Neonatal Nutrition Guide
Canberra Health ServicesClinical Guideline Neonatal Nutrition GuideContents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc19699249 \h 1Guideline Statement PAGEREF _Toc19699250 \h 3Scope PAGEREF _Toc19699251 \h 3Section 1 – Feeding Regimen Including Trophic Feeds PAGEREF _Toc19699252 \h 4Section 2 – Insertion of Nasogastric/Orogastric Feeding Tube PAGEREF _Toc19699253 \h 8Section 4 – Pasteurised Donor Human Milk (PDHM)/Pasteurised Donor Breast Milk (PDBM) PAGEREF _Toc19699254 \h 10Section 5 – Obtaining consent and medical prescription for the supply and administration of PDHM/PDBM PAGEREF _Toc19699255 \h 11Section 6 – Preparation and Administration of PDHM PAGEREF _Toc19699256 \h 12Section 7 – Accidental administration of PDHM/PDBM without Parental Consent/Medical Prescription PAGEREF _Toc19699257 \h 13Section 8 – Donation of Milk PAGEREF _Toc19699258 \h 14Implementation PAGEREF _Toc19699259 \h 14Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc19699260 \h 15References PAGEREF _Toc19699261 \h 15Definition of Terms PAGEREF _Toc19699262 \h 16Search Terms PAGEREF _Toc19699263 \h 16Attachments PAGEREF _Toc19699264 \h 16Attachment 1 PAGEREF _Toc19699265 \h 18Attachment 2: Dietitian Referral Criteria PAGEREF _Toc19699266 \h 21Attachment 3 PAGEREF _Toc19699267 \h 22Attachment 4 PAGEREF _Toc19699268 \h 23Guideline 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. Pasteurised donor human milk (PDHM) is supplied by the Red Cross Milk Bank and pasteurised donor breast milk (PDBM) is supplied by the Mothers Milk Bank.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 > 37 weeks). See Attachment 1: Department of Neonatology Nutrition Guide 2017.Alerts Consent must be obtained from parents or guardians by medical staff prior to administration of PDHM/PDBM.In the event that newly delivered PDHM/PDBM has a broken tamper proof seal or if the cold chain has not been maintained adequately, Nutrition Milk Room staff must inform the Mothers Milk Bank (MMB) or the Red Cross Milk Bank staff so bottles can be recorded and discarded.Provide assistance to ensure mothers are supported to maintain/ increase their own milk supply by offering appropriate advice and lactation support.The 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 who are working within their scope of practice Student nurses under direct supervision Nutrition Milk Room staffBack to Table of ContentsSection 1 – Feeding Regimen Including Trophic FeedsMilk ChoicesMaternal expressed breast milk (EBM)Nutrient enriched preterm formula (PTF)Nominated formulaPasteurised donor human milk (PDHM) or 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 weight.Once the infant is above their birth weight, total daily intake (mL/kg/day) is calculated on the most recent weight.Fluid Regimen The recommended fluid intake regimen is as follows:Day 1. 60-80mL / kg/ day (Extremely Low Birth Weight (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 PDHM/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 100% PDHM/PDBM (no intravenous nutrition), Nutrition 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 dietitian 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 dietitian and referred to nutrition clinics for post discharge follow-up (See attachment 2: Dietitian Referral)For 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, PDHM/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/PDHM/PDBM to 85kCalIf on full PDHM/PDBM, Nutrition 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 dietitian 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 (in-utero growth restriction (IUGR) or surgical condition)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 mL 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 Chart.Equipment 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 ABHR.Check 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 feed.Insert and check position of the nasogastric tube (NGT) or orogastric tube (OGT) as per page 7 of this guideline.Gastric aspirate should be obtained 6 hourly and examined when a baby is first commenced on feeding protocol.Check aspirate for colour and volume.If 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 direction.If 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 feedings.Document all gastric aspirates on fluid balance chart, describing the colour and consistency.All milk (EBM and formula) must be checked (name, date of birth and UR number) by 2 RN/RM/ENs when decanted or prepared and signed by 2 RN/ENs on the label on the milk.Two RN/RM/ENs 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 Breastfeeding Clinical Guideline)When commencing feeds, position the baby in the supine position with the head of the cot elevated as clinically indicated.Offer 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 continuous positive airway pressure (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 immediately.Back 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 nasal CPAP, 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 xiphoid process and umbilicus4.2 Orogastric – measure from centre of mouth to ear lobe, down to halfway between xiphoid 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 baby’s 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 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.