Neonatal Nutrition Management GuidelinesNutrition Committee

March 2018

Updated March 2020

Overall Aim

Provision of appropriate nutrition to neonates in a timely and safe manner to facilitate adequate growth and development

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Topics at a glance

• Nutrition guidelines for premature infants birth weight less

than or equal to 1250 grams

• Vitamin and Iron supplementation guidelines

• Feeding intolerance decision pathway

• Guideline for the use and storage of pasteurized donor

human milk in the NICU

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Guideline Objectives• Standardize enteral nutrition introduction and advancement in

infants with birth weight less than 1250 grams

• TPN initiation, advancement and weaning

• Standardize definition and management of feeding intolerance

• Provision of adequate vitamin and iron supplementation

• Provision of pasteurized donor human milk (PDHM) if mother’s own milk (MOM) is unavailable or inadequate

• Reduce TPN and central line days by optimizing nutritional status

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Nutrition Guidelines for Premature InfantsBirth Weight Less Than or Equal to 1250 grams

Significance

• Extra uterine growth restriction due to inadequate nutrition intake is

common

• Adequate nutrition is related to infection resistance, and long-term

cognitive, neurologic and developmental outcomes

• Nutritional approach where nutrients are administered at a more rapid

rate than previously endorsed recommended to facilitate growth

• Early aggressive parenteral and enteral nutrition is well tolerated and

is effective in improving growth

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Significance

Ultimate nutritional goals for a preterm infant

• replication of in utero growth similar to that of a fetus of the same GA

• reach a functional outcome parallel to infants born at term

• avoid gastrointestinal injury

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Human Milk

• Ideal feeding choice

• Preferred initial feeding choice is Mother’s own milk (MOM)

• Pasteurized Donor Human Milk (PDHM) used if MOM is not

available

• Colostrum used for oral care (via swab or syringe) when it

becomes available

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Enteral FeedingMinimal Enteral Feedings (MEF)

• Initiated within 12 hours of birth

• Exceptions:

Hemodynamic instability

Surgical patients

• Umbilical arterial catheter, treatment with indomethacin, and high

FiO2 requirement not considered absolute contraindications

• Volume:15 – 20 ml/kg/day

• Administration: via NG/OG every 3 hours for 3 days

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Enteral Feeding

• Feeding advancements after 3 days on MEF

• Increase volume by 20ml/kg/day

• Target feeding volume of 150 – 170 ml/kg/day

• If MOM is unavailable and mother declines PDHM, initiate feedings

with Similac Special Care (SSC) 24 kcal/oz High Protein formula

• Feeding advancement adjustments may be needed for

surgical conditions

critical illness

hemodynamic instability

signs of feeding intolerance

electrolyte abnormalities

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Feeding Guideline for BW 1250 grams

DOLTotal fluid

ml/kg/d

Enteralml/kg/d

Breast Milk***kcal/oz

TPN + ILml/kg/d

Proteing/kg/d(TPN)

Lipidg/kg/d

Total Proteing/kg/d(TPN +

Enteral)

1 10015-20(MEF)

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D10 starter TPN: 50D5: 45

Lipids: 5

3 1 3

2 12015-20(MEF)

20 120 4 2 4

3 13015-20(MEF)

20 130 4 3 4

4 140 40 20 100 4 3 4.5

5 150 6026 (Prolact+6)*

24 (Similac HMF)**90 3 3

4.74.5@

6 150 8026 (Prolact+6)*

24 (Similac HMF)**70 2.5 2

4.74.5@

7 150 10026 (Prolact+6)*

24 (Similac HMF)**50 1.5 1

4.34.0@

8 150 12026 (Prolact+6)*

24 (Similac HMF)**

D/C TPN + PICC(start MVI)

