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Title: Version: Ratification Date: Review Date: Approval: Author: Job Title: Consultation: Guideline Contact Distribution: Target audience: Patients to whom this applies: Key Words: Risk Managed: Evidence used:
Feeding Neonates with Surgical Problems
2 March 2012 (circulated November 2012) December 2014 Nottingham Neonatal Service Clinical Guideline Group April 2012 Chris Jarvis, Brian Davies, Helen Budge Specialist Neonatal Dietitian, Consultant Paediatric Surgeon, Consultant Neonatologist Neonatal Service Staff and Clinical Guideline Meeting Chris Jarvis, Specialist Neonatal Dietitian c/o Stephanie Tyrrell, Nottingham Neonatal Service firstname.lastname@example.org Nottingham Neonatal Service, Neonatal Intensive Care Units Staff of the Nottingham Neonatal Service Patients of the Nottingham Neonatal Service who fit the inclusion criteria of the guideline below necrotising enterocolitis, stoma, milk, bowel atresias, feeding Suboptimal perioperative nutrition and necrotising enterocolitis The contemporary evidence base has been used to develop this guideline. References to studies utilised in the preparation of this guideline are given at its end.
Clinical guidelines are guidelines only. The interpretation and application of clinical guidelines remain the responsibility of the individual clinician. If in doubt, contact a senior colleague. Caution is advised when using guidelines after the review date. This guideline has been registered with the Nottingham University Hospitals NHS Trust. 1. Background Nutrition & growth are vital to the quality of outcomes following neonatal surgery. Breast milk is believed to be the best form of enteral nutrition for babies. The incidence of necrotising enterocolitis (NEC) is considerably less in babies breast fed or fed with expressed breast milk (EBM). Mothers of preterm babies or babies expected to have surgical problems should be actively encouraged to express milk as necessary and progress to breast feeding. Our approach to introducing and advancing feeds (Nottingham Neonatal Service Guideline D3) and the choice of milk when breast milk is unavailable (Nottingham Neonatal Service Guideline D4), serve as the basis for this guideline and a summary of these is given as Appendix 1. Poor nutritional intakes which result from the use of low protein and energy, or diluted, feeds can be avoided by the use of the most appropriate milk and appropriate parenteral nutrition (PN) (as detailed in Nottingham Neonatal Service Guideline D6). This guideline (Nottingham Neonatal Service Guideline D10) offers guidance on choice of milk, feeding regimen and management of specific surgical conditions. Appendices 2 and 3 contain additional useful information on the comparable content of available milks.
Breast-feeding/EBM should be encouraged in all babies, especially premature babies and babies with surgical problems. Those with antenatally detected conditions will already have been counselled to this effect if time allowed before delivery
Standard term formula Yes Breast milk If breast milk not available. BW ≥2kg) Neonatal patient with abdominal surgery. fluid balance & weight gain In infants with short bowel. Nutriprem 1 Yes Breast milk If breast milk not available.6% Aptamil Pepti 1 for gastroschisis) Use 2 hourly boluses for first feeds Monitor losses. consider continuous feeds Neonatal dietitian should be involved if babies have on-going problems Summary of enteral feeding decision making for near term surgical babies (≥34 weeks.Nottingham Neonatal Service – Clinical Guideline D10 Summary of enteral feeding decision making for small or preterm surgical babies (<34 weeks and BW <2kg) Neonatal patient with abdominal surgery. short bowel (or gastroschisis)? No Breast milk If breast milk not available. 15% Pepti-Junior (16% Aptamil Pepti 1 for gastroschisis) Use 2 hourly boluses for first feeds Use 2 hourly boluses for first feeds Monitor losses. consider continuous feeds Neonatal dietitian should be involved if babies have on-going problems 2 . fluid balance & weight gain In infants with short bowel.8% Pepti-Junior (13. BW < 2kg Consider PN support early „High‟ stoma. fluid balance & weight gain Use 2 hourly boluses for first feeds Monitor losses. short bowel (or gastroschisis)? No Breast milk If breast milk not available. 12. fluid balance & weight gain Monitor losses. BW > 2kg Consider PN support early „High‟ stoma.
