The American Academy of Pediatrics Committee on Nutrition goal of providing nutrient intakes that permit the rate of postnatal growth and the composition of weight gain to approximate that of a normal fetus of the same postmenstrual age is rarely met by extremely low gestational age neonates. Therefore, postnatal growth failure or growth restriction continues to be a problem experienced by many of these infants, and they are often less than the 10th percentile of reference intrauterine curves at the time of hospital discharge. Variation in nutritional practices, especially those practices concerned with the initiation and advancement of parenteral and enteral nutrition, largely explain the difference in growth observed at different newborn intensive care units. Although limited, the evidence supports recommendations to administer early parenteral and enteral nutrition, specifically initiation of an amino acid infusion providing about 3 g protein/kg/d within hours of birth, initiation of a lipid emulsion of 0.5 to 1.0 g lipids/kg/d within 24 to 30 hours of birth, and the initiation of minimal enteral feedings within the first 5 days of life. It is important that neonatal clinicians recognize the barriers and obstacles to the implementation of these recommendations.