neonatal nutrition guide · web viewbackground the purpose of this document is to provide a guide...

CHHS18/095

Canberra Hospital and Health ServicesClinical Guideline Neonatal Nutrition GuideContents

Contents....................................................................................................................................1

Guideline Statement.................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Feeding Regimen Including Trophic Feeds.............................................................3

Section 2 – Insertion of Nasogastric/Orogastric Feeding Tube.................................................7

Section 4 – Pasteurised Donor Breast Milk (PDBM)..................................................................9

Section 5 – Obtaining consent and medical prescription for the supply and administration of PDBM........................................................................................................................................9

Section 6 – Preparation and Administration of PDBM............................................................10

Section 7 – Accidental administration of PDBM without Parental Consent/Medical Prescription.............................................................................................................................11

Implementation...................................................................................................................... 12

Related Policies, Procedures, Guidelines and Legislation.......................................................12

References.............................................................................................................................. 12

Definition of Terms................................................................................................................. 13

Search Terms.......................................................................................................................... 13

Attachments............................................................................................................................14

Attachment 1: Nutritional Requirements Following Discharge...........................................15

Attachment 2: Dietician Referral Criteria............................................................................18

Attachment 3: Discharge Feeding Flow Chart.....................................................................19

Doc Number Version Issued Review Date Area Responsible PageCHHS18/095 1 15/03/2018 01/04/2022 WY&C - Women's

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Guideline Statement

BackgroundThe 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 2017

Alerts Consent must be obtained from parents or guardians by medical staff prior to

administration of PDBM In 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 discarded

Provide assistance to ensure mothers are able 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 Contents

Scope

This document is applicable to: Babies nursed in the Department of Neonatology Medical Officers caring for babies in the Department of Neonatology Nurses and midwives and who are working within their scope of practice Student nurses under direct supervision Nutrition Milkroom staff



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Section 1 – Feeding Regimen Including Trophic Feeds

Milk Choices Maternal expressed breast milk (EBM) Nutrient enriched preterm formula (PTF) Nominated formula Pasteurised donor breast milk (PDBM) Elemental formula as directed by a Medical Officer

Feeding Calculation For 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 (mls/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 (ELBW infants may need higher intake initially due to insensible

water loss) Day 2. 80-90ml /kg/ day Day 3. 100ml /kg/ day Day 4. 120ml /kg/ day Day 5. 140ml /kg/ day Day 6. 150ml /kg/ day Day 7. 160ml /kg/ day

Feeds can be increased further depending on weight gain or at the recommendation of a Medical Officer.

Commencement 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 orders

For infants < 29 weeks at birth Commence 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/day

Commence fluids at 80mls/kg/per day


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Encourage 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 PTF

Increase feeds by 20-25mls/kg/day as tolerated When on 80ml/kg/day of enteral feeds fortify EBM to 85kCAL If 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 regularly At discharge, fortification of breast milk or fortified discharge formula should continue if

postnatal growth failure as per the discharge flowchart These babies should be discussed with dietician and referred to nutrition clinics for post

discharge follow-up see attachment 2: Dietician 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 birth Commence fluids at 80mls/kg and increase depending on urine output, weight loss and

electrolytes but generally follow:o Day 2: 100ml/kg/dayo Day 3-4:120ml/kg/dayo Day 5:140 ml/kg/dayo Day 6:160ml/kg/day

Commence 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 PTF

Increase feeds 25-30ml/kg/day as tolerated When on 80ml/kg/day of enteral feeds – fortify EBM/PDBM to 85kCal If 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

deviation Continue fortification until 36-37 weeks - assessing requirements regularly At discharge, fortification of breast milk or fortified discharge formula should continue if

postnatal growth failure as per discharge flowchart These babies should be discussed with dietician and referred to nutrition clinics for post

discharge follow-up

For infants >32 weeks at birth Commence full enteral feeds if clinically appropriate with EBM or term formula If IV fluids are required 10% Dextrose is adequate for the first 24 hours If IV fluids are required for a longer period consider peripheral TPN Consider TPN via PICC line if prolonged TPN expected (IUGR or surgical)


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Consider fortification of feeds or PTF for the growth restricted baby (<1.8kg) Commence feeds/fluids at 60-80ml/kg/day Increase dependant on weight loss, feed tolerance but generally follow:

o Day 2. 90-100ml /kg/ dayo Day 3. 120ml /kg/ dayo Day 4. 140ml /kg/ dayo Day 5. 140ml /kg/ dayo Day 6. 160ml /kg/ day

Aim 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 centile

Vitamin 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 gestation. Commence Pentavite at 0.45 mls daily when on full feeds. Cease at 6-12 weeks

corrected age Commence 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 feeding Alcohol based hand rub (ABHR) Milk of choice Syringe pH test strips Stethoscope

Feeding 1. Attend hand hygiene before touching the patient by either hand washing or using ABHR2. 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

3. Insert and check position of the NGT/OGT as per page 7 of this guideline


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4. Gastric aspirate should be obtained 6 hourly and examined when a baby is first commenced on feeding protocol

