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NEONATAL INTENSIVE CARE UNIT

Author: Dr Vennila Ponnusamy, Consultant Neonatologist

Catherine Casewell, Paediatric Dietician

Sue White, Neonatal Community Outreach Team lead

Guideline History

Date Comments Approved By

May 20 Replaces existing nutritional guidance in new format

Multidisciplinary review and feedback

Remote ratification by guidelines chair

Section 1 Organisational

Policy

Current Version is held on the

Intranet

First ratified:May 2020

Review date:May 2023

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Neonatal Nutrition on NICU


Contents

1. Guideline

a. Aims and Objectives b. Nutritional requirements c. Preparati on of Powdered Formula Feeds in Hospital d. Feeding on discharge e. Emergency regimen for breast milk fortifier f. Use of breast milk fortifier g. Transitioning from weighing fortifier to using sachets or green scoop h. Specialised infant formula/supplements i. Donor expressed breast milk – when and how to use, and when to discontinue j. Grading onto formula k. Nutritional issues associated with prematurity l. Halal certified formulas

2. Supporting References

3. Supporting Trust Guidelines

4. Guideline Governance

a. Scopeb. Purposec. Duties and Responsibilitiesd. Approval and Ratificatione. Dissemination and Implementationf. Review and Revision Arrangementsg. Equality Impact Assessmenth. Document Checklist


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a. Introduction: Aims and Objectives

Preterm Infants are classified as infants born <36weeks gestation. They have therefore missed some or all of the 3rd trimester of pregnancy which is a time of rapid growth and establishing nutrient stores. The body composition of a preterm infant differs markedly from that of a term infant.

The nutritional management of preterm infants does have a major impact on growth and development. A standardized approach to feeding in these infants can be effective in reducing malnutrition and adverse effects such as NEC. There are 4 different nutritional phases for preterm infants:

1) Golden Hour – Parenteral Nutrition (PN)2) Transition from PN to Enteral feeds3) Growth4) Discharge

Aim To guide through the transition from PN to establishing enteral feeds.

To achieve growth and nutrient accretion similar to intrauterine rates

To achieve best possible neuro-developmental outcomes

To prevent specific nutritional deficiencies

Objectives• To provide evidence based locally agreed standard nutritional strategies.

• To increase awareness and understanding of the choices of feed available, the difference in nutritional composition of these feeds and indications for their use for premature infants

• To serve as an educational resource for clinical staff involved in the care of premature infants

• To promote mothers own milk as the optimum milk for preterm infants

This guideline has been drawn up using the best available evidence and practice, including the latest ESPGHAN (2010) recommendations. These recommendations are based on data from intrauterine growth and nutrient balance studies and assume that the optimal rate of postnatal growth for preterm infants should be similar to that of normal fetuses of the same post conception age.


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b. Recommended Nutritional Requirements

There are no UK guidelines on the recommended nutrient intakes for preterm infants. Over the last two decades the values used have been from 3 sources – Klein 2002, Tsang 2005 and ESPGHAN 2010. The summary of requirements from the latest evidence is below.

Summary of Requirements (ESPGHAN 2010)

Nutrient Recommended Intake

Infant body wt. < 1kg 1-1.8kg

Fluid (ml/kg/day) 135 - 200

Energy (kcal/kg/day) 110 - 135

Protein (g/kg/day) 4-4.5 3.5-4

Sodium (mmol/kg/day) 3-5

Calcium (mmol/kg/day) 3-3.5

Phosphate (mmol/kg/day) 1.9-2.9

Vit A (μgRE/kg/dayVit A (IU/kg/day)

400-10001332-3330

Vit D μg/dayVit D IU/day

20-25800-1000

Folic acid (μg/kg/day) 35-100

Iron (mg/kg/day) 2-3


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c. Preparation of Powdered Formula Feeds in Hospital

Information for this policy has been utilised from the NHS guidance available online. Bacteria such as Cronobacter sakazakii have been found in powdered formula milk (Centre for disease Control and Prevention, 2019) therefore correct preparation is important to avoid infection.

Please put the date opened on the tin of powder / or do not use after date.

Step by Step

Step 1: Fill the kettle with at least 1 litre of fresh tap water (don't use water that has been boiled before).

Step 2: Boil the water. Then leave the water to cool for 20 to 30* minutes, so that it remains at a temperature of at least 70C. If leaving the room while water is cooling in the kitchen, Please leave a note, so that no one adds cold water or reboils the kettle. *For specialised formulas, please refer to any specific preparation instructions on the tin, due to the presence of probiotics.