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 insertion.Aspiration 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 Human Milk (PDHM)/Pasteurised Donor Breast Milk (PDBM)BackgroundNecrotising enterocolitis (NEC) is one of the most common gastrointestinal emergencies in newborns, with the highest factors of risk being preterm birth (particularly <32 weeks gestation) and very low birth weight. NEC has considerable morbidity and mortality implications. Human milk feeding has been shown to decrease the risk of NEC, and the World Health Organisation recommends that low birth weight infants who cannot be fed mother’s own milk should be fed donor human milk.A partnership service with the Australian Red Blood Service has been developed to provide pasteurised donor human milk (PDHM) to infants at high risk of NEC in NSW and ACT when maternal supply is not sufficient to meet the nutritional needs of the infant. The use of PDHM may be effective in protecting against other high-risk conditions in vulnerable infants, such as late-onset sepsis. PDBM may also be sourced from the Mothers Milk Bank.This guideline outlines best practice for the safe preparation in the Nutrition Milk Room and handling of PDHM/PDBM by staff within the Department of Neonatology. Currently the Centenary Hospital for Women and Children have two suppliers of donor milk.Red Cross Donor Human Milk This guideline is to be used in conjunction with the Pasteurised Donor Human Milk (PDHM) for Vulnerable Infants; NSW Health and Australian Red Cross Blood Service Partnership Service Protocol. Donor human milk from the Australian Red Cross Blood Service (ARCBS) is pasteurised and transported to the Centenary Hospital for Women and Children and is available for eligible babies with insufficient expressed breast milk. Eligible babies for ATCBS PDHM include: Preterm babies <32 weeks and/or <1500gmsBabies recovering from NECAt the individual discretion of a neonatologistBabies transferred on PDHM from other units.Mothers’ Milk Bank Donor 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 MMB PDBM include: Preterm babies <32 weeks and/or <1500gmsPreterm 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 PDHM/PDBM from other units.When babies reach 34 weeks corrected gestational age PDHM/PDBM will be ceased unless there are clinical reasons why this is not appropriate.The NICU will keep records of how many infants who meet eligibility criteria receive PDHM/PDBM and formula milk. SupplyThere is a plan to transition supplier of donated milk from MMB (PDBM) to ARCBS (PDHM) (ARCBS). For a period of time during the transition both will be available. During this time the infants should be consented for PDHM/PDBM. The decision of which to use will be made by the milk room depending on supply. Prioritising during short supply:During periods of short supply there should be a stepped prioritisation. The clinical advisory group will work with individual NICUs in NSW and ACT to ensure that the highest risk infants will receive access. The Clinical Director or Delegate will meet with the milk room coordinator, neonatologist and NICU/SCN CNM to prioritise use. Back to Table of Contents Section 5 – Obtaining consent and medical prescription for the supply and administration of PDHM/PDBMEquipmentPDHM/PDBMPDHM Distribution Record (Nutrition Milkroom)Fluid Order Form with baby’s URN, date of birth and nameFluid Balance ChartConsent formProcedure Medical staff or a neonatal International Board-Certified Lactation Consultant (IBCLC) must obtain signed consent from the parent/guardian for the baby to receive PDHM/PDBM on the PDHM/PDBM consent form. The signed consent form must be filed in the baby’s clinical record.PDHM/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 PDHM/PDBM to be used if insufficent EBM, the nurse must order the required amount of PDHM/PDBM from the Nutrition Milkroom Building 11, Level 3, Room 502, (Ph 5124 7349) in Special Care Nursery.Always use mother’s own expressed breastmilk (EBM) first. To encourage EBM supply, ensure support from a lactation consultant and delay consent for PDHM/PDBM for 24-48 hours post birth.Back to Table of ContentsSection 6 – Preparation and Administration of PDHM Data Collection and documentation:Once the milk has been prepared, the Distribution Record Form from must be completed by the Nutrition allied health assistant staff.The Nutrition allied health assistant staff should document for each bottle of PDHM/PDBM used in the patient record: the batch number and date administered, and in the data registry: the infant name, date of birth, hospital identifier, batch/bottle number, and date administered.