Notes in Neonates محمد ابراهيم مستشفى قوص قنا.WhiteKnightLove

Notes in neonates
Mohamed Ibraheem
‫ قنا‬-‫مستشفى قوص‬
Important medications
Drug infusion
Dopamine (200mg/5ml): 5-20ug/kg/min

: 5ug/kg/min=wtx0.18=ml±24ml D5%→1ml/h
Dobutamine (125mg/10ml): 5-20ug/kg/min
: 5ug/kg/min=wtx0.56=ml±24ml D5%→1ml/h
Isoprenaline (0.2mg/1ml): 0.1-0.5ug/kg/min
: 0.1ug/kg/min=wtx0.72=ml±24ml D5%→1ml/h
Adrenaline (1mg/1ml): 0.1ug/kg/min = wtx0.14=ml±24ml D5%→1ml/h
ProstinE1 (0.5mg/1ml): 0.05-0.1ug/kg/min ( to keep PDA patent)

Xylocaine 1%(10mg/ml)2%(20mg/ml) : 15-50ug/kg/min
Stat1mg/kg repeat PRN every 10min x3doses(don’t mix e´bicarb)
:15ug/kg/min (1%)=wtx2=ml±24ml D5%→1ml/h
(2%)=wtx1=ml±24ml D5%→1ml/h
Morphine (10mg/ml): Stat 100ug/kg then
: 20ug/kg/min=wtx0.048=ml±24ml saline→1ml/h
Heparine (5000mg/ml): 1u/h ( for umbilical catheter)
: 500units(0.1ml)+500ml saline→1ml/h
diazepam (10mg/2ml): neo-infant-children (not for jaundiced baby)
Stat 0.1mg/kg then
0.1mg/kg/h=wtx0.48=ml±24ml D5%→1ml/h
Desferal (500mg powder): 10mg/kg/h
: total amount is diluted e saline and given within 24h
: example :total+500ml saline →20ml/h
Aminophylline (250 mg/10ml) :
Neonates: 0.16mg/kg/h=wtx0.15=ml±24ml saline→1ml/h
Ventolin (0.5 mg/1ml) : Stat 4ug/kg/dose over5min. then
:0.2ug/kg/min (wtx0.57)
EX : dopamine :
Baby 3 kg needs 5mcg/kg/min
5ug/kg/min=wtx0.18=ml±24ml D5%→1ml/h
5ug/kg/min=wtx0.18= 3 kg x 0.18 =0.54 ml dopamine dissolve in 23.46 ml D5%->1ml/h
The above baby needs 10 mcg/kg/min : multiply the above result by 2
So he needs : 0.54 x 2= 1.08 ml dopamine dissolve in 22.92 ml D5%->1ml/h and so on.
6 ‫ وممكن أن تحسب كمية‬، ‫ ملل‬42 ‫ الساعة وهكذا فليس شرطا أن تذيب فى‬/ ‫ ملل‬4 ‫ وتعطى‬%5 ‫ ملل جلوكوز‬24 ‫ممكن تضيف الكمية الى‬
‫ أي خليك مرن‬، ‫ ساعة وهكذا‬42 ‫ ساعة بدال من‬24 ‫ساعات أو‬
2
Doses of special drugs
Morphine(10mg/ml): 0.1mg/kg/dose IM/IV/SC
Pethidine(50,100mg/ml) : 0.5-1mg/kg/dose
Narcan (0.4,1mg/ml):0.1mg/kg/dose IM/IV/SC/ETT
Pancronium (1,2mg/ml):0.02-0.1mg/kg/doseIV (SP/apnea,hypotention,gentamycin)
Indomethacin(25,50mg tab) : (closures of PDA) 0.1mg/kg/dose x 3 doses
Brufen (100mg/5ml ) : (closures of PDA) 0.5ml/kg then 0.25ml/kg after24h then 0.25ml/kg after48h
Theophylline (apnea) : 5mg/kg IV stat then 5mg/kg/day IV/ PO
Diazoxide (hypertensive crisis): 5mg/kg/dose IV over 1/2min.can be repeated after 3-6h
Hydralazine (hypertensive crisis): 0.2-0.5mg/kg/dose IV,IM can be repeated every 3-6h
Nifedipine (10mg/cap): 0.25-05 mg/kg/dose every 8h PO/SL
Propranolol (1mg/ml): 0.02mg/kg slow IV( max: 3mg/dose)(cyanotic spell)
Sodium bicarbonate 8.4% vial/amp : 1ml /kg/dose diluted in distilled water / dextrose 5% (roughly dose)
Parvolex 10% : nebulizer 6-10ml TDS/QID
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Clexane(enoxaparin):20,40,60,80mg syringes,lowparine 40mg amp.(Anticoagulation)-Dosage forms:SC
*thromboembolism prophylaxis
[<2 mo]: 0.75 mg/kg SC q12h;
[>2 mo]: 0.5 mg/kg SC q12h;
Adjust dose to maintain anti-factor Xa level 0.1-0.4 units/mL. D/C if Platelets <100k
*thromboembolism tx
[<2 mo]: 1.5 mg/kg SC q12h;(Fullterm 1.7 mg/kg/dose Q12h SC. preterm 2 mg/kg/dose Q12h SC)
[>2 mo]: 1 mg/kg SC q12h;
Adjust dose to maintain anti-factor Xa level between 0.5-1 units/mL. D/C if Platelets <100k
*Renal dosing [adjust dose,frequency] CrCl 10-29: decr. dose 30% or give q24h; CrCl <10: decr. dose 50%,
give q24h; Hemodialysis/Peritonial D: no supplement) CrCl= Creatinine clearance)
*Hepatic dosing[not defined] hepatic impairment, caution advised
*Monitor :
Anti-factor Xa 4h after a dose. After attaining target level, dose adjustment is needed 1-2 times/month.
Signs of bleeding and thrombosis
*Advers effect :
Bleeding (even in therapeutic range) 4%.
Hematoma at administration site. Compartement syndrome
IC and GI hemorrhage
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Lanoxin : (amp 0.5mg/2ml- elixir 0.05mg/ml - tab 0.25mg)
Digitalizing dose :
Preterm:20ug/kg÷3 (1/2,1/4,1/4 or1/3,1/3,1/3) IV
Term :30µg/ Kg ÷3 (1/2,1/4,1/4 or1/3,1/3,1/3) IV
Maintenance dose:
10µg/ Kg /day (or 1/4 digitalizing dose) ÷2 given after 12h of last Digitalizing dose
Elixir: 0.2ml/kg/day ÷2
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Neostigmine:(0.25,0.5, 1mg/ml)
Myasthenia Diag: 0.02-0.04mg/kg IM once
myasthenia TTT: 0.01-0.04 mg/kg/dose IM,IV,SCq2:4h
Reversal of neuromuscular blockers: 0.02-0.1mg/kg/doseIV+atropine
(SP/asthma,hypotention,bradycardia )
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IV Immunoglobulin
Hypogammaglobulinemia : :100mg/kg/monthly (IV(
ITP,Guillian barre : 250-500mg/kg/dayx5days slow iv over 6h followed by 500mg/kg/mo
Sepsis : 500-750mg/kg/dose over 2-6h x5 days
ABO/RH hemolytic jaundice : 500-750mg/kg/dose over 2-6h – No benefit
3
Vancolon ( vancomycin )
Indications :
Methcillin resistant staph
Septicemia
Endocarditis
Bone infections
Doses :
Neonates : <1wk 10mg/kg/12h infusions over 1h
: >1wk 10mg/kg/8h infusions over 1h
Children : 10mg/kg/6h infusions over 1h
Adult : 1 gm/12h infusions over 1-2 h
Preparations : 0.5gm vial
Dilution : saline / glucose
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Fentanyl
Classification A potent narcotic analgesic , 100 times more potent than morphine
Indications Analgesia – sedation – anesthesia
Doses
Sedation&analgesia Intermittent : 0.5-4mcg/kg/dose iv slowly Prn Q 2-4hrs
Infusion : 1-5 mcg/kg/h ---- tolerance develop rapidly
------------------ -------------------------------------------------------------
Anesthesia 5-50mcg /kg/dose
Duration of action 30-60 min
Monitoring RR, HR, Bowel sounds, muscle rigidity
Adverse effect Drug dependency > if given more 5 days
Respiratory depression
Muscle rigidity
Bradycardia
Laryngospsm
Antidote Naloxone ( narcan )
Compatible solution D5W, NS
Dilution stability 24 hrs in refrigerators
Preparation 0.1mg/2ml vial
Midazolam (dormicum)
Classification Benzodiazepine, 5times more potent than diazepam , doesn’t affect
consciousness – sedative – anticonvulsant
Indications Sedative for patient fighting ventilator -Refractory seizures
Doses
Sedation Intermittent : 0.05-0.15mg/kg/dose iv over 5min Prn Q 2-4hrs may IM
Infusion : 0.01-0.06mg/kg/h ---- tolerance develop rapidly
Intranasal: 0.2-0.3 mg/kg/dose using injectable form.
Sublingual:0.2 mg/kg/dose using injectable form mixed with some fluid
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Anticonvulsant 0.15mg /kg/IV over 5min followed by  0.06-0.4mg/kg/h
Duration of action 2-6hrs, more than 20hrs in preterm
Monitoring RR, blood pressure , hepatic functions
Adverse effect Respiratory depression -hypotension
Compatible solution D5W, NS , sterile water for injection
Dilution stability 24 hrs in refrigerators
Preparation 5mg/1ml amp
4
Tienam(imipenem/cilastatin) 500 mg vial/10ml
Uses:
Non-CNS infections caused by bacteria, primarily Enterobacteriaceae and anaerobes& Pseudomonas.
Not active against MRSA and Enterococcus faecalis, used in seious infections as septicemia ,peritonitis
Not used:
Meningitis,late onset sepsis with meningitis, bilirubin encephalopathy ,asphyxia, renal impairment
Dose:
20mg (0.4ml)-25mg( 0.5ml)/kg/dose Q12h IVI over 30 min.(neonates)
20mg(0.4ml)-25mg(0.5ml)/kg/dose Q6-8h IVI over 30 min.(infants& children)
Monitor :Periodic CBC , trannsaminase , iv sites for phelibitis
Side effects :
Seizures in patients with meningitis, preexisting CNS pathology
Phlebitis -Elevated liver enzymes –Diarrhea-thrombocytosis and Eosinophilia.
Stability :
Stable for 4 hrs in room temp, 24 hrs in refrigerator after dilution with dextrose,
Stable for 10 hrs in room temp, 48 hrs in refrigerator after dilution with saline
Maximum concentration for infusion 5mg/ml
Solution compatibility :
D5/D10/NS/D5% NS
Drug incompatibility :
Amikin, bicarbonate,lorazepam , lactate
Preparations :
500 mg powder vial for IV infusion ,
500 mg vial/ 10 ml saline (50 mg/ml ) then dilute to a final concentration( 5mg/ml )
. ‫ وهو أقل كمية محلول ممكنة أي ممكن تزود أن أردت‬10 ‫ مضروبه فى رقم‬ml ‫كمية المحلول المطلوب للتخفيف= الجرعة مقدرة بالمليللتر‬
Ex : 3kg x 20mg = (o.4ml)x3= 1.2ml,then dilute 10 times = 1.2 x 10=12 ml
so you preparation will be 1.2 ml tienam to be added to 12 ml diluents over 30 min
Storage :Store below 25 degree centigrade
5
Meronem 500 mg/10ml-1 gm/20ml vial
Uses :
Pneumococcal meningitis, Klebsiella pneumoniae,pseudomonas and other G-ve organisms resistant to other
antibiotics.
Doses :
Dose In Sepsis: 20 mg (o.4ml)/kg/dose IVI over 30 min Q12h(<7 days or > 7 days and his weight<2kg)
20 mg (0.4ml)/kg/dose IVI over 30 min Q8h (> 7 days & infants& children)
Dose In Meningitis And Pseudomonas Infection: 40 mg (0.8ml)/kg/dose IVI over 30 min Q8h (all ages)
Infusion solution concentration 5 mg/mL
Monitor :
Periodic CBC for eosinophilia, thrombocytosis., trannsaminase , iv sites for phelibitis ,renal functions
Advers effects:
Diarrhea (4%), nausea and vomiting (1%).
Rash (2%). Inflammation at injection site.
Increase Risk of pseudomembranous colitis and fungal infections
Stability :
Stable for 2 hrs in room temp, 12hrs in refrigerator after dilution with distilled water
Stable for 1 hr in room temp, 8 hrs in refrigerator after dilution with dextrose 5%,
Stable for 2 hrs in room temp, 18 hrs in refrigerator after dilution with saline
Maximum concentration for infusion 5mg/ml
Solution compatibility :
D5/D10/NS/D5% NS
Drug incompatibility :
Ca gluconate, Na bicarbonate, flagyl , acyclovir
Preparations :
500 mg,1gm powder vial for IV infusion , 5oo mg/10ml saline(5omg/ml)
1gm/20ml saline (50mg/ml ) then dilute to a final concentration( 5mg/ml )
‫ وهو أقل كمية محلول ممكنة أي ممكن تزود أن أردت‬21‫ مضروبه فى رقم‬ml ‫كمية المحلول المطلوب للتخفيف= الجرعة مقدرة بالمليللتر‬
Ex : 3kg: 3 kg x 20 mg=3x 0.4 ml= 1.2ml then dilute 10 times = 1.2 x 10=12 ml
so you preparation will be 1.2 ml meronem to be added to 12 ml diluent over 30 min
Caffeine citrate
Mechanism Stimulate respiratory centers
Indications Neonatal Apnea, including post-extubation and post anesthesia
Doses Loading:20mg(1ml)-25mg(1.25ml)/kg IV over 30 min .
Maintenance:5mg(0.25ml)-10mg(0.5ml)/kg/dose Q24h IV slowly .
24 hrs after loading and given for 1wk
Oral solution are the same dose
Duration of action Half life 72 hrs
Monitoring Monitor HR; withdraw if > 180 bpm.

Adverse effect Restlessness,Vomiting,Functional Cardiac symptoms,associated with NEC?
Compatible solution D5%
Dilution stability 24 hrs in room temp after dilution,

Can be given diluted or without dilution
Preparations Caffeinospire 60 mg/ 3ml oral solution- 60mg/3ml vial for injection
6
Diamox
Diuretic: 5 mg/kg/dose Q24h IV or PO.
Anticonvulsant: 4-16 mg/kg/day PO divided every 6-8h (not to exceed 30 mg/kg/day or 1 g/day)
To alkalinize urine: 5 mg/kg/dose PO 2-3 times over 24h.
To decrease CSF production: 5 mg/kg/dose IV or PO Q6h increased by 25 mg/kg/day (maximum of 100
mg/kg/day). Lasix® may be used in combination.
Uses:
Mild diuretic.
Anticonvulsant in refractory neonatal seizures (retards abnormal discharge from CNS neurons).
Decrease CSF production in PHH.
Renal tubular acidosis.
Monitor:
Serum electrolytes (contraindicated in hypokalemia and hyponatremia )
Plasma pH and Chloride.
Advers effects:
GI irritation.
Anorexia. Transient hypokalemia.
Hyperchloremic metabolic acidosis. Growth retardation.
Bone marrow suppression, thrombocytopenia, hemolytic anemia, pancytopenia and leucopenia.
Drowsiness, paresthesia.
Mg sulphate 10%: (1 mL MgSO4 10 % = 100 mg Mg = 0.8 mEq Mg)

Hypomagnesemia or Refractory hypocalcemia:
leading:0.25 mL/kg/dose IV or IM Q6h until the serum magnesium level is normal or symptoms resolve
maintenance: 0.25ml/kg/24 h IV (add to infusion or given IV).
In PPHN:
LD: 2 mL /kg IVI over 20-30 min
MD: 0.2-0.75 mL/kg/h IVI to maintain plasma-Mg concentration between 8.5-13.4 mg/dL given for
up to 5 days.
Perinatal asphyxia :
Mg sulphate 2.5 ml /kg /dose daily for 3 days diluted with 50ml NS over 1h
Monitor :
Monitor serum magnesium, calcium, and phosphate levels.
Infuse IV magnesium sulfate over several hours
Advers effects :
Hypotension
Flushing, Depression of reflexes
Depressed cardiac function
CNS and respiratory depression.
Contraindicated in renal failure.
Notes : Suprasternal palpation shows promise as a simple, safe, and teachable method of confirming
ETT position in neonates.
‫صلى على الحبيب‬

7
Diflucan :fluconazol 100mg/50ml
Systemic infections including meningitis :
LD 12 mg/kg/dose
MD 6 mg/kg/dose IVI over 30 min or PO
Prophylactic in VLBW in NICU with high rates of invasive fungal disease : 3 mg/kg/dose twice
weekly. IVI over 30 min
Fungizone :amphotericin B 50mg/10ml
Dose:
- Initial dose: 0.25-0.5mg/kg IVI over 4-6h.
- MD: 0.5-1 mg/kg IVI over 2-6h Q24-48h for 2-6 wks or longer
Uses: Systemic fungal infections.
Monitor: CBC, liver function every week.,Serum creatinine, BUN, Electrolytes and UOP
Adverse effects:
Anemia, thrombocytopenia.
Consider analgesia before infusion. Nausea, vomiting
Fever, chills
Discontinue if BUN > 40 mg/dL
Notes : Protect from light ,don’t mix with saline
Viagra (sildenafil) 50mg tab/25ml
Dose:
initially 0.25-0.5 mg/kg/dose Q4-8h, adjusted according to response; max. 2 mg/kg/dose Q4h;
start with lower dose and frequency especially if used with other vasodilators; withdraw gradually
Uses :PPHN refractory to iNO and other therapies.
Improve pulmonary blood flow in severe Ebstein’s anomaly
Monitor : Blood pressure ,Oxygenation
Adves effects : Worsening oxygenation and systemic hypotension.
Use with caution in infants with sepsis. Increase Risk of ROP, bleeding??
Notes : Stable for 1 month if refrigerated.
Averozolid (linezolid )
MRSA(mecicillin resistant staph) ‫و‬VRSA(vancomycin resistant staph ),VRE(vancomycin resistant enteroccoci
Others : penicillin-resistant Streptococcus pneumoniae, S. epidermidis
pneumonia (community acquired,nosocomial)
Skin&soft tissues infections(Infected ulcer, wound,burn,abscess,impetigo,necrotizing soft tissue infection
Intraabdominal infections, UTI, Bacteremia
Dose ( 100mg/5ml susp): 0.5ml/kg/dose x3
Side effect : Reversible thrombocytopenia with therapy for more than 2 weeks, A serotonin syndrome
in patients taking a selective serotonin receptor inhibitor
‫أذكر هللا‬
8
Augmentin injection (Amoxicillin & clavulinic acid(
Indications : act against pneumococci ,H influ,moraxella , Strep pyogenes, S aureus , E coli
: URTI,LRTI,UTI, bone infection
Preparation : 600mg/10ml,1200mg/25ml
Doses :
Up to 3mo :<4kg 30mg/kg/dose/12h IV/infusion
:> 4kg 30mg/kg/dose/8h IV/infusion
3mo-12yrs : 30mg/kg/dose/6-8h IV/infusion (practically 45mg/kg/dose/12h)
Practical doses for neonates :
30mg/kg/dose/12h
600mg/10ml : 0.5ml/kg/dose/12h
Dilution should be with 10ml solvent ( saline /distilled water )
Stability: should be given immediately after reconstruction
Unasyn (ampicillin &sulbactum)

