Parenteral nutrition, enteral nutrition and MEF

[kstempn]

Hi Friends,

I am writing to you to ask for help in challenging a problem I have faced lately. In newborns with low birth weight minimal enteral feeding (MEF) should be introduced as soon as possible. Volume of MEF and it's components are not included in daily intake though. How to calculate the composition of food if enteral feeding will exceed MEF? Should the components given with parenteral and enteral nutrition be sumed up or should the part of food corresponing to MEF be removed?

 

These information will help me to improve the spreadsheet describing composition of parenteral nutrition taking into account the enteral feeding.

 

Best Regards

Krzysztof Stempniewicz MD

Neonatologist

Krapkowice, Poland

[Debby]

I would be very interested in the responses to this challenging situation.

[Manan]

There are lots of confusion when it comes to neonatal feeding. At least for my unit, i have made protocols for feeding. Would like to share with you. It may be useful. Mail me on manpal179@gmail.com

[livesynapse]

What is usually done is to not consider MEF in the total daily intake because tolerance is iffy and availability is also uncertain. Once the amount of BM exceeds MEF, it should be included in the fluid balance.

Any comments?

[Akash Sharma]

@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. 

[bimalc]

On 6/18/2019 at 10:18 AM, Akash Sharma said:

@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) 

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.