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FLUID, ELECTROLYTE & NUTIRTION

MANAGEMENT
IN THE NEONATAL ICU

o Standard IV Fluid Orders


o Guidelines for Initiation and Advancement of
Parenteral Nutrition in the NICU
o Starter TPN Information
o TPN Macro/Micronutrient Needs
o Lab Monitoring Guidelines for Parenteral Nutrition
o Enteral Feeding Guidelines
o TPN Weaning, Enteral Nutrition Initiation & Advancement
o Milk/formula Feeding Options
o Milk & Formula Selection
o Lab Monitoring Guidelines for Enteral Nutrition
o Assessing Growth in the NICU
o Nutrition Therapies for Common NICU Disorders
o Vitamin and Fe Supplementation Guidelines
o References
STANDARD FLUID ORDERS
(all fluids should be ordered daily)

UAC fluids: NS with 0.25 units of heparin/mL @ 0.8 ml/hr (minimum rate)
*If an infant is hypernatremic, consider changing to D5W with 0.25 units
heparin/mL @ 0.8 mL/hr. (Note: it is difficult to obtain accurate glucose
measurements from UAC line if D5W infusing).

Peripheral arterial line fluids: NS with 1 unit heparin/mL and 12 mg


Papaverine/100 ml at 0.8 mL/hr.

On admission use starter TPN if infant will be NPO more than 24 hours.

Starter TPN contains D10W with 3 grams of amino acids/kg and 0.54
mEq/kg of calcium.
Run the starter TPN at the patients weight in kg x 1.5
o For example: 500 grams = 0.75 ml/hr
o Provides a GIR of 2.5 mg/kg/min
Piggyback D10W or D12.5W to make up the remainder of the needed
fluids.
On day of life #2, when TPN is being ordered, remember to
discontinue the starter TPN and the piggyback fluids.

Standard pre-op and post-op IVF for infants with normal hydration and
electrolyte balance: D10W NS @ ~100-120 ml/kg/day.

If TPN/maintenance fluids will be running at a rate >2 mL/hr, omit the heparin.

As a general rule, for the first week of life use the infants birth weight for all
fluid calculations. On day of life #8 begin using the infants daily weight.
During rounds and sign-outs, specify what weight is being used for calculations.
GUIDELINES FOR INITIATION AND ADVANCEMENT OF
PARENTERAL NUTRITION IN THE NICU

Introduction:
Early aggressive nutrition in premature infants has been shown to improve
growth outcomes, neurodevelopment and resistance to infection. Timely
intervention with TPN begins with the provision of glucose as soon as
possible after birth, amino acids within 12 hours and intravenous lipids
within 24 hours.

Goal:
To minimize the interruption of nutrient delivery and prevent catabolism,
especially in premature infants with limited nutritional reserves.

Aggressive use of amino acids to prevent metabolic shock that would


trigger endogenous glucose production and catabolism. Amino acids
stimulate insulin secretion to improve glucose tolerance.

To attempt to achieve intrauterine growth and nutrient accretion rates in


preterm infants.

To optimize nutritional status to help both term and preterm infants resist
the effects of trauma and disease and improve overall morbidity rates and
responses to medical and surgical therapy.

To define minimal and maximal acceptable intakes.

This document and the following best practices are based on a review of current literature,
recommended evidence-based better practices and recently revised advisable intakes on
protein and energy for pre-term and term infants. Please see a list of reviews, studies and
references at the end of the document to support the following recommendations.
STARTER TPN
Rationale: Newborn infants who do not receive protein have negative nitrogen
balance and lose up to 1% of their protein stores daily. Catabolism is a
particular problem of the very low birth weight infant who may have minimal
nutritional reserves. Additionally, recent studies have indicated that when there
is a shortage of amino acids, insulin levels fall, resulting in hyperglycemia and
hyperkalemia. Parenteral intakes of 1.5 grams/kg/day of protein appear to be
sufficient to prevent catabolism in newborn infants, and to maintain normal
serum glucose and potassium levels.

Target Patient:

Newly admitted patients <1500 grams


Newly admitted patients 1500-1800 grams who are NPO for 24 hours
Term infants NPO >1-2 days or complex surgical patients.

