Neonatal Nutrition Guide



Canberra Hospital and Health ServicesClinical Guideline Neonatal Nutrition GuideContents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc508886199 \h 1Guideline Statement PAGEREF _Toc508886200 \h 2Scope PAGEREF _Toc508886201 \h 2Section 1 – Feeding Regimen Including Trophic Feeds PAGEREF _Toc508886202 \h 3Section 2 – Insertion of Nasogastric/Orogastric Feeding Tube PAGEREF _Toc508886203 \h 7Section 4 – Pasteurised Donor Breast Milk (PDBM) PAGEREF _Toc508886204 \h 9Section 5 – Obtaining consent and medical prescription for the supply and administration of PDBM PAGEREF _Toc508886205 \h 9Section 6 – Preparation and Administration of PDBM PAGEREF _Toc508886206 \h 10Section 7 – Accidental administration of PDBM without Parental Consent/Medical Prescription PAGEREF _Toc508886207 \h 11Implementation PAGEREF _Toc508886208 \h 12Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc508886209 \h 12References PAGEREF _Toc508886210 \h 12Definition of Terms PAGEREF _Toc508886211 \h 13Search Terms PAGEREF _Toc508886212 \h 13Attachments PAGEREF _Toc508886213 \h 14Attachment 1: Nutritional Requirements Following Discharge PAGEREF _Toc508886214 \h 15Attachment 2: Dietician Referral Criteria PAGEREF _Toc508886215 \h 18Attachment 3: Discharge Feeding Flow Chart PAGEREF _Toc508886216 \h 19Guideline StatementBackgroundThe purpose of this document is to provide a guide for babies in the Neonatal Intensive Care Unit (NICU) and Special Care Nursery (SCN) to ensure the provision of adequate enteral nutrition for infant growth and development. This includes the correct balance of fluid, carbohydrate, fat, protein, vitamins, minerals and electrolytes. Key ObjectiveThe goal of nutrition is to achieve as near to normal weight and length growth as possible. The aim should be to introduce enteral milk feeds as early as possible. The target weight gain when a baby is on full enteral feeds is between 15 and 20 g/kg/day with an average of around 15g/kg/day. (150-200g/week when > 35 weeks) See Attachment 1: Department of Neonatology Nutrition Guide 2017Alerts Consent must be obtained from parents or guardians by medical staff prior to administration of PDBMIn the event that newly delivered PDBM has a broken tamper proof seal or if the cold chain has not been maintained adequately, Milk Room staff must inform the Mothers Milk Bank (MMB) staff so bottles can be recorded and discardedProvide assistance to ensure mothers are able to maintain/ increase their own milk supply by offering appropriate advice and lactation supportThe following is no longer recommended as a method to confirm tube placement: The “Whoosh” test i.e. injecting air down the gastric tube and listening with a stethoscope. This method can be used to dislodge the exit-port of the feeding tube from the gastric mucosa. (NHS NPSA Patient Safety Alert 05)Back to Table of ContentsScopeThis document is applicable to:Babies nursed in the Department of NeonatologyMedical Officers caring for babies in the Department of NeonatologyNurses and midwives and who are working within their scope of practice Student nurses under direct supervision Nutrition Milkroom staffBack to Table of ContentsSection 1 – Feeding Regimen Including Trophic FeedsMilk ChoicesMaternal expressed breast milk (EBM)Nutrient enriched preterm formula (PTF)Nominated formulaPasteurised donor breast milk (PDBM)Elemental formula as directed by a Medical OfficerFeeding CalculationFor infants who weigh less than birth weight their requirements are calculated on their birth weightOnce the infant is above their birth weight, total daily intake (mls/kg/day) is calculated on the most recent weightFluid Regimen The recommended fluid intake regimen is as follows:Day 1. 60-80ml / kg/ day (ELBW infants may need higher intake initially due to insensible water loss)Day 2. 80-90ml /kg/ dayDay 3. 100ml /kg/ dayDay 4. 120ml /kg/ dayDay 5. 140ml /kg/ dayDay 6. 150ml /kg/ dayDay 7. 