Comparative assessment of preterm infant feeding strategies in government versus private neonatal intensive care units in Pakistan: A cross-sectional study

Background Early and adequate nutritional support in neonatal intensive care units (NICUs) is essential for reducing complications and mortality among preterm infants. Despite established guidelines, variations in feeding practices persist across healthcare settings. Aim To evaluate preterm feeding practices across NICUs in Pakistan and compare feeding strategies between government and private hospitals. Methods A cross-sectional study was conducted to assess preterm feeding practices across Pakistani NICUs. Of the 100 NICUs approached, 48 (48%) participated in the study. Data was collected using a self-administered, validated questionnaire developed to evaluate hospital-based feeding practices, including feeding initiation protocols and adherence to clinical guidelines, fortification practices, barriers and challenges influencing feeding decisions, key determinants of feeding choices, growth monitoring protocols, and provision of lactation. The data were analyzed using chi-square, Fisher's exact test, and the Mann-Whitney U test, with significance at a 95% probability level. Summary One neonatologist from each NICU participated; most respondents had 1–5 years of experience (45.8%), and 60.4% were from private hospitals. Both settings showed comparable use of the mother's own milk. However, private hospitals had longer waiting times before initiating alternative feeding (median 1.00 vs. 0.00, p = 0 . 005) and lower immediate Kangaroo Mother Care initiation (48.3% vs. 84.2%, p = 0 . 039). Commercial fortifier use was higher in private hospitals (37.9% vs. 10.5%, p = 0 . 049), while medium-chain triglyceride oil was the most common fortifier overall. Private hospitals more frequently reported unavailability of expressed breast milk (55.2% vs. 26.3%, p = 0 . 049) and insufficient milk supply (89.6% vs. 47.4%, p = 0 . 001). Government hospitals more commonly identified untrained staff (52.6% vs. 17.2%, p = 0 . 01) and parental reluctance (57.9% vs. 27.6%, p = 0 . 036) as barriers.