Recipe:
Central & Peripheral Lines: D10W (Dextrose 10g/100mL) + 8.25 g/100mL
Neonatal amino acids + 1.5 mEq/100mL Calcium Gluconate

Procedure:
Run @ 1.5 mL/kg/hour
For example: Birth weight of 500 grams = run at 0.75 ml/hr
This volume provides 36 ml/kg/day of fluid, a GIR of 2.5 mg/kg/min,
3 g/kg/day of protein and 0.54 mEq/kg/day calcium

Order Writing for Starter TPN:


On admission, 7 days a week, 24 hours per day for target patients
A TPN order is not needed
Check glucose 4 hours after starting
Another maintenance fluid will always need to be ordered to maintain an
adequate glucose infusion rate and fluid intake
Start regular TPN the next scheduled interval and order 3 3.5 grams of
amino acids per kg per day (2.5-3 g/kg/day for term infants).
Do not discontinue the starter TPN if the baby is hyperglycemic or
hyperkalemic as it may make the situation worse. Consider changing the
piggyback maintenance fluids to decrease the dextrose delivery.
You cannot adjust the contents of Starter TPN
TPN Macronutrients:
Initiation and Advancement Guidelines

Initiation Advancement Goal


Dextrose (GIR) 4 6 mg/kg/min 1 2 mg/kg/min 12 mg/kg/min c
Premature Infant

< 1000 grams


< 32 weeks,

Amino Acids 3 3.5 g/kg/d e 0.5 - 1g/kg/d 4 g/kg/d


Lipids 1 g/kg/d 0.5 - 1g/kg/d 3-3.5 g/kg/d d
a
Non-Protein
40 -50 kcals/kg/d b
60 70 kcals/kg/d 85 95 kcals/kg/d
Calories
Total Calories 50 60 kcals/kg/d 70 80 kcals/kg/d 90-100 kcals/kg/d
Dextrose 4 6 mg/kg/min 1 2 mg/kg/min 12 mg/kg/min c
> < 32 36 weeks,
Premature Infant

> 1000 grams

Amino Acids 3 3.5 g/kg/d e 3.5 g/kg/d


DOL: 0

Lipids 1 g/kg/d 0.5 - 1g/kg/d 3 g/kg/d d


a
Non-Protein
40 -50 kcals/kg/d b
60 70 kcals/kg/d 85 95 kcals/kg/d
Calories
Total Calories 50 60 kcals/kg/d 70 80 kcals/kg/d 90-100 kcals/kg/d
Dextrose 6 8 mg/kg/min 2 3 mg/kg/min 12 mg/kg/min c
Amino Acids 2 3 g/kg/d e 0.5 - 1g/kg/d 2.5 3 g/kg/d
37 weeks
Term Infant,

Lipids 2 g/kg/d 0.5 - 1g/kg/d 2.5 3 g/kg/d d


a
Non-Protein
40 50 kcals/kg/d b
50 60 kcals/kg/d 70 80 kcals/kg/d
Calories
Total Calories 50 60 kcals/kg/d 60 70 kcals/kg/d 80 90 kcals/kg/d

a
Goal is to supply ~25 calories per gram of protein. Use a combination of glucose and
lipid as the energy source. Non-protein calories are used to calculate energy
needs in the NICU. Feeding summaries do not include protein calories from TPN.
b
Minimum calorie and amino acid intake for zero balance (i.e. not catabolic) can be
achieved with 40 - 50 kcals/kg/day (basal metabolic energy needs) and 1.5 g/kg/d
protein. Note: a GIR of 6 - 8 mg/kg/min with 1 g/kg lipids will provide ~40 - 50 non-
protein kcal/k/d in ELBW infants.
c
Do not exceed the maximal oxidative glucose capacity of 12.5 mg/kg/min or 18 g/kg/d
of carbohydrate (for cholestatic jaundice keep around 15 g/kg/d of carbohydrate).
Usual maximum concentration: 12.5% peripheral route, 25% central route.
d
Fluid restricted (150 ml/kg/d), growth compromised patients limited by peripheral
access may require lipid infusion as high as 4 g/kg/d. However, this should not
routinely be the end goal of intravenous lipids.
*To prevent essential fatty acid deficiency, provide a minimum of 0.5 g/kg/d
of intravenous lipids.
e
There is no evidence that gradually increasing amino acid intake improves tolerance
to amino acids. Order 3 3.5 g/kg/d amino acids with the first regular TPN
following starter TPN.
f
Use starter TPN for term infants made NPO for >1-2 days or complex surgical patients
TPN Guidelines: Micronutrients, etc.
Order TPN daily by 14:00 to ensure delivery by 20:00
Determine total daily fluids and subtract out other IV fluids, supplemental enteral nutrition and IV fat
emulsion volume to determine TPN fluid volume.
Cycled TPN should be tapered unless a dextrose solution is running while the TPN is off. Consider checking
a serum glucose concentration 1 hour after the TPN is off to ensure cycled TPN rate is tolerated.

