Feeding sick and preterm babies

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Feeding sick and preterm babies

• Go slow and bring a calculator!

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Risk for NEC

• NEC (necrotizing enterocolitis) is a potentially
  life threatening infection
• Risk factors include
• Prematurity
• IUGR decreased splanchnic blood flow
• Hypotension/poor perfusion decreased GI
  perfusion
• Sepsis/infection poor perfusion
• Umbilical lines may decrease perfusion

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Preventing NEC

• Delay onset of feeding do not start feeds until
  babies are hemodynamically stable and showing
  interest in feeding.
• Initiate feeds with breast milk whenever
  possible this reduces the risk of NEC fourfold
• Start feedings slowly and advance gradually
  start at about 20ml/kg/day and advance by about
  20ml/kd/day

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Benefit of Early Breast Milk
This
Not this!
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You are taking care of an infant born at 35
weeks Mom was induced for IUGR. Baby weighs
1850 grams which is SGA. Baby was on oxygen for
the first 4 hours of life and then weaned to room
air. She required 2 fluid boluses for
hypotension and is now normotensive.

• Baby is now 4 hours old stable and sucking on a
  pacifier. How should you start feeds and fluids
  with what volume and how should you advance

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Calculations

• ml/kg - this is the total volume a baby is
  receiving each day.
• Newborns generally require 80 ml/kg on the first
  day and go up by about 20 ml/kg each day to a
  maximum of 150-160ml/kg/day
• Newborns do not generally require electrolytes in
  the first 24 hours of life start with D10W

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Kcal/kg

• If you know the amount of fluid and the
  kcal/ounce you can then calculate the kcal/kg a
  baby is receiving.
• Breast milk and standard formula are 20kcal/ounce
• These can be supplemented to 22 or 24 kcal/ounce
  using human milk fortifier or formula
• To calculate kcal/kg take ml/kg and multiple by
  the appropriate factor
• 20 kcal 20/30 or 0.67
• 22 kcal 22/30 or 0.73
• 24 kcal 24/30 or 0.8

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Kcal for growth

• A baby needs about 60 kcal/kg/day just to prevent
  catabolism 80-100 kcal/kg/day to maintain and
  over 100 for growth. Most preterm babies will
  need 110-120 kcal/kg/day to grow.
• A baby should gain 20 to 30 g a day over the
  first month of life

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What are your initial orders for fluids for a
2150 g infant on the first day of life
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• Feeding a baby through its nose with a gavage
  spoon around 1901.

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What are your initial orders for fluids for a
2150 g infant on the first day of life

• 2.150 X 80 ml/kg 172 ml/day or
• 7 ml/hour of D10W

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How do your orders change on DOL 2
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How do your orders change on DOL2

• The next day you will want to increase fluids to
  100ml/kg
• 2.150 X 100 215ml or 9 ml/h
• Based on the babys electrolytes you likely also
  add 2-3 mEq of sodium and 1-2 mEq of
  potassium/100ml of fluid

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A baby is receiving 154 ml/kg/day of breast milk
how many kcal/kg is the baby receiving

• 154 ml/kg/day X 0.67 103 kcal/kg/day

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Your baby is receiving 115 kcal/kg/day of 24 kcal
breast milk how many milliliters is she
receiving a day

• 115 kcal/kg / 0.8 144 ml/kg

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Your baby is getting 105 kcal/kg/day of breast
milk 20 kcal and you want to increase to 120 kcal
using 22 kcal breast milk how much milk should
the baby get each day

• 120 kcal/kg of BM22 how many ml
• 120 / 0.73 164 ml/day of milk

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35 week IUGR baby weighs 1850g hemodynamically
stable and sucking on a pacifier. How should you
start feeds with what volume and how should you
advance

• Baby needs about 80ml/kg of fluids in the 1st day
• Start feeds with breast milk if possible

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35 week IUGR baby weighs 1850g hemodynamically
stable and sucking on a pacifier. How should you
start feeds with what volume and how should you
advance

• Starting volume of feeds
• 1.850kg X 20ml/kg 37 ml a day
• Given over 8 feedings 4-5 ml per feeding.

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35 week IUGR baby weighs 1850g hemodynamically
stable and sucking on a pacifier. How should you
start feeds with what volume and how should you
advance

• Please start feeds with BM 20kcal at 4 ml q3
  hours and advance by 1 ml q6h
• IV PO 80ml/kg/day
• (therefore the starting IV rate would be)
• 4.8 ml/hour

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35 week IUGR baby weighs 1850g hemodynamically
stable and sucking on a pacifier. How should you
start feeds with what volume and how should you
advance

• Advance feeding by about 20 ml/kg/day
• 1.850kg X 40ml/kg 74 ml/day
• Given over 8 feeding 9 ml/feeding
• Could advance by 1 ml every 6 hours

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practical hints for TPN

• Do not starve babies! The ones who dont complain
  are the ones who need it the most.
• Use birthweight to calculate intake till
  birthweight regained then use daily wt
• Start TPN early if the baby not able to tolerate
  PO feeds
• Start with proteins (2-3 g/kg/d) and increase to
  3-4.
• Start lipids at 1-2 g/kg and increase to 2-3g/kg
• Limit dextrose to 10-12 with peripheral lines
  up to 20 with a central lines
• Avoid calcium in peripheral lines.
• Aim for 90-100 Cal/kg/day with 2.5-3 g/kg/d
  Protein (NPC/N of 150-200)

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IV Carbohydrates

• Dextrose 3.4 Cal/g 34 Cal/100 cc of D10W.
• Tiny babies are less able to tolerate dextrose.
• If blood levels 150-180 mg/dL glucosuria
  osmotic diuresis dehydration
• Insulin can control hyperglycemia
• Hyper- or hypo-glycemia early sign of sepsis
• Avoid Dextrose12.5 through peripheral IV

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Enteral Carbohydrates

• Human milk/formula about 20 Cal/oz
• Lactose is carbohydrate in human milk and term
  formula. Soy and lactose free formula have
  sucrose maltodextrins and glucose polymers
• Preterm formula has 50 lactose and 50 glucose
  polymers (lactase level lower in premies but
  glycosidases active)
• Lactose provides 40-45 of calories in human milk
  and term formula

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Fat

• 20 Intralipid
• High caloric density (2 Cal/cc vs 0.34 for D10W)
• Best bang for your buck with calories

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Protein

• Term infants need 1.8-2.2 g/kg/day
• Preterm (VLBW) infants need 3-3.5 g/kg/day (IV or
  enteral)
• Start early - VLBW neonates may need 1.5-2
  g/kg/day by 72 hours

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