160ml /kg/ dayFeeds can be increased further depending on weight gain or at the recommendation of a Medical mencement of feeds:Trophic feeds are very small volume feeds, given to preterm babies. These minimal volume feeds are considered important for maturation of the gastrointestinal tract. Trophic feeds should commence as soon as EBM is available, as EBM will colonise the gut with normal flora and will limit colonisation by other pathogens:Commence 5-25mls/kg/day every 2- 6 hours as tolerated Feeds may then be increased as per medical ordersFor infants < 29 weeks at birthCommence total parenteral nutrition (TPN) via an umbilical venous catheter (UVC) or percutaneous intravenous central catheter (PICC) immediately from birth. Commence lipids immediately from birth at 2g/kg/dayCommence fluids at 80mls/kg/per dayEncourage mother to express in the first 2 hours after delivery. Commence trophic feeds as soon as possible with mother’s own breast milk. Other options are PDBM (after 48 hours and parental consent), or PTFIncrease feeds by 20-25mls/kg/day as toleratedWhen on 80ml/kg/day of enteral feeds fortify EBM to 85kCALIf on full PDBM, milk room will routinely add 0.5g Beneprotein per 100mL to improve protein content The aim for growth is to regain birth weight by day 7-8 and follow the birth centile within 1 standard deviation (Fenton’s Z-score calculator)Consider dietician involvement if poor weight gain and length (see nutrition flow chart)Continue fortification until 36-37 weeks- assessing requirements regularlyAt discharge, fortification of breast milk or fortified discharge formula should continue if postnatal growth failure as per the discharge flowchartThese babies should be discussed with dietician and referred to nutrition clinics for post discharge follow-up see attachment 2: Dietician ReferralFor infants 29-32 weeks OR > 32 weeks at birth and <1800 gm: Commence TPN via UVC or IV (peripheral ) and lipids within 12 hours of birth but ideally from birthCommence fluids at 80mls/kg and increase depending on urine output, weight loss and electrolytes but generally follow:Day 2: 100ml/kg/dayDay 3-4:120ml/kg/dayDay 5:140 ml/kg/dayDay 6:160ml/kg/dayCommence feeds 20 ml/kg/day as tolerated with EBM, PDBM (after 48 hours, with consent <30 weeks or <1250gms or at the discretion of Neonatologist) or PTFIncrease feeds 25-30ml/kg/day as toleratedWhen on 80ml/kg/day of enteral feeds – fortify EBM/PDBM to 85kCalIf on full PDBM, milk room will routinely add 0.5g Beneprotein per 100mL to improve protein content Aim for growth 15-20g/kg/day (150-200g/week when > 35 weeks)Aim to regain birth weight by day 7-8 and follow birth centile within 1 standard deviationContinue fortification until 36-37 weeks - assessing requirements regularlyAt discharge, fortification of breast milk or fortified discharge formula should continue if postnatal growth failure as per discharge flowchartThese babies should be discussed with dietician and referred to nutrition clinics for post discharge follow-upFor infants >32 weeks at birthCommence full enteral feeds if clinically appropriate with EBM or term formulaIf IV fluids are required 10% Dextrose is adequate for the first 24 hoursIf IV fluids are required for a longer period consider peripheral TPN Consider TPN via PICC line if prolonged TPN expected (IUGR or surgical)Consider fortification of feeds or PTF for the growth restricted baby (<1.8kg)Commence feeds/fluids at 60-80ml/kg/dayIncrease dependant on weight loss, feed tolerance but generally follow:Day 2. 90-100ml /kg/ dayDay 3. 120ml /kg/ dayDay 4. 140ml /kg/ dayDay 5. 140ml /kg/ dayDay 6. 160ml /kg/ dayAim for growth 15-20g/kg/day, 150-200g/week when > 37 weeks)Aim to regain birth weight by day 7-8 and follow the birth centileVitamin and Mineral SupplementsAccretion rates of minerals, vitamins and micronutrients in utero increase exponentially between 24 and 37 weeks gestation. As a result, 80% of the micronutrients that a full-term infant receives accumulates during the third trimester. Neither preterm breast milk or cow’s milk formulas provide sufficient micronutrients to meet the needs of growing preterm babies. Inadequate minerals, vitamins and micronutrient intake is associated with osteopaenia and fractures, anaemia and specific vitamin deficiencies.Supplements will be required for infants <32 weeks, or those <1800g and > 32 weeks mence Pentavite at 0.45 mls daily when on full feeds. Cease at 6-12 weeks corrected ageCommence Folic Acid – 50 mcg daily when on full feeds. Cease at 6-12 weeks corrected age. Cease if on formula only (except Elecare/Peptijunior)Commence Ferrous liquid 0.5ml/kg/dose daily at 14 days if on full feeds or when on full feeds. Cease at 6 months. Cease if on formula only (except Elecare/Peptijunior)DischargeSee Attachment 1 for details of nutritional requirements following discharge.See Attachment 3: Discharge Feeding Flow ChartEquipment for tube feedingAlcohol based hand rub (ABHR)Milk of choiceSyringepH test stripsStethoscopeFeeding Attend hand hygiene before touching the patient by either hand washing or using ABHRCheck baby’s abdomen for bowel sounds, signs of distension, colour and/or visible loops of bowel. If there are concerns about the baby’s gut, consult with medical officer before giving feedInsert and check position of the NGT/OGT as per page 7 of this guidelineGastric aspirate should be obtained 6 hourly and examined when a baby is first commenced on feeding protocolCheck aspirate for colour and volumeIf aspirate is bile or blood stained, refer to the medical officer as it may be indicative of early necrotising enterocolitis (NEC)If volume of aspirate is >50% of feed volume, it may indicate that the baby is not tolerating/digesting feeds. Refer to the medical officer for further directionIf aspirate is not bile stained, and is <50% of feed volume, return the aspirate to the baby via feeding tube, and continue feeding.There is a lack of evidence supporting the relationship between aspirate volume or appearance and feeding intolerance in the neonatal population. In the absence of other clinical signs, studies have shown no correlation between light green aspirates and either NEC or feeding intolerance in premature infants. Hence light green aspirates should not delay advancement of enteral feedingsDocument all gastric aspirates on fluid balance chart, describing the colour and consistencyAll milk (EBM and formula) must be checked (name, date of birth and UR number) by 2 RN/RM/EN’s when decanted or prepared and signed by 2 RN/EN’s on the label on the milk Two RN/RM/EN’s must check the infant’s identification label against the name and UR number on the milk and both sign the flow chart to ensure infant receives the correct mother’s milk or formula (see Breastfeed Clinical Guideline)When commencing feeds, position the baby in the supine position with the head of the cot elevated as clinically indicatedOffer the baby a dummy if awake, to encourage non-nutritive sucking (NNS) (ensure parental permission has been granted)ComplicationsAbdominal distension with or without visible loops of bowel, can indicate poor gastric motility, constipation, trapped gas, or early NEC Vomiting or emesis may result from an over-distended stomach (filled with undigested feeds or air from CPAP), reflux, poor feeding tube placement, oral medications, or over-handling Diarrhoea may signify intolerance of the caloric density of the feed, a transient lactose intolerance, medications, or allergy If apnoeas and bradycardias occur during feeding, cease feed, check tube placement, give the baby time to recover and continue to feed slowly NEC or inflammation of the bowel wall which leads to areas of necrosis. Clinical signs of NEC include: Distended, reddened abdomen Visible loops of bowelAbdominal tendernessReduced or absent bowel soundsGastric residuals (typically bile/blood stained)Lethargy, increasing apnoea and bradycardiasBlood in stoolsTemperature instabilityHypotension and falling urine output If any of the above is present consult medical officer immediatelyBack to Table of Contents Section 2 – Insertion of Nasogastric/Orogastric Feeding TubeEquipment RequiredAlcohol based hand rub (ABHR)Infants <1000g: size 5 French feeding tubeInfants >1000g: size 5-6 French feeding tube10 ml syringePh indicator stripStethoscopeDuodermTapeSucroseOral syringeProcedureDetermine appropriate route, nasogastric or orogastric. Orogastric tubes are appropriate for babies on NCPAP, ventilators, those that have high oxygen requirements, babies <1kg, and those with excoriated nares. Nasogastric tubes are preferable for babies >1kg, babies with a strong gag reflex, and those starting suck feedingDetermine depth of insertion of feeding tube: 4.1 Nasogastric – measure from nare to ear lobe, down to halfway between ziphoid process and umbilicus4.2 Orogastric – measure from centre of mouth to ear lobe, down to halfway between ziphoid process and umbilicusEncourage non-nutritive sucking and administer sucrose to the baby two minutes prior to insertion of feeding tube for analgesiaWrap baby, so arms are out of the way, place baby in the supine positionMoisten tip of tube with babies saliva and gently insert to desired depthTo check placement of feeding tube, firstly attempt to aspirate stomach contents via a 10ml syringe. Place aspirate onto a pH indicator strip. If the reading is pH 5.5 or below the tube