Macronutrients (Protein, Dextrose and Lipids)


Dextrose: Maximum concentration peripherally = 12%; Central 25%
Maintain glucose infusion rate (GIR) < 12 mg/kg/min for optimal glucose utilization

GIR (mg/kg/min) = (% dextrose X rate in mL/hr 6 (wt in kg))

Protein: Begin with 3 g/kg/day and advance to goal of 3.5-4 g/kg/day


Never begin with < 3g/kg/day since this is the amount delivered in Starter TPN
Lipids: 0.5-1 g/kg/day is needed to prevent essential fatty acid deficiency (can develop within 72 hours after
birth)
Advance lipids by 0.5-1 g/kg/day to maximum of 3-3.5 g/kg/day
Consider serum triglyceride level if infused greater than 0.15 g/kg/hr (0.75 mL/kg/hr), or if the patient
is septic
Consider decreasing lipids if serum triglyceride is greater than 200 mg/dL or Direct Bili is > 2 mg/dL

Calcium & Phosphorus

Ideal ratio of Calcium (mEq): Phosphorus (mMol) is 2-2.5:1 for best absorption of both nutrients
Mineral wasting can be caused by a Ca:Phos ratio less than 1.6 mEq:1 mmol
Always attempt to maximize these nutrients for premature infants if able

Goal: 3 mEq/kg/day Calcium and 1.5 mmol/kg/day Phosphorus (MAX= 4mEq/kg Calcium & 2
mmol/kg Phos)
If unable to reach goals due to precipitation, consider the addition of cysteine to the TPN solution to
increase the solubility
Phosphorus is given as NaPhos or KPhos- you will not be able to meet phosphorus goal if there are insufficient amounts of these nutrients
in the TPN

Electrolytes, Vitamins, Minerals & Trace Elements

Sodium/Potassium: Adjust amounts in TPN based on lab values


Magnesium: Consider exogenous maternal tocolytic as a source in the initial days of TPN
Magnesium depletion may precipitate refractory hypokalemia and hypocalcemia
Standard Multivitamins: 2 mL/kg/day (maximum dose of 5 mL/day) of Pediatric MVI
Pediatric MVI contains 40 mcg/mL of Vitamin K
If Vitamin K is ordered, it will be in addition to the standard multivitamin dose

Standard Trace Elements (in 0.2mL/kg):


Pediatric < 3 kg 3-6 kg
20 mcg/kg Copper 20 mcg/kg Copper 20 mcg/kg Copper
6 mcg/kg 1 mcg/kg 1 mcg/kg Manganese
Manganese Manganese
0.2 mcg/kg 0.2 mcg/kg 0.2 mcg/kg Chromium
Chromium Chromium
100 mcg/kg Zinc 400 mcg/kg Zinc 250 mcg/kg Zinc

Omit the manganese and chromium in TPN solutions if an infant has severe hepatic disease (e.g. Direct Bili >2mg/dL) or is
on long-term TPN Continue to provide standard copper for these patients and monitor blood concentrations if there is a
concern for toxicity
Consider a decreased dose or elimination of chromium and selenium (see below) with severe renal disease
Consider extra Zinc if increased ostomy output, diarrhea or significant NG suction

Other Additives:
Cysteine: If unable to meet calcium and phosphorus goals due to precipitation in the TPN,
consider adding 30 mg of . cysteine per gram of protein in the TPN. This reduces the
pH and increases the solubility of calcium/phos.
Monitor acid/base balance if added.
Carnitine: For optimal lipid utilization, consider adding 5-10 mg/kg/day in patients on TPN greater
than 2-4 weeks.
Do not add until lipids are initiated. Discontinue when lipids are not given.
Iron Dextran: Only consider in patients greater than 2 months of age on chronic TPN and unable to provide
enteral iron

Selenium: Consider in patients maintained on TPN for 1 month or with severe GI issues. Do not
give selenium if N
creatinine level is >1. Normal dose = 1.5-4.5 mcg/kg/day; max 30 mcg/day.

LAB MONITORING GUIDELINES FOR PARENTERAL


NUTRITION IN THE NICU

>1 week of TPN


< 1 week of TPN
and clinically stable T
Electrolytes** Daily 2x/week h
Ca, Mg, Phos 2x/week 1x/week i
Glucose Daily Every other day s
BUN/Cr Daily-2x/week 1-2x/week
Bilirubin (T/D) 2x/week 1x/week
Triglycerides As lipids advance 1x/week
Prealbumin ---- Every other week if unable to maximize protein
in TPN
Alk Phos ---- Every other week if inadequate calcium/phos in
TPN
AST/ALT ---- 1x/month
assumes that TPN remains relatively unchanged the first week. With changes, some
labs may need to be checked more frequently. Labs may also need to be checked
more frequently for ELBW or clinically unstable infants.