Inj.: 100mg/kg/day (based on combinations) ( divided Q12h <7days, Q8h >7days (
Preparations : unasyn 375, 750,1500 mg vial ( don’t mix with D5% , given within 1h of dilution (
Special Immunizations
Vaccination of the newborn of hepatitis BSAg +ve mother :
All neonates born to HBS Ag +ve mothers ( especially HBeAg) should receive as soon as possible
0.5ml HBIG + 0.5ml HB vaccine at separate sites deltoids IM within 12h of birth (the effiency is 95%)
HBIG may be given up to 7days of birth but its effiency after 48 h is not known
Two more doses of HB vaccine at 1mo.& 6mo. Should be given .
If HBIG is not available : HB vaccine is given at 0,1,2, 9 mo. (the effiency is 75%)
All neonates born to HBS Ag +ve mothers should be tested for HBsAg at 9-12mo.to identify carrier/non responder
For children with bleeding tendency , pressure should be applied for10minutes / may be given SC
‫تذكر‬
STAGES OF GROWTH
Ovum 0–14 days
Embryo 14 days to 9 weeks
Fetus 9 weeks till birth
Newborn First 28 days
Infant First year of life
Toddler 1–3 years
Preschool 3–5 years
School child 5–9 years
Adolescence 10–19 years
9
Calculations in pediatrics & neonates
Heparin for UVC (5000u/ml) 0.5u/h 50u +25ml D5%------- 0.25ml/h
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Regular insulin for hyperglycemia
Dose in units to be added to 100ml NS = 10xwt
0.5ml/h 0.05u/kg/h
1ml/h 0.1u/kg/h
Regular insulin for hyperkalemia : Add 2units to 100ml D10%Run 5ml/kg over 2hrs ( 0.1u/0.5gm dextrose/kg)
-------------------------------------------------------------- -------------------------------------------------
Albumin 0.5-1gm/kg 20%---dilute 3times 25% dilute 4times over 3/hrs
Albumin given for hypovolemia ,shock & nephrotic syndrome
-------------------------------------------------------------- --------------------------------------------------
Packed Red Cells Hb deficit x wt x 4 approx. 15ml/kg over 3/hrs(2-4h (
Whole blood Hb deficit x wt x 6 approx. 20ml/kg over 3/hrs
PPF 10ml/kg over 3/hrs
FFP 10ml/kg over 3/hrs
Platelets 10ml/kg over 30 min
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Na Bicarbonate 8.4%: (Base deficit x wt x 0. 3) give half the amount diluted e dis. water over 1h
Na replacement
In Asymptomatic hyponatrmia = (35-actual Na)xwtx0.6
1/2 Amount is given with fluids over 8hrs,other 1/2 over 16hrs
The amount can be given with milk PO
In symptomatic hyponatrmia & Na <120 give Nacl 3%5ml/kg over one hour
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Partial exchange transfusion : approx. 20-30ml/kg NS
Size of ETT=gestational age x 0.1,(approximately baby little finger)
Length of OTT = wt+ 6 )‫ )طول األنبوبة الحنجرية من الفم‬1kg(7cm),2kg(8cm),3kg(9cm) rule of 789
Length of ETT = wt+ 6+2 )‫ )طول األنبوبة الحنجرية من األنف‬1kg(7cm+1),2kg(8cm+1),3kg(9cm+1) rule of 789
Size of ETT in age>2yrs= 1/4 age(yrs)+4
Length of OTT in age>2yrs = 1/4 age(yrs)+12 (or internal diameter of the tubex4)
Length of UVC= length of the baby x 0.2 or 1.5wt+5.5cm (‫)طول القسطرة السرية الوريدية‬
A/a ratio = Pao2 / 712 Fio2 - paco2 (N 0.8:0.9 ) < 0.5 severe < 0.2 survanta therapy
Serum osmolarity = 2Na +BUN \3 +glucose/18 (N 280-300mosmol)
Adjusted Ca = Total serum Ca (mg)+ 0.2 [ 4.7 - albumin (mg) ] N>8.4 Abnormal<8.4
Mean blood pressure = minimal range equal to gestational age
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Fluids: in :
in photo : + 20ml/kg
In ARF : - 70 ml/kg + fluids output
In mechanical ventilation : - 10ml/kg
In cardiac failure , CNS infections : - 30ml/kg
Corrected CSF WBC count ( in traumatic lumbar punctures):
Based on : RBC count & WBC count in CSF
subtract 1 WBC For every 1000 RBC
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Exchange transfusions
Volume : 170ml/kg
Type : fresh whole blood
Indications : Cord Hb <12 or bilirubin>5 - TSB exceeding critical level - Hydrops , severe anemia, kernicterus
Rh incomp : Rh-ve ,Blood group of the baby( or 0-ve blood)
ABO incomp: Blood group O, Rh of the baby (or o – ve blood )
Others : Same of infant
TSB exceeding critical level= serum albumin X 6 or guided by jaundice curves
---------------------------------------------------------------
Polycythemia & partial exchange transfusion
Indications :
HCT>65+ symptomatic baby
HCT>70+ asymptomatic baby
Sample should be venous for HCT
VOL: 20-30ML/Kg either ppf,5%albumin,saline
01
Important measures in neonates :
Room temp from 22-24c
Incubator humidity 50%
Incubator temp 36.6-37c
Obstructive jaundice when direct bilirubin> 20% of total bilirubin
Heart rate 120-160 beat/min
Resp. rate 40-60 breath/min
Mean time of blood transfusion 3hrs
Double exchange transfusion = 170ml/kg
Calories for full term 100kcal/kg , for preterm 120kcal/kg.forSGA 150kcal/kg
Premature formula for babies till reach 2kg
No toleration for feeding if residual > 25% of previous feeding
Measure blood sugar for IDM on admission, 1,2,3,6,12,24,36,48h
Hypoglycemia when blood sugar <40mg/dl (N 50-120mg/dl)
hypocalcaemia when blood Ca <7mg/dl (N 8.5-10.5mg/dl)
hypomagnesaemia when serum level <1.2mg/dl (N 1.5-3.5mg/dl)
Amount of urine 2-3ml/kg/h (polyuria> 5 ml/kg/hr, oliguria < 1ml/kg/h,anurea < 0.5 ml/kg/hr )
Urine Sp.Gr. 1.005- 1.010
Apnea , cessation of respiration>20sec. +cyanosis/ bradycardia
Mean blood pressure in full term 80/46 ( abnormal >113/<40 )
length of stretched penis 3.5cm±0.4 cm
Minimum discharge weight is 1.5kg
Prophylactic iron therapy for preterm after doubling wt, for full term after 6mo.
Any ophthalmia develops during the 1st 3 days of life should be considered gonoccocal infections until proved otherwise
Administer vit K, local antibiotic eye drops within one hour after birth
Stomach size 35ml in full term , ↑25ml monthly to reach 100ml by 3rd mo., 250ml by12mo.
Lumbar puncture at left lateral position , 1cm for term & 0.5cm for preterm
HR<100→IPPV,HR<80→IPPV+Chest compression, HR<60→IPPV+Chest compression +medications
Chest compression just below nipple line, the sternum is compressed 2/3 inch
Flow rate of 02 with incubator minimum of 5L /min, water bottle CPAP 5-10L/min, face mask
4L/min, nasal prong 0.5-2L/min
Low birth weight(LBW)=<2.5Kg,very low birth weight(VLBW)=<1.5 Kkg,Etreme low birth weight(ELBW)=<1kg
Glucose infusion rate(GIR)= (ml/kg x dextrose concentrations ) ÷ 144
Glucose infusion rate(GIR)= (ml/kg x dextrose concentrations ) X 0.007
D% = (GIR) ÷ ( ml/kg) x (0.007) OR D% = ( GIR X 144) ÷ (ml/kg)
D (1) ml x D (1) concentration = D (2) ml x D (2) concentration
Estimation of gestational age
GA 28wks 30wks 32 wks 34 wks 36 wks 38 wks 40 wks
Kg 1 1.25 1.5 2 2.5 3 3.5
Solar 6mo 7mo. 8mo. 9mo.
month
Solar month=(lunar wks-4)÷4 or = (lunar wks÷4) -1
Lunar wks =( solar mo x4)+4 or =(solar mo.+1)x4
GA = (HC-5) x 1.334
GA = length x 0.8
Sole creases : absent <32wks
1-2 crease 36wks
All 40 wks
00
Preparation of fluids (Egypt)
Types of fluids :
D5 1/5 NS = 20%NS +5%D25 +75%D5 ( suitable for neonates&pediatrics ) NS= normal saline
D5 ¼ NS = 25% NS + 5% D25+75%D5 ( suitable for neonates & pediatrics )
D5 1/3NS = 33%NS+ 6%D25+71%D5 ( suitable for isonatremic dehydrations)
D5 1/2NS = 50% NS + 12%D25+38%D5 (for diabetic ketoacidoss&hyponatremic dehydrations )
--------------------------------------------------------------------------------------------------------------------------------------
D7.5 = 50%D10+ 50%D5 ( suitable for neonates)
D 7.5 1/5 NS =20%NS+80%D10 ( suitable for neonates)
D7.5 ¼ NS =25%NS+75%D10
D7.5 1/2NS =50%NS+25%D25 +25%D5
----------------------------------------------------------------------------------------------------------------------------
D10 = 25%D25 + 75%D5 ( suitable for neonates )
D10 1/5 NS =20%NS+30%D25+50%D5 OR: =20%NS+14%D25+66%D10 (for neonates (
D10 ¼NS =25%NS+35%D25+40%D5 OR=25%NS+17%D25+58%D10 (for meningitis)
D10 1/2NS =50%NS+38%D25+12%D5 OR=50%NS+34%D25+16%D10
----------------------------------------------------------------------------------------------------------------------------
D12 = 35%D25 +65%D5 ( suitable for neonates with hypoglycemia )
D12 1/5 NS = 20% NS + 40% D25 +40%D5 A dd kcl 10 meq/l (= neomaint )
D12.5 = 38%D25 +62%D5
D12.5 1/5 NS = 20%NS+42%D25+38%D5
D12.5 ¼ NS = 25%NS+44%D25+31%D5
--------------------------------------------------------------------------------------------------------------
Adding : KCL 15% 1ml/kg/day or 1ml/100ml fluids
Ca 10% 2-5ml/kg/day to be added to the total amount of fluids
Bicarb. 8.4% 1ml/kg/prn diluted with distelled water & given very slowly
----------------------------------------------------------------------------------------------------------------------------
Ex : how to prepare 100ml D5 1/5NS?
100ml D5 1/5NS = NS20%X100ml +D25 5%X100ml+D5 75%X100ml
= NS 20ml +D25 5ml+D5 75ml +1 ml KcL 15%
----------------------------------------------------------------------------------------------------------------------------
NS=0.9%=154meq/L
½ NS=0.45%=77meq/L
1/3 NS = 0.3%= 51 meq/ L
¼ NS = 0.225%= 38.5 meq/L
1/5 NS= 0.18%= 30 meq/L
D5=5gm/100ml , D10=10gm/100ml , D25=25gm/100ml
Kcl 15% = 2mmol/ml
Bicarb.8.4%= 1mmol /ml for each Na or bicarbonates
Daily requirement of electrolytes : Na = 2-4 meq/kg/day ( mean 3)
K = 1-2 meq/kg/day( mean 2)
Ca gluconate 10% = 2-5ml/kg/day ( mean3)
----------------------------------------------------------------------------------------------------------------------------
For neonates :<1 kg use DS 1/5 NS guided with blood sugar &serum electrolyte
1-1.5kg use D 7.5 1/5 NS guided with blood sugar & serum electrolyte
>1.5 kg use D10 1/5 NS guided with blood sugar & serum electrolyte
For neonates with hypoglycemia use up to D12.5 1/5 NS guided with bl.sugar& s.electrolyte
For DKA : use D5 1/2NS
For dehydrations:(isonatremic use D5 1/3NS),( hypo.use D5 1/2NS ± bicarb),( hyper.Use D5 1/5 NS )
NB: pediamaint : D10¼NS =25%NS+35%D25+40%D5 OR=25%NS+17%D25+58%D10 add kcl 1ml/dl, ca gluc. 4ml/dl
Neomaint : D12 1/5 NS = 20% NS + 40% D25 +40%D5 A add kcl 0.5ml/dl
02
Different glucose concentrations
Glucose 5% = ready made
Glucose 7.5% = 50% D5 +50% D10
Glucose 12.5% = 38% D25 +62 %D5
Glucose 15% = 50% D5 +50 %D25
Glucose 17.5% = 50% D25 +50% D10
Glucose 20% = 75% D25 +25% D5
Glucose 30% = 50% D10 +50% D50
‫ والتي سيأتي شرحها الحقا‬Mohamed ̉s formula ‫تستطيع تحضير أي تركيز تريده بواسطة‬
GLUCOSE GLUCOSE GLUCOSE

CONCENTRATION 5% 25%
Glucose 6% 0.95 0.05

Glucose 7% 0.9 0.1
Glucose 8% 0.85 0.15
Glucose 9% 0.8 0.2
Glucose 10% 0.75 0.25
Glucose 11% 0.7 0.3
Glucose 12% 0.65 0.35
Glucose 12.5% 0.625 0.375
Glucose 13% 0.6 0.4
Glucose 14% 0.55 0.45
Glucose 15% 0.5 0.5
Glucose 16% 0.45 0.55
Glucose 17% 0.4 0.6
Glucose 18% 0.35 0.65
Glucose 19% 0.3 0.7
Glucose 20% 0.25 0.75
Glucose 21% 0.2 0.8
Glucose 22% 0.15 0.85
Glucose 23% 0.1 0.9
Glucose 24% 0.05 0.95
03
Preparation of fluids (Saudia)
Types of fluids:
D5 1/5 NS = 20%NS +7%D20 +73%D5 ( suitable for neonates )
D5 ¼ NS = 25% NS + 9% D20+665D5 ( suitable for neonates & pediatrics )
D5 1/2NS = 50% NS + 17%D20+33%D5 ( suitable for diabetic ketoacidoss )
D7.5 = 17%D20 + 83%D5 ( suitable for neonates )
D 7.5 1/5 NS =20%NS+23%D20+58%D5 ( suitable for neonates )
D7.5 ¼ NS =25%NS+25%D20+50%D5
D7.5 1/2NS =50%NS+33%D20+18%D5
D10 = 33%D20 + 66%D5 ( suitable for neonates )
D10 1/5 NS =20%NS+40%D20+40%D5 ( suitable for neonates )
D10 ¼NS =25%NS+42%D20+33%D5 ( suitable for meningitis )
D10 1/2NS =50%NS+50%D20
D12 = 47%D20 +53%D5 ( suitable for neonates with hypoglycemia )
D12.5 = 50%D20 + 50%D5
D12.5 1/5 NS = 20%NS+57%D20+23%D5
D12.5 ¼ NS = 25%NS+58%D20+17%D5
D12.5 ½NS = 50%NS+19%D20+30%D10
Adding : KCL 15% 1ml/kg/day or 1ml/100ml fluids
Ca 10% 2-5ml/kg/day or 3 ml/100ml fluids
Ex : how to prepare 100ml D5 1/5NS ?
100ml D5 1/5NS= NS20%X100ml +D20 7%X100ml+D5 73%X100ml
=NS 20ml +D20 7ml+D5 73ml +1 ml Kcl 15%+3 ml Ca
Notes : D=dextrose - NS = normal saline
This preparation is ready made in Saudi Arabia
%45 ‫ بدال من‬%41 ‫ وهى تختلف عن مصر فى توافر الجلوكوز بتركيز‬، ‫هذه التحضيرات موجودة جاهزة في السعودية‬
04
How you can prepare any types of fluids ?
Mohamed ̉s formula
Always choose 2 concentrations suitable for required preparation
Ex: choose D5% (D%1) &D10%(D%2) to prepare D7.5% (D% required)
choose D10% (D%1) &D20%(D%2) to prepare D12.5% (D% required)
Ignore negative signals Ex : - 150 consider it 150
5 5
Use this formula :
D%1 volume = D% required x total IVF - D%2 x Total dextrose volume
D%2- D%1
D%2 volume = the remaining = Total dextrose volume - D%1 volume
Notes: D%1 = lower %Glucose concentration , D%2 =higher %Glucose concentration
Examples :
Total IVF100ml , additives (saline ,ca, kcl ) 20ml , required glucose concentration is D7.5% how to prepare?
Total dextrose volume = 100-20=80ml
Suitable concentration is D5% ( D%1) , D10% (D%2)
D5% volume = 7.5 x 100 – 10 x 80 = 10ml
10-5
D10% volume = the remaining = 80-10=70 ml
*********************************************************
Total IVF 200 ml , additives 50ml , required glucose concentration is D12.5% how to prepare ????
D10% volume = 12.5 x 200 – 25 x 150 = - 1250 =83.3ml
25-10 15
D25% volume = the remaining =150-83.3=66.7ml
*******************************************************
Total IVF 100ml, additives 20ml , required glucose concentration is D5% how to prepare ??????????
D5% volume = 5 x 100 – 10 x 80 = - 300 = 60ml
10-5 5
D10% volume = the remaining = 80-60=20 ml
‫ عندما تختار تحضير المحاليل يجب أن تختار محلول أقل تركيزا ومحلول أكبر تركيزا من المحلول المطلوب‬: ‫ملحوظة‬
%21 ‫ ودكستروز‬%5‫ دكستروز أذن عليك ان تختار دكستروز‬%5.5 ‫فمثال تريد تحضير‬
.‫معظم التحضيرات المطلوبة موجودة وماعليك هو أن تحسب التركيز المطلوب للطفل وتختار أقرب التحضيرات إليه‬
: ‫معظم حديثي الوالدة يحتاجون تركيزيين اثنين هما‬
D10 1/5 NS =20%NS+30%D25+50%D5 OR: =20%NS+14%D25+66%D10
D10 ¼NS =25%NS+35%D25+40%D5 OR=25%NS+17%D25+58%D10
05
‫مثال آخر ‪:‬‬
‫عاوز أحضر ‪ 51‬ملل جلوكوز ‪ %4‬؟‬
‫أختر تركيزين يقع بينهما التركيز المطلوب‬
‫إذن سوف أختار ‪ D5%‬و ‪D10%‬‬
‫سوف أحضر ‪ D5%‬وبقية المحلول هي ‪D10%‬‬
‫بتطبيق المعادلة السابقة ‪:‬‬
‫‪D%1 ml = D5%ml‬‬
‫‪D% required= 8%‬‬
‫‪Total IVF = 50 ml‬‬
‫‪D%2‬‬ ‫‪= D10%‬‬
‫‪Total dextrose volume=50ml‬‬
‫‪D%1 ml ( D%2- D%1 ) = D% required x Total IVF - D%2 x Total dextrose ml‬‬
‫‪D5% ml ( 10 – 5‬‬ ‫‪) =8‬‬ ‫‪x 5o‬‬ ‫‪- 10 x 50‬‬
‫‪D5% ml ( 5‬‬ ‫‪) = 400 - 500‬‬
‫‪D5% ml ( 5‬‬ ‫(تجاهل اإلشارة السالبة ) ‪) = - 100‬‬
‫‪D5% ml = 20 ml‬‬
‫) يساوى الباقي ( ‪D10% ml = 50 ml-20ml= 30ml‬‬
‫‪06‬‬
‫تعديل تركيبة نيومينت‬
‫كثيرون يحبون استخدام تركيبة النيومينت ونظرا ألن الجلوكوز فيها بتركيز عالى فهى‬
‫التصلح لناقصي الوزن وإنما تصلح للطفل المولود ألم مصابة بالسكرى وهنا تحضيرتين‬
‫تناسب معظم األوزان ‪ :‬أوال‬
‫تركيبة نيومينت هي ‪:‬‬

‫‪D12%1/5 NS + Kcl 10meq/L= Dextrose 12%+.0.2%saline+kcl 10meq/L‬‬
‫‪-----------------------------------------------------------‬‬
‫لتعديله الى ‪D10%1/5 NS:‬‬
‫*‪-‬اسحب من زجاجة نيومينت ‪ 65‬سم‬
‫*‪-‬أضف بدال من الكمية المسحوبة ‪ 21‬سم سالين ‪ 54+‬سم جلوكوز ‪ 1.1+ %5‬سم‬
‫كلوريد البوتاسيوم ‪%25‬‬
‫تستخدم فى حديثى الوالدة فوق ‪ 2.5‬كجم بداية من اليوم الثانى‬
‫‪---------------------------------------------------------‬‬
‫لتعديلة إلى ‪D7.5%1/5 NS:‬‬
‫اسحب من زجاجة نيومينت ‪ 221‬سم‬
‫اضف بدال من الكمية المسحوبة ‪ 44‬سم سالين ‪ 222 +‬سم جلوكوز ‪ 1.5 + %5‬سم‬
‫كلوريد البوتاسيوم ‪%25‬‬
‫تستخدم فى حديثى الوالدة من وزن ‪ 2.5-2‬كجم بداية من اليوم الثاني‬
‫‪------------------------------------------------------------‬‬
‫ملحوظات ‪:‬‬
‫نسبة البوتاسيوم ثابتة فى نيومينت والتركيبة المعدلة وهى ‪10meq/L‬‬
‫نيومينت والتركيبة المعدلة خالية من الكالسيوم ويجب إضافته‬
‫‪1/5 NS=0.2%NS=30meq/L sodium chloride‬‬
‫‪07‬‬
‫بروتوكول مستشفى حراء بمكة المكرمه‬
Daily needs of fluids in neonates
Wt /Days 1day 2 3 4 5 7 10 15
< 1200 gm 100-120 130-150 140-160 140-160 160 170 Up180 Up200
>1200gm 70 90 110 130 140 150 160 180
Full term 60 70 80 90 100 150
Increase 10-20ml/kg or 20% of total amount of IVF in phototherapy

Daily allowance of electrolytes
Sodium : 3meq/kg/day
Potassium :2.5 meq/kg/day
Calcium :35-45 mg/kg/day
Magnesium :0.5meq/kg/day
Phosphorus :45mg/kg/day
Sodium (Nacl 3%):3mmol (6ml)/kg/day starting from 2nd day of life. {ml = mmol(meq) x 2 }
nd
Sodium (Nacl 0.9%):3mmol (19.8ml)/kg/day starting from 2 day of life {ml = mmol (meq) x 6.6 }
Potassium (Kcl 15%):2.5 mmol( 1.25ml) /kg/day { ml = mmol(meq) x 0.5 }
Calcium gluc10%:35mg(4ml)-45mg(5ml)/kg/day(mean 3ml/kg/day) {mmol = ml x 0.23 }
Mg sulphate 10%: 0.5meq/kg/day :0.6ml/kg/day {ml = meq x 1.25 }
***************************************************************
Daily allowance of protein
Amino Acid : (10% ) ,(15%) can be started from 3rd day of life by;
*(10%):(0.5 gm =5ml) /kg/day increment 0.5gm/kg/daily Max 3gm/kg/day(for preterm <1200)
&2.5gm/kg/day (for preterm >1200)
*(15%):(0.5gm =3.3ml)/kg/day increment the same-----------------------------------
NB :(0.5gm) from 10%= 5ml , (0.5gm) from 15%= 3.3ml