is in an appropriate position. X-ray is considered to be the gold standard to confirm tube placement but is not routinely used due to cost and radiation exposure. However, gastric tube position should always be noted if the baby is being x-rayed for other reasons.The following is no longer recommended as a method to confirm tube placement: The “Whoosh” test ie. injecting air down the gastric tube and listening with a stethoscope. This method can be used to dislodge the exit-port of the feeding tube from the gastric mucosa.Some factors may contribute to a high gastric pH (pH 6 or above). These include:The presence of amniotic fluid in an infant less than 48 hours oldInfants on continuous, hourly or second hourly feedsMedications to reduce or alter stomach acid: e.g. Ranitidine or OmeprazolePresence of medication or milk left in feeding tube or blood stained aspirateSome babies with none of the above will consistently have pH values of 6 or aboveIf gastric aspirate is unable to be obtained. Ensure that the feeding tube remains securely taped at the desired measurement before feeding.For NGT insertion, cut Duoderm? to appropriate size and place on side of face, abutting the nose. Cut securing adhesive tape to fit over Duoderm?Adhesive tapeFor OGT insertion cut Duoderm? to appropriate size and place on baby’s chin. Cut securing tape into a trouser leg, and wrap one trouser leg tightly round feeding tube to ensure non-slippagePlace a second piece of tape over the top to ensure extra securityAdhesive TapeDuoderm?Second piece of tapeTrouser leg wrapped around feeding tubeIf the tube is for single feed only (e.g. postnatal), use a size 8 tube and remove at the completion of the feed while kinking the tube during removalIf a chest x-ray is planned for a new admission, insert feeding tube prior to x-ray so that correct tube placement can be verified by the x-rayFeeding tube should be labelled with baby’s identification sticker (after checking correct identification with another staff member). On this sticker note the date of insertion, the depth of the feeding tube, and date feeding tube should be replacedComplicationsApnoea, bradycardia, desaturation may occur following stimulation of the vagal nerve. Ensure baby is monitored throughout procedure. If baby does have a vagal response, either remove tube or give baby time to recover Perforation of the oesophagus, stomach or duodenum. The feeding tube should never be forced during insertionAspiration of feed due to feeding tube being placed into trachea. Always verify tube placement thoroughly, upon insertion and every time it is used Back to Table of Contents Section 4 – Pasteurised Donor Breast Milk (PDBM)BackgroundDonor breastmilk from the Mothers’ Milk Bank (MMB) Gold Coast is pasteurised and transported to the Centenary Hospital for Women and Children and is offered as a feeding choice for preterm babies. Babies to be considered for PDBM include Preterm babies <30 weeks and/or <1250gmsPreterm babies 30+0 -31+6 weeks with consistently absent or reversed end diastolic flowBabies post NEC (medically or surgically treated), Enteral feeds intolerance with use of low birth weight formula and Babies transferred on PDBM from other units.This procedure outlines best practice for the safe preparation in the Nutrition Milkroom and handling of PDBM by staff within the Department of Neonatology. The purpose of this procedure is to: clarify how to obtain informed consent for the administration of PDBM from parents and guardians outline the records management of maintaining the cold chain during the transport of PDBMdescribe the documentation required to ensure accurate record keepingBack to Table of Contents Section 5 – Obtaining consent and medical prescription for the supply and administration of PDBMEquipmentPDBMPDBM Distribution Record (Nutrition Milkroom)Fluid Order Form with baby’s URN, date of birth and nameFluid Balance ChartConsent formProcedure Medical staff must obtain signed consent from the parent/guardian for the baby to receive PDBM. The signed consent form must be filed in the baby’s clinical record.PDBM must be ordered on the patient fluid order chart by a medical officerOnce consent has been obtained, and fluid order chart has been completed by the medical staff stating PDBM to be used, the nurse must order the required amount of PDBM from the Nutrition Milkroom Building 11, Level 3, Room 502, (Ph 6244 7349) in Special Care Nursery.Always