Serum electrolytes should be monitored at least daily on infants whose IV fluid


intake exceeds 40% of total intake.

Magnesium may need to be checked in high risk infants with chronic gastrointestinal
losses and infants born to mothers on high dose Magnesium Sulfate to suppress
labor.

Rationale for monitoring patient groups on parenteral nutrition:


Electrolyte abnormalities are the most common metabolic complication in infants
on IV fluids.
Premature infants are at risk for hyper and hyponatremia when establishing
baseline fluid and electrolyte needs.
Indirect bilirubin is used to determine need for phototherapy and/or exchange
transfusions.
Hyperkalemia is frequent in VLBW infants.
BUN and creatinine help to evaluate renal function, hydration and protein status.
Micropreemies (birth weights <700 grams) and IUGR infants are at increased risk
for altered electrolytes.
Infants receiving parenteral nutrition for >2 weeks are at risk for cholestatic
jaundice.
Infants receiving parenteral nutrition for >2 weeks are at risk for developing
metabolic bone disease.

ENTERAL NUTRITION GUIDELINES


Enteral nutrition is the preferred method of nutrient delivery for all infants in the NICU.
The goal is to initiate enteral feeds within a few days of birth. These feeds, known as
trophic feeds or minimal enteral nutrition, will continue for a few days before advancing
to aid in GI priming and help avoid feeding intolerance and necrotizing enterocolitis. For
premature infants, hemodynamic instability often times delays these feeds, and
parenteral nutrition must be initiated first and continued as a supplement until full
enteral feedings can be tolerated. *See the following page for TPN weaning and enteral nutrition initiation and advancement guidelines

The majority of nutrient storage occurs in the third trimester, especially fat and
glycogen stores, iron reserves and calcium and phosphorus deposits. The goal of
enteral nutrition in the NICU is to attempt to achieve nutrient accretion rates similar to
those infants would receive in utero.

While breast milk is the preferred feeding for all infants in the NICU, it lacks sufficient
amounts of vital nutrients that premature infants need for adequate growth and
development. Human milk fortifier (HMF) is added to breast milk to increase the overall
energy, protein, calcium, phosphorus and electrolyte content. Premature formulas are
also available for premature infants when breast milk is not available and contains
similar nutrient profiles to that of fortified breast milk.

Contraindications to starting enteral feeds:


o Any condition associated with decreased gut blood flow
Asphyxia, hypoxemia, hypotension, concomitant use of indomethacin/ibuprofen
o Diastolic intestinal blood flow steal secondary to a PDA
o Sepsis and/or significant clinical instability
o High pressor support

Benefits of Trophic Feeds:


o Stimulates GI tract, promotes GI maturation and improves GI motility
o Reduces intestinal permeability
o Faster transition to full enteral feeds (less TPN)
o Improved mineral absorption and glucose tolerance

Route:
o NG or OG, usually through a soft, indwelling tube.
o Breast/bottle attempts may begin once the infant is showing active feeding
cues, which develop around 33-34 weeks.

Enteral Nutrient Requirements

Preterm Term
Energy 120-130 100-110
(kcal/kg/day)
Protein (g/kg/day) 3.5-4.5 2-3
Calcium 100-220 mg/kg/day 210 mg/day
Phosphorus 60-140 mg/kg/day 100 mg/day
None needed if iron-containing
Iron (mg/kg/day) 2-4 solids are introduced at 4-6 months
of age

TPN Weaning Schedule


For VLBW Infants

Enteral Feeding
Volume NPO 20 40 60 80 100 120 140
(mL/kg/day) ** **
Concentration of 20/2
Breast Milk/Formula 20 20 20 20/24 24 24
4
(kcal/oz)

TPN GIR* (mg/kg/min) 6-12 6-12 6-12 6-10 6-8 6-8 TPN is typically D/Cd
once infants are @
TPN Protein (g/kg) 3.5-4 3.5 3.5 3 2.5 2.5/2 120 ml/kg/day. Use
IVFs to meet fluid
TPN Lipids (g/kg) 3-3.5 3 3 2.5 2 1.5 needs.