:(10%: ml=gmxl0) {15%: ml=gmx6.6}
Daily allowance of lipids (needs special center)
Intralipid sol.10%.20%
(10%) :(0.5 gm =5ml) /kg/day increment 0.5gm/kg/daily Max 2gm/kg/day
NB:(10%: ml=gm xl0) : 10% solution = 1ml/1kcal – 20% solution = 1ml/2kcal
Special precaution :Severe jaundice, sepsis,thrombocytopenia<50000, severe RDS, ELBW before 6th day of life
Control : glycemia ,glucosuria, cholesterol, triglyceride
NB: Ca gluconate 10% -------------- lml=100mg=9mg elemental=0.23mmol

Mg sulphate 10% ------------- lml=100mg=0.8mmol
Kcl l5%--------------------- lml=2mmol
Nacl 14.6%----------------- lml=2.5mmol
Nacl 3%--------------------lml=0.5mmol
Nacl 0.9%------------------lml=0.15 mmol
Na bicarbonate 8.4%---------lml=1 mmol
Amino acid 10 ------------- lml=0.1 gm
Amino acid 15%------------ 1ml=0.5gm
‫بروتوكول وزارة الصحة المصرية‬

08
Wt /Days 1day 2 3 4 5 7 10 15
< 1000 gm 221 D5% 120 130 140 150 170 180 200
1000-1500gm 100 D7.5% 120 130 140 150 160 160 180
1500-2500gm 80 D10% 100 120 130 140 150
> 2500 gm 60 D10% 80 100 120 140 150
Daily allowance of electrolytes

Sodium : 3meq/kg/day- (Nacl 0.9%= 19.8ml/kg/day)
Potassium :2 meq/kg/day-> (Kcl 15%= 1ml/kg/day )
Calcium :35-45 mg/kg/day-> (Calcium gluc10%=4ml-5ml/kg/day(mean 3ml/kg/day)
Magnesium :0.5meq/kg/day (Mg sulphate 10%= 0.5meq/kg/day :0.6ml/kg/day )
Precautions :
Subtract ml/kg/day ( 20 in RD, 70 in ARF,10 in MV,30 in cardiac failure & CNS infections)
Add 20ml/kg/day with phototherapy
Add sodium for VLBW if serum Na <135 & D/C if is >140mcq/L
Don’t add potassium until urine output is established
D/C maintenance iv calcium if the baby is tolerating at least 15ml feed/3h
Don’t infuse a concentration > D12.5% in peripheral vein.
Subtract the volume of dilution drugs( as dopamine) from total IVF volume.
If urine glucose is 2+ readjust glucose infusion
Glucose infusion at a rate of 4-6mg/kg/min in FT& 4-8mg/kg/min in PT to keep serum glucose bet.50-120mg/dl.
Glucose infusion rate(GIR)= (fluid rate(ml/h)
x dextrose concentration) ÷ 6 x kg
Glucose infusion rate(GIR)= (ml/kg x dextrose concentrations ) ÷ 144
Glucose infusion rate(GIR)= (ml/kg x dextrose concentrations ) X 0.007
EX : what is the GIR for baby 1.5 kg , receiving 120 ml/kg/day of D10%?
GIR= (fluid rate(ml/h) x dextrose concentration) ÷ 6 x kg = (7.5 x 10 ) ÷ 6x 1.5=8.3mg/kg/min
GIR= (ml/kg x dextrose concentration ) ÷ 144= (120 x 10) ÷ 144= 8.3mg/kg/min
GIR= (ml/kg x dextrose concentration ) X 0.007= (120 x 10) x 0.007=8.3mg/kg/min
Daily allowance of protein

Amino Acid :
can be started from 3rd day of life added to total fluids .
Start with 1.5-2gm/kg/day advance by 1gm/kg/day to a target of
4.0 gm/kg/day (infant<1,000gm)
3.5 gm/kg/day (infant<1,500gm)
3.0 gm/kg/day (infant>1,500gm)
Advance more slowly in unstable preterm infants and those in shock or renal insufficiency.
When OGT feed is establish decrease amino acid gradually
Monitor BUN if rising don’t increase the rate of infusion.
Available preparation : (250-500ml bottles)
Panamin G 2.7% ->(2.7 gm protein / 100ml)(1gm=37ml)
Panamin SG 8% ->( 8gm protein / 100ml) (1gm=12.5ml)
Aminovenous 10%->(10gm protein /100ml) ( 1gm= 10ml)
Aminovenous 6%->(6gm protein /100ml) ( 1gm= 16.6ml)
Vamin N 7%--> ( 7 gm protein / 100ml) (1gm=14.2ml)
Daily allowance of lipids :
Needs special centers ‫القبل لنا بها‬
Vitamin and trace elements : 1ml/100ml solution
09
Aminovenous10%
10 gm/100ml ( 1gm= 10ml )
Start with 1.5gm/kg/day advance by 0.5gm/kg/day
Start with (15ml/kg/day advance by 5ml/kg/day to a target of (35ml/kg/day) infant<1.500gm)
Start from 3rd day of life

Doses :
Start with 15ml/kg, ↑5ml/kg daily up to 35ml/kg
The amount of glucose % should ↑ to compensate for ↓ of total amount
1st dose : 15ml/kg + fluids
2nd dose : 20ml/kg + fluids
3rd dose : 25ml/kg + fluids
4th dose : 30ml/kg + fluids
Once the bottle is opened don’t use the remain
PanaminG 2.7%( not suitable)

2.7 gm/100ml ( 1gm= 37ml )

Doses :
Pan amin G is not suitable because of low concentration of protein
‫ الجهل وحش ؟؟؟؟؟؟‬، %21 ‫وهللا كنا نستخدمه زمان بجهل على أساس أن تركيزه‬
21
Panamin SG 8%
8gm protein / 100ml (1gm=12.5ml)

Doses :
Calories calculation
Milk (standard f67)= ml/day x 0.67
Milk (preterm f80)= ml/day x 0.80
Protein = aminoacid% x ml/day x 0.04
CHO (Dextrose) = D% x ml/day x 0.034
lipids = intralipid% x ml/day x 0.09
Another methods :
Protein = gm/day x 4
CHO (Dextrose) = gm/day x 3.4
lipids = gm/day x 9
Ex 1:
Parenteral nutrition was established in 1.2kg preterm infant , D12.5% dextrose , 3gm/kg
was running at 120ml/kg/day,intralipid 20% was running at 0.8ml/h calculate total calories ?
1.2kg
D12,5%
Protein 3gm/kg/day
Intralipid 20% 0.8ml/h
Fluids : 120ml/kg/day
Dextrose energy = D% x ml/day x 0.034=12.5 x 120 x 0.034=51 cal
Protein energy = gm/day x 4 = 3 x 1.2 x4 = 14.4 cal
Lipids energy = intralipid% x ml/day x 0.09= 20 x (0.8 x 24) x 0.09= 34.5
Total calories = 51+14.4+34.5= 100
IE : 83 cal/kg
20
Ex 2:
Preterm baby 2kg,day 3 of life , started TPN after 24h of life
Calculate energy & GIR?
Total fluid intake= 110ml/kg/day
Aminoacid : 3gm/kg/day ie aminovenous 10% = 30ml/kg/day
Lipid : 2gm/kg/day ie intralipid 20% = 10ml/kg/day
Na : 3meq /kg/day ie saline 9% = 20ml/kg/day
Kcl 15% : 2meq /kg/day = 1ml/kg/day
Ca gluconate 10%: = 3ml/kg/day
Vitamin and trace elements : 1ml/100ml solution
Total fluid intake =110X2=220 ml
Intralipid 20% = 20ml
Remaining = 200ml composed of
Aminovenous 10% = 60ml
Saline = 40ml
Kcl = 2ml
Ca glu = 6ml
Solu vit = 2ml
Trace = 2ml
Fluid except D% = 112 ml
D% = 200- 112 = 88ml ( which concentration???????????)
If we choose D% 10%
GIR= (ml/kg x dextrose concentration ) X 0.007= 44 x 10 x 0.007= 3mg/kg/min
If we choose D% 20%
GIR= (ml/kg x dextrose concentration ) X 0.007= 44 x 20 x 0.007= 6mg/kg/min
S0 the best choice is D20%
‫من هذا المثال تعالى نحسب تركيز الجلوكوز في هذه التركيبة ؟‬
‫ كم يساوى بالجرامات ؟؟؟؟؟؟‬%41 ‫ ملل جلوكوز‬44 ‫عندنا‬
‫ ملل‬211 ----------------- ‫ جرام‬41
‫ ملل‬44------------------‫؟؟؟؟؟؟؟؟؟‬
‫ جم جلوكوز‬25.6 = 211 / 44× 41 = ‫ ملل فيهم‬44 ‫إذن‬
‫ ملل محلول وهذا هو التركيز ؟‬211 ‫ ملل محلول ياترى كم جرام مذاب في‬411 ‫ جم جلوكوز مذابين قي‬25.6 ‫وبما أن‬
‫ على الرغم‬D8.8% ‫ أي‬4.4 ‫ ملل محلول إذن تركيز الجلوكوز في المحلول هو‬211 ‫ جم جلوكوز مذاب في‬4.4 ‫بالنظر‬
‫ ؟؟؟؟؟؟؟؟؟‬%41 ‫أنك أضفت جلوكوز‬
‫إذا كنت ضعيف في الحساب زى حالتى استخدم عملية المقص علشان ماتوهش بمعنى‬
‫ ملل‬411 ------------- ‫ جم‬25.6
‫ ملل‬211---------------‫؟؟؟؟؟؟؟؟؟؟‬
% 4.4 ‫ إذن التركيز النهائي للجلوكوز هو‬4.4 = 411 / 211 × 25.6 = ‫؟؟؟؟؟؟‬
-----------------------------------------------------------------------------------------------------------------------------------
: ‫هذه المعادلة‬
GIR= (ml/kg x dextrose concentration ) X 0.007
: ‫ و القيم الطبيعيه كاآلتى‬mg/kg/min ‫نحسب منها كمية الجلوكوز مقدرة‬

Glucose infusion at a rate of 4-6mg/kg/min in FT to keep serum glucose bet.50-120mg/dl.
22
‫‪4-8mg/kg/min in PT to keep serum glucose bet.50-120mg/dl.‬‬
‫هل من الممكن عكس المعادلة وتطبيقها على الحالة السابقة ؟؟؟‬
‫كيف ؟؟؟؟؟؟؟؟؟‬
‫يعنى عندنا طفل وزنه ‪ 4‬كجم‬
‫وباقى له من المحلول بعد الحسابات ‪ 44‬ملل‬
‫نريد أن نعطيهم له جلوكوز ؟ والندرى أى تركيز نختار ؟‬
‫ولكن عندنا قاعدة بتقول أنه يأخذ ‪ 4-8mg/kg/min‬؟؟؟؟‬
‫طيب عاوزيين نعطيه فرضا ‪6mg/kg/min‬‬
‫بتطبيق المعادلة ‪،-----------------------------------------------‬‬
‫‪GIR= (ml/kg x dextrose concentration ) X 0.007‬‬
‫‪6 = ( 88/2) x D% X 0.007‬‬
‫‪IE D% = 20%‬‬
‫)‪D% = (GIR‬‬ ‫÷‬ ‫)‪( ml/kg) x (0.007‬‬

‫)‪D% = ( GIR X 144‬‬ ‫÷‬ ‫)‪(ml/kg‬‬
‫نفترض عاوزين نعطية‬

‫‪4mg/kg/min‬‬
‫بتطبيق المعادلة التى ترتاح لها وأنا حأختار الثانية‬
‫)‪D% = ( GIR X 144) ÷ (ml/kg‬‬
‫‪= 8 x 144 ÷ 44‬‬
‫‪= 26%‬‬
‫وهذا التركيز غير موجود لو فيه ‪ % 45‬يمشى ؟؟؟‬
‫إيه الحل ؟؟؟ ال يوجد حل ؟؟؟؟؟‬
‫واحد يقول نحضر ‪ %45‬بواسطة جلوكوز ‪ %51‬والجلوكوز ‪ %21‬نعم يجوز ولكن‬
‫تعالى األول نشوف هذا التركيز بيكون شكله إيه لما يضاف لكامل المحلول ؟؟؟؟ نكمل في وقت الحق ؟؟؟؟‬
‫‪ 45‬جم جلوكوز ‪ 211 --------------‬ملل‬
‫؟؟؟؟؟؟؟؟؟؟؟؟ ‪ 44 ----------------‬ملل‬
‫إذن ‪ 44‬ملل من الجلوكوز ‪ %45‬يحتوى ‪ 44‬جم جلوكوز‬
‫وبما أن ‪ 44‬جم جلوكوز مذابين في ‪ 411‬ملل محلول إذن تركيز الجلوكوز هو‬
‫‪44‬جم ‪ 411 -----------------------‬ملل‬
‫؟؟؟؟؟؟ ‪ 211-------------------------‬ملل‬
‫اذن التركيز هو ‪)D11%( 22‬‬
‫إذن يتضح لنا باختصار شديد أن هذا الجدول هو الجدول العام الذي يجب أن نعتبره كعالمة على الطريق ‪.‬‬
‫‪Wt‬‬ ‫‪D%‬‬
‫‪< 1000 gm‬‬ ‫‪D5%‬‬
‫‪1000-1499gm‬‬ ‫‪D7.5%‬‬
‫‪1500-2500gm‬‬ ‫‪D10%‬‬
‫‪> 2500 gm‬‬ ‫‪D10%‬‬
‫ويمكن أن تعدل طبقا لتحليل السكر بالدم بمعنى لو أعطيت جلوكوز ‪ %5‬ووجدت السكر بالدم هابط ارفع إلى‬
‫التركيز األعلى أي ‪ %5.5‬وهكذا‬
‫ولكن سوف تقابلك مشكلة أخرى وكلنا نقع قيها ‪ ،‬بل أنت بالفعل وقعت قيها وسوف أوضحها بهذا المثال‬
‫?‪Preterm baby 2kg,day 3 of life , IV fluids‬‬

‫‪Total fluid intake= 110ml/kg/day‬‬
‫‪Na‬‬ ‫‪: 3meq /kg/day ie saline 9%‬‬ ‫‪= 20ml/kg/day‬‬
‫‪23‬‬
‫‪Kcl 15% : 2meq /kg/day‬‬ ‫‪= 1ml/kg/day‬‬
‫‪Ca gluconate 10%:‬‬ ‫‪= 3ml/kg/day‬‬
‫‪Total fluids = 110 x 2kg = 220 ml‬‬
‫‪Saline 9%= 20ml/kg/day= 2x 20=40 ml‬‬
‫‪Kcl 15% =1ml/kg/day= 2x 1 = 2ml‬‬
‫‪Ca gluco10%= 3ml/kg/day=3 x2 = 6 ml‬‬
‫)‪The remaining of fluid will be D 10% ( according to above schedule‬‬
‫‪D10% = 220- 48= 254 ml‬‬
‫لو بحثنا عن تركيز الجلوكوز ال ‪ %21‬بعد إضافته للمحلول السابق‬
‫يعنى ‪ 254‬ملل جلوكوز ‪ %21‬مذابين مع محاليل أخرى ليكونوا ‪ 441‬ملل محلول‬
‫يصبح تركيز الجلوكوز بالعملية الحسابية السابقة ( موش كل مرة أكتب الطريقة؟؟ ) يصبح ‪%5.4‬‬
‫أي بعد اإلضافات تغير تركيز الجلوكوز وهذا هو الخطأ الفادح الذي نقع فيه ؟؟؟؟؟؟؟؟؟؟؟؟؟؟؟؟؟؟؟‬
‫فى البروتوكول السعودي يستخدمون محلول ‪ Nacl 3%‬ونحن فى مصر نستخدم ‪Nacl 0.9%‬‬
‫وهذا يؤدى فى البروتوكول السعودي إلى صغر كمية المحاليل المضافة والتي ال تؤثر كثيرا في تركيز الجلوكوز‬
‫‪Sodium (Nacl 3%):3mmol (6ml)/kg/day starting from 2nd day of life.‬‬
‫‪Sodium (Nacl 0.9%):3mmol (19.8ml)/kg/day starting from 2ndday of life‬‬
‫ففى المثال السابق كمية السالين = ‪ 21‬ملل‬
‫أما لو استخدمنا )‪ 24 = 4 × 6 = (Nacl 3%‬ملل‬
‫ولو طبقنا نفس المعطيات السابقة مستخدمين الطريقة السعودية سيصبح تركيز الجلوكوز بعد اإلضافات هو ‪) D9%( %9‬‬
‫إذن أنت أمام عدة خيارات وعليك أن تختار السهل والسريع والقريب من الصح‬
‫أما الطريقة الجديدة السهلة والبسيطة والتي سوف تنال إعجابك هي طريقة التحضيرات الثابتة وهى دقيقة مائه بالمائة وسهله سهولة شرب الماء‬
‫ألن فيها تركيز ثابت للجلوكوز والصوديوم وهى كالتالي‬
‫أقل من ‪2‬كجم‬
‫‪D5 1/5 NS = 20%NS +5%D25 +75%D5 start with this preparation if Na is low shift to‬‬
‫‪D5 ¼ NS‬‬ ‫‪= 25% NS + 5% D25+75%D5‬‬
‫‪2‬كجم إلى أقل من ‪ 2.5‬كجم‬

‫‪D 7.5 1/5 NS =20%NS+80%D10‬‬
‫‪D7.5 ¼ NS‬‬ ‫‪=25%NS+75%D10‬‬
‫‪ 1.5‬كجم إلى مافوق ‪:‬‬

‫‪D10 1/5 NS =20%NS+30%D25+50%D5 OR: =20%NS+14%D25+66%D10‬‬
‫‪D10 ¼NS‬‬ ‫‪=25%NS+35%D25+40%D5 OR=25%NS+17%D25+58%D10‬‬
‫لو طفل ألم مصابة بالسكري وتريد تركيز عالي من الجلوكوز‬

‫‪D12.5 1/5 NS‬‬ ‫‪= 20%NS+42%D25+38%D5‬‬
‫‪D12.5 ¼ NS‬‬ ‫‪= 25%NS+44%D25+31%D5‬‬
‫‪Or use neomaint= D12%1/5 NS + Kcl 10meq/L‬‬
‫وهى مشروحا شرحا وافيا أعاله واليك هذا المثال للتذكرة ‪:‬‬
‫?‪Ex : how to prepare 100ml D5 1/5NS‬‬

‫‪100ml D5 1/5NS = NS 20% X 100ml + D25 5% X100ml + D5 75% X 100ml‬‬
‫‪= NS 20ml + D25 5ml + D5 75ml‬‬
‫‪24‬‬
‫إذن عليك فقط تحديد كمية المحاليل والمعادلة تكمل لك نوعية المحاليل ‪،،،،،،،،،،،،،،،،،،،،،،،،،،،،،،،،،،،،‬‬
‫دعنا نأخذ بعض االمثلة للتحضيرات ‪:‬‬
‫أوال نسمى الطرق المختلفة بمسمياتها‬
‫طريقة الترزى ‪ :‬وهى الطريقة التى تفصل فيها لكل طفل محاليله على حدة وهى أدق طريقة‬
‫طريقة المستسهل ‪ :‬وهى الطريقة التي نحسب بها كل حسابات المحاليل والباقى نجعله جلوكوز حسب الجدول المتعارف عليه‬
‫الطريقة الثابتة ‪ :‬وهى طريقة المحاليل الثابتة وهى جيدة أيضا ودقيقة وتتغير التركيزات قليال في حالة إضافة البروتين‬
‫ولكنها عامله زى القطار الذي اليقف االفى المحطات الكبيرة‬
‫دعنا نأخذ مثال واحد للجميع حتى تتضح الصورة ‪:‬‬
‫& ‪How to calculate fluid requirement as regards water, electrolyte ,minerals‬‬