The proportion of the intestine remaining should be clearly documented by the surgical team in the operation notes as length of small intestine remaining is a major factor in the likelihood of weaning PN and establishing full enteral nutrition. it is unlikely that lactose intolerance will be clinically significant in the majority of babies.6%) is a hydrolysed protein formula that we plan to use for babies with gastroschisis due to the better palatability while not needing MCT and the low lactose levels provided by Pepti-Junior. 2. a hydrolysed protein formula may be beneficial.Nottingham Neonatal Service – Clinical Guideline 2. 3. However. The decision to feed with a milksubstitute where maternal breast milk is available should only be made following review by Consultant Paediatric Surgeon and Attending Consultant Neonatologist. although not necessarily a predictor of ultimate enteral tolerance . The presence of the ileocaecal valve. clinical assessment (including weight gain.1). for conditions such as NEC and gastroschisis it may be necessary to progress more slowly. breast milk or a lactose containing formula may be tried in the first instance and reviewed closely. may also be important. electrolytes. If lactose intolerance is thought to be a significant issue. Certain considerations may be necessary for some babies with surgical conditions of the bowel: Lactose tolerance Whilst breast milk contains lactose. The stepwise approach to introducing milk outlined in Appendix 1 serves as a good starting point and guide. Where bile salt metabolism is thought to be substantially impaired. However. Protein tolerance Breast milk contains readily absorbed whole protein and is usually well tolerated. Advice should also be sought from the Neonatal Dietitian. as the length of intestine remaining can only be an estimate. Pepti-Junior (12. None of the above formulas meet the nutritional requirements of preterm infants nor are they available as ready to feed preparations.1. may be a factor and is important in preventing bacterial overgrowth so should also be documented. Therefore.1 Special circumstances influencing choice of enteral feed for surgical babies in NICU Occasionally.2 Neocate LCP is an amino acid containing term formula that is very rarely required. 3 . but may be useful where partially hydrolysed formulas have failed. although it is a theoretical possibility in injured or shortened bowel. all the formulas recommended are supplemented with LCPs. short bowel and/or high stoma). Choice of enteral feed for surgical babies in NICU (Appendices 2 and 3) D10 Breast-feeding/EBM should be encouraged in all babies especially premature babies and babies with surgical problems. stool frequency and size) must be taken into account. a formula containing medium chain triglycerides (MCT) (such as Pepti-Junior) may be beneficial. in some abdominal surgical conditions. there is currently no suitable product in the UK so enriched versions of Aptamil Pepti 1 or Pepti-Junior provide the best option. This can be done by daily review of feeding strategy by the Attending Consultant Neonatologist and Consultant Paediatric Surgeon. In the occasional circumstances when protein intolerance becomes a feature of short bowel and high stomas. As the provision of long chain polyunsaturates (LCPs). Enteral feeding in specific surgical conditions PN should be considered early and used to avoid periods of suboptimal nutrition.1. feeding with breast milk may need to be temporarily suspended. the use of a minimal lactose formula containing glucose polymer (Pepti-Junior) may be necessary after review by Consultant Paediatric Surgeon and Attending Consultant Neonatologist. naturally present in breast milk. Breast milk and normal formulas contain long chain triglycerides which are dependent upon bile salt emulsification for absorption. The Neonatal Dietitian should be consulted.2 Aptamil Pepti 1 (13. However. It can also be enriched (16% solution) for infants born preterm – see section 3. This should be recorded in the surgical notes as cm resected and remaining and the approximate proportion or percentage remaining. hydration. Fat absorption Fat may be affected in some conditions (cholestatic jaundice. (see 3.8%) is a hydrolysed protein formula designed for infants born at term but can be modified for preterm infants to 15% to more closely meet increased requirements .see section 3. Parents should be consulted and mothers supported to maintain lactation by expressing and freezing breast milk for future use. Frequency of expression should not be reduced even though breast milk is not currently being fed to the baby or future supply may be affected.  Where possible an estimate of the amount of small intestine remaining should be documented as this will be used as a predictor of feed choice.1.