use mothers own expressed breastmilk (EBM) first. To encourage EBM supply, ensure support from a lactation consultant and delay consent for PDBM for 24-48 hours post birth.Back to Table of ContentsSection 6 – Preparation and Administration of PDBMPreparation of PDBMThe required volume of PDBM will be thawed, alloquoted and delivered to the individual baby and placed in baby’s bedside refrigeratorThe PDBM bottles will be clearly identified as ‘Pasteurised Donor Breastmilk’ and be pre-labelled by the Nutrition Milkroom staff with the baby’s URN sticker (name, UR number, address, DOB), identify any additives (e.g. Human Milk Fortifier (HMF), caloric value (eg. 85kcal) date dispensed and a use-by date. Any PDBM taken from the freezer in the above circumstances should be clearly identified with the baby’s UR number, the date thawed and the expiry date.Additives including HMF will be added to PDBM by the nutrition room staff as per the Nutrition Milkroom’s Feeding Regimes Guideline prior to dispensing to the baby.Once PDBM is decanted from the original bottle, the new container/syringe must be labelled with the baby’s name, UR number, date and time. This is checked by a second nutrition allied health assistant and signed by both staff. The PDBM is then stored in the baby’s refrigerator. The Nutrition Milkroom staff monitors a data logger to ensure the cold chain has been maintained during transport.The Neonatal Intensive Care Unit (NICU) and Special Care Nursery (SCN) fridges have a data logger for each fridge which is monitored shift to shift by the nursing staff. Administration of PDBM in NICU or Special Care Nursery: The PDBM for the baby will either be supplied in individual bottles containing the amount for each feed or as a total daily dose (bulk) that requires decantingWhen decanting from a bulk supply use an oral syringe with supplied cap to store the PDBM. This must be checked, labelled and signed by 2 RNs or 1 EN and 1 RN Just prior to administration, PDBM should be heated in warm water using the Avent Bottle Warmer. This may either be the whole bottle if the volume of the feed is >27mL per feed or in an oral syringe (with supplied cap) placed in a small plastic bag if the volume is <27mLFollowing warming, and prior to administration of PDBM to the baby, check the UR number and name on baby’s identification labels against the label on PDBM container, with a second staff member, not a parent. A parent may check as well as two RNs/ EN and RN. Both staff members sign that the PDBM is checkedDocument the batch number on the Fluid Balance ChartAny unopened, expired bottles of PDBM should be recorded and disposed of by the Nutrition Milkroom staffAny partially used bottles that have expired can be emptied and the bottles rinsed and placed in the designated recycling bin for cleaning and reuse (Nutrition Milkroom staff)PDBM will continue to be provided until the baby has sufficient EBM or reaches 34 weeks corrected age. After this time PDBM will be discontinued unless specifically requested by the consultant. Once the milk has been prepared, the Distribution Record Form from the Mothers Milk Bank must be completed by the Nutrition Milkroom staff. They are also responsible for sending a copy of the Distribution Record to the Mothers Milk Bank on the first Wednesday of each month and the original will be sent with the baby’s medical records at the completion of PDBM administration.Thawing of PDBM by unit staff if required:use the oldest milk firstideally breastmilk should be thawed in the fridge otherwise place the container in a pan or jug of tepid waterthawed milk should be refrigerated if not used immediatelyshake the container to evenly distribute the fatdiscard any thawed milk not used within 24 hoursBack to Table of ContentsSection 7 – Accidental administration of PDBM without Parental Consent/Medical PrescriptionAlways ensure appropriate follow-up when PDBM is given to a baby who has not been consented or prescribed and allocated PDBM. Refer to Expressed Breast Milk Incident Guide.Following Accidental Sharing of PDBMIf the infant has a feeding tube insitu aspirate the ingested PDBM as soon as possible. The feed may be aspirated up to 30 minutes after feedingReport incident to neonatal registrar/consultant and nurse-in-charge immediately.Ensure open disclosure to the birthmother/parents takes place informing them that the risk of transmission and possible acquisition of infection