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. For PDBM the Nutrition allied health assistant staff monitor any data loggers to ensure the cold chain has been maintained during transport for each delivery of PDHM and PDBM. The Nutrition allied health assistant should note the condition of the milk on arrival following transport (hard frozen) and the expiry date, If there is any concern, the milk is discarded. The required volume of PDHM/PDBM will be thawed, alloquoted and delivered to the individual baby and placed in baby’s bedside refrigerator.The PDHM/PDBM bottles will be clearly identified as ‘Pasteurised Donor Human Milk’ or “Pasteurised Donor Breast Milk” 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 removed from the freezer, date dispensed and a use-by date. Any PDHM/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 PDHM/PDBM by the infant feeding room staff as per the Infant feeding room’s Feeding Regimes Guideline prior to dispensing to the baby.Once PDHM/PDBM is decanted from the original bottle, the new container/syringe must be labelled with the baby’s name, UR number, date and time and batch number. This is checked by a second nutrition allied health assistant and signed by both staff. The PDHM/PDBM is then stored in the baby’s refrigerator. Administration of PDHM/PDBM in NICU or Special Care Nursery: The PDHM 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 PDHM/PDBM. This must be checked, labelled and signed by 2 RNs or 1 EN and 1 RN Just prior to administration, PDHM/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 PDHM/PDBM to the baby, check the UR number and name on baby’s identification labels against the label on PDHM/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 PDHM /PDBM is checkedDocument the batch number on the Fluid Balance ChartAny unopened, expired bottles of PHBM/PDBM should be recorded and disposed of by the Infant feeding room 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)PDHM/PDBM will continue to be provided until the baby has sufficient EBM or reaches 34 weeks corrected age. After this time PDHM/PDBM will be discontinued unless specifically requested by the consultant. Thawing of PDHM/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 hours HYPERLINK \l "Contents" Back to Table of ContentsSection 7 – Accidental administration of PDHM/PDBM without Parental Consent/Medical PrescriptionAlways ensure appropriate follow-up when PDHM/PDBM is given to a baby who has not been consented or prescribed and allocated PDHM/PDBM. Refer to Expressed Breast Milk Incident Guide, on the CHS policy registerFollowing Accidental Sharing of PDHM/PDBMIf the infant has a feeding tube insitu aspirate the ingested PDHM. 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 ARCBS /Mothers Milk Bank and ask them to provide the original infection screen from the source mother and infection screen of the PDHM/PDBM and document in recipient baby’s records.Back to Table of ContentsSection 8 – Donation of MilkCurrently donation of milk is not actively sought from women in the ACT. If a woman has excess milk and is requesting donation the woman will be put in touch with the ARCBS and the NSW Health and Australian Red Cross Blood Service Partnership Service Protocol would be adhered to. The neonatal department would liaise with the ARCBS regarding milk preparation and delivery. The on-call neonatologist is the contact for any abnormal screening results or batch recall obtained from the milk bank (see Attachment 4).Back to Table of ContentsImplementation Implementation is by nursing in-services, allied health departmental meetings 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 includes CNMs, CDNs, CSN, Nutrition Allied Health Assistants, Dietitians, 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 GuideProceduresCHS Healthcare Associated Infections Clinical ProcedureCHS 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 Human Milk (PDHM) - Human breastmilk heated to 62.5oC for 30 minutes then passed as sterile by microbiology and supplied by the Red Cross Blood ServicePasteurised Donor Breast Milk (PDBM) – Human breastmilk heated to 62.5 oC for 30 minutes then passed as sterile by microbiology and supplied by the Mother Milk BankBack to Table of ContentsSearch Terms Breastmilk, Pasteurised Donor Breastmilk, PDHM, Infant feeding room, feeding tube, naso-gastric tube, nutrition, feeding, trophic feedBack to Table of ContentsAttachmentsAttachment 1: Discharge Feeding FlowchartAttachment 2: Inpatient and Discharge Dietitian Referral CriteriaAttachment 3: Discharge Feeding Flow ChartAttachment 4: Notification pathway for hospital based donorsDisclaimer: This document has been developed by Canberra 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 28/08/2019Complete ReviewTina Bracher, A/g ED WY&CCHS Policy CommitteeThis document supersedes the following: Document NumberDocument NameCHHS18/095Neonatal Nutrition GuidelineAttachment 1The 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; PDHM = Pateurised Donor Breast Milk; PTF = Preterm Formula; BMF = Breast Milk FortifierIn hospital options for increased calories in EBM/PDHM or formula milkPreterm formula – currently only available for inpatients – 80 kCalEBM/PDHM – 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 – dietitian referral.Elecare/PeptiJunior (67kCal or 80kCal) for malabsorption/allergy (Consider dietitian referral for commencement of these products – fortification only with dietitian 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: Dietitian Referral CriteriaInpatient Dietitian Referral CriteriaDischarge Dietitian 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 Attachment 4 ................
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