Pepti-Junior and Aptamil Pepti 1 are only available in powdered format requiring reconstitution with water.in babies where birthweight <2kg with <⅔ of small intestine up to stoma/anus: 15% Pepti-Junior . For infants with gastroschisis where insufficient maternal EBM is available.in babies where birthweight >2kg.6% Aptamil Pepti 1 (standard dilution) – as per manufacturer‟s instructions . However. colon will partially determine likely tolerance of feeds.1.8% Pepti-Junior This can only ever be a guide as the actual type of bowel remaining – jejunum.in babies where birthweight <2kg with ≥⅔ of small intestine up to stoma/anus: Nutriprem 1 . will be a combined decision between the Attending Consultant Paediatric Surgeon and Attending Consultant Neonatologist which will be assessed daily with clear guidance given. feeds can be commenced from the 7 post-operative day with EBM where at all possible.3) 3. Modifications to this guidance should only be made where change to clinical condition or tolerance occurs between the daily reviews. (Section 3. the choice of formula is suggested above. with <⅔ of small intestine up to stoma/anus: 12.Nottingham Neonatal Service – Clinical Guideline 3.1 Choice of feed (see Summary Algorithm Page 2) EBM is the milk of first choice When EBM is unavailable the following can be used as a guide: . in conservatively managed NEC (without surgery).2 Preparation of powdered infant formulas (PIF) When EBM is unavailable or there is insufficient supply.1 level scoop + 30ml water 16% Aptamil Pepti 1 gives an enriched nutritional profile for preterm infants – 1 level scoop + 25ml water Neonatal unit guidance is available for reconstituting feeds and must be followed carefully to ensure safe and accurate reconstitution. Antibiotics are needed for this 10-day period (Nottingham Neonatal Service Guideline C1). the baby will require 10 days nil by mouth (NBM) from operation (if undertaken) to allow recovery before a joint decision regarding commencing feeds is made between the Consultant Paediatric Surgeon and Attending Consultant Neonatologist.8% Pepti-Junior (standard dilution) as per manufacturer‟s instructions – 1 level scoop + 30ml water 15% Pepti-Junior gives an enriched nutritional profile for preterm infants – 1 level scoop + 25ml water 13.1 Enteral Feeding following NEC D10 In NEC requiring surgery. 4 . ileum. Starting feeds post-surgery or following medical management of NEC after surgical opinion.1. with ≥⅔ of small intestine up to stoma/anus: standard term formula . - These differences in the length of NBM recommended in NEC above relate to the presence or removal of diseased intestine which will come into contact with the milk. but there is a preference to avoid whole cow's milk protein.in babies where birthweight >2kg. 3. Feeds should be commenced with EBM where possible. commencing feeds depends on operative findings and clinical condition postsurgery:if there is no residual disease or no proximal disease between the stomach and the stoma and a good th post-operative recovery. or where there is residual disease and/or clinical evidence of ongoing NEC at operation. 12. Nutriprem 1 and standard term formulas are available in ready to feed (RTF) bottles. Aptamil Pepti 1 is the initial feed of choice.
For example:1) Under the standing order of “losses greater than 30ml/kg/day should be „replaced‟ with an equal volume of intravenous fluids”. Patients with “high stomas”. Urine potassium should be measured on the same urine sample.2. 5 . there is only a short length of bowel between mouth and stoma. Ideally. stoma output and serum and urine electrolytes. stoma losses should be less than 20ml/kg/day when on enteral feeds at 150ml/kg/day. Sodium supplements should not be discontinued solely on normal serum sodium if losses continue.1 Managing babies with jejunal/ high ileal stomas (<⅔ small intestine proximal to stoma) Babies with jejunal/ high ileal stomas are liable to high losses of fluid initially and should be carefully managed with the following principles: aim to support nutrition with PN and start gut priming start with a trial of 1ml/kg as 2 hourly bolus feeds with EBM if it is available if EBM is not available. 3. In both these circumstances. feed absorption is suboptimal and they are likely to need a prolonged period of partial enteral nutrition supported by PN. Commonly. A low urine sodium (<20 mmol/l) even with normal serum sodium.2 High volume stoma losses In babies where a stoma has been formed “high” in relation to the usual bowel length . If it is higher than the sodium level. this may be an instruction such as “losses greater than 30ml/kg/day should be „replaced‟ with an equal volume of IV fluids. 3. If potassium supplements are required due to low serum levels. Where infants are receiving PN an increase in nutrition would be achieved by replacing with the aqueous solution. For these babies with “high stomas” and those with short bowel following surgical resection. 3. IV fluids replacement would usually be made using 0.2 for details of making up. suggests the baby is trying to conserve sodium and implies that stoma Na losses are significant.2 Stomas D10 Babies may have stomas sited for a variety of reasons including congenital obstruction and NEC. the actual decision to „replace‟ stoma losses should consider the need in that individual infant so that intravenous „replacement‟ of small volumes does not occur. Stoma losses >50ml/kg/day are usually excessive. 