5. Check aspirate for colour and volume6. If aspirate is bile or blood stained, refer to the medical officer as it may be indicative of

early necrotising enterocolitis (NEC)7. 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 direction8. If aspirate is not bile stained, and is <50% of feed volume, return the aspirate to the baby

via feeding tube, and continue feeding.9. 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

10. Document all gastric aspirates on fluid balance chart, describing the colour and consistency

11. All 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

12. 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)

13. When commencing feeds, position the baby in the supine position with the head of the cot elevated as clinically indicated

14. Offer the baby a dummy if awake, to encourage non-nutritive sucking (NNS) (ensure parental permission has been granted)

Complications Abdominal 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: o Distended, reddened abdomen o Visible loops of bowelo Abdominal tendernesso Reduced or absent bowel soundso Gastric residuals (typically bile/blood stained)o Lethargy, increasing apnoea and bradycardias


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o Blood in stoolso Temperature instabilityo Hypotension and falling urine output

If any of the above is present consult medical officer immediately


Section 2 – Insertion of Nasogastric/Orogastric Feeding Tube

Equipment Required Alcohol based hand rub (ABHR) Infants <1000g: size 5 French feeding tube Infants >1000g: size 5-6 French feeding tube 10 ml syringe Ph indicator strip Stethoscope Duoderm Tape Sucrose Oral syringe

Procedure1. Determine 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 feeding

2. Determine depth of insertion of feeding tube: i. 4.1 Nasogastric – measure from nare to ear lobe, down to halfway between ziphoid

process and umbilicusii. 4.2 Orogastric – measure from centre of mouth to ear lobe, down to halfway

between ziphoid process and umbilicus3. Encourage non-nutritive sucking and administer sucrose to the baby two minutes prior to

insertion of feeding tube for analgesia4. Wrap baby, so arms are out of the way, place baby in the supine position5. Moisten tip of tube with babies saliva and gently insert to desired depth6. To 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.

7. 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.


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This method can be used to dislodge the exit-port of the feeding tube from the gastric mucosa.

8. 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 old Infants on continuous, hourly or second hourly feeds Medications to reduce or alter stomach acid: e.g. Ranitidine or Omeprazole Presence of medication or milk left in feeding tube or blood stained aspirate Some babies with none of the above will consistently have pH values of 6 or above

9. If gastric aspirate is unable to be obtained. Ensure that the feeding tube remains securely taped at the desired measurement before feeding.

10. 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 tape

11. For 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-slippage

12. Place a second piece of tape over the top to ensure extra security

Adhesive Tape

Duoderm®Second piece of tape

Trouser leg wrapped around

feeding tube

13. If 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 removal

14. If 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-ray

15. Feeding 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 replaced

Complications1. Apnoea, 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

2. Perforation of the oesophagus, stomach or duodenum. The feeding tube should never be forced during insertion

3. Aspiration of feed due to feeding tube being placed into trachea. Always verify tube placement thoroughly, upon insertion and every time it is used


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Section 4 – Pasteurised Donor Breast Milk (PDBM)

Background 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 PDBM include Preterm babies <30 weeks and/or <1250gms Preterm babies 30+0 -31+6 weeks with consistently absent or reversed end diastolic

flow Babies 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

PDBM describe the documentation required to ensure accurate record keeping


Section 5 – Obtaining consent and medical prescription for the supply and administration of PDBM

Equipment PDBM PDBM Distribution Record (Nutrition Milkroom) Fluid Order Form with baby’s URN, date of birth and name Fluid Balance Chart Consent form

Procedure 1. 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.2. PDBM must be ordered on the patient fluid order chart by a medical officer3. Once 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.


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4. 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.


Section 6 – Preparation and Administration of PDBM

Preparation of PDBM1. The required volume of PDBM will be thawed, alloquoted and delivered to the individual

baby and placed in baby’s bedside refrigerator2. The 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.

3. 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.

4. 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.

5. 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.

6. The Nutrition Milkroom staff monitors a data logger to ensure the cold chain has been maintained during transport.

7. 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 decanting1. When 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 2. 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 <27mL

3. Following 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 checked

4. Document the batch number on the Fluid Balance Chart5. Any unopened, expired bottles of PDBM should be recorded and disposed of by the

Nutrition Milkroom staff


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6. Any 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)

7. 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.

8. 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 first ideally breastmilk should be thawed in the fridge otherwise place the container in a pan

or jug of tepid water thawed milk should be refrigerated if not used immediately shake the container to evenly distribute the fat discard any thawed milk not used within 24 hours


Section 7 – Accidental administration of PDBM without Parental Consent/Medical Prescription

Always 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 PDBM1. If 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 feeding2. Report incident to neonatal registrar/consultant and nurse-in-charge immediately.3. 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.

4. If screening is to be performed ensure pre-test counselling by the neonatal registrar/consultant occurs

5. Complete an incident form immediately and submit via Riskman6. Nutrition Milkroom manager is to be notified of the incident7. Inform 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.



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Implementation

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.