TPN Calcium/Phos 3/1. 2.5/1. Do not give Starter


3/1.5 3/1.5 2/1 2/1 TPN if feeds are
(mEq/mmol) 5 3 fortified- this leads to
90- 50/4 excessive protein
TPN Total kcals/kg/day 90-100 70 65 40/25
100 0 intake.

*GIR will vary based on glucose levels. The GIR should be adjusted as needed to
meet overall energy goals of 90-100 kcal/kg/day (TPN only) & 100-110 kcal/kg/day
(TPN + enteral feeds)

**Fortify feeds to 24 kcal/oz. once the infant is tolerating 80-100 ml/kg/day


enterally

Enteral Nutrition Feeding Initiation & Advancement


Initiation Rate
Advanceme
Birth (ml/kg/day) Goal Volume
Frequency nt Rate* Type of Feeding
Weight (g) *Continue for (ml/kg/day)
(mL/kg/day)
3-5 days
Q2H or
<750 10-20 20 150 Breast milk**
less
751-1250 20 Q2H 20 150 Breast Milk**
1251-
20-30 Q3H 20-40 150 Breast Milk**
1500
MBM or
1501-
20-40 Q3H 20-40 150 Preterm
2000
Formula
MBM or
2001- 30-50 or ad Transitional
Q3H 30-50 150-180
2500 lib with cues formula
(Neosure/Enfacare)
Q3H if
50 or ad lib MBM or Term
>2500 schedule 50 180
with cues Formula
d
*Advancement rates will vary based on tolerance.
** Breast milk, either Mothers own or donor milk (with consent), should be the
first feeding for all infants born <1500 grams. Preterm formula would only be
given to these infants if the mother refuses to provide her own milk and does
not consent to the use of donor milk.
MILK/FORMULA OPTIONS IN THE NICU

Breast milk should be the first feeding for all infants in the NICU,
unless contraindicated due to medication use or infections.
Contraindiations to using breast milk:
o Infants with galactosemia or some inborn errors of protein metabolism
o Mothers with herpes simplex lesions on the breast; with active, untreated
tuberculosis, or who are HIV-positive
o Mothers receiving radioactive isotopes, chemotherapeutic agents, and certain
medications
o Mothers using drugs of abuse

Donor Breast Milk


o Donor breast milk (DBM) is available for all infants born <1500 grams and <34
weeks in our NICU. The goal is to avoid the use of formula in these infants. DBM
allows us to start enteric feeds as soon as the infant is medically ready, even if
the mothers milk has not come in. It can also be used to supplement feeds if a
mother has a low milk supply.
o DBM is continued until the infant reaches 34 weeks and 1500 grams. At this time,
the infant would transition to a premature formula.
o Consent must be obtained before administering DBM.

Human Milk Fortifiers: Used to fortify breast milk for infants born <2kg & <35weeks
Similac HMF & Enfamil HMF (contain bovine proteins)
Prolacta
o This is the only human milk-based HMF. Infants with a birth weight <1250 grams
qualify for the use of Prolacta only after 2 failed attempts at the use of powdered
HMF. Never order Prolacta without a discussion with the MD and dietitian.
Premature Formula: For infants born <2kg & <35 weeks if the mother does not provide
her own milk or does not consent to the use of donor milk if the infant is <1500g and/or <34
weeks
Similac Special Care (SCF): 20 kcal/oz, 24 kcal/oz. High Protein & 30 kcal/oz.
Enfamil Premature Formula: 24 kcal/oz.
Transitional Formula: Used at discharge or for late-preterm infants
Neosure & Enfacare
These formulas have a nutrient profile that is between premature formula and term
formula. When made as directed on the can, it will make 22 kcal/oz. formula and provide
higher amounts of protein, calcium and phosphorus.

Term Formula: For infants >36weeks and >2500g when breast milk is not available
Similac: Advance or Similac Sensitive (lactose-free)
o 24 kcal/oz. Similac Advance is available for term, hypoglycemic infants
Enfamil Premium
Specialized Formula: For infants with severe GI issues and/or allergies
Alimentum: semi-elemental formula used for cows milk protein intolerance
Neocate/Elecare: Elemental formulas with completely hydrolyzed proteins. This
formula should only be used as a last resort if an infant is unable to tolerate any
other feeds.