2) A baby on full enteral feeds in a significant positive fluid balance is unlikely to need replacement.2. changes should be made daily based on the previous day‟s tolerance. then this is evidence of compensatory/secondary hyperaldosteronism. as well as sodium supplementation. consider starting 15% Pepti-Junior (for preterm infants) or 12.9% NaCl with 10mmol KCl in 500ml. D4).3 Intravenous “Replacement” Fluids „Replacement‟ of fluid losses should be considered in infants with high stoma losses and a guide will be suggested by the Consultant Paediatric Surgeon and Attending Consultant Neonatologist. This should be a consultant decision based on the nutritional needs with neonatal dietitian advice if available.4 Urinary Electrolyte Measurement Where stoma losses of 20ml/kg/day do occur. observing hydration. stoma losses of 35ml/kg/day would lead to an additional 5ml/kg/day intravenous fluid which is unlikely to be clinically indicated. Continuous enteral feeding may be considered in short bowel syndrome where bolus feeds aren‟t tolerated.1. sodium supplements should usually be started at 3mmol/kg/day or increased by approximately 50% if the infant is already receiving additional supplements. These should be given in divided doses.2. Detailed records should be transferred to a flow chart (Appendix 4). The Neonatal Dietitian will also advise as required. so called “low stomas”. they should be continued for a week after serum level returns to normal in order to allow intracellular levels to normalise. as the body is conserving sodium at the expense of losing potassium. urinary electrolytes should be measured weekly. weight.8% Pepti-Junior (for term infants). as this may improve tolerance of enteral feeds and growth . Such babies require careful reconsideration of the enteral feeding regimen with the Attending Consultant Neonatologist and Consultant Paediatric Surgeon. should usually be managed according to the standard enteral feeding guideline (Nottingham Neonatal Guidelines D3. Where feed intolerance is suspected or likely. Those infants with ≥ ⅔ of healthy small intestine between mouth and stoma. Enteral feeding should be slowly increased when tolerated.2. often have large volume stoma losses. 3. However. Sodium supplements are usually required where an infant has an ileostomy.Nottingham Neonatal Service – Clinical Guideline 3. See section 3.
or there is very little extra intestinal length to be gained. The surgical team should do at least the first three attempts before requesting that the NICU nursing staff take this on.  Loperamide binds to the opiate receptor in the gut wall. loperamide should not be required and. stenosis or skin excoriation). When it is indicated. Where stoma losses remain excessive on review. prolapse. However. dosage should be reviewed no more than twice per week. it is recommended that total daily dose of loperamide should usually be increased as below. The need for loperamide should be made as a joint decision between the Consultant Paediatric Surgeon and the Attending Consultant Neonatologist. The fluid replaced into the distal stoma must not be recorded as stoma loss on the fluid balance charts as this will risk “double counting” and the baby receiving unnecessary additional fluids. (500micrograms/kg/dose 4 times per day) Loperamide should be used with caution in severe hepatic impairment – discuss with Attending Consultant Neonatologist and Neonatal Pharmacist.Nottingham Neonatal Service – Clinical Guideline 3. As changes in loperamide dose take a little time to result in altered stool volumes. if there are significant losses with feeding following stoma closure. loperamide may be considered in order to inhibit intestinal secretion. 3. Following stoma closure where a good length of bowel remains. a decision for late closure will usually be made. reducing propulsive peristalsis and increasing intestinal transit time. as well as increasing tone of the anal sphincter. 3. reintroduction of loperamide may be considered by the Consultant Paediatric Surgeon and Attending Consultant Neonatologist. If the infant is growing well and there are no problems. retraction. 6 . preventing atrophy of the bowel and increased nutrient and electrolyte absorption thereby reducing need for PN which may reduce risk of cholestatic jaundice. DAILY Loperamide dose 400 micrograms/kg/day 1000 micrograms/kg/day 1600 micrograms/kg/day = = = QDS Loperamide dose 100 micrograms/kg/dose 250 micrograms/kg/dose 400 micrograms/kg/dose Allow 3-4days between increases for loperamide to have an effect The maximum dose of loperamide is unknown but for chronic diarrhoea in infants 1m-1y a total daily dose of 2mg/kg/day may occasionally be required (BNF for Children). sorbitol-free version manufactured as a special product in pharmacy) should be commenced at 400 micrograms/kg/day (100 micrograms/kg/dose 4 times a day). therefore. loperamide (1mg/ml as sugar-free.6 Loperamide As the feed volume increases in a baby with high volume stoma losses. 6] This practice will be requested by the surgeon if required and detailed guidance given. given 30 minutes before feeds where possible.2. it should be discontinued after stoma closure. Factors which are considered are whether there is a useful length of unused intestine and any existing problems related to the stoma (poor growth.2. electrolyte disturbances.2.5 Recycling stoma losses D10 There are case reports to suggest that collecting losses from a proximal stoma and repassing them into the distal mucous fistula is beneficial in terms of stimulating mucosal growth. [5.7 Stoma Closure All decisions to close a stoma early will be made by the Consultant Paediatric Surgeon and Attending Consultant Neonatologist.