Step 3: Clean and disinfect the surface you are going to use with green Clinell wipes.

Step 4: It's important that you wash your hands using the 7 step guide located near the sink.

Step 5: If you are using a cold-water steriliser, shake off any excess solution from the bottle and the teat, or rinse them with cooled boiled water from the kettle (not tap water).

Step 6: Stand the bottle on the cleaned, disinfected surface.

Step 7: Follow the manufacturer's instructions and pour the amount of water you need into the bottle. Double check that the water level is correct. Always put the water in the bottle first, while it is still hot, before adding the powdered formula.

Step 8: Loosely fill the scoop with formula powder, according to the manufacturer's instructions, and level it off using either the flat edge of a clean, dry knife or the leveller provided. Different tins of formula come with different scoops. Make sure you only use the scoop that comes with the formula.

Step 9: Holding the edge of the teat, put it on the bottle. Then screw the retaining ring onto the bottle.

Step 10: Cover the teat with the cap and shake the bottle until the powder is dissolved.

Step 11: It's important to cool the formula so it's not too hot to drink. Do this by holding the bottle (with the lid on) under cold running water.

Step 12: Test the temperature of the formula on the inside of your wrist before giving it to your baby. It should be body temperature, which means it should feel warm or cool, but not hot.

Step 13: If there is any made-up formula left after a feed, throw it away.


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The dedicated milk preparation area is located in the milk kitchen; milk should only be made up there and not in the nursery. The kettle should be emptied after use to avoid accidental burns. No children should go into the milk kitchen.

References

1. https://www.nhs.uk/conditions/pregnancy-and-baby/making-up-infant-formula/

2. https://www.cdc.gov/features/cronobacter/index.html

3. https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2008/02/ start4life_guide_to_bottle_-feeding.pdf


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https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2008/02/start4life_guide_to_bottle_-feeding.pdf

https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2008/02/start4life_guide_to_bottle_-feeding.pdf

https://www.cdc.gov/features/cronobacter/index.html

https://www.nhs.uk/conditions/pregnancy-and-baby/making-up-infant-formula/


d. Feeding on Discharge

The discharge planning of babies on NICU begins on the day of admission. Hospital stay does not need to be prolonged because of tube feeding. Some babies are discharged home with exclusive nasogastric feeding (e.g. babies with neurodevelopmental problems) or as top ups to compliment breast or bottle feeds. Close liaison with the Neonatal Community Outreach Team (NCOT) and the Paediatric Dietitian will be required and parents/carers will need to complete the Nasogastric tube feeding competency prior to discharge. A risk assessment should be completed by nursing staff prior to discharge. http://trustnet/docsdata/paed/Guidelines_Neonatal/Transition%20from%20Tube%20to%20Enteral%20Feeds%20Oct%202019.pdf

Families will have the opportunity to stay in the parents’ accommodation on NICU, or on the Transitional Care Unit, to develop confidence in feeding and establish a 24hr feeding pattern. Nursing staff/community neonatal nurses can organise this as necessary.

Breast Feeding on Discharge

Some preterm or low birth weight babies on breast milk feeds may be discharged home on additional breast milk fortifier (BMF) supplements to support catch-up growth. Please refer parents to parent information booklet on ‘’ Breast Feeding at home with Breast Milk Fortifier Supplements”

Follow the advice as below in hospital when preparing babies for discharge, as it helps parents to learn this technique to do at home.

Exclusive breast feeding

Document % amount of BMF given on discharge Add BMF to expressed breast milk and use within 12hours Either give as:

o 1 sachet dissolved in 5mls expressed breast milk and give off a plastic weaning spoon as a paste

Or o 1 sachet dissolved in 10mls expressed breast milk and give cautiously via a syringe

Always offer the BMF paste (or dissolved with milk as above) with breast feeds spread equally throughout 24hours (no more than 5 sachets per day). The exact amount for each baby is to be advised by Neonatal Community Nurse or Neonatal consultant

Bottle feeding with expressed MEBM

Document % amount of BMF given on discharge The dose is either ½ sachet into 50mls (2%) or ½ sachet into 25mls (4%) and spread equally

throughout 24hours (no more than 5 sachets per day). The exact amount for each baby is to be advised by Neonatal Community Nurse or Neonatal consultant


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http://trustnet/docsdata/paed/Guidelines_Neonatal/Transition%20from%20Tube%20to%20Enteral%20Feeds%20Oct%202019.pdf

http://trustnet/docsdata/paed/Guidelines_Neonatal/Transition%20from%20Tube%20to%20Enteral%20Feeds%20Oct%202019.pdf


Advice parents to continue BMF as advised by NCOT. Weekly review of BMF dose and supplementation will be done by NCOT and lead community consultant. BMF will be stopped on discussion with community consultant or in outpatient consultant review at 6 weeks.