MILK & FORMULA SELECTION


During Hospital Admission
Gestational Age & Birth Appropriate Formula (at goal feeds)
Weight
24 kcal/oz. BM + HMF (Maternal or Donor if
<36 weeks, <2000 gm <1500g)
24 kcal/oz. Premature formula
>36 weeks and >2500 gm Unfortified MBM or Term Formula

Borderline (Late Preterm) 22-24 kcal/oz. MBM + HMF (based on intake, growth &
labs)
34-37 weeks, 2000-2500 gm Transitional Formula (Neosure or Enfacare)
Consider 22-24 kcal/oz. MBM/HMF or preterm
IUGR, >35 weeks, <3%ile
formula until ~2.5 kg

Approaching Discharge:
Attempt to transition to the diet regimen the infant will be going home on a few days
before discharge. This will allow us to determine whether or not the infant will be
able to meet volume and weight gain goals on this regimen.

If the infant is receiving premature formula, transition to a Transitional formula prior


to discharge.

For infants going home on MBM, continue to use HMF until discharge or until the
infant weighs 3.5kg (we are unable to use any other powdered formula in the NICU).
Discharge
Gestational Age/Birth MBM & Formula All Formula
Weight
Breast feeding ALD Transitional Formula
<36 weeks + 22 kcal/oz
<2000 gm 2-4 bottles of 24 kcal/oz *May need 24 kcal/oz. if unable
to meet weight gain goals or
MBM + Transitional formula discharge weight is <2kg
Breast feeding ALD
Late Preterm + Consider using
34-37 weeks 2-4 bottles of 22-24 cal/oz Transitional Formula (22
2000-2500 gm MBM + Transitional Formula kcal/oz) until 40 weeks,
*Concentration depends on intake, then term formula
growth & labs
>36 weeks
Breast Feeding ALD Term Formula
>2500 gm
*IUGR infants may need specialized discharge formula/regimen please consult
Dietitian*

Indications for Transitional Formula Length of Time to Continue Transitional


Formula
<35 weeks Birth Weight: Duration
<2000 gm (regardless of GA)
Infants with elevated Alk Phos <750 gm = Up to 12 months CGA
Poor weight gains 751-1000 gm = Up to 9 months CGA
Poor volumes 1001-1500 gm = Up to 6 months CGA
IUGR at any age 1501-2000 gm = Up to 3 months CGA
Growth delays (<10% or <3%) 2001-2500 gm = 1-3 months CGA if needed

LAB MONITORING GUIDELINES FOR ENTERAL


NUTRITION IN THE NICU
Alkaline Phosphatase, Phosphorus and Prealbumin are considered nutrition
labs

Begin to check these labs once an infant is off TPN and on full, fortified
enteral feeds for at least 1 week.
The theory behind not checking these while on TPN is that calcium, phosphorus and
protein should always be maximized in TPN solutions for preterm infants

These labs are followed every other week until stable x2

Alk Phos & Phosphorus measure bone mineralization


Always check these 2 labs together- elevations in alk phos can also come from
periods of rapid bone growth as well as hepatic issues

Prealbumin measures protein stores


Check a BUN in place of prealbumin for infants receiving steroids. A BUN
<5mg/dL indicates a need for additional protein.
Lab Goal Considerations Possible Interventions
Up to 600 u/L is acceptable if Increase calcium/phosphorus
the infant is growing well as intake, decrease use of calcium
Alk Phos <400 u/L
this may reflect rapid bone wasting meds (diuretics), increase
growth vitamin D
Falsely elevated with steroid
Prealbumi use
>10 mg/dL Begin protein supplementation
n May be low with an elevated
CRP
Maximize amount in TPN or consult
Phosphor 4.5-6.5 May see levels up to 8 mg/dL
RD about supplementation if on
us mg/dL in premature infants
enteral feeds

Other Labs:
Electrolytes
o Monitor for infants receiving diuretics and/or electrolyte supplements
Hemoglobin/retic %
o Check approximately every 2 weeks once an infant is stable
o If low, adjust iron supplement if needed. May also be transfused based on
the level
Direct Bilirubin
o Monitor weekly for infants with cholestasis or on TPN >2 weeks. Continue
to monitor this lab until level is <1mg/dL.
Trace elements
o Certain trace elements may need to be monitored, especially for infants
with significant GI losses. The NICU dietitian can help you determine which
nutrients are at risk for malabsorption and may need supplementation.