babies whose birth weight was <2kg: 16% Aptamil Pepti 1 should be used. jejunal or ileal atresias PN should be considered for babies with intestinal atresias. 7 .  Therefore. hence the appearance and name. including Gaviscon Infant or Instant Carobel as a feed thickener should be considered. Once the baby is stable. If EBM is unavailable: .Nottingham Neonatal Service – Clinical Guideline 3. Breast milk is preferred as. most of the small intestine gets a precarious blood supply from the marginal vessels. see Section 3. the washouts are made easier. they may take some weeks to adapt and grow on full enteral feeds. with no defect in mesentry – normally no loss of intestinal length Type 3a: Defect in the mesentery. then an early stoma is the safest option. This will be agreed at surgical review . Once thriving at home. feeds should be started as 2 hourly bolus feeds. even in term infants. Early trophic feeds (1ml/kg. If they are unwell. there is a risk of NEC as bowel motility returns. 3.7 Hirschsprung’s disease If stable. may have lost intestinal length.3 Gastroschisis D10 In babies with gastroschisis. Once thriving at home Nutriprem 2 can usually be introduced. Many of these babies seem to tolerate standard formula milks poorly.1 for the choice of milk. The intestines wrap themselves around the vessels. As babies with Type 3a. especially with high jejunal or duodenal atresias. 2hourly) can usually be introduced even if gastric aspirates are moderately high. The superior mesenteric vessels are absent. Medical anti-reflux treatment. Thus. PN is usually needed.5 Oesophageal Atresia without distal TOF Babies born with oesophageal atresia without distal TOF will usually require a gastrostomy to be formed.6 Duodenal. or not decompressing with washouts. EBM is the milk of first choice and breast-feeding should be strongly encouraged antenatally and actively supported postnatally. PN is rarely needed. additionally. enteral feeds can be commenced. these babies are managed with rectal washouts and a single operation at several weeks of age. Type 3b: “Apple peel”. 3. a standard formula can usually be introduced. This will be agreed at surgical review with dietetic input. This represents loss of intestine.babies whose birth weight was >2kg. 3b & 4 atresias. Gastro-oesophageal reflux is very common once these infants reach full feeds.6% Aptamil Pepti 1 should be used. Special feeds are not required.4 Oesophageal Atresia with distal TOF Babies born with oesophageal atresia with distal TOF will usually feed enterally early via transanastomotic tube (TAT) and prolonged PN is seldom needed. If less than 2/3 of small intestinal length is available for absorption and breast milk is not available. as well as the intestine. 13. These are categorised as:Type 1: Membrane across the lumen – no loss of intestinal length Type 2: Proximal and distal segments separated by a cord. Type 4: Multiple atresias. PN is rarely required for these infants born near term providing full enteral feeds can be reached in a timely fashion. 3. 3. As these infants have a very small stomach. Continuous feeds are only very rarely necessary.
