Nutrition and Hydration Decisions in Neonatal Palliative Care

Medically administered nutrition and hydration (MANH) is a routine component of neonatal intensive care, yet it becomes ethically and emotionally complex when an infant's condition is recognised as life-limiting and care is reoriented towards comfort. Decisions to continue, withhold, or withdraw MANH are challenging because feeding carries profound physiological, emotional, cultural, and relational meaning for families, while neonates cannot reliably communicate hunger, thirst, or discomfort. This commentary examines the ethical, clinical, and legal considerations surrounding MANH at the end of life in neonates and proposes a practical, individualised approach to decision-making. Evidence specifically addressing MANH withdrawal in dying neonates remains limited, requiring clinicians to draw substantially on pediatric and adult palliative care literature. MANH should be regarded as a medical intervention guided by the infant's comfort, proportionality, goals of care, and best interests rather than an assumed moral obligation. Its potential benefits, including relief of hunger or thirst, preservation of parental caregiving roles, and cultural or spiritual significance, warrant explicit recognition. Comfort feeding should be considered where tolerated, with MANH continued when it provides meaningful benefit and reconsidered when it causes discomfort, imposes significant burdens, or prolongs dying without corresponding benefit. Australian and international legal frameworks broadly support withdrawal where MANH is non-beneficial. Clear communication, shared decision-making, cultural humility, multidisciplinary consensus, and regular reassessment are essential. Further prospective research is needed to better understand hunger, thirst, comfort, survival trajectories, and parental experiences following MANH withdrawal in dying neonates.