‫‪aminoacids of PT baby weighing 1.5kg , 5 day old admitted in NICU with RD.‬‬
‫طريقة الترزي‬
‫‪*Total fluids : 130 ml/kg/day‬‬
‫‪*Subtract 20 ml/kg/day bec. RD‬‬
‫‪*Total fluids after subtraction= 110ml/kg/day= 1.5 x 110= 165ml/day‬‬
‫)‪*Na requirement : 1.5 x 20= 30 ml ( saline 0.9%‬‬
‫)‪*Ca requirement : 1.5 x 3 = 4.5 ml ( ca gluco 10%‬‬
‫)‪*Ka requirement : 1.5 x 1 = 1.5 ml ( Kcl 15%‬‬
‫‪*Aminoacid‬‬ ‫)‪:3gm/kg/day=1.5x 3x 10=45ml( Aminovenous 10%‬‬
‫‪*Glucose is the remaining = 165- (30+4.5+1.5+45)=84 ml‬‬
‫)‪GIR for preterm baby = 4-8mg/kg/min ( start with 4‬‬
‫)‪D% = ( GIR X 144‬‬ ‫÷‬ ‫)‪(ml/kg‬‬
‫)‪= (4 x 144) ÷ (84/1.5‬‬
‫‪= 576 ÷ 56‬‬
‫‪= 10%‬‬
‫‪So glucose needed= 84 ml D10%‬‬
‫وعلشان نسهل المقارنة تعالى نشوف تركيز الجلوكوز على كامل المحلول‬
‫‪ 42‬ملل جلوكوز ‪ %21‬مذابين فى ‪ 265‬ملل محلول ‪ ---‬إذن تركيز الجلوكوز بعد الحسابات والذي منه هي ‪D5%‬‬
‫واذا رفعنا ال ‪ GIR‬الى ‪: 8 mg /kg/min‬‬
‫)‪D% = ( GIR X 144‬‬ ‫)‪÷ (ml/kg‬‬
‫‪= 8 x 144‬‬ ‫)‪÷ (84/1.5‬‬
‫‪= 20%‬‬
‫‪ 48‬ملل جلوكوز ‪ %02‬مذابين فى ‪ 561‬ملل محلول إذن تركيز الجلوكوز النهائى يصبح ‪D10%‬‬
‫اذن ‪ 4mg/kg/min‬تعطينا تركيز ‪ D5%‬و ‪ 8mg/kg/min‬تعطينا تركيز ‪D10%‬‬
‫اذن هذا الطفل يحتاج من ‪ D5%‬يزداد بحد أقصى الى ‪D10%‬‬
‫طريقة المستسهلين ‪:‬‬

‫بما أن الطفل ‪ 2.5‬كحم سوف نضيف كمية الجلوكوز المتبقية فى صورة ‪ D10%‬أي سوف نضيف ‪ 42‬ملل ‪D10%‬‬
‫وبالعملية الحسابية إياها ‪ 42‬ملل ‪ D10%‬مذابين فى مجموع ‪ 265‬ملل محلول إذن تركيز الجلوكوز النهائي هو ‪D5%‬‬
‫ولو أردنا أن نحسب ‪ GIR‬لهذا التركيز‬
‫‪GIR= (ml/kg x dextrose concentration ) ÷ 144‬‬
‫‪= 56 X 10 ÷ 144‬‬
‫‪= 3.8 mg/kg/min‬‬
‫‪25‬‬
‫الطريقة الثابتة ‪:‬‬
‫‪D10 ¼NS‬‬ ‫‪=25% NS + 35% D25 + 40% D5‬‬
‫‪We want to prepare fluid without aminoacid& ca&kcl = 165-(45ml+4.5+1.5) = 114 ml‬‬
‫‪D10 ¼NS‬‬ ‫‪=25%NS+35%D25+40%D5‬‬
‫)‪= NS (114 X 25%) + D25 (114 X 35%) + D5 (114 X 40%‬‬
‫)‪= NS (28.5) + D25 (39.9) + D5 (45.6‬‬
‫‪Saline= 28.5 ml‬‬

‫) ‪Dextrose = D25 (39.9) + D5 (45.6)= (D14.3%- 85.5 ml‬‬
‫‪Ca = 4.5 ml‬‬
‫‪Ka = 1.5 ml‬‬
‫‪Aminoacid =45ml‬‬
‫‪Total = 165 ml‬‬
‫ياترى التركيز النهائى للجلوكوز كام ؟؟؟؟؟؟؟؟؟؟ هو ‪D7.4%‬‬

‫وبحساب ‪ GIR‬لهذه الطريقة‬
‫أوال ‪ :‬مجموع دكستروز بالجرامات يساوى ‪ 24.45‬ومجموع دكستروز مقدرا بالملل يساوى ‪ 45.5‬ملل‬
‫اذن عندنا دكستروز بتركيز‪ 22.1 %‬جم مذابين فى ‪ 45.5‬ملل محلول‬
‫اذن خلطة دكستروز ‪ %5 +%45‬تعمل لنا تركيز ‪% 22.1‬‬
‫اذن نستطيع أن نشيل دكستروز ‪ %5 +%45‬ونعوض عنها بتركيز جلوكوز ‪%22.1‬‬
‫ونحسب منه التركيز النهائى للجلوكوز عندما يضاف للمحاليل الكلية‬
‫أى نقول عندنا ‪ 45.5‬ملل جلوكوز بتركيز ‪ %22.1‬عند اذابتهم مع العناصر االخرى ليكونوا محلوال كليا قدره ‪ 265‬ملل‬
‫فان تركيز الجلوكوز النهائى فى كامل المحلول يصبح ‪D7.4‬‬
‫‪GIR= (ml/kg x dextrose concentration ) ÷ 144‬‬

‫‪= 85.5/1.5 x 14.3 ÷ 144‬‬
‫‪= 57‬‬ ‫‪X 14.3 ÷ 144‬‬
‫‪=5.6 mg/kg/min‬‬
‫اذن خالصة القول لو الحظت لوجدت أن الطريقة الثابتة طريقة وسطية وسهلة ودقيقة ولك الخيار‬
‫حييجى واحد يقوللى الكالم اللى انت بتقوله موش عاجبنى أنا عاوز تركيز الجلوكوز الكلى ثابت واليتغير مهما كانت اإلضافات‬
‫ونأخذ المثال السابق وتعالى نأخذ طريقة المستسهلين ‪:‬‬
‫بما أن الطفل ‪ 2.5‬كحم سوف نضيف كمية الجلوكوز المتبقية فى صورة ‪ D10%‬أي سوف نضيف ‪ 42‬ملل ‪D10%‬‬
‫وبالعملية الحسابية إياها ‪ 42‬ملل ‪ D10%‬مذابين فى مجموع ‪ 265‬ملل محلول إذن تركيز الجلوكوز النهائي هو ‪D5%‬‬
‫أل أناعاوز تركيز الجلوكوز النهائى ‪ %21‬حسب الجدول العام للتركيزات اللى هو ‪:‬‬
‫‪Wt‬‬ ‫‪D%‬‬
‫‪< 1000 gm‬‬ ‫‪D5%‬‬
‫‪1000-1499gm‬‬ ‫‪D7.5%‬‬
‫‪26‬‬
1500-2500gm D10%
> 2500 gm D10%
‫ ملل من المحاليل‬265 ‫ ملل من الجلوكوز ( بتركيز كذا ) ليذاب فى مجموع‬42 ‫يعنى باختصار شديد أنا عاوز أضيف‬
‫؟‬%21 ‫ليعطينى تركيز نهائى‬
‫ ( كمية السكر بالملل للمحلول األول × تركيزه = كمية السكر بالملل للمحلول الثاني × تركيزه‬: ‫نستخدم هذه المعادلة‬
84 ml x D1 concentration = 165 ml x 10
D1%= 165X 10 ÷ 84 = 19.6%
‫ ملل والتركيز = مطلوب معرفته‬42 = ‫حيث أن كمية الجلوكوز للمحلول االول‬
%21 = ‫ ملل والتركيز المطلوب‬265 = ‫وحيث أن كمية الجلوكوز للمحلول الثانى‬
‫؟‬%21 ‫ ملل معطينا تركيزا نهائيا‬265 ‫ مذابين فى محاليل مجموعها الكلى‬% 29.6 ‫ ملل جلوكوز بتركيز‬42 ‫إذن مطلوب‬
‫كيف تدلل على صدق ماتقول ؟‬
‫نحسب كمية الجلوكوز المذابه فى المحلول الكلى كيف ؟؟؟‬
‫ ملل‬211 ‫ جم مذابين فى‬41 ‫ ملل وللتسهيل خليهم‬211 ‫ جم مذابين فى‬29.4 ‫ يعنى‬% 29.4 ‫جلوكوز‬
‫ ملل‬211 ------- ‫جم‬20
‫ ملل‬42--------- ‫؟؟؟؟؟؟؟‬
‫ جم جلوكوز‬26.4 ‫ ملل بها‬42 ‫إذن‬
‫ ملل من هذا المحلول يحتوى كام جرام جلوكوز وهذا هو التركيز‬211 ‫ ملل محلول اذن‬265 ‫ جم مذابين فى‬16.8
‫ ملل‬265---------------------- ‫ جم‬26.4
‫ ملل‬211 ----------------------- ‫؟؟؟؟؟؟؟؟؟‬
D10% ‫ جم وهو التركيز النهائى معطيا‬21 ‫ ملل من هذا المحلول يحتوى‬211 ‫اذن‬
: ‫ولو حولنا الكالم السابق الى معادلة للتسهيل سنقول‬

D (1) ml x D (1) % = D (2) ml x D (2) %
D1% = (D (2) ml X D (2) %) ÷ D (1) ml
‫ولو طبقنا المثال السابق بالمعادلة السابقة‬
D1% = 165 X 10 ÷ 84 = 19.6%
Feeding Formulas
Humanized milk formula ( healthy infants up to 6mo. When breast milk is scanty or unavailable)
Aptamil1 -------------------1 measure/30ml (prebiotics)
Bebelac 1 ----------------------1 measure/30ml (prebiotics)
Nan 1 -----------------------1 measure/30ml (probiotics)
Bebelac EC ----------------------1 measure/30ml ( low lactose help digestion )
Hero 1 & nutradefence ----------1 measure/30ml (-----, prebiotics, AA,DHA)
S26 gold milk -----------------------1 measure/60ml (vegetabe AA,DHA – near than other F to breast milk)
Similac advance ----------------------1 measure/60ml (prebiotics, high proteins,AA,DHA,)
Follow on formula: ( healthy infants>6mo.—malnutrition)
Aptamil 2 ------------------------1 measure/30ml(Prebiotics)
Bebelac 2----------------------------1 measure/30ml
Nan 2 ------------------------------1 measure/30ml(probiotics)
Hero 2 & nutradefence ---------------1 measure/30ml(-----, prebiotics, AA,DHA)
promil gold milk ---------------------------1 measure/60ml (AA,DHA, 5 nucleotides)
Similac gain advance -------------------------1 measure/60ml
Growing up formula: ( healthy infants>12mo)
27
Progress gold ---------------------1 measure/42ml (80 calories/dl- 5 nucleotides-lutein)(5 measures/210ml)
Bebelac 3 (bebejunior)------------1 measure/30ml
Milupa 3-------------------------------1 measure/30ml (70 calories/dl-prebiotics)
Nan3--------------------------------------1 measure/30ml (probiotics)
Hero 3 nutradefence---------------------1 measure/30ml
Similac gain plus advance----------------1 measure/60ml
low birth weight formula :( preterm<2.5kg) calories 70- 80/dl – high protin,MCT,low lactose)
Bebelac premature ---------------------1 measure/30ml(80cal/dl)
Similac neosure--------------------------------1 measure/60ml (AA,DHA- 4 nucleotides,MCT) (74 cal/dl)
S26 low birth weight RTF (bottle) ready to feed (80cal/dl) ( not avialble )
S26 PDF --------------------------------------1 measure/30ml (AA,DHA- 5 nucleotides,MCT) (preterm post discharge formula)(73.4cal/dl )
Vegetable milk :(Cows milk allergy, lactose intolerance, galactosemia ) (Soy protein, lactose free)
Isomil 1 baby formula <6mo. -------------1 measure/60ml
Isomil 2 follow up >6mo ----------------------1 measure/60ml
Isomil 3 advance->12mo ------------------------1 measure/60ml
Nursoy-------------------------------------------------1 measure/60ml ( not availablenow days )
lactose free :(lactose intolerance, galactosemia )(lactose is replaced by glucose or sucrose)
S26 LF --------------------------------------1 measure/60ml (whey to casein 60/40- corn syrup)
Bebelac FL-------------------------------------1 measure/30ml ( casein 100%- glucose, polysaccarides)
Al 110---------------------------------------------1 measure/30ml
Predigested formula:( intractable diarrhea, malabsorption,cows milk &soy protein allergy)
Pregestimil milk (Protein hydrolysate (peptides), Medium chain triglyceride MCT, lactose free)
Bebelac Pepti junior
Aptamil pepti 1&2
S26 HA ( Not available in egypt)
Aminoacid formula : contains amino acids (peptide free) for severe protein allergy
Neocate LCP
Nutramigen AA(gluten& lactose free)
Anti Regurgitation formula : thickend with cooked cornstarch
S26 AR----------------------------1 measure/30ml
Bebelac AR -----------------------1 measure/30ml
Metabolic formula :
Lofenalac ( for phenyketonuria)
Ketonex ( for maple syrup urine disease)
Hominex ( for homocystinuria)
Specific diseases formula :
Renastart – nephro-lonalac formula ( for renal failure ) low( salt, protein,K,Ph& fluid volume)
Heparon junior , generaid formula ( acute or chronic liver disease)
Protein milk :(used in malnutrition to be added to humanized or any special formula, high protein 3gm/dl)
Sustagen, ,creacon packets, kids formula, growth pediatric formula
Pediasure ---1 measure/60ml(100Kcal%-4 nucleotides-lactose&gluten free-MCT,pre&probiotics) 2-3 serving/day
Items Breast Standard Fresh cows milk Goat Fresh buffalo milk
milk formula
Energy kcal/dl 67 67 67 76 100
Protein gm/dl 1.3 1.5 3.5 higher 4 4.3 gm higher
Whey 80/20 Variable 40/60 20/80 not optimal 20/80 not optimal
(soluble)/casein(insoluble)
Fat gm/dl 3.5 3.5 4.5 higher 4.8 7 higher
CHO gm/dl 7.2 7.2 4.5 lower 4.5 4 lower
(lactose)
Minerals (ash) mg/dl 0.2 0.3-0.4 0.8 0.8 0.8
Ca mg/dl 35 76-115 115 higher 115 higher
Phosphorus mg/dl 15 44-65 95 higher 95 higher
Ca/p ratio 2/1 variable 1.1/1 not optimal 1.1/1 not optimal
Sodium meq/dl 0.9 1.5 2.5 higher 2.5 higher
Vitamin D Variable 400
28
Osmolarity mosm/l 273 300
Renal solute load 75 100-126
mosmol/l
Iron mg/dl 0.1----50% 0.05--- 20% 0.05---- 20% absorbed
absorbed absorbed
Types of breast milk :colostrum ( up to 5 days)transitional milk(up to 21 days) mature ( > 21)
Types of mature milk :foremilk at the beginning of feed rich in nutrient and water, hindmilk at the end rich in fat
Duration of breast feeding : usually 5-20 min - allow to suck until satisfied.
Frequency :two hourly(premature) three hourly(the usual feeding schedule) four hourly(>4 mo.)
Adequate feeding criteria: calm-sleep well-normal motions- normal amount of urine-normal weight gain
Under feeding criteria: crying before, during, after feeds, short sleep, constipation, air colic,oliguria, poor
weight gain., stays long time on the breast
Over feeding criteria: frequent regurgitation , colic’s, large bulky stool, polyuria, stocky
Absolute contraindication of breast feeding : inborn error, maternal hepatitis in non vaccinating baby ,
mother receiving dangerous drugs
Product S26 gold Bebelac1 Aptamil1 Hero1ND Nan1 Similac Becbelac EC
advance
Energy kcal/dl 67 67 67 66 67 68 66
Protein gm/dl 1.3 1.4 1.4 1.4 1.2 1.5 1.3
Whey/casein 65/35 40/60 40/60 40/60 40/60
Fat gm/dl 3.6 3.5 3.5 3.5 3.4 3.7 3.5
LCPUFA Vegetable precursors precursors Fish oil Tuna fish Vegetable precursor
AA,DHA AA,DHA AA,DHA AA,DHA
CHO gm/dl 7.3 7.5 7.5 7.2 7.4 7.02 7.3
Lactose 100% 96% 96% 100% 100% 94% 63%
Other CHO Glucose,galactose Glucose,galactose GOS Glucose,galactose
carotenoids + + +
Nucleotides 5 4 4 5 4 4 4
Taurine mg/dl 4.7 6.7 6.7 4.7 4.1 4.5 5.2
Iron mg/dl 0.8 0.75 0.75 0.8 0.54 0.6 0.53
Ca mg/dl 42 52 52 50 36 53 47
Phosphorus 24 26 26 29.9 20 28 26
mg/dl
Sodium mg/dl 16 20 20 20.2 15 16 19
Chloride 43 47 47 41.6 40 44 41
mg/dl
Selenium 1.4 1.4 1.4 2.5 1 1.5 1.5
mcg/dl
Others Choline,inositol Choline,inositol, Choline,inositol Choline,inositol, Choline,inositol Choline,inositol
L carnitine L carnitine probiotics
Product promil gold Aptamil2 Hero2 ND Nan2 Similac gain Bebelac2 Liptomilk2
advance
Energy 67 68 70 63 73.8 68 66
kcal/dl
Protein gm/dl 2.1 2.3 1.7 1.89 2.8 2.3 1.6
Fat gm/dl 3 3.3 2.9 3.07 3.62 3.3 2. 9
LCPUFA Vegetable precursors Fish oil Tuna oil vegetable precursor Precursor
AA,DHA AA,DHA AA,DHA
Vegetable oil Palm Palm Palm Sunflower.soy,coconut Palm Palm
,coconut,soybean ,coconut,soybean ,coconut,soybean ,coconut,soybean ,coconut,soybean
CHO gm/dl 7.7 7.3 9.1 6.94 7.5 7.3 8.3
Sucrose Free free available free
Glucose, maltodextrin sucrose

Other CHO oligofructose fructose
Lactose 7.7 6.8 7.2 6.94 available 6.9 6.1
Nucleotides 5 4 5 4 4 4 4
Iron mg/dl 1.2 1 1.1 0.69 1.19 1 1.1
Ca mg/dl 76 102 72 57 114.96 103 74
29
Phosphorus 51 63 53.3 38 66.2 64 47
mg/dl
Sodium mg/dl 34 27 25 18 36.38 27 27
Chloride 76 70 48.8 45 84.24 71 51
mg/dl
Others Choline,inositol,l Choline,inositol, Choline,inositol Choline Choline,inositol,l Choline,inositol
carnitine-luten L carnitine carnitine
Product Progress Nido1 bebejunior Milupa3 pediasure Nan3 Hero3ND Similac

gold gain
plus
advance
Energy
kcal/dl
80 66 70 70 100 67 69 74
Protein gm/dl 2.6 2.45 2.3 2.3 3 2.06 2 2.5
Whey/casein 40/60
Fat gm/dl 3 2.9 3.4 3.4 5 3.02 2.9 3.6
LCPUFA Vegetable no precursors precursors Tuna fish Fish oil
AA,DHA AA,DHA AA,DHA
CHO gm/dl 10 7.6 7.6 7.6 10.7 7.9 8.7
Other CHO Maltodextrin Corn , Glucose,galactose Glucose,galactose fos maltodextrin GOS
,oligofructose sucrose
Nucleotides 5 NO 4 4 4 4 4 5
Iron mg/dl 1.2 1 1 1 1.4 0.97 1.1
Ca mg/dl 91 120 104 105 98 61 69.2
Phosphorus 61 73 63 65 61 43.9 44.4
mg/dl
Sodium mg/dl 45 36 27 28 46 19.4 28.1
Chloride 80 71 72 100 42.8 62.2
mg/dl
Selenium 2 1.9 1.9 3 0.8 3
mcg/dl
OTHERS lutein P12%F44%C43
Functions of some components of milk formula:
Nucleotides : support immunity, enhance digestion
Lutein : support visual development
LCPUFAS (AA,DHA):for visual & mental development (vegetable source is the best)
Prebiotics : (GOS &FOS): enhance immunity and improving GIT tolerability
Whey (soluble- easy digestion)/casein(insoluble-dificult digestion)
Long chain fatty acids transported as chylomicron---- thoracic duct--- circulation (difficult absorption)
Medium chain triglyceride (MCT)  portal circulation-- liver (easy absorp. useful in fat malabsorption)
NB : LCPUFAS ( long chain polyunsaturated fatty acids), GOS &FOS : glucose , fructose oligosaccharides
Preterm Term formula

