Feeding policy in preterm newborns

[kpsanghvi]

Namaste

What are your policies regarding feeding of the preterm of newborns specifically pertaining the following questions.

When to start feeds (LBW/VLBW/ELBW) ?

What should be the initial volume of feeds and volume of increment ?

What to feed (EBM/Donor milk/Preterm formula) ?

When to add HMF ?

How long do you store the milk after adding HMF ? Where do you store it?

How do you define feed intolerance and how do you tackle it ?

Any other information on feeding of the preterm newborn

Would be obliged if you could provide references ?

You can send me an answer to my directly on kpsanghvi@hotmail.com

[Stefan Johansson]

Here's some comments from our strategies.

- We start minimal feeding as soon as possible, generally the first day (-s) depending on the grade of early morbidity.

- Depends on the infant's gestational age and weight, but from 1-2 ml to 5-10 ml in extr/very/moderat preterm infants

- We always use banked (donated) breast milk in extr and very preterm infants, and to most moderat preterm's too, until the mother's own milk production is initiated. Most mother start pumping the day after delivery.

- In all infants with an expected longer duration with partial enteral nutrition, we give also partial parenteral nutrition. Our strategy is to start HMF when the baby is on full enteral feeds. (however, this strategy, to start supplementation after full feeds might be less good (http://www.ncbi.nlm.nih.gov/pubmed/23855971))

- we have a dedicated person who works with formulas, milk, fortification etc. She prepares for 12-24 hours of feeds per baby and store the ready made milk/formula cooled until the feed, when the volume to give is heated in warm water bath.

- Feed intolerance... difficult to define but as you know very common We allow some retention as long as it is melted food or just gastric juice. If the volume is "large" - typically more than 3-5 millliters (depending on infant size) we may skip the coming feed or reduce the planned volume.

[AngelaCondie]

We usually start 2-3 cc/kg/feed every 3 hours with EBM or preterm formula if the baby is well. We don't have banked milk. If there are aspirates after the second day, then we begin to replace the aspirate, subtracting it from the total amount of milk scheduled to be given. (For example, if the aspirate is 2 cc and the scheduled amount is 5 cc, we give the 2cc aspirate back plus 3cc of EBM.) This way, we can see if they can tolerate the feeds. If the aspirate is large, then we hold the feed until the next scheduled time.

We don't have HMF, so we use preterm formula to fortify the EBM. When they seem able to suck, we start breast feeding three times a day. When a baby is on 30cc/feed, then we add 1/3 scoop of dry preterm formula to the feed to increase the calories to 24/ounce. As they are able to tolerate breastfeeding, we change from NG feeds to cup and spoon. We discourage bottle feeding because of the hygienic conditions in the villages. As the baby gets stronger in breastfeeding and taking the cup and spoon, we gradually decrease the amount of extra feeds, so that he only gets breastfeeding by the time he goes home at 1800gm.

If you have any comments on this, I would really appreciate any feedback or suggestions. We don't have ventilators or central lines. We have amino acid solution that we use to supplement feeds in the early days.

[Neon8al]

Namaste

Namaste Dr Sanghvi :-)

What are your policies regarding feeding of the preterm of newborns specifically pertaining the following questions.

When to start feeds (LBW/VLBW/ELBW)

We also try to start tropgic feeds/ gut priming as soon as baby is considered stable (within first 1-2 days) at a volume of 0.5 to 1 ml every 2 hours via NG tube.

What should be the initial volume of feeds and volume of increment ?

The rate of increment is variable between hospitals I have worked in and ranges from 1ml/kg increment in feed volume given 2 hourly done every 12-24 hours in first few days and faster after day 4-5 of feeding. All this is in extreme preterms (24-29 weekers) and quicker in bigger ones. Most 32 weekers and above just get fed fully from day 1. There is a trial going on in UK called SIFT trial (Speed if increasing feed) trial.

What to feed (EBM/Donor milk/Preterm formula) ?

We do not use donor EBM. Preferable EBM and if not available formula.

When to add HMF ?

Once reached a feed volume of 150ml/kg/day

How long do you store the milk after adding HMF ? Where do you store it?

Fortifier added just before feed to the feed volume. Not stored after adding fortifier.

How do you define feed intolerance and how do you tackle it ?

Variable definition and practice there (Mihatsch et. al. Pediatrics 2002, 109, 457-459 and Cobb et.al Pediatrics 2004, 113, 50-53)). Volume of aspirate a bigger factor than colour of the aspirate. Prompting clinical review of patient and resumption of feed only if clinically well.