If on BMF for longer than 4 weeks post discharge, blood tests for renal function and bone profile will need to be arranged by NCOT in phlebotomy clinic prior to consultant review in OPD. Please inform parents about this prior to discharge.

Formula Feeding on Discharge

An infant should be transitioned onto post-discharge formulas for example Nutriprem 2 or SMA Prem 2 either 3 days’ prior to discharge or at 1.8kgs whichever comes first. Additional vitamins (e.g. Abidec) will be required but folic acid and iron are not necessary with post discharge formulas.

Infants discharged home on preterm post discharge formula may continue with this formula until 6 months corrected age and appropriate weaning diet established. A change to a term formula may be considered earlier than this if the infant is gaining excessive weight (increasing over 2 centiles above that which is expected).

Vitamins and Mineral Supplements

Abidec: All infants should continue their vitamins until they are taking 3 solid meals per day of a wide variety of foods including fruits, vegetables, a source of protein and carbohydrates and approximately 3-5 breast/bottle feeds per day. It is recommended by the Department of Health that all infants should remain on their vitamin drops until they are 5 years of age.

Iron: All infants should continue with iron supplementation if exclusively breast feeding, breast feeding with breast milk fortifier or receiving a specialist infant formula or term formula with volumes <150 mls/kg/day. Iron fortification should only be stopped if the infant is receiving 100% of their feeds from post discharge pre-term formula.

Iron supplements are stopped at 6 months gestational age and when weaning diet is established.

Folic acid and sodium acid phosphate supplements are not routinely given to babies at discharge.


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e. Emergency Regimen for breast milk fortifier

1) This emergency regime can be used if the dietician is not available and the purple sheet has not been updated by a senior nurse or Consultant.

2) This emergency regimen can be used if the scales are faulty / unavailable when using BMF.

1% 2% 3% 4%

Per 100ml 1 small green scoop 1 sachet (2.2g) 3 small green

scoops2 sachets (2 X 2.2g)

Per 50mls ½ small green scoop 1 small green scoop 1½ small green

scoops1 sachet (2.2g)

Per 25mls ½ small green scoop 1 small green scoop

Any fortified breast milk that is made up and can’t be given immediately should be sealed and placed in the milk feed refrigerator on the ward and used within 12 hours.

Please note that this is for emergency regimen only; the ideal time for use-by is within 4 hours as documented later in the guidelines. Breast milk must not be warmed after adding the fortifier so consider warming first.

Any excess defrosted EBM that has not been fortified must be discarded if not used within 12hours.

Note – The nutritional composition of BMF with maternal milk and other formulas are available in the additional document as an excel attachment.


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% of Breast milk fortifier (BMF) x mls/feed = g BMF per feed

100


f. Use of Breast Milk Fortifier (BMF)

While breast milk is obviously superior (with benefits that cannot always be measured in terms of nutritional content), it has been established that breast milk is not, in isolation, adequate to meet the increased nutritional requirements of infants born prematurely.

Preterm infants have higher nutrient requirements than term infants and after the first 2-3 weeks of lactation the protein content of human milk is usually insufficient to meet the nutritional demands of rapidly growing preterm infants (Weber et al., 2001). The majority of preterm infants born <34 weeks gestation exclusively fed on human milk are at risk of slower rate of weight gain than in utero. This deficit in growth is largely due to the additional protein requirements needed to accelerate preterm growth. If energy is also insufficient then the infant will use protein for energy, which will compound the deficit further. Poor nutritional status is additionally associated with worse outcome in neurodevelopmental scores at 18 months. The Cochrane Review of Breast Milk Fortification in 2004 established that use of fortifier improves short term weight gain, length and head growth without significant evidence of increased morbidity and mortality. There are currently no studies linking BMF to an increase in NEC.

By routinely using BMF as standard in our unit, we aim to avoid early ex-utero growth restriction, with its inherent disadvantages.

