The DART Protocol for Nutrition in the Neonatal Intensive Care Unit (NICU) is a structured, evidence-based system designed to optimize the feeding and growth of premature newborns. This approach, often standing for a Data-driven Accelerated Regimen/ Therapy, aims to replicate the rapid growth and nutrient accumulation that occurs in the womb. The protocol prioritizes aggressive, targeted nutritional support to meet the high metabolic demands of the premature infant. Its goal is to achieve optimal physical growth and neurological development in infants born before their systems are fully mature.
The Physiological Need for Specialized NICU Nutrition
Preterm infants face unique physiological challenges that make standard feeding insufficient for healthy development. The last trimester of gestation is a period of rapid, exponential growth, where the fetus accumulates significant body mass and nutrient stores. When an infant is born prematurely, this intense growth phase must be supported outside the womb, requiring nutrient intake significantly higher than a term infant’s.
The limited nutrient reserves of premature infants are quickly depleted in the first days of life. Their gastrointestinal tracts are immature, making it difficult to utilize nutrients efficiently and increasing the risk of feeding intolerance. Without aggressive intervention, these infants are at high risk for postnatal growth failure, also known as extrauterine growth restriction. Targeting this nutritional deficit is important during the window for brain development, as poor early growth is a recognized risk factor for adverse long-term neurodevelopmental outcomes.
Mechanics of the DART Protocol
The DART protocol relies on a dynamic, cyclical process of data collection, analysis, and rapid adjustment to the feeding regimen. This data-driven strategy begins with the early initiation of both parenteral and enteral nutrition immediately after birth. Parenteral nutrition, delivered intravenously, provides high concentrations of protein, calories, and micronutrients to meet immediate needs while the gut matures.
The protocol features the accelerated advancement of enteral feedings, often using the mother’s own milk or donor human milk. Feedings are advanced in daily increments of up to 30 milliliters per kilogram of body weight. This rapid advancement aims to achieve full enteral nutrition—typically 160 milliliters per kilogram per day—within the first five to seven days of life to minimize the use of intravenous nutrition. Once enteral feeds are established, the milk is fortified to increase its caloric and protein density, moving from a standard 20 calories per ounce up to 24 or 30 calories per ounce.
The adjustment component involves tracking specific metrics to guide fortification and protein supplementation. Daily weight gain velocity, head circumference tracking, and blood urea nitrogen (BUN) levels are monitored to assess the adequacy of protein and calorie delivery. If the infant’s growth velocity lags or if the BUN level suggests insufficient protein intake, the protocol dictates specific increases in fortification levels or the addition of modular protein supplements. Extremely low birth weight infants often require a high protein dose, ranging from 3.5 to 4.5 grams per kilogram per day, to support their rapid development.
Measurable Improvements in Infant Health
Adherence to the DART protocol has led to measurable improvements in infant health outcomes. The most immediate benefit is the successful achievement of target growth velocity, which helps minimize the severity of extrauterine growth restriction. Infants following this accelerated regimen spend fewer days relying on total parenteral nutrition (TPN), which reduces the risk of long-term complications associated with intravenous feeding.
By shortening the time required to reach full enteral feeds, the protocol often leads to a shorter overall length of stay in the NICU. The early and consistent provision of human milk and its fortification is associated with a decreased incidence of specific morbidities, such as necrotizing enterocolitis (NEC). The optimized nutritional delivery supports better linear growth and head circumference growth, which are markers for neurodevelopment. This attention to early nutrition helps ensure the infant’s brain receives the necessary building blocks, improving the likelihood of better long-term cognitive and developmental outcomes.