Advice should be sought from the Consultant Paediatric Surgeon and Attending Consultant Neonatologist. Assessing Feed Tolerance Feed tolerance is assessed using a number of factors including vomiting.„replace‟ half of the aspirate itself via ng or og tube and discard the rest if aspirate ≥ whole feed volume since previous aspirate – do not „replace‟ the aspirate. quantity and type of aspirate. stop feeding until senior medical and surgical review This should only ever be a guide and decisions. weight gain and growth.2 Stools All stools must be recorded on daily nursing charts and details of consistency. For many infants. standard recording is adequate for decisions on progressing feeds. 4. Detailed recording of fluid input and losses alongside actual nutritional intake will help with meaningful interpretation. (Nottingham Neonatal GuidelineD17) Careful interpretation of weight gain is necessary. 4. the medication should be stopped. Guidance will be given daily on proportion of aspirate to be replaced and this may differ from the advice in Guideline D3 due to the surgical condition and it‟s potentially altered anatomy. thus. See Section 3. interfering with absorption. particularly those on the borderline of this guidance. growth should be recorded and plotted weekly on a UK-WHO Neonatal & Infant Close Monitoring Chart. These will be summarised in the daily medical review and used as a basis for decision making for the following days feed progression. particularly where large fluctuations are more likely explained by fluid changes. However. as for all infants on NICU.1 Aspirates High volume aspirates are common following gastrointestinal surgery and feeds will not be started until these have settled. 8 .2. 4. the degree of hypersecretion is proportional to the degree of bowel resected and may contribute to malabsorption by inactivating pancreatic enzymes.3 Weight gain and growth Daily weight gain is only necessary for detailed fluid management and should not be continued and used as a basis for weight gain and growth. 4.8 Meconium ileus D10 These babies require consultation with the CF team for consideration of pancreatic supplementation (Nottingham Neonatal Service Guideline F4). though early trophic feeding is beneficial. Where feed tolerance is poor and variable such as found with high stomas.2. as with jejunal and high ileal stomas.1 Stomas Where a stoma is present consideration should be given to use of the detailed flow chart (Appendix 4) if feed intolerance is likely. The Neonatal Dietitian will advise as necessary. If present. If no improvement during the trial of treatment. Detailed nursing and medical recording is essential for informed decision making. must be made according to the individual baby‟s clinical condition. Gastric acid hypersecretion is common in patients with short bowel syndrome. Treatment with an H2 blocker (ranitidine) or a proton pump inhibitor (omeprazole) should be considered where stoma output is watery and losses high (>30% of intake) and if the gastric pH is <3.Nottingham Neonatal Service – Clinical Guideline 3. The volume of aspirate that is relevant will be dependent on the volume of feed given so instructions will be given to stop or reduce feeds or continue and „replace‟ the aspirate itself according to the following guide: if aspirate <½ feed volume since last aspirate – „replace‟ the aspirate itself via ng or og tube and continue feeding if aspirate ≥ ½ feed volume but < whole feed volume . a summary flow chart of these parameters can be useful and should be completed as part of the daily medical review where this is requested by the medical and surgical team (Appendix 4). colour and volume stated. In such cases. 4. a trial of ranitidine initially (followed by a two week trial of omeprazole if there is no improvement) should be considered. volume and frequency of stool or stoma loss. consistency.1 for further details.
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What is the evidence on the practice of mucous fistula refeeding in neonates with short bowel syndrome? J Pediatr Gastroenterol Nut. Evolving concepts and improving prospects for neonates with short bowel syndrome.. 267 7.. In Vitro Cow's Milk Protein-Specific Inflammatory and Regulatory Cytokine Responses in Preterm Infants With Necrotizing Enterocolitis and Sepsis. H.. Hydrolyzed v nonhydrolyzed protein in short bowel syndrome in children.E. Journal of Pediatrics. 75-80. REFERENCES 1..
