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Enteral Nutrition - Neonatal - Inpatient

Enteral Nutrition - Neonatal - Inpatient - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nutrition


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Enteral Nutrition – Neonatal - Inpatient
Clinical Practice Guideline
Table of Contents
EXECUTIVE SUMMARY ................................................................................................ 3
SCOPE ............................................................................................................................ 4
METHODOLOGY ............................................................................................................ 4
INTRODUCTION ............................................................................................................. 5
RECOMMENDATIONS ................................................................................................... 6
1. Initiation of Enteral Nutrition (EN) ...................................................................... 6
2. Human milk ....................................................................................................... 8
3. Advancement of Enteral Nutrition ..................................................................... 9
4. Fortification of Human Milk................................................................................ 9
5. Feeding Intolerance ........................................................................................ 10
6. Oral Feedings ................................................................................................. 10
7. Vitamin and Mineral Supplementation ............................................................ 10
8. Dosing Weight ................................................................................................. 11
UW HEALTH IMPLEMENTATION................................................................................ 11
REFERENCES .............................................................................................................. 12
CPG Contact for Content:
Name: Laura Bodine, MS, RD, CNSC, CD- Clinical Nutrition
Phone Number: 608-890-6492
Email Address: lbodine@uwhealth.org
CPG Contact for Changes:
Name: Lindsey Spencer, MS –Center for Clinical Knowledge Management (CCKM)
Phone Number: 608-890-6403
Email Address: lspencer2@uwhealth.org
Copyright © 2014 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2014CCKM@uwhealth.org

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Guideline Author: Laura Bodine, MS, RD, CNSC, CD
Coordinating Team Members:
Amy Hood, MPH, RD, CNSC, CD – Clinical Nutrition
Peter Nichol, MD – Department of Surgery – Pediatric Surgery
Jamie Limjoco, MD – Department of Pediatrics - Neonatology
Tina Spellman, SLP – Rehab-Inpatient Pediatrics
Committee Approvals/Dates:
UWHC Nutrition Committee (09/25/2014)
Center for Clinical Knowledge Management Council (09/25/2014)
Release Date: September 2014
Next Review Date: September 2016
Copyright © 2014 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2014CCKM@uwhealth.org