formula
Energy (kcal)/ 100 ml 80 67
Protein (g)/ 100 ml 2 1.4
Fat (gm)/ 1oo ml 4.5 3.5
Ca %/ 100 ml 77-110 39-66
Phosphate (mg) /100 ml 33-63 27-42
Program of formula feeding
Small scoop = 4gm /30 ml -Big scoop = 8gm / 6o ml
Number :6- 8 feed/ day
Amount :
caloric method :Preterm 120cal/kg/day- term 100cal/kg/day- SGA 150cal/kg/day
31
Weight method :Amount / feed = weight in kg x 150/ feeding number, or = weight in kg x 20+20
Age method : not accurate
Types of formula feeding :
Substitutive (on formula only)
Complementary : ( in one meal, formula to complete breast feeding)
Supplementary (some meals are breast feeding , other meals are formula feeding)
Modifications of animal milk ‫لم يعد ينصح بها في الوقت الحالي لخطورة لبن الجاموس والبقر على الرضيع‬
1/2 milk + 1/2 water + sugar 5gm/100ml
Example: to prepare 100 ml of humanized milk:
50 ml buffalo milk+50 ml of water+5 gm (one teaspoonful) of sugar. Mix well then boil for 15 minutes.
Items Breast milk Standard Modified Cow's milk Modified buffalo milk
formula
Energy kcal/dl 67 67 67 67
Protein gm/dl 1.3 1.5 1.75 2
Whey 80/20 Variable 40/60 20/80 20/80
(soluble)/casein(insoluble)
Fat gm/dl 3.5 3.5 2.25 3.5
CHO gm/dl 7.2 7.2 7.2 7
(lactose) after adding sugar after adding sugar
Minerals (ash) mg/dl 0.2 0.3-0.4 0.4 0.4
‫بعض الآراء الأخرى المختلف حولها‬
Modifications of animal milk
Fresh cows&buffalo milk are not recommended before 1yr
Cows milk :
<6mo. : 1/2 milk + 1/2 water + suger
>6mo. : 2/3 milk + 1/3 water + suger ( some doctors recommend to give without dilutions above 6mo)
Buffalo milk :
1st 3mo. : 1/3 milk + 2/3 water + suger
2nd 3mo. : 1/2 milk + 1/2 water + suger
>6mo. : as cows milk (2/3 milk + 1/3 water + suger)
Sugar& boiling
Add sugar = 5gm/100ml of diluted milk
The modified milk should be boiled for 15 minutes.
Full cream milk powder:
Nido , celia
> 6mo.& older children
One measure(4gm)/ 45ml boild water+suger
‫ يفرغ الرضيع الثدي فى‬، ‫ ثم يتم إدخال الحلمة ومعظم الهالة فى فمه‬، ‫ يتم تنبيه الطفل بالحلمة عند زاوية الفم‬: ‫طريقة الرضاعة‬
‫ تبدأ الرضعة التالية بالثدي الذي‬، ‫ يجب إفراغ الثدي حتى يتم االستفادة من الدهون ولزيادة إدرار اللبن‬، ‫ دقيقة‬41-5 ‫خالل‬
‫ التكريع بعد انتهاء الرضعة‬، ‫انتهت به الرضعة السابقة إذا لم يكن قد أفرغ تماما‬
‫ مصات بطيئة وعميقة يليها عملية البلع التى يكون لها صوت أحيانا‬: ‫علامات الرضاعة بفعالية‬
‫ يحك انفه فى صدر أو كتف أمه‬، ‫ يحرك شفتيه‬، ‫ يخرج لسانه‬، ‫ يفتح فمه‬، ‫يحرك رأسه‬: ‫عالمات الجوع عند الرضيع‬
. ‫يقوم أخيرا بالبكاء قائال ناء ناء ناء‬
‫ ساعات‬2 ‫ درجة لمدة‬45 ‫ بالشفاط اليدوى أو الشفاط الكهربائي ويحفظ فى درجة حرارة الغرفة‬: ‫تعصير لبن الثدى‬
‫ ساعة‬42 ‫وفى الثالجة فى الرف تحت الفريزر لمدة‬
30
Five Common Mistakes in Bottle-Feeding:
1. Leaving the child with the feeding bottle unattended:
The newborn/ infant should be held so that he doesn’t take in air along with milk, where the bottleneck is
not always covered with milk.
2. Too large or too
narrow hole in Average intake of colostrums in healthy baby the teat:
Time intake ml /feed
The hole should be
large enough so
that milk 1st 24 hours 2–10 flows easily
in slow 24–28 hours 5–15 steady drops
(about 48–72 hours 15–30 16 drops/
minute in the first
days 72–96 hours 30–60 then 60 drop
/ min. in older infants).
If too large, the baby will chock.
If too narrow, he may tire and/ or suck air.
3. Use of any Available Bottle:
Use of any bottle that may not be easily sterilized (like Coca-Cola or medicine bottle).
4. Over diluted feed:
The mother doesn’t add the required amount of dry milk as a result of ignorance about formula preparation or due
to poverty and desire to keep the milk can longer.
5. Frequent Crying of Baby because of Underfeeding:
If the baby is underfed, he is hungry and cries often. This is interpreted as abdominal pain and the baby is often
given unnecessary medications.
Enteral feeding
Nutritional practices in preterm infants vary not only between neonatal units, but also between practitioners within the same unit
Criteria for starting feeding :
Normal bowel sounds, soft abdomen
Should have passed meconium
Infant should be stable(HR, CR)
Absence of abdominal distention or peritonitis
No bilious aspirates or emesis
32
Serum electrolytes normal
At least 6 hrs. after extubation
Respiratory rate <60/min
Contraindication for early feeding :
Significant HIE
Homodynamic instability
Severe respiratory distress
NEC
Intestinal obstruction
Symptomatic PDA
Presence of umbilical lines is not contraindication to feed.
Monitoring :
The infant should be monitored for any evidence of feed intolerance including abdominal
girth, gastric residuals or clinical signs of NEC.
Stop feeding :
If the abdominal girth has increased by 2 cm, gastric residual volume
(>25% of feed or >3mL whichever is more) , bilious or blood stained aspirates
Trophic feeding(minimal enteral feeding- hypocaloric feeding) 7-14 days
To enhance maturation of gastrointestinal tract.( not to provide calories for growth)
BW<1.25kg- baby recovered NEC-baby NBO for long time- term with sepsis
Start feeding on 3rd day of life if stable (may be started on day 4–8, or sometimes after day 10)
Active bowel sounds, no abd.distension,stable blood pressure ,stable respiratory status (may be on ventilator)
OGT bolus feeding
Start with formula 67cal% (preterm or term)
Some recommend to start initial feeding with D5% for 3 feeding .
Start with 1mlQ6hx 2days , 1mlQ4hx 4days ,(1mlQ3h,1mlQ2h , 2mlQ2h – and so on)
Vomiting ,abdominal distension , residual>30% of feed, or >3ml intolerance.
In significant feed intolerance after a trophic feed , withheld the next feed
In significant feed intolerance persists , withheld all enteral feed
If trophic feeds are withheld for<24 hrs they should be reintroduced at the last rate given prior to intolerance
If trophic feeds are withheld for > 24 hours, they should be reintroduced at an initial rate .
Trophic feeding schedule
Day of life ml / frequency ml/day Type of milk
1 NPO ------ -----------------

2 NPO ------- ----------------------
3 1ml Q 6h 4ml 1/2 St. formula 67 ( Preterm or term)
7 1ml Q 4h 6ml Full St. formula 67 ( Preterm or term)
8 1ml Q 4h 6ml Full St. formula 67 ( Preterm or term)
Term formula = standard formula , 1/2 St. formula = half strength formula
33
1,000 gm = 28wks Low birth weight ( < 2500 g
1,250gm = 30 wks Very low birth weight ( < 1500 g)
1,500 gm =32 wks Extremely low birth weight (<1000 g)
2,000gm =34 wks

2,500 gm =36wks
Nutritive feeding :
OGT bolus feeding
Maximum OGT feeding 120kcal/kg (150ml/kg preterm f – 180ml standard formula )
Use preterm formula up to 2kg ( some recommend up to 2.5kg)
Start TPN/PPN nutrition on 3rd to 5th day and increase gradually till OGT feeding is established then decrease gradually .
D/C IVF when reaching to full OGT feeding
When increasing concentration of milk don’t advance volume of feeds that day
Actual increase in quantity of feeding not based on weight
Feeding volume is increased by increasing frequency>concentration> bolus volume
Hold feed during blood& its products transfusions
No increase in bolus feeds on day of transfusions
Maximum OGT feeding 120kcal/kg/day(preterm F80 150ml/kg/day)(term F67 180ml/kg/day)
Maximum increments (advancements) is 20ml/kg/day
In general bolus feeding frequency 2hourly for infants <1.250kg &3hourly for infants >1.250kg .
If there is a strong suspicion of short gut then a more elemental formula may be started.
At >34wks (corrected age)D/C aminophylline
At 1.6 kg start oral feeding on demand
At 1.7 kg cot care
At 1.8 kg for discharge
Supportive therapy in growing preterm on formula fed:

Once on full fed & should continue for 2 mo. after discharge
Folic acid 50 mcg OD
Ferinsol drops 0.3ml OD
Multivitamin drops 0.5ml OD( with milk.)
Supportive therapy in growing preterm on breast fed :

Human milk fortification :
When tolerating 100ml/kg/day expressed breast milk
1 packet HMF to each 50ml expressed breast milk(73cal/dl) (HMF=humam milk fortifier)
Continue up to 2kg or establish breast feeding
Iron :
Breast fed preterm ,At one month age ,2-4 mg/kg/day, Continue for to 9-12 mo.
Vitamin D:
Breast fed preterm, Once on full fed ,400- 800 IU/day ,Continue for to 9-12 mo.
Nutritive feeding protocol

34
Nutritive feeding general schedules (increments once to twice daily )
kg not based on weight ( practical ) based on weight (not practical ) Formula
Trophic feeding as above Trophic feeding as above
1.2kg 1-2ml Q2h 1ml/kgQ2h Preterm or term f 67
(<30wk) advance by advance by10-20ml/kg/day once 100ml/kg/day
(1mlQ24h-2mlQ24h,2mlQ12h as change to preterm F 80
tolerated)
1.2-1.5 kg 2ml Q3h 2ml/kgQ3h Preterm or term f 67

(30-32wk) advance by advance by 15-20ml/kg/day once 100ml/kg/day
(1mlQ24h -2mlQ12h as tolerated) ) change to preterm F 80
1.5-2.0 kg 3ml Q3h 3 ml/kgQ3h Preterm formula 80

(32 -34wk) advance by advance by 15-20ml/kg/day
(2mlQ12h as as tolerated)
2.0-2.5 kg 5ml Q3h 5 ml/kgQ3h Preterm formula 80

(34 -36wk) advance by advance by 20-ml/kg/day (some recommend term f
(2mlQ12h as as tolerated) >2kg)
> 2.5 kg 10mlQ3h 5 ml/kgQ3h Term formula

(>36wks) Advanced by advance by 20-ml/kg/day Pretem f80 if ELBW
( 3mlQ12-4mlQ12h as tolerated )
Types of milk : < 1.5 kg start( preterm/term) formula 67 once reach 100ml/kg change to preterm f80
> 1.5 – 2.5kg start preterm f 80 ( some advice term formula above 2kg)
> 2.5 kg start term formula 67
After discharge-> preterm formula up to a weight of 2.5 kg then continue with term formula/ breast fed or (S26 pdf for 12 mo.)
NB : Preterm F 67 not available in Egypt
: ‫الحظ مايلى‬
20 kcal/oz formula = 20kcal/30 ml=67 kcal/100ml= term(standard) formula =term F67

24 kcal/oz formula = 24kcal/30 ml=80 kcal/100ml= preterm formula 80= preterm F80
OZ = 30 ml
NB : Preterm F 67 not available in Egypt
35
Another nutritive feeding protocol
Nutritive feeding general schedules(increments once daily )

1.2kg 1mlQ2h advance 1-4mlQ24h as tolerated Preterm or term f 67
(<30wk) maximum increment 10-20 ml/kg/day once 100ml/kg/day
change to preterm F 80
1.2-1.5 kg 2mlQ3h advance 1-4mlQ24h as tolerated Preterm or term f 67
(30-32wk) maximum increment 10-20 ml/kg/day once 100ml/kg/day
change to preterm F 80
1.5-2.0 kg 3mlQ3h advance 3-4mlQ24h as tolerated Preterm formula 80
(32 -34wk) maximum increment 10-20 ml/kg/day
2.0-2.5 kg 5mlQ3h advance 3-4mlQ24h as tolerated Preterm formula 80

(34 -36wk) maximum increment 10-20 ml/kg/day ( some recommend term f >2kg)
> 2.5 kg 10mlQ3h advance 5-8mlQ24h as tolerated Term formula

(>36wks) maximum increment 10-20 ml/kg/day Pretem f80 if ELBW
Types of milk : < 1.5 kg start( preterm/term) formula 67 once reach 100ml/kg change to preterm f80
> 1.5 – 2.5kg start preterm f 80 ( some advice term formula above 2kg)
> 2.5 kg start term formula 67
After discharge-> preterm formula up to a weight of 2.5 kg then continue with term formula/ breast fed or (S26 pdf for 12 mo.)
NB : Preterm 67 not available in Egypt
‫ محمد إبراهيم – أخصائي طب األطفال وحديثي الوالدة – مستشفى قوص‬/‫إعداد د‬
36
Nutritive feeding protocol for preterm infants <1,20kg
( GA<30wks)increments once to twice daily )
Day
of
Formula
Feeding sessions(Q2h) ml/
day
advanceme
nt
feedin 2 4 1 2 5 6 5 4 9 21 22 24
g
5 full 2 2 2 2 2 2 2 2 2 2 2 2 12 0
St.PF67 ml
or term f
4 full 2 2 2 2 2 2 2 2 2 2 2 2 24 1mlQ24h
St.PF67 ml
or term f
9 full 1 1 1 1 1 1 1 1 1 1 1 1 36 1mlQ24h
St.PF67 ml
or term f
21 full 4 4 4 4 4 4 4 4 4 4 4 4 48 1mlQ24h
St.PF67 ml
or term f
22 full 6 6 6 6 6 6 6 6 6 6 6 6 72 2mlQ24h
St.PF67 ml
or term f
24 full 4 4 4 4 4 4 4 4 4 4 4 4 9 2mlQ24h
St.PF67 6ml
or term f
21 full 8 8 8 8 8 8 8 8 8 8 8 8 96 0
St.PF80 ml
14 full 10 10 10 10 10 10 12 12 12 12 12 12 132 2mlQ12h

St.PF80 ml
25 full 14 14 14 14 14 14 16 16 16 16 16 16 180 2mlQ12h

St.PF80 ml
OGT bolus feeding

When tolerating trophic feeding for few days start nutritional feeding.
Preterm formula 67 or standard formula 67
On 3rd day start vamin10% 0.5gm/kg/day increase gradually to 3gm/kg/day, added to iv fluids.
When OGT feed is establish 5-6 ml 2hourly decrease vamin gradually.
When reaching 100 ml/kg/day of feed --- change to preterm formula 80.
When milk feeds reaches to full feeding 100cal/kg/day DC IV fluids
Your aim 120kcal/kg/day=150ml/kg/day preterm f80( for 1.2kg15ml/feedx12)
Average weight gain 10 gm/kg/day.
When weight reaches 1.6kg start oral feeding on demand.
Preterm formula are not needed after 36wks(2.5kg) unless infant is an ELBW .
37
Nutritive feeding protocol for preterm infants <1,20kg
( GA<30wks) (increments once daily )
Day
of
Formula
Feeding sessions(Q2h) ml/
day
advance
ment
feedin 2 4 1 2 5 6 5 4 9 21 22 24
g
5 full 2 2 2 2 2 2 2 2 2 2 2 2 12 0
St.PF67 ml
or term f
4 full 2 2 2 2 2 2 2 2 2 2 2 2 24 1mlQ24
St.PF67 ml h
or term f
9 full 1 1 1 1 1 1 1 1 1 1 1 1 36 1mlQ24
St.PF67 ml h
or term f
21 full 4 4 4 4 4 4 4 4 4 4 4 4 48 1mlQ24
St.PF67 ml h
or term f
22 full 6 6 6 6 6 6 6 6 6 6 6 6 72 2mlQ24
St.PF67 ml h
or term f
24 full 4 4 4 4 4 4 4 4 4 4 4 4 96 2mlQ24
St.PF67 ml h
or term f
21 full 8 8 8 8 8 8 8 8 8 8 8 8 96 0
St.PF80 ml
14 full 11 11 11 11 11 11 11 11 11 11 11 11 132 ml 3ml

St.PF80 Q24h
25 full 15 15 15 15 15 15 15 15 15 15 15 15 180 ml 4ml

St.PF80 Q24h
OGT bolus feeding

When tolerating trophic feeding for few days start nutritional feeding.
Preterm formula 67 or standard formula 67
On 3rd day start vamin10% 0.5gm/kg/day increase gradually to 3gm/kg/day, added to iv fluids.
When OGT feed is establish 5-6 ml 2hourly decrease vamin gradually.
When reaching 100 ml/kg/day of feed --- change to preterm formula 80.
When milk feeds reaches to full feeding 100cal/kg/day DC IV fluids
Your aim 120kcal/kg/day=150ml/kg/day preterm f80( for 1.2kg15ml/feedx12)
Average weight gain 10 gm/kg/day.
When weight reaches 1.6kg start oral feeding on demand.
Preterm formula are not needed after 36wks(2.5kg) unless infant is an ELBW .
38
Nutritive feeding protocol for preterm infants 1,25-1.5kg
( GA30-32wks) (increments once to twice daily )
Day of
feeding
formula
Feeding sessions(Q3h) ml/day advancement
2 4 1 2 5 6 5 4
2 Preterm or 2 2 4 4 4 4 4 4 16 ml 0
term f 67
4 Preterm or 4 4 4 4 4 4 4 4 16 ml 0
term f 67
1 Preterm or 1 1 1 1 1 1 1 1 24ml 1mlQ24h
term f 67
term f 67
term f 67
6 Preterm or 22 22 22 22 22 21 21 21 96 ml 2mlQ12h
term f 67
5 Preterm F80 11 11 22 22 22 21 21 21 96 ml 0
4 Preterm F80 25 25 25 25 25 25 25 25 128ml 2mlQ12h
9 Preterm F80 29 29 29 29 42 42 42 42 160 ml 2mlQ12h
21 Preterm F80 41 41 23 23 45 45 45 45 192 ml 2mlQ12h

22 Preterm F80 45 45 45 45 49 49 49 49 224ml 2mlQ12h
OGT bolus feeding

Start feeding on 3rd day of life
Trophic feeding not needed
Start with Preterm formula 67 or term formula 67 ( preterm f67 not available in Egypt)
When reaching 100 ml/kg/day of feed --- change to preterm formula 80
Maximum tube feeding 150-180 ml/kg/day increase to 200ml/kg/day if not growing well
Aim to give 120kcal/kg/day=150ml/kg/day preterm f80 (for1.25kg->23ml/feedx8) for( 1.5kg->28ml/feed x8)
39
Nutritive feeding protocol for preterm infants 1,25-1.5kg
( GA30-32wks) (increments once daily )
Day of
feeding
formula
Feeding sessions(Q3h) ml/day advancement
2 4 1 2 5 6 5
4
2 Preterm or 2 2 4 4 4 4 4 4 16 ml 0
term f 67
4 Preterm or 4 4 4 4 4 4 4 4 16 ml 0
term f 67
term f 67
term f 67
term f 67
6 Preterm or 12 12 12 12 12 12 24 12 96 ml 4mlQ24h
term f 67
5 Preterm F80 12 12 12 12 12 12 24 12 96 ml 0
Concentration
increased
4 Preterm F80 16 16 16 16 16 16 26 16 128ml 4mlQ24h
9 Preterm F80 41 41 41 41 41 41 41 41 160 ml 4mlQ24h
21 Preterm F80 24 24 24 24 24 24 42 42 192 ml 4mlQ24h
22 Preterm F80 28 28 28 28 28 28 44 44 224ml 4mlQ24h
OGT bolus feeding

Trophic feeding not needed
Start with Preterm formula 67 or term formula 67 ( preterm f67 not available in Egypt)
Maximum tube feeding 150-180 ml/kg/day increase to 200ml/kg/day if not growing well
Aim to give 120kcal/kg/day=150ml/kg/day preterm f80 for (1.25kg->23ml/feedx8) for( 1.5kg->28ml/feed x8)
41
Nutritive feeding protocol for preterm infants 1.5-2kg
( GA32-34wks) (increments once to twice daily )
Day of formula ml/day advancement
feeding Feeding sessions(Q3h)
2 4 1 2 5 6 5 4
1 Preterm or 3ml 3ml 3ml 3ml 3ml 3ml 3ml 3ml 24ml 0
term f 67
2 Preterm or 5 ml 5 ml 5 ml 5 ml 7 ml 7 ml 7 ml 7 ml 48ml 2mlQ12h
term f 67
3 Preterm or 9 ml 9 ml 9 ml 9 ml 11 ml 11 ml 11 ml 11 ml 80 ml 2mlQ12h
term f 67
4 Preterm or 13ml 13ml 13ml 13ml 15ml 15ml 15ml 15ml 112ml 2mlQ12h
term f 67
5 Full St.PF80 13ml 13ml 13ml 13ml 15ml 15ml 15ml 15ml 112ml 0
↑concentration
6 Full St.PF80 17ml 17ml 17ml 17ml 19ml 19ml 19ml 19ml 144 ml 2mlQ12h
7 Full St.PF80 21ml 21ml 21ml 21ml 23ml 23ml 23ml 23ml 176 ml 2mlQ12h
8 Full St.PF80 25ml 25ml 25ml 25ml 27ml 27ml 27ml 27ml 208ml 2mlQ12h
9 Full St.PF80 29ml 29ml 29ml 29ml 31ml 31ml 31ml 31ml 240ml 2mlQ12h

