Breastfeeding is the ideal way to feed babies, but not all neonates can do this (and we must respect mothers who choose not to breastfeed). Here, formula milk is a viable alternative , as is expressed breast milk (EBM-technique). EBM is often inadequate to supply the increased demands of preterm infants. If <2kg, powder sachets of Breast Milk Fortifiers (Cow & Gate) have a role.
Gavage tube feeding
Indications
Any sick infant who is too ill or too young to feed normally (eg respiratory distress syndrome). Expressed breast milk or formula milk is fed via a naso-or oro-gastric tube either as a bolus or as a continuous infusion.[bomb] If gastro-oesophageal reflux or aspiration is a problem, then a silastic naso-jejunal tube can be used. After entering the stomach, the tube enters the jejunum by peristalsis: confirm its position on x-ray. When the baby improves, start giving some feeds by mouth (PO), eg 1 PO per day, progressing to PO every 3rd feed. Then try alternating PO and gavage; then gavage every 3rd feed; finally try all PO. If during PO feeds, cyanosis, bradycardia or vomiting supervene, you may be trying too soon.
Trophic feeding
Synonyms
Minimal enteral feeding; gut priming; hypocaloric feeding. Rationale: If prems go for weeks with no oral nutrition, normal GI structure and function are lost despite an anabolic body state. Villi shorten, mucosal DNA is lost, and enzyme activity is less. Feeding a small volume of milk may prevent this.
Technique
Typically, milk volumes of ~1mL/kg/h are given by tube starting on day 2-3. The milk employed is ideally expressed breast milk or a preterm formula (eg Nutriprem).
Effects
Studies show that weight gain and head growth is improved, and that there are fewer episodes of neonatal sepsis, fewer days of parenteral nutrition are needed, and time to full oral feeding is less.
Eligibility
Experience shows that almost all prems with non-surgical illness tolerate at least some milk as trophic feeds.
Parenteral nutrition (PN)
This is given into a central vein. Indications: post-op; trauma; burns; if oral nutrition is poor (eg in ill, low-birth-weight babies) and necrotizing enterocolitis (when the gut must be rested). Day-by-day guide: see BOX. รข™£Sterility is vital; prepare using laminar flow units. Monitoring needs to be meticulous.1
Daily checks
Weight; fluid balance; U&E; blood glucose; Ca2+. Test for glycosuria. Change IVI sets/filters; culture filters, Vamin & Intralipid samples.
Weekly
Length and head circumference; skin fold thickness. LFT; Mg2+; PO43-; alk phos; ammonia; triglycerides; FBC; ESR or CRP (helps determine if sepsis is present).
Complications
Infection; acidosis; metabolic imbalances; thrombophlebitis; hepatobiliary stenosis; cholelithiasis; osteopenia. If plasma PO43-, consider giving PO43- (0.25-0.5mmol/kg/day) as the potassium salt. Mix with dextrose, but not Vamin or trace element mixtures. PN is complex: get expert help. In addition, some precipitation errors are preventable by using computer-based decision support.
Stopping IV nutrition
Do in stages to prevent hypoglycaemia.
Parenteral nutrition: day-by-day guide. All values are per kg/day
| PROTEIN | CARBOHYDRATE | FAT | IONS (mmol) | FLUID | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Type of baby | Day of PN | Age days | Vaminon mL | Dextrose 10%; mL | Itralipid 20%; mL | Na | K | Ca | PO4 | PN volume; mL1 |
| Neonates & low birth Weight babies | 1 | 3 | 20 | 97.5 | 2.5 | 3 | 3 | 1 | 0.4-1 | 120 |
| 2 | 4 | 30 | 115 | 5 | 3 | 3 | 1 | 0.4-1 | 150 | |
| 3 | 5 | 40 | 115 | 10 | 3 | 3 | 1 | 0.4-1 | 165 | |
| M | >5 | 50 | 100 | 15 | 3 | 3 | 1 | 0.4-1 | 165 | |
| Infants >1 month1 & <10kg | 1 | 20 | 95-125 | 5 | 2.5 | 2.5 | 0.6 | 0.4 | 120-150* | |
| 2 | 30 | 80-110 | 10 | 2.5 | 2.5 | 0.6 | 0.4 | 120-150* | ||
| M | 40 | 65-125 | 15 | 2.5 | 2.5 | 0.6 | 0.4 | 120-150* | ||
| 10-30kg | 1&2 | 14 | 23.5-78.5 | 7.5 | 2 | 2 | 0.2 | 0.1 | 45-100* | |
| M | 28 | 7-57 | 10-15 | 2 | 2 | 0.2 | 0.1 | 45-100* | ||
| >30kg | 1&2 | 14 | 26-56 | 5 | 1.5-2 | 1.5-2 | 0.2 | 0.1 | 45-75* | |
| M | 21 | 14-51.5 | 10-12.5 | 1.5-2 | 1.5-2 | 0.2 | 0.1 | 45-75* | ||
Advertisements