It is started at half strength (2%) when the infant has tolerated 150mls/kg/day of MEBM or DEBM for 24hours. By starting fortification at 2% early, it is possible to achieve good growth and nutrition. Follow the Early Feeding Pathway to initiate breast milk fortifier http://trustnet/docsdata/paed/Guidelines_Neonatal/Risk%20stratified%20approach%20to%20enteral%20feeding%20on%20NICU%20Feb%202020.pdf

Only very few babies need to use 3-4% which increases the osmolality of the feeds.

Adding BMF also helps to keep the total milk volume to 150mls-165mls/kg/day and thereby reducing GORD in preterm infants.

Review of growth and nutrition should be done on a weekly basis including head circumference, weight, metabolic profile and additional needs of the baby. Once a baby achieves and maintains good growth trajectory, aim to stop BMF prior to discharge. It is preferable to stop around 34 weeks’ gestation to allow review of growth without BMF before discharge. Please discuss with consultant on ward rounds.

If growth is sub-optimal, then babies can be discharged home on BMF. Please refer to discharge section for further information.


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http://trustnet/docsdata/paed/Guidelines_Neonatal/Risk%20stratified%20approach%20to%20enteral%20feeding%20on%20NICU%20Feb%202020.pdf



g. Transitioning from weighing fortifier to using sachets or green scoop

This is used when transitioning a baby on to using full sachets of BMF (commonly known as( ‘BMF Bombs’) instead of weighing BMF for each feed. This is suitable for babies when they are establishing more breast feeds prior to going home.

Example: 3hourly

Weight = Approximately 1.3kgs Volume = 150mls/kg/day Volume/feed = 24mls x 3hourly x 8 of MEBM + 2% BMF

= 24 mls x 0.02 BMF = 0.48 grams of BMF

Therefore, they require 0.48g BMF per feed

0.48 per feed x 8 feeds a day = 3.84 grams of BMF / day

= roughly 4 x 1 gram (green scoop) in 24 hrs

= 4 BMF bombs /day – each with 1 green scoop, given with feeds.

If babies are requiring top-up tube feeds, alternate options to weighing BMF are as below:

1 sachet 2.2g to 50mls = 4%

1 sachet 2.2g to 100mls = 2%

1 green scoop to 50mls = 2%

1 green scoop to 25mls = 4%

1 green scoop (1g) to 25mls (4%) can be used for babies who are receiving 25mls at each

feed.

1 sachet (2.2g) to 50mls (4%) can be used as alternate feeds for babies receiving

approximately 25mls/feed

Breast milk fortifier can also be given as complete sachets added to a given number of feeds

divided evenly within a 24hour period. This is calculated as total amount of fortifier required

in a 24hour period and divided by 2.2g sachets.


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h. Specialised Infant Formula/Supplements

These are not designed for routine use in preterm infants due to nutritional profile of the formula. Most specialist formula are only available as powder and therefore need to be reconstituted (see safe preparation on powdered feeds).

SMA Gold Prem 1 is partially hydrolysed whey protein with MCT fats and so may be an alternative for very mild symptoms of constipation, and other signs of intolerance to a whole protein formula

For Pre-term Infants requiring an extensively hydrolysed formula, consider the following: Hydrolysed Nutriprem 1 (partially hydrolysed whey protein and extensively hydrolysed

casein) Aptamil Pepti (hydrolysed whey) Aptamil Pepti-junior (hydrolysed whey/lactose free/MCT) Mead Johnson Pregestimil (hydrolysed casein/lactose free/MCT)

For Pre-term infants requiring an amino acid formula, consider Neocate LCP

Infants requiring an alternative formula for symptoms of reflux are given Enfamil AR or SMA Anti-reflux.

Do not give Omeprazole. An acid in the stomach is required for these feeds to thicken in the stomach.

Do not use Gaviscon with these feeds as this will predispose to milk bolus obstruction.

High Energy Infant Formulas are used for term infants with IUGR/growth faltering e.g. Infatrini or SMA High Energy (which has a slightly lower protein content and therefore useful for lower weight infants)

Infatrini Peptisorb is a ready to feed formula useful for term infants who are growth faltering and malabsorbing. Care should be taken with high energy formulas that the protein intake should not exceed 4.0 - 4.5g/kg/day

Nutriprem Protein Supplement ONLY use under the direction of Paediatric Dietitian and Consultant Formulated to provide extra protein to meet the requirements of infants <1000g only Extensively hydrolysed protein alone – no micronutrients Calculate energy and protein intakes and compare to requirements prior to addition of

protein supplements Check blood urea twice a week and if within the normal range do not add protein

supplement – discuss with MDT Add to Donor or Mother’s Expressed Breast milk alongside BMF or directly into preterm

formula: 1 g sachet: 0.82g protein/100mls Monitor blood urea x2/week and stop when urea levels are >6


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i. Donor expressed Breast Milk – When and How to Use and When to Discontinue?