Aim to give 120kcal/kg/day = 150ml/kg/day preterm f 80 for (1.5kg->28mlx8 feed) (2.5kg->37mlx8 feed)
Start with Preterm formula 67 or term formula 67
Bottle feeding at 1.6kg or 34wks & neurologically intact.
Infants on oral feed can receive a larger amount of milk
Hold feed during blood& its products transfusion
No increase in bolus feeds on day of transfusion
40
Nutritive feeding protocol for preterm infants 1.5-2kg
( GA32-34wks) (increments once daily )
Day of formula ml/day advancement
feeding Feeding sessions(Q3h)
2 4 1 2 5 6 5 4
1 Preterm or 3ml 3ml 3ml 3ml 3ml 3ml 3ml 3ml 24ml 0
term f 67
2 Preterm or 6 6 6 6 6 6 6 6 48 3mlQ24
term f 67
3 Preterm or 10 10 10 10 10 10 10 10 80 4mlQ24
term f 67
4 Preterm or 14 14 14 14 14 14 14 14 112 4mlQ24
term f 67
5 Full St.PF80 14 14 14 14 14 14 14 14 112 0
↑concentration
6 Full St.PF80 18 18 18 18 18 18 18 18 144 4mlQ24
7 Full St.PF80 22 22 22 22 22 22 22 22 176 4mlQ24
8 Full St.PF80 26 26 26 26 26 26 26 26 208 4mlQ24
9 Full St.PF80 30 30 30 30 30 30 30 30 240 4mlQ24

Aim:to give 120kcal/kg/day = 150ml/kg/day preterm f 80 for (1.5kg->28mlx8 feed) (2.5kg->37mlx8 feed)
Start with Preterm formula 67 or term formula 67
Bottle feeding at 1.6kg or 34wks & neurologically intact.
42
Nutritive feeding protocol for preterm infants 2-2.5kg
( GA34-36wks) (increments once to twice daily
Day of formula ml/day advanceme
feeding Feeding sessions(Q3h) nt
2 4 1 2 5 6 5 4
1 Preterm f80 5ml 5ml 5ml 5ml 5ml 5ml 5ml 5ml 40ml 0
2 Preterm f80 7 ml 7 ml 7 ml 7 ml 7 ml 7 ml 7 ml 7 ml 56ml 2mlQ24h
3 Preterm f80 9 ml 9 ml 9 ml 9 ml 11 ml 11 ml 11 ml 11 ml 80 ml 2mlQ12h
4 Preterm f80 13ml 13ml 13ml 13ml 15ml 15ml 15ml 15ml 112ml 2mlQ12h
5 Preterm f80 17ml 17ml 17ml 17ml 19ml 19ml 19ml 19ml 144ml 2mlQ12h
6 Preterm f80 21ml 21ml 21ml 21ml 23ml 23ml 23ml 23ml 176 ml 2mlQ12h
Aim : to give 120kcal/kgday= 150ml/kg/day(Preterm f 80) for(2kg->37ml/feed ) for(2.5 kg->46ml/feed)
Start Full Strength preterm formula 80
In infants>36wks(2.5kg) can be given standard formula
Preterm formulas are not needed after 36 weeks unless infant is an ELBW .
43
Nutritive feeding protocol for preterm infants 2-2.5kg
( GA34-36wks) (increments once daily
2 4 1 2 5 6 5 4
1 Preterm f80 5ml 5ml 5ml 5ml 5ml 5ml 5ml 5ml 40ml 0
2 Preterm f80 7 7 7 7 7 7 7 7 56 2mlQ24h
3 Preterm f80 10 10 10 10 10 10 10 10 80 3mlQ24h
4 Preterm f80 14 14 14 14 14 14 14 14 112 4mlQ12h
5 Preterm f80 18 18 18 18 18 18 18 18 144 4mlQ12h
6 Preterm f80 22 22 22 22 22 22 22 22 176 4mlQ12h
7 Preterm f80 26 26 26 26 26 26 26 26 208 4mlQ12h
8 Preterm f80 30 30 30 30 30 30 30 30 240 4mlQ12h
9 Preterm f80 34 34 34 34 34 34 34 34 272 4mlQ12h
10 Preterm f80 38 38 38 38 38 38 38 38 304 4mlQ12h

Aim : to give 120kcal/kgday= 150ml/kg/day(Preterm f 80) for(2kg->37ml/feed ) for(2.5 kg->46ml/feed)
Start Full Strength preterm formula 80
44
Nutritive feeding protocol for preterm infants >2.5kg
( GA34-36wks) (increments once daily
2 4 1 2 5 6 5 4
1 Term 10 ml 10 ml 10 ml 10 ml 10 ml 10 ml 10 ml 10 ml 80 ml 1
formula
2 Term 25 25 25 25 25 25 25 25 241 5mlQ24h
formula
3 Term 41 41 41 41 41 41 41 41 261 5mlQ24h
formula
4 Term 45 45 45 45 45 45 45 45 411 5mlQ24h
formula
5 Term 11 11 11 11 11 11 11 11 421 5mlQ24h
formula
6 Term 15 15 15 15 15 15 15 15 441 5mlQ24h
formula
7 Term 21 21 21 21 21 21 21 21 141 5mlQ24h
formula
4 Term 25 25 25 25 25 25 25 25 161 5mlQ24h
formula

Aim : to give 100kcal/kg/day= 150ml/kg/day(term f67) for(2.5 kg->46ml/feed)
Start Full Strength term formula 67
In infants>36wks(2.5kg) can be given standard formula( term formula 67)
: ‫تذكر أن‬
45
Saudi feeding protocols for preterm infants
General schedules
<1,000 gm 1.000- 1.250- 1.500- 1.800-
1.250 kg 1.500 kg 1.800kg 2.000 kg
Trophic f. See -------------- ------------- ----------- --------------
initiation protocol
Trophic f. See ------------- ------------- -------------- -------------
amount protocol
Nutritional 1ml Q2h 1ml Q2h 1ml Q3h 1ml Q3h 1ml Q3h
feeding
Advancement 1mlQ24h x 1mlQ24h x 1mlQ6h 1mlQ6h 2mlQ6h
2days then 1day then
1mlQ12h 1mlQ12h
In general bolus feeding frequency 2hourly for infants <1.250kg
&3hourly for infants >1.250kg .
Trophic feeding protocols for preterm infants< 1,000gm or GA<28wks
Day of ml / frequency Feeding sessions ml/day Type of milk

feeding
1 1ml Q 6h 2-2-2-2 4ml 1/2 st. preterm formula 67 cal
2 1ml Q 6h 2-2-2-2 4ml 1/2 st. preterm formula
3 1ml Q 4h 2-2-2-2-2-2 6ml 1/2 st. preterm formula
4 1ml Q 4h 2-2-2-2-2-2 6ml 1/2 st. preterm formula
5 1ml Q 4h 2-2-2-2-2-2 6ml Full st. preterm formula 67 cal
6 1ml Q 4h 2-2-2-2-2-2 6ml Full st. preterm formula
46
Nutritive Feeding protocols for
Day of formula ml/day Advancement
feeding
preterm infants 1,000- 1,250gm

Feeding sessions(2 hourly)
1 2 3 4 5 6 7 8 9 10 11 12
1 Full 1 1 1 1 1 1 1 1 1 1 1 1 12 ml 1mlQ24h
St.PF67
2 full 4 4 4 4 4 4 3 3 3 3 3 3 30ml 1mlQ12h
St.PF67
3 full 4 4 4 4 4 4 5 5 5 5 5 5 45 ml 1mlQ12h
St.PF67
4 full 6 6 6 6 6 6 5 5 5 5 5 5 68ml 1mlQ12h
St.PF67
5 full 4 4 4 4 4 4 9 9 9 9 9 9 102ml 1mlQ12h
St.PF67
6 full 21 21 21 21 21 21 22 22 22 22 22 22 128ml 1mlQ12h
St.PF80
7 full 24 24 24 24 24 24 21 21 21 21 21 21 150ml 1mlQ12h
St.PF80
8 full 22 22 22 22 22 22 25 25 25 25 22 25 174ml 1mlQ12h
St.PF80
9 full 26 26 26 26 26 26 25 25 25 25 25 25 198ml 1mlQ12h
St.PF80
47
Nutritive feeding protocols for preterm
feeding
infants 1,250-1,500gm
1 2 3 4 5 6 7 8
1 Full 1 1 1 1 1 1 1 1 12 ml 1mlQ24h
St.PF67
2 full 4 4 3 3 4 4 5 5 28 ml 1mlQ6h
St.PF67
3 full 6 6 7 7 8 8 9 9 60ml 1mlQ6h
St.PF67
4 full 10 10 11 11 12 12 13 13 92 ml 1mlQ6h
St.PF67
5 full 14 14 25 25 26 26 25 25 124 ml 1mlQ6h
St.PF67
6 full 18 18 19 19 20 20 21 21 156 ml 1mlQ6h
St.PF80
7 full 44 44 41 41 42 42 45 45 188ml 1mlQ6h
St.PF80
8 full 46 46 45 45 44 44 49 49 220ml 1mlQ6h
St.PF80
: ‫تذكر‬
48
Nutritive feeding protocols for preterm
feeding
infants 1,500-1,800gm
1 2 3 4 5 6 7 8
1 Full 1 1 1 1 1 1 1 1 12 ml 1mlQ24h
St.PF67
2 full 4 4 3 3 4 4 5 5 28 ml 1mlQ6h
St.PF67
3 full 6 6 7 7 8 8 9 9 60ml 1mlQ6h
St.PF67
4 full 10 10 11 11 12 12 13 13 92 ml 1mlQ6h
St.PF67
5 full 14 14 25 25 26 26 25 25 124 ml 1mlQ6h
St.PF80
6 full 18 18 19 19 20 20 21 21 156 ml 1mlQ6h
St.PF80
7 full 44 44 41 41 42 42 45 45 188ml 1mlQ6h
St.PF80
8 full 46 46 45 45 44 44 49 49 220ml 1mlQ6h
St.PF80
9 full 30 30 31 31 32 32 33 33 252 ml 1mlQ6h
St.PF80
49
Nutritive feeding protocols for
feeding
preterm infants 1,800-2,000gm

1 2 3 4 5 6 7 8
1 Full 1 1 1 1 1 1 1 1 12 ml 1mlQ24h
St.PF67
2 full 3 3 5 5 7 7 9 9 48 ml 2mlQ6h
St.PF67
3 full 22 22 21 21 25 25 25 25 112 ml 2mlQ6h
St.PF80
4 full 29 29 42 42 23 23 25 25 176 ml 2mlQ6h
St.PF80
5 full 27 27 29 49 12 12 11 11 240 ml 2mlQ6h
St.PF80
6 full 35 35 37 37 39 39 41 41 304 ml 2mlQ6h
St.PF80
51
Strategies for Managing & preventing Feed Intolerance in Preterm Neonates
Antenatal Glucocorticoids:
promote gastrointestinal maturation and function and increased activity of enzymes like lactase,maltase, and
sucrase
Breast Milk:
Human milk has been reported to reduce the incidence of NEC by up to seven fold compared with formula milk
Lactase Treated and Low Lactose Feeds:
Feed intolerance in preterm may relate to their transient low functional lactase activity
Early Trophic Feeds :
promote gastrointestinal maturation and function
Body Position and Gastric Emptying:
A strategy of right lateral position for the first postprandial hour, and changing to left lateral position
thereafter promotes gastric emptying and reduces liquid GER in the late postprandial period
Prokinetics :
judicious use of erythromycin as rescue therapy was probably justifiable in preterm neonates???
Additives and Medications:
Addition of multivitamins increases the osmolality of feeds and slow gastric emptying
Thickened milk feeds are often used in preterm neonates with GER, are associated with enterocolitis,
Enteral theophylline has been shown to delay gastric emptying
Indomethacin may inhibit gastric emptying
Indomethacin and dexamethasone are also associated with focal small bowel perforations
Erythromycin may cause hypertrophic pyloric stenosis, and cardiac toxicity.
PDA, Sepsis, and Phototherapy:
Both, significant PDA and sepsis have been reported to independently influence feed tolerance
Manifestations of ileus are frequent in preterm neonates undergoing phototherapy(photorelaxation of GIT
smooth muscle)
Probiotics and Prebiotics:
Probiotics (bifidbacilli),prebiotics (bifid factor-oligosaccharides)
Prophylactic probiotic supplementation has been shown to reduce NEC& facilitating feed tolerance .
50
‫حساب مجموع الزيادة اليومية في الرضاعة بجدول التغذية لحديثي الولادة‬
Advancement 2 Hourly system 3 Hourly system
1mlQ24h 12ml/day 8ml/ day
1mlQ12h 18ml/day 12ml/day
1mlQ8h 24ml/day ‫اليمكن تطبيقه‬
1mlQ6h 30ml/day 20ml/day
1mlQ4h 42ml/day 28 ml/day
1mlQ3h ‫اليمكن تطبيقه‬ 36ml/day
1mlQ2h 78 ml day ‫اليمكن تطبيقه‬
:) ‫ ساعة ( نظام الساعتين‬12 / ‫ ملل‬1 ‫ الزيادة‬: ‫شرح المثال الثانى‬

Total ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫عدد‬
advance
/ day 12 11 10 9 8 7 6 5 4 3 2 1 ‫الرضعات‬
18 ml / 2ml 2ml 2ml 2ml 2ml 2ml 1ml 1ml 1ml 1ml 1ml 1ml ‫مجموع‬
day ‫الزيادة‬
:) ‫ ساعات‬3 ‫ ساعة ( نظام‬12 / ‫ ملل‬1 ‫الزيادة‬

Total ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫عدد‬
advance
8 7 6 5 4 3 2 1 ‫الرضعات‬
/ day
12 ml / 2ml 2ml 2ml 2ml 1ml 1ml 1ml 1ml ‫مجموع‬
: ‫لو حولنا هذه الطريقة الى معادلة بسيطة للتسهيل فتكون كالتالى‬
Total advance / day= (Sum advance per feeds ) x Frequency of advance

Frequency of system of feed
Frequency of system of feeds ‫ القسمة على‬Frequency of advance‫ولكن هناك شرط يجب تطبيقة وهو أن يقبل‬
Sum advance per feeds= 1+2

Frequency of advance = 12 hourly
Frequency of system of feed= 2hourly
Total advance / day= (1+2) X 12/2 = 3 X6= 18 ml ( ‫)في نظام الساعتين‬
------------------------------------------------------------------------------------------------
Sum advance per feeds= 1+2
Frequency of advance =12 hourly
Frequency of system of feed= 3hourly
Total advance / day= (1+2) X 12/3 = 3 X4= 12 ml ( ‫)في نظام الثالث ساعات‬
: ‫مثال أخر‬
) ‫ ساعة‬0 ‫ ساعات ) نظام‬8 / ‫ ملل‬1 ‫ الزيادة‬: ‫شرح المثال الثالث‬
Total ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫عدد‬
advance
12 11 10 9 8 7 6 5 4 3 2 1 ‫الرضعات‬
/ day
24 ml / 3ml 3ml 3ml 3ml 2ml 2ml 2ml 2ml 1ml 1ml 1ml 1ml ‫مجموع‬
52
‫الزيادة ‪ 1‬ملل ‪ 8 /‬ساعات ) نظام ‪ 3‬ساعات )‬
‫‪Total‬‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫عدد‬
‫‪advance‬‬
‫‪/ day‬‬ ‫‪8‬‬ ‫‪7‬‬ ‫‪6‬‬ ‫‪5‬‬ ‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫الرضعات‬
‫الينطبق آلن بين كل رضعة واالخرى ثالث ساعات وبذا لن تأتى رضعة تتوافق مع كل ‪ 8‬ساعات‬ ‫مجموع‬
‫الزيادة‬
‫لو طبقنا المعادلة ‪:‬‬

‫‪Total advance / day= (Sum advance per feeds ) x‬‬ ‫‪Frequency of advance‬‬
‫‪Frequency of system of feed‬‬
‫ولكن هناك شرط يجب تطبيقة وهو أن يقبل‪ Frequency of advance‬القسمة على ‪Frequency of system of feeds‬‬
‫شرح المثال الثالث ‪ :‬الزيادة ‪ 1‬ملل ‪ 8 /‬ساعات ‪:‬‬

‫فى نظام الساعتين ‪:‬‬
‫‪Sum advance per feeds = 1+2+3‬‬

‫‪Frequency of advance = 8 hourly‬‬
‫‪Frequency of system of feed = 2 hourly‬‬
‫‪Total advance / day=( 1+2+3) x 8/2 = 6 x4= 24 ml/day‬‬
‫‪------------------------------------------------------------------------------------------ -----------------------------------------‬‬
‫في نظام الثلاث ساعات ‪:‬‬
‫‪Sum advance per feeds = 1+2+3‬‬
‫‪Frequency of advance = 8 hourly‬‬
‫‪Frequency of system of feed = 3 hourly‬‬
‫)ثمانية التفبل القسمة على ثالثة( التنطبق المعادلة = ‪Total advance / day=( 1+2+3) x 8/3‬‬
‫طريقة أخرى مجموع الرضعات فى اليوم ‪:‬مجموع الزيادة فى كل رضعة × تكرار كل رضعة ‪:‬‬
‫الزيادة ‪ 5‬ملل ‪ 4 /‬ساعات ( نظام الساعتين )‬
‫‪Total‬‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫عدد‬
‫‪advance‬‬
‫‪12‬‬ ‫‪11‬‬ ‫‪10‬‬ ‫‪9‬‬ ‫‪8‬‬ ‫‪7‬‬ ‫‪6‬‬ ‫‪5‬‬ ‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫الرضعات‬
‫‪/ day‬‬
‫‪24 ml /‬‬ ‫‪3ml‬‬ ‫‪3ml‬‬ ‫‪3ml‬‬ ‫‪3ml‬‬ ‫‪2ml‬‬ ‫‪2ml‬‬ ‫‪2ml‬‬ ‫‪2ml‬‬ ‫‪1ml‬‬ ‫‪1ml‬‬ ‫‪1ml‬‬ ‫‪1ml‬‬ ‫مجموع‬
‫‪day‬‬ ‫الزيادة‬
‫مجموع الزيادة فى كل رضعة ‪ ، 6 = 3+0+5 :‬تكرار الرضعة ‪ :‬كل ‪ 8‬ساعات‬
‫مجموع الزيادة فى الرضعات اليومية = ‪ 42 = 2 × 6‬ملليتر‪ /‬اليوم‬
‫الزيادة ‪ 5‬ملل ‪ 4 /‬ساعات ( نظام ‪ 3‬ساعات )‬
‫‪advance‬‬
‫‪/ day‬‬ ‫‪8‬‬ ‫‪7‬‬ ‫‪6‬‬ ‫‪5‬‬ ‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫الرضعات‬
‫الينطبق آلن بين كل رضعة واالخرى ثالث ساعات وبذا لن تأتى رضعة تتوافق مع كل ‪ 8‬ساعات‬ ‫مجموع‬
‫الزيادة‬
‫شرح المثال الثانى ‪ :‬الزيادة ‪ 1‬ملل ‪ 12 /‬ساعة ( نظام ‪ 0‬ساعة )‬
‫‪53‬‬
‫‪Total‬‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫رضعة‬ ‫عدد‬
‫‪advance‬‬
‫‪12‬‬ ‫‪11‬‬ ‫‪10‬‬ ‫‪9‬‬ ‫‪8‬‬ ‫‪7‬‬ ‫‪6‬‬ ‫‪5‬‬ ‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫الرضعات‬
‫‪/ day‬‬
‫‪18 ml /‬‬ ‫‪2ml‬‬ ‫‪2ml‬‬ ‫‪2ml‬‬ ‫‪2ml‬‬ ‫‪2ml‬‬ ‫‪2ml‬‬ ‫‪1ml‬‬ ‫‪1ml‬‬ ‫‪1ml‬‬ ‫‪1ml‬‬ ‫‪1ml‬‬ ‫‪1ml‬‬ ‫مجموع‬
‫مجموع الزيادة فى الرضعات اليومية = ) ‪24 = 6 × 3 = 6 × )1+2‬‬

‫الزيادة ‪ 5‬ملل ‪ 50 /‬ساعة ( نظام ‪ 3‬ساعات )‬
‫‪advance‬‬
‫‪8‬‬ ‫‪7‬‬ ‫‪6‬‬ ‫‪5‬‬ ‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫الرضعات‬
‫‪/ day‬‬
‫‪12 ml /‬‬ ‫‪2ml‬‬ ‫‪2ml‬‬ ‫‪2ml‬‬ ‫‪2ml‬‬ ‫‪1ml‬‬ ‫‪1ml‬‬ ‫‪1ml‬‬ ‫‪1ml‬‬ ‫مجموع‬
‫مجموع الزيادة فى الرضعات اليومية = ( ‪24 = 2×1 = 2× ) 4+2‬‬
‫تذكر أن ‪:‬‬
‫‪Composition of enteral feeding :‬‬