The RD will post a list of patients needing nutrition labs in the workroom at
the end of each week- nutrition labs are checked every Monday for IC
patients.
ASSESSING GROWTH IN THE NICU
The Fenton growth chart is used to assess the length, weight and OFC for
premature infants in the NICU from 22 weeks to 50 weeks gestational age

The WHO growth chart is used for term infants

Growth Goals:

Frequency of
Measurement Goals Measuremen
t
15-20 grams/kg/day (<2kg)
Weight Daily
25-35 grams/day (>2kg)
Length 1 cm/week Weekly
OFC 0.7-1 cm/week Weekly

Factors that may inhibit adequate growth:


Inadequate protein intake
o 80% of inadequate growth is related to inadequate protein intake
Inadequate or excessive energy intake
Increased energy expenditure
o CHF, severe sepsis, increased WOB, BPD, wean from isolette (temperature control)
Malabsorption
Medications- steroids, diuretics
Use of continuous drip feeds with breast milk
o Breast milk fat adheres to the feeding tube, reducing the overall concentration of feeds
Electrolyte/acid-base imbalance

Interventions for poor growth:


Calculate intake of energy and protein to ensure the infants needs are
being met (minimum of 120 kcal/kg/day and 3.5 grams of protein/kg/day)
Maximize protein intake by adding a protein supplement
Increase feeding volume
Consult Dietitian about increasing the concentration of feeds
Correct low sodium and chloride levels
Transition to bolus feeds if administering breast milk continuously
Return to isolette or resume oxygen if infant demonstrates temperature
instability or increased work of breathing

NUTIRITON THERAPIES FOR COMMON NICU


DISORDERS
Osteopenia of Prematurity: Metabolic bone disease
Cause: Lack of calcium and phosphorus in bones (up to 80% of skeletal mineralization
occurs in the 3rd trimester)
Defined by: Alkaline Phosphatase value >900 u/L and Phosphorus <4 mg/dL
Treatment:
o Parenteral:
Maximize the calcium and phosphorus in the TPN solution. Make sure the
Ca:Phos ratio is 2-2.5:1. If unable to maximize these nutrients, add
cysteine to the TPN solution.
If phosphorus is significantly low, consider adjusting the Ca:Phos ratio to
1:1 until phosphorus levels correct, then return to the 2:1 ratio
o Enteral:
Decrease the use of calcium wasting medications (diuretics).
Consult Dietitian about adjusting the fortification of feeds or beginning
calcium and/or phosphorus supplementation (may only need phosphorus).
Begin or increase Vitamin D supplementation.

Cholestasis: Interruption in the excretion of bile flow


Cause: Intra/extrahepatic obstruction. In the NICU, typically from prolonged use of TPN
Defined by: Direct Bilirubin >2 mg/dL
Treatment:
o Begin enteral feeds or attempt to discontinue TPN if able
o Parenterally:
Omit the manganese and chromium from TPN solution
Limit the lipid content of TPN solution (may need to increase the GIR in
order to still meet energy needs)
o Enterally:
Consider beginning Ursodiol (Actigall) and fat-soluble vitamins
May need to consider feeds higher in Medium Chain Triglycerides
MCTs do not require bile salts for digestion/absorption

Anemia of Prematurity: Lack of red blood cells due to early birth


Cause: Inadequate iron stores (iron is stored in the 3rd trimester)
Defined by: Low hemoglobin/hematocrit levels
Treatment:
o Transfusions may be necessary
o Limit blood drawing for labs
o Begin iron supplementation once an infant is at least 2 weeks old and on full,
fortified enteral feeds.
Goal from feeds + supplement= 4 mg/kg/day (BW <1500g)
Infants on all formula feeds or breast milk fortified with Enfamil HMF will already be
receiving 2 mg/kg/day, so the supplement should provide the other 2 mg/kg/day.
Infants on breast milk fortified with Similac HMF or Prolacta will need an iron supplement
that provides 3.5-4 mg/kg/day (these HMFs contain little to no iron).
VITAMIN & IRON SUPPLEMENTATION GUIDELINES
Human milk fortifiers and premature formulas contain nutrients meant to meet the
increased needs of premature infants. With the exception of iron and vitamin D, most
vitamin and mineral needs will be met if an infant is on full, fortified enteral feeds. Your
dietitian will also be able to help you calculate the nutrient needs of your infant to
assess their need for supplementation.

Iron supplementation during hospitalization:

Feeding Regimen Iron Supplementation (mg/kg/day)


Birth Weight <1.5kg Birth Weight >1.5kg
Formula 2 None
MBM + EHMF 2 None
MBM + SHMF or Prolacta 4 2
MBM + formula (1:1) 3 1
Iron supplementation is started when full enteral feedings are tolerated and the infant is at least 2 weeks old. EHMF
and formulas provide ~2 mg Fe/kg/d with the exception of SHMF. This amount has already been subtracted in the
guidelines listed above.

Even though MBM contains iron that is well absorbed, it is a small amount and is usually not included when
determining iron supplementation needs. Iron should not exceed 6 mg/kg/day (formula and supplement combined).