is negligible due to donor screening and the pasteurisation process. Screening of the mother or baby is unlikely to be necessary unless requested by the Neonatal Consultant following a risk assessment and discussion with the parents. If screening is to be performed ensure pre-test counselling by the neonatal registrar/consultant occursComplete an incident form immediately and submit via RiskmanNutrition Milkroom manager is to be notified of the incidentInform the MMB and ask them to provide the original infection screen from the source mother and infection screen of the PDBM and document in recipient baby’s records.Back to Table of ContentsImplementation Implementation is by nursing in-services and dissemination of information via Journal Club for medical staff. Emails will be sent to all staff prior to implementation of this procedure.Support staff available within the unit includes CNCs, CDNs, CSN and consultant medical staff.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesHealth Directorate Nursing and Midwifery Continuing Competence PolicyConsent and TreatmentExpressed Breast Milk Incident GuideProceduresCHHS Healthcare Associated Infections Clinical ProcedureCHHS Patient Identification and Procedure Matching PolicyLegislationHuman Rights Act 2004United Nations Convention on the Rights of the ChildBack to Table of ContentsReferencesDitzenberger, G. R. (2010). Nutritional Management. In M. T. Verklan & M. Walden (Ed’s) Core Curriculum for Neonatal Intensive Care Nursing (4th ed.) (pp. 182-207). St Louis: Saunders Elsevier.Anderson, M. S., Wood, L. L., Keller, J. & Hay, W. W. (2006). Enteral Nutrition. In G. B. Merenstein & S. L. Gardner (Ed’s) Handbook of Neonatal Intensive Care (6th ed). (pp. 391-428). St Louis: Mosby Elsevier.Halbardier, B. H. (2010). Fluid and Electrolyte Management. In M. T. Verklan & M. Walden (Ed’s) Core Curriculum for Neonatal Intensive Care Nursing (4th ed.) (pp. 156-171). St Louis: Saunders Elsevier.Schurr, P, & Perkins, E.M. (2008). The relationship between feeding and necrotisizing enterocolitis in very low birth weight infants. Neonatal Network, 27(6). 397-407Smith, J. R. (2005). Early enteral feeding for the very low birth weight infant: The development and impact of a research-based guideline. Neonatal network, 24(4), 9-18. Spence, K. (2010). Nutritional management of the infant in NICU. In G Boxwell (Ed.) Neonatal Intensive Care Nursing (2nd ed). (pp. 279-301). New York: Routledge.Gardner, S. L., Snell, B. J., & Lawrence, R. A. (2006). Breastfeeding the neonate with special needs. In G. B. Merenstein, & S. L Gardner (Eds.) Handbook of Neonatal Intensive Care (6th ed.) (pp. 467-519). St. Louis: Mosby Elsevier.Donor breastmilk banks: the operation of donor breastmilk bank services. National Institute for Health and Clinical Excellence (2010)Best Practice for Expressing, Storing and Handling Human Milk in hospitals, homes, and Child Care Settings. Frances Jones and Mary Rose Tully 2nd Edition ? HMBANA 2006 Effect of Holder Pasteurization and Frozen Storage on Macronutrients and Energy Content of Breastmilk, Journal of Paediatric Gastroenterology & Nutrition, September 2013 - Volume 57 - Issue 3 - p 377–382Donor Human Milk Banking in Australia - Department of Health.au/.../ Donor%20Human%20Milk%20Banking%20in%20Australia%20pa Ditzenberger, G. R. (2010). Nutritional Management. In M. T. Verklan & M. Walden (Ed’s) Core Curriculum for Neonatal Intensive Care Nursing (4th ed.) (pp. 182-207). St Louis: Saunders Elsevier.Unomedical feeding tubes. Unomedical Pty Ltd. 2000-2007. Accessed 15 June 2011. Back to Table of ContentsDefinition of Terms Donor Breastmilk - Human breastmilk donated by a mother to the milk bank for pasteurisation and use by a baby other than her ownOsteopenia - a condition in which bone mineral density is lower than normal.Pasteurised Donor Breastmilk (PDBM) - Human breastmilk heated to 62.5oC for 30 minutes then passed as sterile by microbiologyBack to Table of ContentsSearch Terms Breastmilk, Pasteurised Donor Breastmilk, PDBM, Nutrition Room, feeding tube, naso-gastric tube, nutrition, feeding, trophic feedBack to Table of ContentsAttachmentsAttachment 1: Discharge Feeding FlowchartAttachment 2: Inpatient and Discharge Dietician Referral CriteriaAttachment 3: Discharge Feeding Flow ChartDisclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 14/03/2018Complete ReviewKaren Faichney, A/g ED WY&CCHHS Policy CommitteeThis