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MANAGEMENT
IN THE NEONATAL ICU
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).
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.
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.
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:
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
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.
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
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.
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.
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.
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.
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
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.
*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)
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
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.
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.
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*
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
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
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
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
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).
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