Donor breast milk is a useful resource until maternal milk is available, particularly for babies at high risk of gut problems. It is usually not practical to have infants sustained on donor milk due to its variable and often lower nutrient profile compared to MEBM and formula.

If mother’s milk is limited or unavailable refer to Infant Feeding Lead by email and refer to trouble shooting checklist on MAM checklist to maximise milk production.

Consent for use of donor expressed breast milk

• If a mother's own milk is not available or contra-indicated, or use of formula is contraindicated according to Early feeding pathway, consent for the use of donor breast milk should be sought from the mother and recorded together with the feeding intention in the admission form.

Which infants should be considered for donor breast milk?

DEBM should only be considered in high risk babies where maternal milk is not available or is in short supply e.g..

• <1000g receiving intensive care • <29 weeks gestation• Recovering from necrotizing Enterocolitis• Had consistently Absent or Reversed End Diastolic Flow• Intra Uterine Growth Restricted <2nd centile

Documentation

• Each bottle of donor milk has a batch number which should be recorded on the infant’s fluid / feeding chart and in the DEBM record book kept on the fridge.

How long to use DEBM?

• If mothers are intending to breast feed their babies long term and actively expressing her milk:Use DEBM until mothers can establish their own adequate milk supply usually until 14 days of age (maximum of 21 days if very preterm). Please support mothers well with expressing, including use of Domperidone where appropriate. Refer to Assessment of Breast Milk Expression guide.

• If mothers are not intending to breast feed or their supply is very low:Transition from full DEBM to formula feeds when the baby is >29 weeks and fully established on DEBM. This will be a Consultant decision.


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If transfer is planned to another hospital which doesn’t have a milk bank, it may be possible to send a small supply with the infant. Please discuss potential transfer at the earliest opportunity during daily ward rounds to plan transition of milk where appropriate.


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j. Grading on to formula (use the quarters rule)

If mother’s milk is unavailable:• Start with ¼ formula for 24hr (i.e. 3 MEBM to 1 formula feed, 3:1)• Increase by ¼ every 24hr as tolerated i.e. re-grading should take 3 days (2:1→ 1-1 →all

formula feeds). If donor milk is to be supplied to another hospital, the re-grading steps should be explained clearly to the parents and to the hospital as they may be unfamiliar with using donor EBM

• If mother’s milk is limited, use a combination of MEBM and formula (e.g.3:1, 2:1 or 1:1 depending on the milk available and check supplies daily

• Do not mix maternal milk with formula in each feed.

Supplies of donor breast milk

• Milk Bank coordinators will inform the nurse in charge when supplies are low. The amount of available milk is also displayed on the unit

Storage

• Expressed milk can only be accepted if it has been collected and stored in milk collection containers provided by, or accepted to, the ASPH milk bank

• Milk collection for donation should be frozen as soon as possible to maintain its nutritional and microbiological quality and it should be kept frozen

• If needed, refrigerate expressed milk collected over 24hours and freeze the batch• Frozen milk should be transported to the milk bank as soon as possible• Expressed milk can be stored before transport to the milk bank for up to 3 months in a

domestic freezer at -18degrees or lower.

For further information on DEBM – Please refer to DEBM bank guidelines


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k. Nutritional Issues associated with prematurity

Intolerance of feeds

NEC, gastro-intestinal obstruction and complete ileus are the only absolute contraindications to feeding.

Bile staining implies that there is a degree of duodeno-gastric reflux / stasis. There are many causes for this in infants and, in the preterm and/or growth restricted infant the most likely cause is gut immaturity or a malpositioned NGT/OGT. Ileus due to sepsis is probably the next most common cause.

It is common, in the early stages of increasing milk feeds, to find small volumes of lightly bile stained aspirates. Bile stained aspirates should prompt clinical examination and review, but not necessarily cessation of feeds. Clinical judgement needs to be used, as many of these infants will be stable, well and active, with normal abdominal examination. Clear documentation of review and clinical impression including a management plan should be documented in baby’s records.

In babies on Extremely high risk and High risk feeding pathway, Continuous assessment via observations of clinical status including trend of heart rate & saturations, and 4 hourly nursing assessment of: Gastric residual, Abdominal distension, Passing stool and Vomiting needs to be assessed and documented. http://trustnet/docsdata/paed/Guidelines_Neonatal/Risk%20stratified%20approach%20to%20enteral%20feeding%20on%20NICU%20Feb%202020.pdf

In all other babies, there is no need for regular assessment of gastric residual.