Any other information on feeding of the preterm newborn

Early parenteral nutrition important in avoiding energy deficit.

Would be obliged if you could provide references ?

​Hope above helps.

You can send me an answer to my directly on kpsanghvi@hotmail.com

[NICU RN 7]

What are your policies regarding feeding of the preterm of newborns specifically pertaining the following questions.

When to start feeds (LBW/VLBW/ELBW) ?

We start on the second or third day when the infant is somewhat stable respiratory-wise

What should be the initial volume of feeds and volume of increment ?

Our unit uses a series of feeding guidelines which increase feedings and fortification according to the infant's weight at birth.

The lower-weight guidelines start at 10ml/kg/day and increase after 3-5 days.

What to feed (EBM/Donor milk/Preterm formula) ?

Our infants under 32 weeks get either EBM or Donor milk unless parents refuse, in which case they get preterm formula.

When to add HMF ?

HMF is added on day 10 of the <750g guideline, day 8 of the 751-1250g guideline, and day 6 of the 1251-2000g guideline. Doubling of fortification occurs two days later, and beneprotien is added within a week.

How long do you store the milk after adding HMF ? Where do you store it?

Milk is considered safe on our unit for 24 hours after fortification, and is stored in a breastmilk refrigerator

How do you define feed intolerance and how do you tackle it ?

Feeding intolerance is a residual of >50% of the ordered feed with other gut symptoms such as a loopy belly, or bilious residual. It is first tackled by holding a feeding, and then by some time NPO, and finally by stopping any fortification which has been ordered.

Any other information on feeding of the preterm newborn

We begin PO feedings after infants have been scoring 1-2 on our feeding readiness scale for 50% of at least 48 hours (meaning that the infant has been waking up prior to feeds and staying awake through the feeding time, rooting).

Would be obliged if you could provide references ?

[kpsanghvi]

What are your policies regarding feeding of the preterm of newborns specifically pertaining the following questions.

When to start feeds (LBW/VLBW/ELBW) ?

We start on the second or third day when the infant is somewhat stable respiratory-wise

What should be the initial volume of feeds and volume of increment ?

Our unit uses a series of feeding guidelines which increase feedings and fortification according to the infant's weight at birth.

The lower-weight guidelines start at 10ml/kg/day and increase after 3-5 days.

What to feed (EBM/Donor milk/Preterm formula) ?

Our infants under 32 weeks get either EBM or Donor milk unless parents refuse, in which case they get preterm formula.

When to add HMF ?

HMF is added on day 10 of the <750g guideline, day 8 of the 751-1250g guideline, and day 6 of the 1251-2000g guideline. Doubling of fortification occurs two days later, and beneprotien is added within a week.

How long do you store the milk after adding HMF ? Where do you store it?

Milk is considered safe on our unit for 24 hours after fortification, and is stored in a breastmilk refrigerator

How do you define feed intolerance and how do you tackle it ?

Feeding intolerance is a residual of >50% of the ordered feed with other gut symptoms such as a loopy belly, or bilious residual. It is first tackled by holding a feeding, and then by some time NPO, and finally by stopping any fortification which has been ordered.

Any other information on feeding of the preterm newborn

We begin PO feedings after infants have been scoring 1-2 on our feeding readiness scale for 50% of at least 48 hours (meaning that the infant has been waking up prior to feeds and staying awake through the feeding time, rooting).

Would be obliged if you could provide references ?

[kpsanghvi]

Thanks everyone for the reply. I would like a question again. Is there any reference or study to tell us that " For how long can we store breast milk after fortification". Yes 'nursignicurn' from US has replied that they store for 24 hours and Neon8al from UK has replied they don't store. I would like to know the policy of other units. Thanks once again

[nashwa]

We start as early as possible (day 2)

Start with EBM and if not available we use formula 20cal/oz till 100ml/of then shift to 24 /cal/oz

We increase 10ml/kg/day

[Stefan Johansson]

Thanks everyone for the reply. I would like a question again. Is there any reference or study to tell us that " For how long can we store breast milk after fortification". Yes 'nursignicurn' from US has replied that they store for 24 hours and Neon8al from UK has replied they don't store. I would like to know the policy of other units. Thanks once again

 

We also keep fortified breast milk (in the fridge) up to  24 hours.