Start feeds in first 24 hours and review at 24 hours Delay starting feeds Patient condition >30 weeks and well 23-30 weeks and well If on Inotropes (any gestation) <33 weeks and AEDF Review abdomen at 24 hours of age. 10 . then start step 1 feeds and review regularly IUGR Start and review abdomen at 24 hours and thereafter AEDF . at step 2 or 3.intrauterine growth retardation (< 10 centile for weight) Advancing Feeds – low risk – „green regimen‟ Step 1 2 3 Volume 2 hourly Increment End of day rate 1 ml/kg 24 hours 12 ml/kg 2 ml/kg 12 hours 36 ml/kg 3 ml/kg 12 hours 4 ml/kg 8 hours 72 ml/kg 5 ml/kg 8 hours 6 ml/kg 8 hours 7 ml/kg 6 hours 120 ml/kg 8 ml/kg 6 hours 9 ml/kg 6 hours 10 ml/kg 6 hours At Attending Consultant Neonatologist‟s discretion 4 5 Advancing feeds . 1-2ml/kg of gastric residual volume is not important and should simply be replaced. Some babies will tolerate full feeds immediately and this can be tried in those 32/40 and above.absent end-diastolic flow on antenatal scan th IUGR .Nottingham Neonatal Service – Clinical Guideline D10 APPENDIX 1: Current Approach to At Risk Premature Non-Surgical Babies (Guideline D3) Starting feeds – 2 hourly bolus feeds are preferred regimen First feed advice Start 2 hourly bolus feeds from birth.high risk – „yellow regimen‟ Step 1 2 3 4 5 6 7 8 Volume 2 hourly 1 ml/kg 2 ml/kg 3 ml/kg 4 ml/kg 5 ml/kg Increment 24 hours 12 hours 12 hours 12 hours 12 hours End of day rate 12 ml/kg 36 ml/kg 60 ml/kg (an increase of 24ml/kg /day) (an increase of 24ml/kg /day) 6 ml/kg 12 hours 84 ml/kg (an increase of 24ml/kg /day) 7 ml/kg 12 hours 8 ml/kg 12 hours 108 ml/kg (an increase of 24ml/kg /day) 9 ml/kg 12 hours 10 ml/kg 12 hours 132 ml/kg (an increase of 24ml/kg /day) 11 ml/kg 12 hours 12 ml/kg 12 hours 156 ml/kg (an increase of 24ml/kg /day) 13 ml/kg 12 hours At Attending Consultant Neonatologist‟s discretion Feed Intolerance In at risk groups. Where the gastric residual at higher volumes is equivalent to 100% of the bolus. reassess feed tolerance after the first 24 hours and decide whether continued „gut priming‟ or advancing feeds should be undertaken according to whether infant is low or high risk. Bilious aspirates or significant abdominal distension requires cessation of feeds and a clinical review. then stop advancing the feeds or stop the feeds and organise a clinical review.
Lactose: Pepti-Junior is clinically lactose free. 12]. there is contradictory published evidence and it is likely that whole protein may be as well utilised [14. 15]. The further a protein is hydrolysed. Aptamil Pepti 1. so lactose is usually replaced with glucose polymer to help reduce osmolality of the final product. Although MCT is said to be more easily absorbed. 11 . Therefore. Whilst it has been postulated that cow‟s milk protein may have a role in the development of NEC and sepsis  and that dietary antigen sensitisation may have a role in promoting or sustaining inflammation in both . 3. Breast milk confers significant advantages. [11. evidence in support of this is awaited. the greater the osmotic effect. Pepti-Junior has 50% of fat as MCT. especially LCPs. LCPs: long chain polyunsaturated fats are thought to be essential for normal brain and retinal development in LBW infants who do not have the maturity of enzyme function to produce them from essential fatty acids. rather than peptides) in reducing duration of parenteral nutrition (PN) . semi-elemental formulas may also help in decreasing peak bilirubin concentration. None of these formulas are available as ready to feed preparations so carry the risk of variable composition due to reconstitution from powder. whether this is intentional or just because semielemental/elemental feeds nearly always contain a reduction in lactose is unknown. this still does not meet the specific nutritional needs of preterm infants. breast milk would still be our first feed of choice. with chain length of peptides decreasing from BMF>Aptamil Pepti 1>PeptiJunior and Neocate LCP containing protein as amino acids – the most basic form of protein. 5. A source of MCT may be beneficial in babies with conjugated jaundice which is often present in some infants requiring gut surgery due to need for long term PN. There is also a suggestion that amino acids may be of benefit in SBS as they eliminated the need for PN in a small number of children with SBS in whom peptide formulas had been unsuccessful .  and are known to be major trophic factors in short bowel. The degree of hydrolysis is different. There is a retrospective review in neonates with SBS which supports the use of EBM or fully elemental formulas (amino acids. infants growing well on breast milk or standard formulas should not be changed routinely. Lactase activity increases 5 fold throughout the last trimester. in promoting mucosal adaptation.  They are naturally present in EBM and added to Nutriprem 1 & 2. Although low lactose feeds appear to have been used automatically in short bowel syndrome (SBS) in published studies. Hydrolysed protein: Whole proteins are found in EBM.Nottingham Neonatal Service – Clinical Guideline D10 APPENDIX 2: Issues to consider when deciding on a feed 1. Aptamil Pepti 1 and Pepti-Junior. although transient lactose intolerance may occur following any gut trauma and EBM has all the CHO as lactose. which are unlikely to be tolerated in SBS. However. This may be critical to infants with malabsorption. Pepti-Junior and Neocate. 4. Hydrolysed protein as peptides are found in breast milk fortifier (BMF). would optimise the appropriate gut micro flora. However. 2. so care should be taken when making up feeds to ensure greatest accuracy. Although a higher concentration can be used. animal studies suggest that it is probably less beneficial than LCT. Nutritional profile: Currently available hydrolysed protein/amino acid based formulas in the UK do not meet the nutritional requirements of preterm infants even if fed at large volumes. Nutriprem 1 & 2. term and preterm formulas contain lactose. though is the best option at present. if breast milk is not tolerated. Aptamil Pepti 1. is increased by early feeding and is thought to be inducible by the presence of lactose. whereas EBM. MCT: EBM and Nutriprem 1 are not sources of MCT.  The presence of lactose if tolerated. the presence of undigested CHO in the bowel could in theory predispose to necrotising enterocolitis. However. Although it may seem logical that the further protein is hydrolysed the more readily it will be absorbed.
