Feeding+Late+Preterm+Infants


 * GUIDELINE FOR FEEDING THE LATE PRETERM INFANT (LPI):**

This is a general feeding guideline for uncomplicated LPI babies. In some circumstances, babies might require a completely different management, e.g. TPN, special formulas (hydrolyzed).

Late Preterm infants, 34 to 36 6/7 weeks gestational age.
 * POPULATION:**

Depending on the gestational age (< 35 weeks GA) and/or clinical problems (mild to moderate respiratory distress, etc.), consider leaving the baby NPO for 6 – 12 hours. As soon as possible, skin-to-skin contact with the mother needs to be initiated. Early skin-to-skin has been shown to be highly beneficial for the baby as well as the mother. Apart from better breastfeeding success it helps stabilize the baby’s blood sugar, respiration and temperature. All late preterm infants should have oral feedings offered in this order of preference: 1. breastfeeding, 2. expressed colostrum by SNS (supplemental nursing system), syringe or other methods, 3. bottle of expressed colostrum, 4. formula by bottle. If we do not anticipate the infant to take oral feedings well, we will start the baby’s nutrition with parenteral fluids, typically D10W.
 * FIRST DAY:**

If baby is on IV fluids, be guided by the following total fluid volumes: Day 1…. 60 – 80 ml/kg/day Day 2…. 80 – 100 ml/kg/day Day 3…. 100 – 120 ml/kg/day Day 4…. 120 – 140 ml/ kg/day Day 5…. 140 – 160 ml/kg/day Day 6 and on …. 150 – 160 ml/kg/day

Start with D10W. After 1-2 days, sodium and potassium need to be added. Generally, 3-4 mEq NaCl/100ml and 2mEq KCl/100ml are added. Starting at 24 hours of age, electrolytes, including calcium, need to be checked for infants receiving IV fluids. Electrolytes need to be checked every 24 hours until the baby is off IV fluids. Phosphorous and magnesium should also be checked as needed, e.g. if the infant has had in-utero exposure to magnesium sulfate. Add supplemental calcium to the parenteral fluids if the baby is not feeding within 24 hours or if the serum calcium concentration is less than 7.2 mg/dl (Peripheral IV: Calcium gluconate 10% [100mg/ kg/dose q 8 hours], dilute Ca in 10 ml NS or sterile water, bolus over 1 hour. UVC: Calcium gluconate 10% 200 – 400 mg/100ml in continuous IV fluids).

Oral feedings should be initiated within the first 24-48 hours of life, and the earlier the better. When initiating enteral feeds, the mode of delivery needs to be established. Breastfeeding (possibly with nipple shield), SNS (supplemental nursing system), finger feeding, cup feeding, bottle-feeding and gavage feeding (OGT or NGT) are the choices. Sometimes a combination of the above is the best way to go, e.g. IV fluids, breast and cup-feeding. It all depends on the baby’s vigor and ability to coordinate its suck and swallow. If a baby proves unable to nipple, you should start with gavage feeds. Gavage feedings are then slowly transitioned to PO feedings (breast, nipple) as tolerated. For example: all gavage (G) may be changed to GGN, then GN alternating, then all nipple. That usually takes place in a matter of a few days. The nurses, lactation consultants and mothers are the best sources to help you decide what feeding regimen to choose. Issues to discuss with them include efforts expended when feeding, audible swallowing and the sufficiency of the milk supply.
 * INITIATION OF ENTERAL FEEDINGS:**

Breast milk is the best and preferred nutrition for the baby. The early promotion of breastfeeding is very important. In order to find out if a baby is able to breastfeed, just give it a try without over-stimulating the baby. Begin by placing babies skin-to-skin on mother and observe for rooting. Guide babies to breast. Do not expect the babies to do too much. Even recreational breastfeeding for infants who do not have much of a suck can help stimulate mother’s milk supply. If you challenge them too much, they will tire out, since they are expending excessive calories in the process of nippling. It is all about taking gentle “baby steps.” Sometimes babies surprise us with great abilities when we do not expect it. If a baby breastfeeds without significant problems, let it breastfeed ad lib and on demand. Allow skin to skin as much as possible. The nurses and lactation consultants should support late preterm infants with cue-based feeds, careful positioning and nipple shields as needed. Infants whose feedings require more than 30 minutes to complete should be evaluated for supplemental feedings.
 * BREASTFEEDING:**