‫‪@Breast milk‬‬
‫)‪@Human milk fortifier (HMF) packets:(Enfamil HMF,SimilacHMF‬‬
‫‪54‬‬
It is added to expressed breast milk to increase its energy, protein& minerals
Used in preterm <2kg
Start with expressed breast milk ,once preterm tolerates 100ml/kg/day(12ml/kg/feed)
Add HMF& continue till time of discharge or at a weight of 2kg
When tolerate 100ml/kg/day--1 packet HMF to each 50ml expressed breast milk(73cal/dl)
When tolerate 150ml/kg/day- -2 packet HMF to each 50ml expressed breast milk(100cal/dl)
@Formulas :
*Term formula: humanized formula( 67cal/dl) ( Bebelac EC, Aptamil1, Hero 1,--------)
*Preterm formula: (high protein ,MCT, low lactose)
Preterm standard formula (67 cal/dl): eg similac special care 20 (not available in Egypt)
Preterm formula (80 cal/dl): egBebelac premature
Preterm follow up formula (73.3 cal/dl) :eg : S26 PDF, intermediate between preterm f & term formula
*suitable for preterm < 2.5kg

*Start with preterm F 67once reach 100ml/kg/day change to preterm F80 up to a weight of 2.5kg or at time of discharge
*At discharge preterm can be fed breast milk/term formula or preterm post discharge formula which may be used until 12 mo.
*preterm follow up formula :post discharge formula from 2kg to 1yr of age .(S26 pdf)
67 cal/dl formula = Similac special care with iron 20 (20cal/oz/30 ml)(standard preterm formula) ( not available)
73.3 cal/dl formula = similac neocare,S26 PDF formula
74 cal/dl formula = similac neosure
80 cal/dl formula = S26 LBW RTF, prenan, Enfamil premature formula, Similac special care with iron 24
*Specialized formula : for inborn error of metabolism, malabsorption syndrome, protein allergy
Vegetable milk is not suitable for preterm infants.
Caloric enhanced feeding :

When feeding volumes cant be tolerated eg BPD, renal failure
This is can be done by adding : HMF, Corn oil ,MCT oil to the formula or milk (not exceed 100cal/dl)
Doses of MCT oil : 0.3ml /6h
Item Kcal/ml
Corn oil 8.3 kcal/ml
MCT oil 7.7kcal/ml
Safflower oil 8kcal/ml
Polycose 3.8kcal/ml
67 cal/dl.formula or breast milk (20cal/oz/30ml) 0.67 kcal/ml
73.3 cal/dl formula (22cal/oz/30ml) 0.73 kcal/ml
74 cal/dl formula (22.2cal/oz/30ml) 0.74 kcal/ml
80 cal/dl formula (24cal/oz/30ml) 0.8 kcal/ml
100 cal/dl formula (30cal/oz/30ml) 1.0kcal/ml
1 packet HMF +50ml E.breast milk(73cal/dl) 0.73 kcal/ml
2 packet HMF +50ml E.breast milk(80cal/dl) 0.8 kcal/ml
55
Growing preterm :
*->34 wks ---------D/C aminophylline, caffeine citrate
*-< 1.6 kg --------OGT feeding ↑ gradually up to 170 ml/kg/day
*-> 1.6 kg --------oral feeding on demand
*-> 1.7 kg --------cot care
*- 1.8 kg --------for discharge
*- Total fluids including milk not more than 180 ml/kg/day
*- Maximum OGT feed can be given is 25 ml/2hourly
*- When milk feeds reach 100kcal/Kg/day(15ml/feed) D/C iv fluids
*- CBC , U/E weakly
*- brain U/S within days of admission &after 2wks, weakly follow up in IVH.
*- fundoscopy by the age of 1mo. & when required
*- supportive therapy for full feeder & should continue 2mo. After discharge
Folic acid 50 mcg OD
Ferinsol drops 0.3ml OD
Polyvisol drops 0.5 ml OD (with milk)
Arterial blood gases interpretation

Normally :
56
PH 7.35-7.45 ( average 7.40)
PCO2 35-45 mmHg ( average 40 )
PO2 80-100 mmHg for term (80-100) for preterm (60-80)
HCO3 22-26 meq/l ( average 24) for term (24±2) for preterm (22±2)
BE ±2 meq/l ( average 0)
O2sat% >95
Normal
↓ ↑
PH 7.35-7.45 acidosis alkalosis
PCO2 35-45 alkalosis acidosis
HCO3 22-26 acidosis alkalosis
PO2 80-100 hypoxemia Hyperoxemia
SaO2 95-100 Hypoxia ---------------
Definitions :
PH :concentration of H+ in cells & body fluids
It reflects the acid base status of the blood ( the amount of acid & base of the blood)
PH= -log (H+)
EX: PH water = -log (10-7) = - (-7) = 7
Low PH = high concentration of H+
High PH = low concentration of H+
PH scale of some material :
PH scale of water :
O acidic 7neutral 14 alkaline
*---------------------------------*-----------------------------------*
H+ 1mol/l 10-7 mol/l 10-14 mol/l
<-------------------------------------------------------------------
decrease PH rising of H+ concentration
PH scale of blood :
6.8 7.35 7.40 7.45 7.8

Death- *-----------------------------*-----*------*---------------------------------*-death
158nmol/l 45 39.8 35 15.8 nmol/l
<------ maximal range compatible with life-------------------------------
The PH of the body is carefully regulated by :
Buffers(seconds), lung (min) , kidney ( days)
57
1- Buffers : solutions mop up both excess H+or OH + and prevent large exchange in PH (Proteins , phosphates , carbonates)
2- lung : hyperventilation ( washing CO2) (with M. acidosis)
Hypoventilation ( retaining CO2 ) (with M. alkalosis)
3- Kidney: Reabsorption of bicarb& excrete H+ (with R. acidosis) H+ is excreted as phosphate& ammonia in urine
Excreting bicarb. & retaining H+ ( with R.alkalosis )
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Carbonic acid is the major blood acid( reflected by Paco2) , bicarbonate is the major blood base
lungs regulate carbonic acid ( reflected byPaco2) by hyper & hypoventilations
Kidney: regulate bicarbonate by reabsorption & excretions
The lungs decrease H+ (increase PH) by washing CO2 in expired air
The kidneys decrease H+ (increase PH) by reabsorption of HCO3- & excretion of H+
The relationship between PH, bicarbonate,pco2is expressed by Henderson equation
HCO3- ( kidneys)
PH is proportional to --------------
PCO2 ( lungs)
NB : in the proximal convoluted tubules : bicarbonate is reabsorped
in the distal convoluted tubules : H ions is excreted as phosphate & ammonia
Imbalance of acid base force the lungs &kidneys to compensate for the change in PH
PaCO2: reflects the respiratory component of acid base

Normal 35:45 mmHg (average 40)
58
Paco2 <35 respiratory alkalosis , >45 respiratory acidosis
---------------------------------------------------------------------------------------
HCO3: reflects the metabolic component of acid base
Normally : 22-26 meq/l ( average 24)
HCO3 <22 metabolic acidosis , >26 metabolic alkalosis
--------------------------------------------------------------------------------
BE : reflects the function of buffer system in the blood
Intracellular buffer(HB, Oxy HB, inorganic &organic phosphate)
Extra cellular buffer (bicarb,proteins, inorganic phosphate)
Normally BE -2:+2 (average 0)
<-2 metabolic acidosis , >+2 metabolic alkalosis
---------------------------------------------------------------------------------------------------------------------------------
PaO2 : reflects the amount of physically dissolved oxygen in the blood ( reflects blood oxygenation)
Decrees pao2 = hypoxemia
Normally : PO2 80-100 mmHg
Mild hypoxemia : 60-80
Moderate hypoxemia : 40-60
Sever hypoxemia : <40
--------------------------------------------------------------------------------------------------------------------------------
SaO2 : % saturation of HB with O2 in arterial blood ( reflects tissue oxygenations )
percentage of Hb that are loaded with oxygen
the percentage of saturated hemoglobin with oxygen in the blood.
the percentage of oxy hemoglobin in the blood.
the ratio of oxyHb to the total Hb in the arterial blood (ie OxyHb + reduced Hb)
measures by pulse oxymeter.
Decrease SaO2 = hypoxia ( insuffient amount ofO2 bound to HB)
Normally > 95%
Mild hypoxia : 90-95% (paO2 60-80)
Moderate hypoxia : 75-90% (paO2 40-60)
Sever hypoxia :< 75% ( paO2< 40)
Nb : O2 is transportes physically dissolved in blood (small amount) and is measured by ABG (PaO2)
& in combine with HB as oxyHb(big amount) and is measured as O2 saturation by pulse oxymeter.
----------------------------------------------------------------------------
Now 6 steps for Arterial blood gases interpretation

Step 1: Evaluate PH
Normally : 7. 35-7.45
< 7.35 acidemia
> 7.45 alkalemia
Step 2 : Evaluate ventilation (lung )
59
Normally PCO2 35-45
< 35 Respiratory alkalosis
> 45 Respiratory acidosis
Step 3 : Evaluate metabolic process (kidney )
Normally HCO3 22-26
HCO3 < 22 , BE > -2 metabolic acidosis
HCO3 > 26 , BE > +2 metabolic alkalosis
------------------------------------------------------------------------------
Step 4 : determine primary and compensating disorder;
Often two acid base imbalances coincide , one is the primary , the other is the body's attempt to return the
PH to normal (body's compensation )
Check PH :the primary lesion follows PH & the other is the compensation
For example if step2 and 3 indicate that the patient has respiratory acidosis and metabolic alkalosis
And the PH is 7.25 , the primary disorder must be respiratory acidosis the remaining disorder is compensating
for the primary problem .
PH 7.2 ----- academia ( for simplicity we are calling acidosis)
Pco2 60 ----- respiratory acidosis
Hco3 30 ------- metabolic alkalosis
Primary lesion is resp. acidosis coinside with ph , the other is the compensations
3 stages of compensation are possible :
Non compensation(acute disorder) : change in PH and either PCO2 orHCO3 (example2)
Partial compensation (sub acute disorder ) : change in PH ,PCO2 & HCO3 (example1)
Complete compensation (chronic disorder) : normal PH , change in PCO2 & HCO3 (example3)
What is the primary disorder in complete compensation ? (remember that PH is normal )
Consider PH 7.35 to 7.40 ----- acidotic side
PH 7.40 to 7.45 ----- alkalotic side
) ‫ وأحد الطرفين المتنافسين‬PH ‫ ولم يتدخل الطرف الثاني للمساعدة ( أدى إلى تغيير في‬PH‫حدث مشكلة في أحد الطرفين أدت إلى تغيير‬: )‫الحالة الحادة(الالمعاوضة‬
)) ‫ والطرفين المتنافسين‬PH ‫ إلى طبيعته ( أدى الى تغيير فى ال‬PH ‫ وهنا تدخل الطرف الثانى للمساعدة ولكن ليست المساعدة المطلوبة التي تعيد‬:)‫حالة المعاوضة الجزئية (تحت الحادة‬
)‫ طبعا بمجهودهما‬.‫ طبيعى‬PH ‫ إلى وضعه الطبيعي ( تغيير في الطرفين المتنافسين لجعل‬PH ‫ وهنا تدخل الطرف الثاني بشكل جدي أدى إلى رجوع‬: )‫حالة المعاوضة التامة (المزمنة‬
Step 5 : Evaluate oxygenation (PaO2, O2saturation)
80-100 adequate oxygenation >95%
60-80 mild hypoxemia 90-95%
40-60 moderate hypoxemia 75-9o%
< 40 severe hypoxemia < 75%
----------------------------------------------------------------------------
Step 6 : interpretation
Examples : 1
PH = 7.28
PCO2 = 28.9 mmHg
HCO3 = 11mEq/L
BE = - 13
PO2 = 100
O2 saturation = 96%
Evaluate PH : 7.28 ( below 7.35 ) indicate academia

Evaluate ventilation : PCO2 = 28.9 mmHg ( below 35 ) indicate Respiratory alkalosis
61
Evaluate metabolic process = HCO3 = 11mEq/L& BE = - 13 indicate metabolic acidosis
Determine primary and compensating disorder: the primary disorder is metabolic acidosis
( coincide with PH ) the compensating disorder is the other one ( respiratory alkalosis )
Degree of compensation : partial compensation because there is change in PH , PCO2&HCO3
Evaluate oxygenation : 100 mmHg is adequate
Your interpretation : partially compensated metabolic acidosis with adequate oxygenation
Example 2 :
PH = 7.46 --------alkalemia*
PCO2 = 45 mmHg normal
HCO3 = 32mEq/L metabolic alkalosis*
BE =+8 metabolic alkalosis*
PO2 = 120 hyperoxemia
Primary lesion = metabolic alkalosis
Compansatation : no compensation
degree of compensation : no compensation
Your interpretation :non compensated metabolic alkalosis with hyperoxemia
NB; partial &complete compensated metabolic alkalosis is rare because of the body defense mechanism to
prevent hypoventilation
‫مو ش معقول الرئه حتتجنن وتبطىء التنفس‬
Example : 3
PH = 7.35 -------normal
PCO2 = 28 mmHg-------respiratory alkalosis
HCO3 = 14mEq/L ----------metabolic acidosis*
BE = - 10 ----------------- metabolic acidosis*
PO2 = 50 ---------------------moderate hypoxemia
Primary lesion = metabolic acidosis
Compansatation : respiratory alkalosis
degree of compensation : complete (PH normal- change in the two competitor)
Your interpretation : : complete compensated metabolic acidosis with hypoxemia
More rapid examples:
PH = 7.38 -------normal
PCO2 = 55 mmHg-------respiratory acidosis
HCO3 = 31mEq/L ----------metabolic alkalosis
Primary lesion = resp. acidosis (PH on acidotic side)
Compansatation : metabolic alkalosis
degree of compensation complete bec (PH is normal & change in pco2&Hco3 ie the 2 competitor)
so your comment : complete compensated respiratory acidosis
---------------------------------------------------------------------------------------------------------------------------------------------------------------
PH = 7.31 -------acidosis
PCO2 = 24 mmHg-------respiratory alkalosis
HCO3 = 12mEq/L ----------metabolic acidosis
Primary lesion =metabolic acidosis
degree of compensation partial because there is change in all
so your comment : partial compensated metabolic acidosis
60
------------------------------------------------------------------
PCO2 = 35 mmHg-------normal
Compansatation : no compensation
degree of compensation : non
so your comment : non compensated metabolic acidosis ( acute disorder because lung didn’t interfere yet)
-----------------------------------------------------------------------------
PCO2 = 28 mmHg-------resp alkalosis
degree of compensation : partial ( change in all )
so your comment : partial compensated metabolic acidosis
--------------------------------------------------------------------------------
PH = 7.50 -------alkalosis
PCO2 = 24 mmHg-------resp alkalosis
Primary lesion = resp alkalosis
Compansatation : metabolic acidosis
degree of compensation : partial
SO your comment : partial compensated respiratory alkalosis
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
PCO2 = 55 mmHg-------resp acidosis
Primary lesion =respiratory acidosis
Compansatation : no
so your comment : non compensated mixed respiratory& metabolic acidosis
=acute mixed respiratory & metabolic acidosis
: ‫كيف تستفيد من قراءة غازات الدم‬
‫ او نقص االكسيجين ) فالطفل يحتاج الى عناية تنفسية سواء باستخدام السيباب او التنفس الصناعى‬CO2‫ (فشل بزيادة‬Respiratory failure‫اذاكان الطفل عنده فشل فى التنفس‬
‫ سنتعطية بيكربونات الصوديوم ونعالج السبب‬metabolic acidosis‫اذا كان الطفل يعانى من‬
‫ ( قديكون السبب اعطاء بيكربونات كتير أو اعطاء الزكس أو القيىء المستمر ) عالج السبب‬metabolic alkalosis ‫اذا كان الطفل يعانى من‬
‫) مثال‬encephalitis) ‫ ) اضبط جهاز التنفس اذا كان متصال به أو عالج السبب اذا لم يكن متصال به‬respiratory alkalosis( ‫اذا كان الطفل يعانى من‬
‫ وبعض أمراض التمثيل الغذائى‬، ‫( و النزالت المعوية‬diabetic ketoacidosis) ‫ مع‬metabolic acidosis : ‫من خالل غازات الدم تستطيع اثبات التشخيص مثال‬
mixed respiratory& metabolic acidosis ‫ قد تجد معه‬: ‫التسمم الدموى‬
metabolic alkalosis ‫(بيكون معاها‬congenital pyloric stenosis( ‫ضيق فتحة البواب الخلقى‬
‫ ويساعدك على فطام الطفل من الجهاز‬--- ‫من خالل غازات الدم أيضا تستطيع أن تضبط جهاز التنفس الصناعى‬
‫غازات الدم تقول لك هل الحالة حادة أو تحت الحادة أو مزمنة‬
....................................................‫ تتوقع غازات الدم عن ده حتكون ايه؟؟ نقص االكسيجين وحموضة بالدم وهكذا‬shocked ‫لو عيان‬
)Anoin gap( ‫ الغيبوبة السكريه ) يما يسمى‬-DKA( ‫وحتى حموضة الدم نستطيع أن نفرق بين اسبابها هل هى بسبب ضياع البيكربونات (النزالت المعوية ) أو استهالك البيكربونات‬
primitive neonatal reflexes‫المنعكسات البدائية لحديثي الوالدة‬

62
‫ترتبط األفعال المنعكسة بحصول المولود على الغذاء واإلبقاء على حياته وتتم بواسطة جذع المخ والحبل الشوكى وهى موجودة قبل الوالدة‬
‫ويختفي معظمها على الشهر الرابع ويعتبر غيابها أو استمرارها بشكل مخالف ألوقاتها المحددة مؤشرا قويا على سوء وظيفة الجملة العصبية‬
‫المركزية وأهمها ‪:‬‬
‫منعكس مورو ‪Moro reflex:‬‬
‫بداية المنعكس ‪ :‬قبل الوالدة (‪ 45‬أسبوع )‬
‫اختفاء المنعكس ‪ :‬الشهر الرابع‬
‫يترك المولود يشعر بسقوط رأسه أو أطرافه السفلية فيقوم بحركات متناظرة تشبه العناق‬
‫حيث يقوم بفرد الذراعين والرجلين ومباعدة األصابع ثم انثناء الذراعين والرجلين‬
‫االستجابة غير المتناظرة ‪ :‬كسر الترقوة – شلل نصفى – شلل اربس‬
‫الغياب ‪ :‬إصابة الجملة العصبية المركزية‬
‫منعكس قبضة اليد ‪Grasp reflex :‬‬
‫بداية المنعكس ‪ :‬قبل الوالدة (‪ 16-12‬أسبوع )‬
‫اختفاء المنعكس ‪ :‬الشهر الرابع‬
‫لمس راحة يد المولود باإلصبع يؤدى إلى إطباقه عليها‬
‫منعكس الضوء ‪Light reflex:‬‬
‫تعرض العين للضوء الشديد يؤدى إلى ضيق حدقة العين‬
‫منعكس مفرق الحاجبين ‪Glabellar reflex :‬‬
‫بالطرق الخفيف على مفرق الحاجبين يؤدى إلى إغالق الجفون‬
‫منعكس الجذر ‪Rooting reflex :‬‬
‫عند مالمسة خد المولود أو زاوية الفم فانه يدير وجهه لتلك الجهة محاوال التقاط الشيىء المالمس‬
‫منعكس المص ‪Suckling reflex :‬‬
‫مالمسة الشفاه أو سقف الحنك يؤدى إلى حركات المص‬
‫غياب منعكس المص ‪ :‬إصابة الجملة العصبية المركزية – تسمم الدم – مرض خطير‬
‫منعكس تماسك الرقبة‪Tonic Nick Reflex‬‬
‫يظهر أثناء األسبوع األول من الميالد( يسمى ايضا ً منعكس عدم التماثل لحركة الرقبة‪).‬‬
‫اختفاء المنعكس ‪ :‬الشهر السادس الى التاسع‬
‫يكون الرضيع مستلقي على ظهره‪ ،‬قم بلف (رأسه) إلى الجهه اليمين مثال فانه يحدث امتداد للذراع والساق لنفس الجهه اليمنى‬
‫بينما الجهه اليسرى تكون الذراع واليد فيها منثنية‪.‬‬
‫اذا استمر هذا المنعكس لفترة اطول مما هو متوقع له فان ذلك ينذر بوجود خلل في الجملة العصبية المركزية‬
‫منعكس المشي او الخطو‪Stepping Reflex‬‬
‫فإذا أمسكت طفلك الرضيع تحت ذراعيه‪ ،‬مع المحافظة على إسناد رأسه‪ ،‬ثم جعلت أقدامه تالمس سطح مستوي‪ ،‬فان الرضيع يبدأ ويقوم بحركات‬
‫الخطوات المتبادلة ومحاولة المشي ‪ .‬يظهر هذا المنعكس أثناء األسابيع السته األولى بعد الميالد ويختفي هذا المنعكس عادة بعد‪ 3‬شهر‪ ،‬إلى أن يظهر‬
‫ثانية عندما يتعلّم المشي عند سن ‪ 01-01‬شهر ‪.‬‬
‫منعكس الهبوط المفاجئ‪Parachute Reflex‬‬
‫هذا المنعكس يعتبر رد فعل وقائي يحمي الطفل الرضيع عند الشعور بفقدان التوازن او السقوط المفاجئ‪ .‬فعندما تمسك طفلك وتميل به إلى اإلمام في‬
‫اتجاه األرض أو عندما ترفعه وتهبط به بسرعة نحو األرض ‪ ،‬فيظهر التوتر على الطفل نتيجة توقعه السقوط فانه يبدأ بمد يديه ورجليه ويباعد بينهما‬
‫ليحاول تفادي أو الوقاية من السقوط‪ .‬يظهر هذا المنعكس ‪ 6-4‬شهور من الميالد‪.‬‬
‫‪63‬‬
‫‪moro reflex‬‬ ‫‪Suckling reflex‬‬
‫منعكس تماسك الرقبة‬