3.43.0@

9 150 14026 (Prolact+6)*

24 (Similac HMF)**

3.93.6@

10 150-160 150-16026 (Prolact+6)*

24 (Similac HMF)**

4.2-4.53.8-4.1@

* For infants 1000g or 26 6/7 weeks GA at birth use Prolact+6 for 26 kcal/oz** For infants ≥1001g or ≥ 27 weeks GA at birth use Similac Human Milk Fortifier (HMF) Hydrolyzed Protein Concentrated Liquid for 24 kcal/oz*** If breast milk is unavailable, begin feedings with Similac Special Care (SSC) 24 kcal/oz High Protein formula.@ Total Protein in g/kg/d if Similac HMF is usedRefer to ”Nutrition Guidelines for Premature Infants Birth Weight Less Than or Equal to 1250 grams”

Revised Mar 2020

Fortification• Prolacta human milk-based fortifier will be used for infants

≤ 1000 grams or ≤26 6/7 weeks GA at birth

• Initiated at +6 kcal/oz at feeding volume of 60ml/kg/day

• Additional fortification done on a case-by-case basis

• Similac Human Milk Fortifier (HMF) Hydrolyzed Protein

Concentrated Liquid will be used to fortify to 24 kcal/oz

for

• Infants ≥1001grams or ≥27 weeks GA at birth

• Infants with no consent to use donated human milk products

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Prolacta Weaning Protocol

• Begins at 33 0/7 weeks PMA

• All feedings fortified with Similac HMF

by 33 4/7 weeks

• SGA who are still < 1250g at 33 0/7

weeks, delay Prolacta wean until

either > 1250g or 14 days

chronological age, whichever occurs

later

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Feeding sequence q 3 hours

1 2 3 4 5 6 7 8

Day 1 Prolacta Prolacta Sim HMF

Prolacta Prolacta Sim HMF

Prolacta Prolacta

Day 2 Prolacta Sim HMF

Prolacta Sim HMF

Prolacta Sim HMF

Prolacta Sim HMF

Day 3 Sim HMF

Sim HMF

Prolacta Sim HMF

Sim HMF

Prolacta Sim HMF

Sim HMF

Day 4 Sim HMF

Sim HMF

Sim HMF

Sim HMF

Sim HMF

Sim HMF

Sim HMF

Sim HMF

Weaning protocol off Prolacta to bovine fortifier:33 0/7 weeks: add 2 feedings Simlac HMF33 1/7 weeks: add 4 feedings Simlac HMF33 2/7 weeks: add 6 feedings Simlac HMF33 3/7 weeks: all feedings of Simlac HMF

Vitamins and Iron Supplementation

15PRETERM INFANTS (<37 weeks GA)

Milk Type Weight Vitamin/Iron Supplementation Iron Goals

(mg/kg/day)

Vitamin D Goals

(IU/day)

Human milk alone or in combination

with preterm formula (regardless of

caloric density)

<750g

0.5 mL PVS (no Iron) q12h AND

1.5mg Elemental Iron

q day

2-4 400750-1249g

0.5 mL PVS (no Iron) q12h AND

1.5mg Elemental Iron q12

1250-2500 gms0.5 mL PVS with Iron q day

AND 0.5mL D-Vi-Sol q day

>2500 gms 1 mL PVS with Iron q day

Preterm formula (>24 cal/oz)

<2500 gms0.5 mL PVS q day AND 0.5 ml D-

Vi-Sol q day2-4 400

>2500 gms 1 mL PVS (no Iron) q day

Term formula Any 1 mL PVS (no Iron) q day

2 400

Transition formula (eg, Neosure) (22

cal/oz)Any 1 mL PVS (no Iron) q day

Human milk with term or transition

formula (closer to discharge)Any 1 mL PVS (no Iron) q day

TERM INFANTS (>37 weeks GA)

Milk Type Weight Vitamin/Iron Supplementation Iron Goals

(mg/kg/day)

Vitamin D Goals

(IU/day)

Human milkAny Provider preference 1 400

Human milk with term formula

Feeding Intolerance Decision Pathway

Feeding Intolerance

• Some feeding intolerance expected due to

gut immaturity

intestinal dilation related to noninvasive ventilation

• Feeding should not be withheld unless pathologic signs

of feeding intolerance are present.