Successful breastfeeding is dependent on a multitude of things: breast anatomy, ability of infant to suck and swallow, milk production, etc. A good subjective measure of successful breastfeeding is when the baby is audibly sucking and swallowing. A more objective measure is weighing the baby before and after feedings once the mother’s milk is in (Note: Pre- and post-weights are usually not helpful in the colostral stage, because very little milk is being transferred). The weight difference is an approximation for what the baby took in. Premies need more calories than term babies (110 – 140 kcal/kg/day)! Watch the baby’s weight closely: premature infants should not lose more than a few percent of body weight a day. After first losing weight for 5 – 7 days (generally up to 8-10 % from birth weight), premies need to start gaining weight. They should gain an average of 10 -15 gm/kg/day. Exclusively breastfed infants may have difficulties getting enough milk because they do not latch effectively, cannot coordinate suck and swallow. These babies may have unstable glucose levels, excessive weight loss or dehydration. Breastfeeding infants who appear to be tiring, losing too much weight or not receiving adequate amount of breastmilk during feedings should be supplemented with expressed breast milk or formula. If breast feeding is deemed inadequate based on lack of weight gain, inability to latch, etc., supplemental breast milk or formula should be ordered. For supplementation, a 5 French feeding catheter attached to a syringe can be used. SNS (supplemental nursing system), cup feeding, or finger feeding are additional ways to supplement feedings. These are the preferred methods of supplementation to avoid so-called “nipple confusion.” If supplementation with these methods does not work, formula or expressed breast milk may be offered with a bottle. Supplemental amounts of expressed breastmilk or formula per feeding are approximately: Day 1: 5- 15 ml, Day 2: 10 - 20 ml, Day 3: 15 - 25 ml, Day 4: 20 - 30 ml. Note: these volumes are generally lower than the calculated total fluid volume (TFV) when the baby is on IV fluids. The infants should be encouraged to breastfeed for 15 to 30 minutes, with the feeding catheter or SNS in place. If a baby does not tolerate these methods, gavage feeding or IV fluids need to be considered. Breastfeeding infants requiring prolonged supplementation may be given a higher calorie preparation by mixing HMF (human milk fortifier) with expressed breast milk to make a 22 kcal/ounce or 24 kcal/ounce formula. Note: Human milk fortifier (HMF): 1 packet in 50 ml makes 22 kcal/oz, and 1 packet in 25 ml makes 24 kcal/oz. HMF is only available in the hospital, not for home use.
 * EVALUATION OF SUCCESSFUL BREASTFEEDING:**

In order to evaluate feeding well, it is important to involve the nurse, the mother and the lactation consultant in the conversation. The mother should be expressing colostrum as soon as possible after birth of the baby. Please write an order in the chart! This will stimulate the milk production and provide breast milk to be fed to the baby. If the baby is unable to breast feed, be sure to encourage the mother to start pumping as early as possible (6 – 12 hours after birth). Ensure that a breast pump is made available to the mother. Note: Not emptying the breast in one way or another will lead to cessation or delay of milk production.

