Late+Preterm+and+Preterm+Infants

Feeding the Late Preterm Infant: Population: Premature infants, 33 to 36 6/7 weeks gestational age. First day: Consider leaving the baby NPO for 12 – 24 hours, before initiating enteral feedings. In most cases, we start the baby’s nutrition with parenteral fluids (typically D10W), especially if the baby is relatively premature or not able to feed (floppy, uncoordinated suck-swallow reflex, perinatal depression, etc.). 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, then, after 1-2 days, sodium and potassium need to be added. Generally, 3-4 mEq NaCl/100ml and 2mEq KCl/100ml are added. Electrolytes need to be checked every 12- 24 hours as long as a baby is on i.v. fluids. Also consider checking calcium, phosphorous and magnesium. Initiation of enteral feeds: When initiating enteral feeds, the mode of delivery needs to be established. Breast-feeding, SNS (supplemental nursing system), bottle-feeding, cup feeding and gavage (OGT or NGT) are the usual 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. Nurses and lactation consultants are the best people to judge this and help you in the decision-making process. Advancing feeds: It is important to note that you only advance as tolerated; 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. One possible way of starting and advancing enteral feedings is as follows (this does not apply to breast-feeding). For patients >1250 grams (use birth weight to calculate for first week) Start on the 1st day of feeding with 15 – 30 ml/kg/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 write: Start feedings (formula or EBM) with 5ml Q 3 as tolerated. 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. Remember: This regimen needs to be modified if the baby shows signs of feeding intolerance. Note: 1) Some providers prefer to advance the feedings gradually. For example they would write: “increase feedings by 1-3 ml (pick a number that seems appropriate for a given baby) with every feed (every other feed) as tolerated to a maximum of ……”. Other providers only increase once a day. For example: “increase feeds from 5 ml q 3 hours to 10 ml q 3 hours as tolerated”. This is a personal preference. 2) If a baby feeds ad lib/ on demand, a much wider range of total fluid volumes is acceptable (e.g. a baby might end up feeding a lot more than the above stated maximum. Choice of formulas: Breast milk is the best nutrition for the baby. If possible give EBM (expressed breast milk), unless the baby can breast-feed. If no breast milk is available and the baby is less than 35 weeks gestational age, start with Special Care formula 20, then switch to Special Care formula 24 once the infant has achieved 100ml/kg/day (usually day 3-4). You may also choose to change to a 22 kcal/oz formula if you have an “older” premie. Watch the weight gain/loss closely. Premies need more calories (110 – 140 kcal/kg/day)! If the baby is older than 35 weeks GA, the formula of choice is regular 20 kcal/oz formula. If breast-feeding is possible and desired, this should be encouraged. However, if the baby does not get enough calories to achieve sufficient weight gain (10 – 15 g/kg) after the initial few days, it may be necessary for the mother to pump and add human milk fortifier to the EBM. 1 packet in 50 ml makes 22 kcal/oz, and 1 packet in 25 ml makes 24 kcal/oz. The EBM can be given by gavage, bottle, cup or SNS, as needed. Moving on: As the enteral feedings are increased, the i.v. fluids need to be decreased in order to not exceed the daily total fluid volume (TFV). See above. Gavage feedings are slowly changed to p.o. feedings (breast, nipple or cup) 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. Communication with the nurses is essential in order to establish a practical plan. Note: the nurses and lactation consultants are the best sources to help you decide what feeding regimen to choose; they are the ones who observe the feeding, listen for audible swallows, can tell you if mom’s milk supply is sufficient, etc. Residuals: 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. It is an ominous sign if the residuals are bilious. 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 for one or two feeding cycles. Evaluate the baby before restarting feeds. If necrotizing enterocolitis (NEC) is a consideration, feedings must be stopped altogether and the baby needs to be put NPO. Beware of NEC!! If the residuals consist of undigested formula, they should be re-fed, with the addition of new formula to get the desired volume for the next feeding. Discard the residuals only if they contain old blood, meconium and lots of mucous secretions. Almost ready for discharge: Generally, formula-fed infants are transitioned to Neosure or Enfacare before discharge and may stay on these formulas until they are a few months old (up to 6 months). On occasion we get transfers of ex micro-premies (“feeders and growers”) for further care from Alta Bates or John Muir. If the gestational age is less than 33 weeks, exclusively breastfed babies need to go home on two 4-ounce bottles of Neosure in addition to breastfeeding. Vitamins and iron: generally, babies of 34 weeks or less gestational age are discharged on Iron (2 –3 mg/kg/day) and Polyvisol (1ml/day).

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