonstrate that donor human milk is associated with a reduced risk of NEC compared with preterm infant formula.
However, the report notes that donor milk does not provide all of the same benefits as a mother’s own milk, including reductions in late-onset sepsis or improvements in neurodevelopment. For this reason, pasteurized donor human milk is described as a temporary “nutritional bridge” until a sufficient maternal milk supply is established.
Fortification of human milk is essential for growth in very low birth weight infants
Human milk—whether maternal or donor—requires supplementation with multi-nutrient fortifiers to meet the elevated nutritional needs of very low birth weight infants. The report explains that unfortified human milk alone does not provide sufficient protein, energy, minerals, and micronutrients to support growth comparable to fetal accretion.
Evidence reviewed in the report shows that fortified human milk helps protect very low birth weight infants from NEC while supporting appropriate growth and development. Current data do not support routine preference for human-derived over hydrolyzed bovine-derived fortifiers when human milk is used as the base diet.
Key nutrition recommendations for very low birth weight infants
According to the AAP clinical report, optimal nutritional care for very low birth weight infants includes:
Mother’s own milk, fortified as needed, as the preferred base dietPasteurized donor human milk when maternal milk is unavailable or insufficientMulti-nutrient fortification to meet protein and energy requirementsPreterm infant formula when human milk options are unavailable or declinedIndividualized feeding plans based on infant growth, clinical status, and family preferencesPreterm infant formula remains an appropriate alternative when human milk is unavailable
If neither mother’s own milk nor pasteurized donor human milk with fortifiers is available—or if families choose not to use donor milk—the AAP recommends preterm infant formula. The report emphasizes that preterm formulas are nutritionally appropriate and preferable to prolonged parenteral nutrition or the use of non-preterm formulas that do not meet the needs of very low birth weight infants.
NICU clinicians play a central role in supporting breastfeeding and lactation
The clinical report underscores the role of physicians and NICU teams in helping families initiate and sustain lactation. Recommended strategies include early and frequent milk expression, access to high-quality double electric breast pumps, encouragement of skin-to-skin contact, counseling on the benefits of maternal milk, and support for direct breastfeeding when physiologically appropriate.
“Clinicians, birthing centers, and hospitals can support families who all share the same goal – to provide the best source of nutrition possible for their baby, especially those who are born early and need extra attention,” Parker said.
Addressing disparities in human milk access in the NICU
The AAP also highlights persistent racial, ethnic, and socioeconomic disparities in access to mother’s own milk and donor human milk among very low birth weight infants. The report emphasizes the importance of peer lactation support, interpreter services, equitable donor milk availability, and institutional policies aimed at reducing disparities in NICU nutrition and care.
Physicians are encouraged to counsel families on maternal medication use, infection risk, and the potential risks associated with informal milk sharing. By combining evidence-based nutritional guidance with comprehensive lactation support, the AAP aims to improve outcomes for very low birth weight infants during a critical period of development.
References
Parker MG, Stellwagen L, Miller ER, et al. Promoting Human Milk and Breastfeeding for the Very Low Birth Weight Infant: Clinical Report. Pediatrics. Published online January 12, 2026. doi:https://doi.org/10.1542/peds.2025-073625AAP. American Academy of Pediatrics Updates Clinical Recommendations Promoting Use of Human Milk for Preterm Infants. AAP. January 12, 2026. Accessed January 13, 2026. https://www.aap.org/en/news-room/news-releases/aap/2025/american-academy-of-pediatrics-updates-clinical-recommendations-promoting-use-of-human-milk-for-preterm-infants/