1 1. # Figures for osmolality are as quoted in company literature and can only ever be a guide.8 <2% 66 50 28 210 77 59 32 ~ 240 8. Those for concentrated solutions are an estimate based on figures given for standard dilution.9 Pepti-Junior 12.0 Fortified EBM is 1 sachet of Nutriprem breast milk fortifier to 50ml EBM Term/Mature Preterm EBM .8% 1.Addition of BMF should be done just prior to feeding where possible to reduce time for amylase in EBM to breakdown lactose leading to increased osmolality.5 4.2 Yes 7.2 72% 86 101 53 450 Nutriprem 1 Aptamil Pepti 1 13.2 Yes 10.1 *peptides 3.8 amino acids 3.4 100% 70 35 15 284 Fortified EBM (term/mature preterm) 2. $ Peptides– from fortifier * Peptides– degree of hydrolysis variable with longer chain peptides in BMF > Aptamil Pepti 1 > Pepti Junior 12 .9 8% Yes 8.3 (estimate) Whole protein 4.6 ~16% 1.Nottingham Neonatal Service – Clinical Guideline D10 APPENDIX 3: Table of nutritional comparison of feeds that may be considered in surgical patients Per 100ml Feed Unfortified EBM (term/mature preterm) 1.3 4.6 Whole protein 3.8 ~15% 2.0 Whole protein 4.5 3% Yes 7.4 5% MCT Yes 7.4 78% 75 87 47 340 Neocate LCP Nutriprem 2 Protein g Degree of Hydrolysis Fat g % Fat as MCT LCP‟s CHO g % Lactose Energy kcal Ca mg P mg Osmolality # mosm/kg *peptides 3.2 Nil 67 66 47 340 2.1 41% 67 47 26 280 79 55 30 ~ 320 8.6% 2.5 (estimate) Whole protein $ + peptides 4.4 56% 80 94 62 375 1.0 9% Yes 7.1 50% MCT Yes 6.
loperamide. decisions on fluid replacement. This table should be completed daily by the doctor performing the daily review to allow informed decisions to be made on the Consultant Ward Round N O T E S 13 . Milk. etc should be made based on the previous day‟s tolerance using table below. of vomits IV replacement* (ml/kg/d) Serum Na (mmol/l) Urine Na (mmol/l) PN . feed advancement.Nottingham Neonatal Service – Clinical Guideline D10 Patient Name: Date of Birth: Hospital Number: Appendix 4 14 Day Summary Chart for Feed Tolerance in Infants with Surgical Stomas NHS Number: (attach label) Date Weight (kg) Total fluids (ml/kg/d) P N E N T E R A L O U T P U T Na S T A T U S PN (ml/kg/d) Type of milk Volume & Frequency Amount (ml/kg/d) Stoma output (ml/kg/d) No. Where infants are receiving PN an increase in nutrition would be achieved by replacing with the aqueous solution. Changes should not necessarily be made daily as the infant may need longer than this to adjust to a change.Na intake (mmol/kg/d) Na Supp (mmol/kg/d) Total Na intake (mmol/kg/d) 1. This should be a consultant decision based on nutritional needs with neonatal dietitian advice if available. 2. need for Na supplements. IV replacement will generally be with 0.9% NaCl with 10mmol KCl in 500ml. preferably EBM should be increased according to individual tolerance using rates in the NICU Yellow Regimen (Appendix 1) as a maximum Where feed intolerance is suspected or likely.
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