document supersedes the following: Document NumberDocument NameCHHS16/090Pasteurised Donor Breastmilk (PDBM) - Management and AdministrationCHHS12/104Department of Neonatology - Feeding Regimen Including Trophic FeedsCHHS13/625Department of Neonatology - Nasogastric and orgastric tube insertionAttachment 1: Nutritional Requirements Following DischargeThe baby stays in the same colour column for their entire stay at the gestation they were born at – they do not cross into the other colour column. Feeds may be 2 hourly or 3 hourly depending on gestation and birth weight and current corrected age, and is at the Neonatologists discretion, and advised by nursing staff.EBM = Expressed Breast Milk; PDBM = Pateurised Donor Breast Milk; PTF = Preterm Formula; BMF = Breast Milk FortifierIn hospital options for increased calories in EBM/PDBM or formula milkPreterm formula – currently only available for inpatients – 80 kCalEBM/PDBM – fortified with Nutricia HMF (2.1 g – 1 sachet to 40 mls EBM) – 85 kCalInfatrini – 100kCal – for babies > 1800 grams requiring reduced volume (e.g. cardiac babies). Not recommended for preterm babies because of reduced micronutrient content – dietician referral.Elecare/PeptiJunior (67kCal or 80kCal) for malabsorption/allergy (Consider dietician referral for commencement of these products – fortification only with dietician referral)S26 lactose free (67kCal)Discharge optionsPremGro –intermediate formula for discharge if formula feeding – provides protein, calcium and phosphate supplementation between that provided by breast milk/term formula and Preterm formula- 73kCalConcentrated term formula- 80kCalEBM fortified with formula or polyjoule – 80-85kCal (depending on formula)References:Agostini et al – Enteral nutrient supply for preterm infants: commentary from the European Society for Paediatric Gastroenterology, Hepatology and Nutrtion Committee JPGN 2010, 50:85-91Curtis MD, Rigo J – The nutrition of preterm infants. Early Hum Dev 2012; 88: S5-S7Klingenberg C et al – Enteral feeding practices in very preterm infants: an international survey. Arch Dis Child Fetal Neonatal Ed 2012: 97: F56-F61Tudehope D et al – Nutritional needs of the micropreterm infant. J Pediatrics 2013; 162: S72-S80Koletzko B et al – Guidelines on pediatric parenteral nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition and the European Society for Clinical Nutrition and Metabolism, Supported by the European Society of Paediatric Research. JPGN 2005; 41: S1-S4Drenckpohl D, McConnell C, Gaffney S, Niehaus M, Macawan KS – Randomised trial of very low birth weight infants receiving higher rates of infusion of IV fat emulsions during the first week of life. Pediatrics 2008; 122: 743-751.Peripheral TPN Starter TPN Starter concentrated TPNStandard preterm TPNConcentrated pretermmL/kg/day608010012060 80 1001206080100120140160120140160Protein (g/kg/day)1.381.842.32.762.2533.754.53453.64.24.84.85.66.4Sodium (mmol/kg/day)1.522.531.21.622.41.82.434.084.765.44678Potassium (mmol/kg/day)1.21.62.02.400000002.643.083.524.24.95.6Calcium (mmol/kg/day)0.91.21.51.81.021.361.72.041.522.52.042.382.722.643.083.52Phosphate (mmol/kg/day)0.720.961.21.440.60.811.20.91.21.51.561.822.081.82.12.4Attachment 2: Dietician Referral CriteriaInpatient Dietician Referral CriteriaDischarge Dietician Referral CriteriaRestricted fluid intake ≤ 160 mL/kg/day – at greater than 1 week of age< 75% of prescribed quota is nutritional fluids for more than one weekWeight/Length on or below 10th%ile (Fenton Growth Chart) when born on a higher centile, or any baby who has a discharge weight/length > 2 percentiles below birth weight or >1SD on Fenton’s Z score calculator< 15 g/kg/day weight gain (<33/40 CGA) or < 10 g/kg/day (< 37/40 CGA)Not regained birthweight by 14 daysHome oxygenGrowth faltering/crossing centiles/>1SD on Fenton’s Z score calculatorIntolerance to preterm formula of breast milk fortifierExclusive naso-gastric feeding>200mL/kg/day of preterm formula or fortified breast milk intakeCLD where growth impairment is likelyBabies with ongoing gastrointestinal issues – stomaShort bowel syndrome/NEC where use of elemental formula is consideredMalabsorptionBabies with ongoing cardiac failure requiring restricted fluidsGastrointestinal anomalyCongenital heart disease where growth impairment is likelyChylothoraxRenal failureAttachment 3: Discharge Feeding Flow Chart ................
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