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It is evident that intubation generates a feeling of discomfort in the child who undergoes this procedure. For the method IN.SUR.E. We started using fentanyl, but the results were not good. Currently, we are not using any medication for that procedure, although we are aware that the procedure is annoying for the baby.   Fernando Agama C. Unidad de Neonatología Hospital Enrique Garcés Quito-Ecuador

The practical problem with this claim (which I think we all believe in in principle) is that, at the time the initial plan for the day is made, TPN must be ordered and a fluid goal set.  In the setting of MEF, you have no sense of how much will be tolerated and absorbed, whose belly will blow up, etc.  As a practical matter, one has to simply assume that volume does or does not 'count' and accept that you will be 'off' in one direction or another.  It actually does not matter, as long as one is consistent within the unit and if there is ambiguity when sharing with other units, that you are clear on what your practice is.  As long as all sides of a discussion understand the chosen convention, you can have an informed discussion about the specific needs of the patient and any needed changes in the plan over time. My experience in 5 NICUs over the years is that none has counted MEF towards calories or volume and instead relied upon TPN to meet all nutritional needs during this period.  Again, for ease of computation (and thus safety) the practice in ICUs I've worked in (and a practice I subscribe to) is that once you are past MEF you are implying a belief in physiologic tolerance of the feeding volume (otherwise you would not be ordering feeds) and so you should count all the volume/calories.

We've been using remyfentanil previous to LISA, but we've experienced some undesirable side effects (apnea) needing naloxone to revert.  Previously we used small doses of propofol, but it has been abandoned due to the concerns about its neurotoxicity...This was the last topic of discussion in the last session of Catalan Neonatal Studies  Group...a lot of variability in practice, fears, lack of evidence and safety data... What about bolus of dexmedetomidine?  Seems safe but still few studies..

@kstempn and @livesynapseWhatever the amount of intake may be (even as low as 10-20 ml per kg) the intake has to be accounted for in the total daily intake. ( for fluids as well as for calories)  If you are using a milk analyzer the amount of calories and proteins being administered can be adjudged accordingly. Otherwise a standard calorie intake of 65 cal/100 ml for breast milk can be taken. We have our own unit data showing lesser calories so we take that.    Hope this helps. 

We usually don't use any sedation for LISA. If the baby is big and vigorous, I prepare some remyfentanyl and use it only if needed.