Related Policies, Procedures, Guidelines and Legislation

Policies Health Directorate Nursing and Midwifery Continuing Competence Policy Consent and Treatment Expressed Breast Milk Incident Guide

Procedures CHHS Healthcare Associated Infections Clinical Procedure CHHS Patient Identification and Procedure Matching Policy

LegislationHuman Rights Act 2004United Nations Convention on the Rights of the Child


References

1. 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.

2. 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.

3. 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.

4. Schurr, P, & Perkins, E.M. (2008). The relationship between feeding and necrotisizing enterocolitis in very low birth weight infants. Neonatal Network, 27(6). 397-407

5. Smith, 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.

6. 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.


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7. 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.

8. Donor breastmilk banks: the operation of donor breastmilk bank services. National Institute for Health and Clinical Excellence (2010)

9. 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

10. 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 377–382

11. Donor Human Milk Banking in Australia - Department of Health 12. www.health.gov.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.

13. Unomedical feeding tubes. Unomedical Pty Ltd. 2000-2007. http://www.unomedical.net/au/section05/pdf/medical.pdf#page=4 Accessed 15 June 2011.


Definition of Terms

Donor Breastmilk - Human breastmilk donated by a mother to the milk bank for pasteurisation and use by a baby other than her own

Osteopenia - 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 microbiology


Search Terms

Breastmilk, Pasteurised Donor Breastmilk, PDBM, Nutrition Room, feeding tube, naso-gastric tube, nutrition, feeding, trophic feed


Attachments

Attachment 1: Discharge Feeding FlowchartAttachment 2: Inpatient and Discharge Dietician Referral CriteriaAttachment 3: Discharge Feeding Flow Chart


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http://www.google.com.au/url?q=http://www.health.gov.au/internet/main/Publishing.nsf/Content/D94D40B034E00B29CA257BF0001CAB31/$File/Donor%2520Human%2520Milk%2520Banking%2520in%2520Australia%2520paper%2520(D14-1113484).docx&sa=U&ved=0ahUKEwj9mra0hYbMAhVJ4mMKHZZmBV8QFggUMAA&usg=AFQjCNHDqs7f37Hz8B_ZQ8R047bgmtQSZQ

http://journals.lww.com/jpgn/toc/2013/09000

http://journals.lww.com/jpgn/toc/2013/09000

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Disclaimer: 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 Amended Section Amended Divisional Approval Final Approval 14/03/2018 Complete Review Karen Faichney, A/g ED

WY&CCHHS Policy Committee

This document supersedes the following: Document Number Document NameCHHS16/090 Pasteurised Donor Breastmilk (PDBM) - Management and AdministrationCHHS12/104 Department of Neonatology - Feeding Regimen Including Trophic FeedsCHHS13/625 Department of Neonatology - Nasogastric and orgastric tube insertion


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Attachment 1: Nutritional Requirements Following Discharge


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The 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 Fortifier

In 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.


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Peripheral TPN Starter TPN Starter concentrated TPN

Standard preterm TPN

Concentrated preterm

mL/kg/day 60 80 100 120 60 80 100 120 60 80 100 120 140 160 120 140 160Protein (g/kg/day) 1.38 1.84 2.3 2.76 2.25 3 3.75 4.5 3 4 5 3.6 4.2 4.8 4.8 5.6 6.4Sodium (mmol/kg/day) 1.5 2 2.5 3 1.2 1.6 2 2.4 1.8 2.4 3 4.08 4.76 5.44 6 7 8Potassium (mmol/kg/day) 1.2 1.6 2.0 2.4 0 0 0 0 0 0 0 2.64 3.08 3.52 4.2 4.9 5.6

Calcium (mmol/kg/day)

0.9 1.2 1.5 1.8 1.02 1.36 1.7 2.04 1.5 2 2.5 2.04 2.38 2.72 2.64 3.08 3.52

Phosphate (mmol/kg/day) 0.72 0.96 1.2 1.44 0.6 0.8 1 1.2 0.9 1.2 1.5 1.56 1.82 2.08 1.8 2.1 2.4


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CHHS18/095

Attachment 2: Dietician Referral Criteria

Inpatient Dietician Referral Criteria Discharge Dietician Referral Criteria

Restricted fluid intake ≤ 160 mL/kg/day – at greater than 1 week of age

< 75% of prescribed quota is nutritional fluids for more than one week

Weight/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 days

Home oxygen

Growth faltering/crossing centiles/>1SD on Fenton’s Z score calculator

Intolerance to preterm formula of breast milk fortifier

Exclusive naso-gastric feeding

>200mL/kg/day of preterm formula or fortified breast milk intake

CLD where growth impairment is likely

Babies with ongoing gastrointestinal issues – stoma

Short bowel syndrome/NEC where use of elemental formula is considered

Malabsorption Babies with ongoing cardiac failure requiring restricted fluids

Gastrointestinal anomaly Congenital heart disease where growth impairment is likely

Chylothorax Renal failure


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CHHS18/095

Attachment 3: Discharge Feeding Flow Chart


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neonatal nutrition guide · web viewbackground the purpose of this document is to provide a guide...

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