Infants less than 35 weeks gestational age who require supplemental formula should be started on Special Care formula (premie formula), 20kcal/oz (e.g. PE 20). Infants 35 weeks and older should be started on regular 20kcal/oz formula. Use the birth weight to calculate feeding volumes for first week of life: Start on the 1st day of feeding with 15 – 30 ml/kg/day, divided by 8 feedings per day. For example: Baby weighs 2 kg and you decide to start with 20 ml/kg/day: 20 x 2 = 40. 40/8 = 5. You will order: Start feedings (EBM or formula) with 5ml Q 3 as tolerated. You should specify the feeding method in the order, e.g. gavage q feed. If the baby does well on this regimen, you may advance the feedings after 24 hours. Typically, you advance every day by 15 – 30 ml/kg/day, as tolerated, until you arrive at a maximum of 150 –160 ml/kg/day. This will usually be achieved in 5 – 6 days. If a baby wants to feed more than the “allotted” volume it should be allowed, as long as there are no signs of feeding intolerance. Feedings should not be advanced if the baby shows signs of feeding intolerance; the younger a baby is, the more careful the advance needs to be. Be sure to monitor carefully for vomiting, residuals (if gavage-fed) and abdominal distension. Make sure to adjust the IV fluids in order not to exceed the daily total fluid volume (TFV). If babies are feeding well, you should write a weaning order. For example: wean IV fluids by 3 ml/hour with each good breast /bottle feeding, as tolerated. “Saline lock” at 3 – 4 ml/hour.
 * FORMULA FEEDING:**

For infants less than 35 weeks, switch to a 24 kcal/oz formula such as Special Care formula 24 kcal/oz (e.g., PE 24) once the baby’s intake is approximately 100ml/kg/day (usually day 3-4). For late preterm infants older than 35 weeks, consider (optional) switching to a 22 kcal/oz formula, such as Enfacare (or Neosure), once the baby’s intake is approximately 100ml/kg/day (usually day 3-4).

If a baby is being gavage-fed, the nurse routinely aspirates the stomach content before the next feeding in order to determine if a baby has residuals. Normally, there are no or only trace residuals. If the residuals are greater than 50 % of the previous feeding, the baby may have become intolerant to feedings. Make sure to do a thorough exam with special emphasis on the abdomen. If the findings are benign try to improve gastric emptying by placing the baby prone or right side down. If there is another significant residual, oral feeding may need to be put on hold or be reduced for one or two feeding cycles. Evaluate the baby frequently. It is an ominous sign if the residuals are bilious. Beware of NEC! If you are worried about developing necrotizing enterocolitis (NEC), feedings must be stopped altogether and the baby needs to be put NPO. If NEC is a serious consideration, it is important to act quickly (NPO, IVF, antibiotics, KUB, transfer). If the residuals consist of undigested formula they should be re-fed, adding new EBM/formula to make up the difference for the desired feeding volume at the next feeding. Example: if the feedings are supposed to be 50ml Q 3 hours and the residual is 25 ml, re-feed the 25 ml plus add 25 ml of new EBM/ formula to make a total of 50ml. Only discard the residuals if they contain old blood, meconium or lots of mucous secretions!
 * RESIDUALS:**

Many of our late preterm infants will be sent home exclusively breastfeeding. In order to get more calories into these babies, we generally recommend that late preterm infants less than 35 weeks gestational age (GA) be discharged with additional 22 kcal/oz supplementation. For breastfeeding infants who need to be supplemented, we ask the mothers to pump between feeds and offer 2 bottles a day of the EBM fortified with Enfacare Powder to make 22 kcal/oz. We have recipes in English and Spanish of how to make this solution. Essentially, it is ½ teaspoon of Enfacare Powder in 3 ounces of EBM. We are not allowed to use Enfacare Powder in the hospital, but we have a “practice can,” which we can use for teaching and demonstration purposes. If there is no EBM available, but the infant is breastfeeding, we recommend giving 2 bottles of Enfacare (22kcal/oz) per day.
 * ALMOST READY FOR DISCHARGE:**

Formula-fed infants should be discharged on Enfacare if their gestational age was less than 35 weeks at birth. Babies may have these higher calorie preparations (EBM +Enfacare or straight Enfacare) for an extended period of time, up to 9 months. Ultimately, the length of giving higher calorie preparations depends on their weight gain. If babies start becoming overweight, they will need to be put on regular formula. Vitamins and iron: generally, babies of 36 weeks gestational age or less will be discharged on iron (ferrous sulfate 2 –3 mg/kg/day) and multivitamins (Polyvisol 1ml/day). Iron and Polyvisol should be started after full feedings have been attained. Please order these medications as outpatient medications on RXM so families do not have to wait for these meds to be re-processed in the pharmacy upon discharge.

//Guenter Hofstadler, MD February, 2011// //Pediatric Department//

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