IDM and IUGR infants are at increased risk for low iron stores, so their Fe requirement may be more than
the usual amount for their birth weight. These infants should be assessed and monitored on an individual
basis.

Vitamin D Supplementation:
All infants born <34 weeks should receive an additional 400 IUs of vitamin D per
day on DOL 1. This is done regardless of NPO status, with the exception of major
GI complications.
Vitamin D may be increased as needed based on lab values measuring
osteopenia.

Discharge Supplementation:
Feeding Regimen Vitamin Supplement
Term MBM or Formula 1mL/day D-Vi-Sol
0.5mL/day Tri-vi-sol or D-vi-
Preterm Formula
sol
Fortified MBM 1mL/day Poly-vi-sol with iron

D-vi-sol= 400 IUs Vitamin D/1mL


Tri-vi-sol= Vitamins A, C & D
Poly-vi-sol= Vitamins A, C, D, E & B complex; 1mL with iron= 10mg Fe

Re-evaluate vitamin and iron supplementation requirements as needed based on MBM/formula intake and lab values for Fe
status.
Infants should continue vitamins with Fe as long as they are receiving predominantly MBM (<1000 ml of formula per day).

REFERENCES

Adamkin DH. (2010). Nutritional Strategies for the Very Low Birthweight Infant. New York, Cambridge
University Press.
Adamkin DH. (2005). Pragmatic Approach to In-Hospital Nutrition in High-Risk Neonates. Journal of
Perinatology, 25:S7-S11.

American Academy of Pediatrics, Pediatric Nutrition Handbook. (2004). 5th edition.

ASPEN Board of directors and the clinical guidelines task force. (2002). Guidelines for the use of
parenteral and enteral nutrition in adult and pediatric patients. J Parenter Enteral Nutr, 26(1Suppl): 1SA-
138SA.

Brine E, Ernst JA. (2004). Total Parenteral Nutrition for Premature Infants. Newborn and Infant Nursing
Reviews, 4(3):133-155.

Evans RA, Thureen, PJ. (2001). Early Feeding Strategies in Pretem and Critically Ill Neonates. Neonatal
Network, 20(7):7-18.

Groh-Wargo S, Thompson M, Hovasi Cox J, eds. (2009). ADA Pocket Guide to Neonatal Nutrition. Chicago,
IL. American Dietetic Association.

Groh-Wargo S, Thompson M, Hovasi Cox J, eds. (2000). Nutritional Care for High Risk Newborns. 3 rd
edition, Chicago, IL. Precept Press.

Iowa Neonatology Handbook: Parenteral Nutrition. (2004).

Koletzko B, Tsang RC, Uauy R, Zlotkin, SH. (2005). Nutrition of the Preterm Infant, Scientific Basis and
Practical Guidelines, 2nd edition., Cincinnati, OH, Digital Educational Publishing Inc.

Koruda MJ, Rolandelli RH, Settle RG, et al. The effect of pectin supplemented elemental diet on intestinal
adaptation to massive small bowel resection. J Parenter Enteral Nutr 10: 343-350, 1986.

Kuzma-OReilly B, Duenas ML, Greecher C, Kimberlin L, Mujsce D, Miller D, Walker DJ. (2003). Evaluation,
Development, and Implementation of Potentially Better Practices in Neonatal Intensive Care Nutrition.
Pediatrics, 111(4):e461-470, URL: www.pediatrics.org/cgi/content/full/111/4/e461.

Mayhew SL, Gonzalez ER. (2003). Neonatal Nutrition: A Focus on Parenteral Nutrition and Early Enteral
Nutrition, ASPEN, Nutrition in Clinical Practice, 18(5):406-413.

Parker P, Stroop S, Greene H. A controlled comparison of continuous versus intermittent feeding in the
treatment of infants with intestinal disease. J Pediatr. 99:360., 1987.

Poindexter BB, Denne SC. (2003). Protein Needs of the Preterm Infant. AAP NeoReviews, 4(2):52e.

Porcelli PJ, Jr., Sisk PM. (2002). Increased Parenteral Amino Acid Administration to Extremely Low-Birth-
Weight Infants During Early Postnatal Life. J. Pediatr. Gastroenterol. Nutr., 34(2):174-179.

Tsang RC. (2005) Nutrition of the Preterm Infant, Scientific Basis and Practical Guidelines, 2 nd ed.,
Cincinnati, OH, Digital Eduacational Publishing Inc.

Wessel J, Kocoshis S. Nutritional Management of Infants with Short Bowel Syndrome. Semin
Perinatol 31: 104 111, 2007.

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