In preterm gut dysmotility, the infants remain well and feeding should be continued (at amounts to be prescribed by the clinical team). Prokinetics (low dose Erythromycin 3 mg/kg qds) may be used.

Obstruction, sepsis and NEC should be considered, particularly if the infant appears unwell.

In cases of persistent malabsorption of feeds despite attempts to feed over a number of days or post gut surgery, a hydrolysed formula is indicated with some Medium Chain Triglyceride (MCT) component. The suggested formula is Hydrolysed Nutriprem. This will be a consultant decision.

Gastro-Oesophageal Reflux Disease (GORD)

Mild gastro-oesophageal reflux is common in all preterm infants. This can be managed conservatively by early recognition, slow feeds and nursing baby in elevated position. Suspected significant reflux called GORD that does not respond to conservative management can be diagnosed without the need for intense/invasive investigations. Acidity on a cotton bud placed at the back of the mouth when the infant is refluxing and then pressed onto pH paper may be sufficient evidence however, not all reflux is related to an increase in acid production.

If the infant is completely stable on examination consider increasing the frequency of feeds prior to reducing the total volume (for example, choose to feed every 3 hours instead of every 4 hours). If this is unsuccessful, consider reducing the volume and it may be necessary to increase the amount of fortifier prescribed if receiving expressed breast milk.


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If there are no contraindications and reflux is clinically significant that may warrant medical management, please request pH Study to confirm GORD and identify if its acid reflux. A milk thickener or a change in the type of milk may be used in non-acid reflux. http://trustnet/docsdata/paed/Guidelines_Neonatal/Multichannel%20Intraluminal%20Impedance%20pH%20Study%20May%202020.pdf

1. Carobel can be used with MEBM, MEBM and BMF or specialist powdered feeds. Carobel needs to be stirred well and not shaken when made up and left to thicken for 3-4 minutes. It will continue to thicken for 5-10 minutes after being made up. Start at 1% concentration of Carobel (1/2 scoop to 90mls) and increase the concentration as required. If using with BMF, consider reducing the amount of Carobel added by ½ usual amounts.

2. Enfamil AR or SMA Anti-reflux can be used as an alternative to a standard term formula fed infants or pre-term infants on pre-term feeds with adequate growth after discussion with Consultant.

3. Gaviscon Sachets can be used with MEBM (only if not on fortifier) They can also be used if fully breast feeding as directed on back of sachet

4. Consider the use of Domperidone as a motility agent. An ECG need to be done to check QT interval prior to commencing Domperidone, and ongoing monitoring every 3-4 weeks if on long term use. Please discuss with Consultant for follow up ECG’s.

5. Currently Ranitidine is unavailable due to withdrawal of product due to contamination with NMDA. Omeprazole should be used for acid suppression in acid reflux only after discussion with a consultant. Optimise the dose in babies with severe GORD who have associated bradycardia, desaturation and the need for nasal cannula oxygen which is not due to Chronic Lung Disease.

Hypoglycaemia

In preterm babies, when enteral feeds are commenced, they may be prone to hypoglycemia due to feed intolerance and prematurity. As for term babies, the aim is to keep the blood sugar level at or above 2.0 mmol/l. Please follow hypoglycemia guideline for investigations and appropriate management. http://trustnet/docsdata/paed/Guidelines_Neonatal/Hypoglycaemia%20Guideline%20Sep%202017.pdf

There are occasionally infants who are borderline hypoglycaemic on a maximum regular feeding regime. For these infants, please follow this guide to increase their supplementation.

For treatment of term infants, consider:• On MEBM and growing well: add 4% Maxijul (MJ) (4 small blue scoops to 100mls of milk)• On MEBM but growth is faltering: add 4% BMF• Formula fed and growing well: add 4% MJ• Formula fed but growing is faltering: change to Infatrini

For treatment of pre-term infants, consider:• On MEBM and growing WELL: add 4% MJ• On MEBM but growth is faltering: add 4% BMF• On Pre- term Formula fed - Use preterm formula and 4% MJ


