Postnatal growth failure remains a nearly universal complication of extreme prematurity. The incidence of postnatal growth failure is inversely related to gestational age. Unfortunately, by the time growth faltering is recognized, the nutrient deficits that have accumulated can be difficult, if not impossible, to recover. The perceived severity of illness in the first week can significantly impact decisions made related to early nutritional support. It is becoming increasingly clear that optimizing nutrient intake in the first few weeks of life is critical to reduce growth faltering. In order to promote growth and reduce growth faltering, a goal of 120 kcal/kg/day and 3.8 g/kg/day of protein should be supplied to very low birth weight infants by the end of the first week. A combined strategy of both parenteral and enteral nutrition is necessary to ensure that adequate protein and energy intake is delivered and that nutrient deficits are minimized. Finally, careful monitoring of growth-including both linear and head circumference growth-is necessary to achieve optimal outcomes.