‫منعكس الدوران او الجذر‬
‫‪Tonic neck reflex‬‬
‫‪Rooting reflex‬‬
‫منعكس المظلة‪Prarchute‬‬
‫‪Stepping reflex‬‬ ‫‪Placing reflex‬‬

‫‪Grasp reflex‬‬
‫منعكس الخطو‬
‫أرقى ما يتعلمه اإلنسان في الحياة‬

‫أن يتــعلم ‪:‬أن يستــمع لكل رأي ويحــترمه وليــس بالضرورة أن يقتنــع به‬
‫أن يتــعلم ‪:‬أن اليســرف بحــزنه وفرحه الن الحــياة ال تــبقى على وتيــره واحــــده‬
‫أن يتــعلم ‪:‬أن اليتدخــل فيمــا ال يعنيــيه حتى ولــو باإلشارة‬
‫أن يتــعلم ‪:‬أن الصــداقة عطــاء ثــم عطــاء ثم عطــاء ولكــن من الــطرفين‬
‫أن يتــعلم ‪:‬أنه عندمــا يغــيب المنــطق يرتفــع الصــراخ‬
‫أن يتــعلم ‪:‬أن يتــحمل المسـئؤليه مهــما عظــمت طالــما و يتصــدي لهــا بــكل إرادتــه الــحرة ويتحمل كــافة نتائجــها‬
‫أن يتــعلم "أن يحــزن كثــيرا عندما يقــول وداعا ألي صديــق فقد يكون وداعا ال لقــاء بعــــده‬
‫أن يتــعلم "أن التكــون نهاية عالقتــه مع الصديــق هي بداية كرهه له فقــد تنتــهي المحــبة ولكن يبقــى التقدير و االحتــــرام‬
‫أن يتــعلم ‪:‬أن يكــون النجــــم الذي يقضــي عمــره من أجــل بث النــور للجمــيع دون أن ينتــظر من أحد رفــع رأسه ليقــول شكــــرا‬
‫‪64‬‬
‫كيفية حساب ‪ fio2‬بدون الرجوع لجدول جهازالسيباب في األجهزة المصرية التي التحتوى خالط‬
‫‪Air‬‬ ‫‪O2‬‬ ‫‪Fio2‬‬
‫‪4‬‬ ‫‪1‬‬ ‫‪42‬‬
‫‪5‬‬ ‫‪2‬‬ ‫‪11‬‬
‫‪6‬‬ ‫‪4‬‬ ‫‪21‬‬
‫‪5‬‬ ‫‪1‬‬ ‫‪51‬‬
‫‪2‬‬ ‫‪2‬‬ ‫‪61‬‬
‫‪1‬‬ ‫‪5‬‬ ‫‪51‬‬
‫‪4‬‬ ‫‪6‬‬ ‫‪41‬‬
‫‪2‬‬ ‫‪5‬‬ ‫‪91‬‬
‫‪1‬‬ ‫‪4‬‬ ‫‪211‬‬
‫ه‬
‫هذا الجهاز اليحتوى على خالط لخلط الهواء واألكسيجين تلقائيا ومن ثم يتم الخلط يدويا بضبط مفتاحى األكسيجين والهواء‬
‫معدل السريان ثابت وفدرة ‪ 8‬لتر ويشمل الهواء واألكسيجين‬
‫كيفية الحساب ‪:‬‬
‫ان ت ت ري د ‪ %41 fio2‬وعندك األكسيجين غير معلوم والهواء غير معلوم ومعدل السريان و مقداره ‪ 8‬؟‬
‫‪ =O2‬اطرح رقم ‪ ( 2‬رقم ثابت ) من الرقم العشري لل ‪ fio2‬فيصبح ‪2 = 2 – 4‬‬

‫‪ = Air‬اطرح كمية األكسيجين الناتج سابقا من رقم ‪ ( 8‬وهومجموع األكسيجين والهواء معا ) = ‪6 = 2-8‬‬
‫اذن للحصول على ‪ %41‬نحتاج ‪ 2‬لتر أكسيجين و ‪ 6‬لتر هواء‬
‫أمثلة توضيحية ‪:‬‬
‫انت تريد ‪% 61 = fio2‬‬
‫‪4 = 2 -6 = O2‬‬
‫خليك فاكر رقم ‪ 4‬ورقم ‪4‬‬ ‫‪4 = 4 -8 = Air‬‬

‫‪1 = 2 -0 = O2‬‬
‫‪3 = 1 -8 = Air‬‬

‫‪6 = 2 -8 = O2‬‬
‫‪2 = 6 -8 = Air‬‬

‫‪8 = 2 -01 = 12‬‬
‫‪1 = 8 -8 = Air‬‬

‫‪4.5 = 2 -6.5 = O2‬‬
‫‪3.1 = 4.5-8 = Air‬‬

‫‪ 1 = 2 -2.0 = O2‬تقريبا‬
‫‪8 = 1 - 8 = Air‬‬
‫الحظ أن رقم ‪ fixed number 2‬ورقم ‪ 8‬يمثل ‪ flow‬وهو مجموع كمية األكسيجين وكمية الهواء‬
‫‪65‬‬
Term Definition
SGA small for gestational age refers to the weight status at birth
Intra-uterine growth failure
Infants that are born after 37 weeks of gestation and weigh less than 2500 g
IUGR
at birth are considered IUGR
OR birth weight is less than 10th percentile for gestational age
Premature less than 37 completed weeks gestational age
LBW low birth weight; less than 2.5 kg
VLBW very low birth weight; less than 1.5 kg
ELBW extremely low birth weight;
Corrected
Equal to chronological age; minus the number of weeks premature at birth
age
Growth serial weighing and measuring of the length/height (and head circumference
monitoring in under 2's) of a child and graphing both measurements on a growth chart
Growth describes the growth pattern of a defined population without making any
reference claims about health status
defines a recommended pattern of growth that has been associated
Growth empirically with specific health outcomes and minimization of long-term
standard risks of disease. It represents 'healthy' growth of a population and suggest a
model or target pattern of growth for all children to achieve.
Failure to
general description for child with growth faltering
Thrive
deficiencies (excesses or imbalances) in intake of energy, protein and
Malnutrition
or/other nutrients.
Over food is in excess of dietary energy requirements, resulting in overweight or
nutrition obesity.
Under result of food intake that is continuously insufficient to meet dietary
nutrition requirements, poor absorption, and/or poor biological use of food consumed.
Also known as standard deviation (SD) scores. Z-scores have no 'units' and
are used to describe how far a measurement is from the mean (average).
Percentiles are commonly used in the clinical or community setting because
Z-scores
they indicate simply and clearly a child's position within the context of the
reference population. Z-scores are useful for population and research
purposes. For comparison purposes, the 50thcentile is equal to a z-score of 0.
Term Definition
Gestational age (GA) First day of LMP to birth

Chronologic age (CA) Age since birth
Postmenstrual age GA + CA
Corrected age CA – weeks preterm
AGA Appropriate for gestational age
LGA Large for gestational age
SGA (IUGR) Small for gestational age/intrauterine growth
restricted,
weight <2 SD below mean for gestational age
NB : LMP, last normal menstrual period; SD, standard

deviation.
66
•Stillbirth – fetus born with no signs of life 24 weeks of pregnancy
•Perinatal mortality rate - stillbirths + deaths within the first week per1000 live births and stillbirth
•Neonatal mortality rate - deaths of live-born infants within the first 4weeks of age per 1000 live births
•Neonate - infant28 days old
•Preterm - gestation <37 weeks of pregnancy
•Term - 37-41 weeks of pregnancy
•Post-term - gestation >42 weeks of pregnancy
•Low birth weight (LBW) - <2500 g
•Very low birth weight (VLBW) - <1500g
•Extremely low birth weight (ELBW) - <1000 g
•Small for gestational age - birth weight <10th centile for gestational age
•Large for gestational age - birth weight >90th centile for gestational age
Frequency of Congenital Infections which are Not Apparent

"Rubella (60-70%)
"Toxoplasmosis (75%)
"Syphilis (50%)
"HSV (rare; less than 5%)
"CMV (> 90%)
Distinctive Features:
" Intracranial calcifications (Toxo, CMV)
" Cataracts (rubella, HSV)
" Chorioretinitis (Toxo, CMV)
" Bone lesions (syphilis, rubella.varcella)
" Congenital heart disease (rubella)
" Microcephaly (CMV)
" Hydrocephalus (Toxo)
" Vesicles (HSV, VZV, syphilis)
‫الجزء التالي عن التنفس الصناعي‬
67
‫تعـاريف هامـة‪:‬‬
‫•الوليد الحي‪:‬‬
‫هو نتاج الحمل بغض النظر عن طول فترة الحمل‪ ،‬والوالدة بغض النظر عن نوعها‪ ،‬وهو الوليد الذي الذي يبدي أيا ً من عالمات الحياة من تنفس ونبضان الحبل‬
‫السري والحركات العفوية‪ .‬وبغض النظر عن انفصال المشيمة أو ربط الحبل السري‪.‬‬
‫•الجهيض‪:‬‬
‫محصول الحمل الذي توفي قبل إتمام عشرين أسبوعا حمليا ً‪.‬‬
‫•المليص‪:‬‬
‫محصول الحمل الذي توفي بعد إتمام عشرين أسبوعا ً حملياً‪ ،‬وقبل الوالدة‪.‬‬
‫•وزن الولادة‪:‬‬
‫وهو أول وزن يزنه الجنين‪/‬حديث الوالدة بعد الوالدة مباشرة‪ ،‬ويفضل أن يتم وزن الطفل خالل ساعة من الوالدة‪.‬‬
‫•الوليد ناقص وزن الولادة‪:‬‬
‫وهو الوليد الذي يزن أقل من ‪ 4511‬غ‪.‬‬
‫•الوليد شديد نقص وزن الولادة‪:‬‬
‫وهو حديث الوالدة الذي يزن اقل من ‪2511‬غ‪.‬‬
‫•الوليد شديد نقص وزن الولادة جدا‪:‬‬
‫وهو حديث الوالدة الذي يزن اقل من ‪2111‬غ‪.‬‬
‫•العمر الحملي‪:‬‬
‫وه و امتداد فترة الحمل والتي تبدأ من اليوم األول من آخر دورة طمثية‪ ،‬ويمكن التعبير عنه باأليام أو األسابيع التي يقضيها الطفل داخل الرحم‪.‬‬
‫•الخديج‪:‬‬
‫وهو محصول الحمل الذي يبلغ عمره الحملي أقل من ‪ 15‬أسبوع (أقل من ‪ 459‬يوم)‪.‬‬
‫•الوليد بتمام الحمل‪:‬‬
‫وهو محصول الحمل الذي يبلغ عمره الحملي ما بين ‪ 15‬أسبوعا حمليا ً ولكن أقل من ‪ 24‬أسبوعا ً (‪491-459‬يوما ً)‪.‬‬
‫•الحمل المديد‪:‬‬
‫وهو الحمل الذي استكمل ‪ 24‬أسبوعا ً حمليا ً أو أكثر (‪ 492‬يوم أو أكثر)‬
‫•فترة ما حول الولادة‪:‬‬
‫وهي الفترة من الحمل التي تبدأ من نهاية األسبوع ‪ 44‬الحملي (‪ 252‬يوم حملي‪ ،‬اذ يبلغ وزن الجنين ‪ 511‬غرام) وتنتهي بانتهاء اليوم السابع بعد الوالدة‪.‬‬
‫•الوليد‪:‬‬
‫تعرف األيام الثمانية والعشرون األولى من العمر بفترة الوليد‪.‬‬
‫الجزء التالي عن التنفس الصناعي بالصور التوضيحية وفرانكوآرب‬
‫توقف ال ‪ flow‬بعد نهاية الشهيق هو ده = ‪plateau pressure‬‬

‫‪ plateau‬السطح المستوى أو سفح الجبل أو الصفحة والترجمة الدارجة له هي( ضغط الصفحة – أو ضغط االستواء )( واستوت على الجودى )‬ ‫وكلمة‬
‫طريقة جديدة لتوصيل الصمام الثلاثى لتغيير الدم‬
‫‪68‬‬
‫تغيير الدم بصمامين ثالثيين‬
‫أسهل طريقة لعمل تغيير الدم ‪ ،‬الحظ وضعية الصمامين الثالثيين ‪ ،‬موضوعين بطريقة جانبية وليست طولية ‪ ،‬مما يسهل سحب الدم من القسطرة السرية ألن المسافة قصيرة ‪،‬‬
‫اضافة الى انك لن تتلخبط فى الصمامات ‪ ،‬مين تفتح ومين تقفل ‪ ،‬ولتسهيل معرفة مكان الوريد السرى فمكانه هو عند الساعة ‪ ، 24‬تأكد أن القسطرة السرية مفتوحة من‬
‫األمام والجانب وكل ماكانت واسعة يكون أفضل ‪ ،‬بالنسبة للمسافة هى غالبا ‪ 5‬سم للمبتسر و‪ 9‬سم لكامل النمو ‪ ،‬ان شاء هللا بعد هذا الفيديو حتعمل تغيير الدم وانت مغمض ‪،‬‬
‫يتبقى لك معرفة نوع الدم الذى ستقوم بالتغيير به‬
‫مخرجي الصمام األول للقسطرة السرية وسرنجة السحب‬

‫مخرجي الصمام الثاني لكيس الدم والنفايات‬
‫الصمامين يتم تركيبهما بطريقة جانبية وليست طولية بالترتيب االتى ‪:‬‬
‫‪ -2‬القسطرة السرية‬
‫‪ – 4‬سرنجة السحب‬
‫‪69‬‬
‫ كيس الدم‬-1
‫ – النفايات‬2
‫حركة مؤشر الصمام كالتالي‬
‫تحريك اتجاه مؤشر صمام واحد لكيس الدم‬
‫تحريك اتجاه مؤشر صمام واحد لدخول الدم للسرة االنتظار قليال ثم سحب الدم‬
‫تحريك اتجاه مؤشر الصمامين اللقاء الدم في النفايات‬
‫ مؤشر صمامين وهكذا‬-‫مؤشر صمام واحد‬-‫ مؤشر صمام واحد‬: ‫فيصبح العمل اتوماتيكيا كاالتى تحريك‬
Exchange transfusion
Volume : 170ml/kg
Type : fresh whole blood
Indications -: - Cord Hb <12 or bilirubin>5
- TSB exceeding critical level
- Hydrops , severe anemia, kernicterus
NB: TSB exceeding critical level= serum albumin X 6 (‫ مجم بليروبين‬6 ‫)أقصى مايحمله جزيء األلبومين هو‬
or guided by jaundice curves
Items Blood for exchange Alternative
Rh incomp. Rh-ve ,Blood group of the baby 0-ve blood
ABO incomp Blood group O, Rh of the baby 0-ve blood
Others Same of infant 0-ve blood
Jaundice graphs
71
70
72
‫‪73‬‬
‫‪74‬‬
‫للتحويل إلى ‪ mg/dl‬اقسم على ‪( 25‬لم استطع تحويلها على الجراف ألني الأفهم فى الفوتوشوب ) المصدر وزارة الصحة الكويتية‬
‫‪75‬‬
76
Congenital cyanotic heart disease
Cyanotic heart diseases: 5 types(5T)

1 finger up: Truncus Arteriosus (1 vessel)
2 fingers up: Transposition Great Arteries (2 vessels transposed)
3 fingers up: Tricuspid Atresia (3=Tri)
4 fingers up: Tetralogy of Fallot (4=Tetra)
5 fingers up: Total Anomalous Pulmonary Venous Return (5=5 words)
Cardiac positions
Situs solitus : viscera , lungs , atria are normal ( situs= location)( solitus = normal)
Situs inversus : viscera , lungs , atria are inverted
Situs ambiguous ( isomerism)
Asplenia syndrome:R iso., no spleen,central liver,bilateral R. lungs
Polysplenia syndrome : L iso., multiple small spleen, absent intrahepatic portion
of IVC, bilateral LT lungs
PEEP ‫هو ده ال‬
‫الجزء التالي عن التنفس الصناعي‬
77

Notes in Neonates محمد ابراهيم مستشفى قوص قنا.WhiteKnightLove

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Notes in neonates

Dopamine (200mg/5ml): 5-20ug/kg/min

ProstinE1 (0.5mg/1ml): 0.05-0.1ug/kg/min ( to keep PDA patent)

Monitoring Monitor HR; withdraw if > 180 bpm.

Compatible solution D5%

Dilution stability 24 hrs in room temp after dilution,

Mg sulphate 10%: (1 mL MgSO4 10 % = 100 mg Mg = 0.8 mEq Mg)

‫صلى على الحبيب‬

Unasyn (ampicillin &sulbactum)

GLUCOSE GLUCOSE GLUCOSE

Glucose 6% 0.95 0.05

D%2 volume = the remaining = Total dextrose volume - D%1 volume

Notes: D%1 = lower %Glucose concentration , D%2 =higher %Glucose concentration

‫تركيبة نيومينت هي ‪:‬‬

‫‪1/5 NS=0.2%NS=30meq/L sodium chloride‬‬

>1200gm 70 90 110 130 140 150 160 180

Full term 60 70 80 90 100 150

Increase 10-20ml/kg or 20% of total amount of IVF in phototherapy

NB :(0.5gm) from 10%= 5ml , (0.5gm) from 15%= 3.3ml

Daily allowance of lipids (needs special center)

NB: Ca gluconate 10% -------------- lml=100mg=9mg elemental=0.23mmol

‫بروتوكول وزارة الصحة المصرية‬

Daily allowance of electrolytes

Daily allowance of protein

Start from 3rd day of life

PanaminG 2.7%( not suitable)

Start from 3rd day of life

Start from 3rd day of life

: ‫ و القيم الطبيعيه كاآلتى‬mg/kg/min ‫نحسب منها كمية الجلوكوز مقدرة‬

‫)‪D% = (GIR‬‬ ‫÷‬ ‫)‪( ml/kg) x (0.007‬‬

‫نفترض عاوزين نعطية‬

‫?‪Preterm baby 2kg,day 3 of life , IV fluids‬‬

‫‪2‬كجم إلى أقل من ‪ 2.5‬كجم‬

‫‪ 1.5‬كجم إلى مافوق ‪:‬‬

‫لو طفل ألم مصابة بالسكري وتريد تركيز عالي من الجلوكوز‬

‫?‪Ex : how to prepare 100ml D5 1/5NS‬‬

‫& ‪How to calculate fluid requirement as regards water, electrolyte ,minerals‬‬

‫طريقة المستسهلين ‪:‬‬

‫‪Saline= 28.5 ml‬‬

‫ياترى التركيز النهائى للجلوكوز كام ؟؟؟؟؟؟؟؟؟؟ هو ‪D7.4%‬‬

‫‪GIR= (ml/kg x dextrose concentration ) ÷ 144‬‬

: ‫ولو حولنا الكالم السابق الى معادلة للتسهيل سنقول‬

Glucose, maltodextrin sucrose

Product Progress Nido1 bebejunior Milupa3 pediasure Nan3 Hero3ND Similac

Preterm Term formula

1 NPO ------ -----------------

4 1ml Q 6h 4ml 1/2 St. formula 67 ( Preterm or term)

5 1ml Q 4h 6ml 1/2 St. formula 67 ( Preterm or term)

6 1ml Q 4h 6ml 1/2 St. formula 67 ( Preterm or term)

7 1ml Q 4h 6ml Full St. formula 67 ( Preterm or term)

8 1ml Q 4h 6ml Full St. formula 67 ( Preterm or term)

2,000gm =34 wks

Supportive therapy in growing preterm on formula fed:

Supportive therapy in growing preterm on breast fed :

Nutritive feeding protocol

1.2-1.5 kg 2ml Q3h 2ml/kgQ3h Preterm or term f 67

1.5-2.0 kg 3ml Q3h 3 ml/kgQ3h Preterm formula 80

2.0-2.5 kg 5ml Q3h 5 ml/kgQ3h Preterm formula 80

> 2.5 kg 10mlQ3h 5 ml/kgQ3h Term formula

20 kcal/oz formula = 20kcal/30 ml=67 kcal/100ml= term(standard) formula =term F67

Nutritive feeding general schedules(increments once daily )

2.0-2.5 kg 5mlQ3h advance 3-4mlQ24h as tolerated Preterm formula 80

> 2.5 kg 10mlQ3h advance 5-8mlQ24h as tolerated Term formula

‫ محمد إبراهيم – أخصائي طب األطفال وحديثي الوالدة – مستشفى قوص‬/‫إعداد د‬