• Gastric residuals should not be routinely checked prior to

feeding stable infants

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Feeding Intolerance

Observations which would warrant holding subsequent feeds until

medical clearance include:

• Significant abdominal distention(≥ 2cm from baseline)

• Tender, firm or discolored abdomen

• Bilious emesis

• Bilious or dark green gastric aspirates

• Hypoactive/absent bowel sounds

• Blood in stool

• Non-bilious emesis of >50% of feed x 2 consecutive feeds if receiving ≥

40ml/kg/day enteral feeds

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Feeding Intolerance

Observations which may require alteration of current feeding

regimen, but not necessarily cessation of subsequent feeds, include:

• Mild abdominal distention (<2cm from baseline)

• Persistent regurgitation/emesis of

25-50% of feeding volume x 2 consecutive feeds

or

>50% of feeding volume x 1 feed

• Significant feeding related apnea/bradycardia/desaturation

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Use and Storage of Pasteurized Donor Human Milk (PDHM) in the NICU

Donor Milk

Banked donor human milk that is screened, pooled, and

pasteurized

Milk is obtained from one of the Human Milk Banking

Association of North America (HMBANA) milk banks

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Definitions

• Preterm Donor Milk: collected from mothers who deliver infants

< 37 weeks’ gestation, within the first month after delivery

• Early Term Donor milk: collected from mothers who deliver infants

> 37 weeks’ gestation, within the first month after delivery

• Term Donor Milk: collected from mothers who deliver infants

> 37 weeks’ gestation, within the first year after delivery

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Criteria for using PDHM• Birth gestational age (GA) < 35 weeks

• Per parental request if >35 weeks birth GA at sites where this option is

available

• GI diagnosis (eg. short-gut syndrome, Hirschsprungs, malabsorption,

GI surgery)

• Post NEC or a history of NEC

• Renal failure

• Feeding intolerance

• Some inborn errors of metabolism

• Provider discretion

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Considerations

• Mother’s own milk (MOM) is always used first

• PDHM may be mixed with MOM to achieve desired feeding quantity

• If MOM is unavailable, PDHM is used exclusively

• PDHM can be fortified similar to MOM per current NICU protocol

• Multiples: If one infant is eligible, all siblings will receive PDHM

• Preterm PDHM used for infants < 1000 grams if available

Early Term PDHM used if preterm PDHM not available

Term PDM used if Preterm or Early Term PDHM not available

• Term PDHM used for all infants >1000 grams

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PDHM initiation steps• Obtain signed consent from parent/guardian

Telephone consent obtained if parents are not physically

available to sign consent

• Physician to order PDHM for the eligible infant as a nutrition order

• A formula order will not be written for these infants

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PDHM weaning process

• Physician enters Nursing Communication Order “Wean donor milk per

protocol.”

• General criteria for weaning PDHM

Stable and tolerating enteral feedings well

Absence of conditions that warrant the extended use of BM

• May extend weaning process if feeding intolerance develops

• Ideally, weaning should be completed at least 2 days prior to discharge

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PDHM weaning process

• Infants born <35 weeks GA

after 14 days on PDHM or 35 weeks PMA, whichever is longer

until on ad lib feedings

• Infants born >35 weeks GA

after 14 days of life

• Suggested weaning schedule

Day 1: Two formula feedings intermittently throughout the day

Day 2: Four formula feedings

Day 3: Six formula feedings

Day 4: All formula

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Ordering/Storing/Handling of PDHM• NICU Lactation Consultants (LC) or designated healthcare provider

(HCP) notified if the PDHM stock is low

• LC or HCP will arrange for milk delivery with the milk bank

• PDHM will be stored in accordance with the current Safe Human Milk

Handling Policy

• PDHM stored in the NICU freezer until the milk bank designated

expiration date

• A single “Unit Bottle” of PDHM can be used for several infants

• RN to chart the feeding as “Donor Human Milk” in electronic medical

record

• Human Milk, Bovine Fortifier and Prolacta Conservation guidelines

should be followed

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