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http://trustnet/docsdata/paed/Guidelines_Neonatal/Hypoglycaemia%20Guideline%20Sep%202017.pdf

http://trustnet/docsdata/paed/Guidelines_Neonatal/Hypoglycaemia%20Guideline%20Sep%202017.pdf

http://trustnet/docsdata/paed/Guidelines_Neonatal/Multichannel%20Intraluminal%20Impedance%20pH%20Study%20May%202020.pdf

http://trustnet/docsdata/paed/Guidelines_Neonatal/Multichannel%20Intraluminal%20Impedance%20pH%20Study%20May%202020.pdf


Nutritional Information on the above combinations of feeds and supplements

:

Weight must be monitored carefully

Table showing mg/kg/m of Glucose for Infatrini fed at different feeding volumes

Volume of feedsml/kg/day

Protein (g/kg/d)

Fat (g/kg/day)

Carbohydrate(g/kg/day)

Glucose (mg/kg/min)

100 2.6 5.4 10.3 7.2

120 3.1 6.5 12.4 8.6

140 3.6 7.6 14.4 10.0

150 3.9 8.1 15.5 10.7

165 4.3 8.9 16.9 11.9

180 4.7 9.7 18.5 13.0


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Per 100mls Calories Protein Carbohydrate

Breast milk 65 1.5 6.9

MEBM +4% BMF 80 2.6 9.6

MEBM + 4% MJ 80 1.5 10.7

Term Formula + 4% MJ 82 1.6 10.9

Infatrini 100 2.6 10.3

Preterm Formula 80 2.6 8.4

Preterm Formula + 4% MJ 95.2 2.6 12.2


l. Halal Certified Formulas

(Please note that these may not be vegetarian due to DHA component being fish oil )

April 2020

Cow & Gate pre-term formula milks that are halal certified

Cow & Gate Nutriprem 1 70ml ready-to-use bottle hospital use only Cow & Gate Hydrolysed Nutriprem 90ml ready-to-use bottle hospital use only Cow & Gate Nutriprem 2 (post discharge formula )90ml ready-to-use bottle Cow & Gate Nutriprem 2 (post discharge formula )200ml ready-to-use bottle Cow & Gate Nutriprem 2 (post discharge formula) 800g Tin

Cow & Gate specialist infant formula milks that are halal certified

Cow & Gate Anti-Reflux Infant Formula Milk 800g eazypack Cow & Gate Comfort Infant Formula Milk 800g eazypack

SMA PRO pre-term formula milks that are halal certified

SMA specialist infant formula milks that are halal certified

SMA Organic range SMA Comfort- easy to digest (with omega 3 and 6 – vegetarian source) SMA LF- lactose free infant milk


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Neocate

Infatrini

There are no 'forbidden' ingredients in Infatrini but the manufacturing process has not had official Halal certification. Infatrini is not suitable for vegans as it contains milk and other non-vegan ingredients

Nutramigen Lipil 1 & 2 are not Halal or Kosher approved and contain pork enzyme.


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Specialised infant milks suitable for vegetarians, vegans and those wishing to use halal products

Category of infant milk Name of milk Suitable for Vegetarians

Suitable for Vegans

Suitable for Halal

Preterm or low birth weight

Cow & Gate Hydrolysed Nutriprem Cow & Gate Nutriprem 1 SMA Gold Prem 1

Preterm post discharge Cow & Gate Nutriprem 2 SMA Gold Prem 2

High-energy infant milks suitable for term infants from birth

Abbott Nutrition Similac High Energy Nutricia Infatrini SMA High Energy

Yes

Yes

Yes

Yes

Thickened anti-reflux Aptamil Anti-Reflux Cow & Gate Anti-Reflux HiPP Organic Combiotic Anti-reflux Mead Johnson Enfamil AR SMA Staydown Yes Yes

Lactose-free infant milks suitable from birth1

Aptamil Lactose Free Mead Johnson Enfamil O Lac SMA LF Yes Yes

Partially hydrolysed infant milks suitable from birth

Aptamil Comfort Cow & Gate Comfort HiPP Organic Combiotic Comfort SMA ComfortSMA HA

Yes Yes

Extensively hydrolysed peptide-based infant milks suitable from birth

Abbott Nutrition Similac Alimentum Aptamil Pepti 1 Mead Johnson Nutramigen 1 with LGG SMA Althéra

Extensively hydrolysed peptide-based infant milks with MCT, suitable from birth

Cow & Gate Pepti-junior Mead Johnson Pregestimil LIPIL Nutricia Infatrini Peptisorb

Amino-acid based infant milks for nonmetabolic disorders, from birth

Mead Johnson Nutramigen Puramino Nutricia Neocate LCP SMA AlfaminoAbbott Elecare

YesYes

YesYes


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2. Supporting relevant trust guidelines

Intranet Neonatal guidelines/clinical guidelines/nutrition


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4. Guideline Governance

a. Scope

This guideline in relevant to all staff caring for babies across neonatal intensive care, transitional care and maternity.

b. Purpose

i. This guidelines aims to facilitate a common approach to the management of babies admitted under neonatal care. At times deviation from the guideline may be necessary, this should be documented and is the responsibility of the attending consultant.

ii. This guideline is subject to regular review to ensure ongoing evidence based practice.

c. Duties and Responsibilities

All health care professionals involved in caring for neonates should be aware of and follow the advice given in this guidance.

d. Approval and Ratification

This guideline will be approved and ratified by the Neonatal Guidelines Group.

e. Dissemination and Implementation

i. This guideline will be uploaded to the trust intranet ‘Neonatal Guidelines’ page and thus available for common use.

ii. This guideline will be shared as part of ongoing education within the Neonatal Unit for both medical and nursing staff.

iii. All members of staff are invited to attend and give comments on the guideline as part of the ratification process.

f. Review and Revision Arrangements

a. This policy will be reviewed on a 3 yearly basis.b. If new information comes to light prior to the review date, an earlier review will be

prompted.c. Amendments to the document shall be clearly marked on the document control

sheet and the updated version uploaded to the intranet. Minor amendments will be ratified through the Neonatal Guidelines Group. A minor amendment would consist of no major change in process, and includes but is not limited to, amendments to documents within the appendices.


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g. Equality Impact Assessment

Background Who was involved in the Equality Impact Assessment

Neonatal guidelines chairMethodology

A brief account of how the likely effects of the policy was assessed (to include race and ethnic origin, disability, gender, culture, religion or belief, sexual orientation, age)

The data sources and any other information used The consultation that was carried out (who, why and how?)

All patient and staff groups were considered for impactKey Findings

Describe the results of the assessment Identify if there is adverse or a potentially adverse impacts for any equalities groups

No evidence of discriminationConclusion

Provide a summary of the overall conclusions

Guideline appropriate to useRecommendations

State recommended changes to the proposed policy as a result of the impact assessment Where it has not been possible to amend the policy, provide the detail of any actions that

have been identified Describe the plans for reviewing the assessment

Guideline to be shared, review will take place as per NGG TOR


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h. Document Checklist To be completed (electronically) and attached to any document which guides practice when submitted to the appropriate committee for approval or ratification.Title of the document: Policy (document) Author: Executive Director:

Yes/No/ Unsure/NA

Comments

1. TitleIs the title clear and unambiguous? YIs it clear whether the document is a guideline, policy, protocol or standard?

Y

2. Scope/PurposeIs the target population clear and unambiguous?

Y

Is the purpose of the document clear? YAre the intended outcomes described? YAre the statements clear and unambiguous? Y

3. Development ProcessIs there evidence of engagement with stakeholders and users?

YWide MDT involvement in development

Who was engaged in a review of the document (list committees/ individuals)?

Neonatal nutrition groupWider members of neonatal team

Has the policy template been followed (i.e. is the format correct)?

Y

4. Evidence BaseIs the type of evidence to support the document identified explicitly?

Y

Are local/organisational supporting documents referenced?

Y

5. ApprovalDoes the document identify which committee/group will approve/ratify it? Y

If appropriate, have the joint human resources/staff side committee (or equivalent) approved the document?

NA

6. Dissemination and ImplementationIs there an outline/plan to identify how this will be done?

Y

Does the plan include the necessary training/support to ensure compliance?

Y


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Yes/No/ Unsure/NA

Comments

7. Process for Monitoring Compliance YAre there measurable standards or KPIs to support monitoring compliance of the document?

N

8. Review Date 2023Is the review date identified and is this acceptable?

Y

9. Overall Responsibility for the DocumentIs it clear who will be responsible for coordinating the dissemination, implementation and review of the documentation?

Y

10. Equality Impact Assessment (EIA)Has a suitable EIA been completed? Y

Committee Approval (Neonatal Guidelines Committee)If the committee is happy to approve this document, please complete the section below, date it and return it to the Policy (document) OwnerName of Chair M. S. Edwards Date 11 May 2020

Ratification by Management Executive (if appropriate)If the Management Executive is happy to ratify this document, please complete the date of ratification below and advise the Policy (document) OwnerDate: n/a


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ashfordstpeters.net€¦ · web viewneonatal intensive care unit section 1 organisational policy...

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