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Executive Summary
Guideline Overview
This guideline contains recommendations for initiating, advancing and fortifying enteral
nutrition and supplementation and management in neonatal patients.
Key Practice Recommendations
1. Initiation of Enteral Nutrition: ideally initiate within the first 3 days of life and when
medically stable to promote gut maturation and motility
2. Human milk is the preferred feeding for all infants, unless contraindicated.
3. Advancement of Enteral Nutrition: advance by 10-30 mL/kg/day depending on birth
weight, gestational age, and medical status to an initial EN goal volume of 150-160
mL/kg/day
4. Fortification of Human Milk: fortification of human milk is recommended for all infants
born < 32 weeks gestation and for some born between 32-26weeks gestation.
Fortification of human milk will occur at 100-120 mL fluid/kg/day using the
appropriate fortifier.
5. Feeding Intolerance: clinicians should refer to the Feeding Intolerance Algorithm.
6. Oral Feedings: recommend to order a speech therapy consult for initiation and
advancement of oral feedings. Begin oral feedings as clinically able and based on
patient’s gestational age and maturity.
7. Vitamin and Mineral Supplementation: start supplementation for preterm infants
once full enteral nutrition has been achieved and at least 2 weeks of age.
8. Dosing Weight: use patient’s birth weight as dosing weight until birth weight is
regained. After the patient has regained birth weight, adjust 1-2 times per week to
support growth.
Companion Documents
1. EN Pathway for Neonates Tables (By Birth Weight and/or Gestational Age)
2. Feeding Intolerance Algorithm
3. Vitamin and Mineral Supplementation Table
Pertinent UWHC Policies & Procedures
1. UWHC Policy 4.01- Infant Formulary
2. UWHC Policy 4.03- Human Milk and Formula Storage
3. UWHC Policy 4.06- Procedure for Use of Donor Human Milk From a HMBANA Milk
Bank
4. UWHC Policy 4.07- Procedure for Skimming Human Milk
5. UWHC Policy 4.08- Nutrition Screening in the NICU
6. UWHC Policy 4.09- Formula and Donor Human Milk Recall Policy
Patient Resources:
1. Health Facts For You #7633: Providing Milk for Your Baby
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Scope
Disease/Condition (s):
Initiation, advancement, and fortification of enteral nutrition (EN) as well as
supplementation and management of feeding intolerance for the neonatal population in
the inpatient setting.
Clinical Specialty:
Neonatology
Intended Users:
Neonatologists
CPG objective(s):
To assist clinicians by providing a framework for the initiation, advancement, and
fortification of enteral nutrition in neonatal patients.
Target Population:
Neonatology patients seen in the American Family Children’s Hospital NICU.
Methodology
Methods Used to Collect/Select the Evidence:
A literature search was completed using PubMed with search terms including enteral
nutrition, neonatal, and feeding guidelines. Preference was given to articles published
from 2010-2014.
Methods Used to Assess the Quality and Strength of the Evidence:
Comprehensive review of literature from 2001 to 2014, and weighing according to rating
scheme below.
Methods Used to Formulate the Recommendations:
Review of published data and expert opinions.
Rating Scheme for the Strength of the Evidence and
Recommendations:
A modified Grading of Recommendation Assessment, Development and Evaluation
(GRADE) has been used to assess the Quality and Strength of Evidence in this Clinical
Practice Guideline.
Copyright © 2014 Univ ersity of Wisconsin Hospitals and Clinics Authority
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Cost Analysis
A formal cost analysis was not performed nor was a published cost analysis reviewed.
Introduction
The purpose of this guideline is to provide a standardized approach to enteral nutrition
(EN) initiation, advancement, and fortification in the Neonatal Intensive Care Unit
(NICU) to optimize growth and development. Providing sufficient nutrition to support
growth is crucial during the transition from PN to EN, especially protein intake, since
total nutrient requirements fluctuate during this time and can lead to extrauterine growth
failure. Feeding intolerance is a common problem for patients in the NICU due to
immature GI function, intestinal dysmotility, and illness. A standardized approach to EN
has been shown to improve growth outcomes, feeding tolerance, promote earlier
achievement of full EN, decrease reliance on parenteral nutrition (PN), and can reduce
morbidities associated with prematurity such as necrotizing enterocolitis (NEC).
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Recommendations
1. Initiation of Enteral Nutrition (EN)
1.1. Ideally initiate EN within the first 3 days of life and when medically stable to
promote gut maturation and motility.1-5 (Class I, LOE B)
1.2. EN is contraindicated with the following1,2,6: (Class IIa, LOE C)
1.2.1. Hemodynamic instability or impaired GI perfusion (i.e. large PDA,
hypotension etc)
1.2.2. High dose pressor support
1.2.3. Hypoxic ischemic encephalopathy
1.2.4. Severe metabolic acidosis
1.2.5. GI anomaly or bowel obstruction
1.2.6. NEC
1.2.7. Post-operative ileus
1.2.8. It is suggested to hold EN during blood transfusions to reduce incidence of
transfusion-associated NEC, especially for infants < 34 weeks PMA.7
1.3. EN is not necessarily contraindicated when a patient has an umbilical line
catheter.
1.4. Initiate EN according to gestational age, birth weight and medical status. (Class I,
LOE B) See appropriate EN feeding pathway for further details (Tables 1-4).1-3,5,8-
12
1.4.1. For those with birth weight < 1250 g, initiate EN at 10-20 mL/kg/day.
1.4.2. For those with birth weight > 1250 g, initiate at 20-30 mL/kg/day.
1.4.3. It is suggested to continue trophic EN for 2-6 days depending on
gestational age, birth weight, and medical status.
1.4.4. For surgical neonates initiate EN within 12 to 24 hours after NG-tube
output is clear & NG-tube has been removed.13-18 (Class IIa, LOE B)
Table 1: EN Pathway for Neonates < 1250 g birth weight and/or < 29 weeks gestation
Day of Feeding Feeding Volume
(mL/kg) Comments
Day 1 10 Use human milk (maternal or donor)
Initate feedings every 2-3 hours
Day 2 10
Day 3 10
Day 4 20
Day 5 20
Day 6 20
Day 7 40
Day 8 60
Day 9 80
Day 10 100 Discontinue lipids
Day 11-12 100-200 Fortify using Prolacta 4+
Day 13 140 Discontinue PN
Day 14 150-160 Initial Goal
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Table 2: EN Pathway for Neonates 1250 - 2000 g birth weight and/or < 34 weeks gestation
Day of Feeding Feeding Volume
(mL/kg) Comments
Day 1 20
Use human milk (maternal or donor)
Initiate feedings every 3 hours
*May maintain volume at 20 mL/kg for 2-3 days
for those < 1500 g
Day 2* 40
Day 3 60
Day 4 80
Day 5 100 Discontinue lipids
Day 6-8 100-120 Fortify human milk to 22 kcal/oz x24 hours Fortify human milk to 24 kcal/oz x24 hours
Day 9 140 Discontinue PN
Day 10 150-160 Initial Goal
**May advance ad lib if patient is orally feeding.
Table 3: EN Pathway for Neonates > 2000 g birth weight and/or > 34 weeks gestation*
Initation Rate When to Advance Advancement Rate
20 ml/kg/day If tolerated, advance after
24-48 hours
20-40 ml/kg/day
May advance ad lib if infant
is PO feeding
*Those patients that are small for gestational age (SGA), intrauterine growth restriction (IUGR),
high acuity, receiving PN for >2-4 weeks, suboptimal growth, or limited ability to tolerate
adequate feeding volume may benefit from EN pathway for Neonates 1250-2000 g birth weight.
Table 4: EN Pathway for Surgical Neonates
Day of Feeding Feeding Volume
(mL/kg) Comments
Day 1 20 Use human milk (maternal or donor)
Initiate feedings continuously
Day 2 20
Day 3 20
Day 4 40
Day 5 60
Day 6 80
Day 7 100 Consider fortifying to 22 kcal/oz
Day 8 100 Consider fortifying to 24 kcal/oz
Day 9 120
Day 10 140
Day11 150 Initial Goal
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1.5. EN should be initiated using bolus feedings, especially with human milk to
minimize fat loss and adherence to tubing.2,19-21 (Class IIa, LOE C)
1.5.1. For patients receiving trophic feedings, administer by gravity
1.5.2. For patients on full EN, are not taking anything by mouth and are too
unstable to be taken out of bed, may administer feedings on syringe pump
over 20-30 minutes.
1.5.3. For patients taking part of feedings orally or those stable enough to be
held during gavage feeding, hold patient for gavage feeding and deliver by
gravity over 20-30 minutes. Avoid pushing with closed syringe due to the
pressure this creates.
1.5.4. It is suggested to initiate EN using a continuous infusion for surgical
neonates, especially for those with short bowel syndrome to promote
intestinal adaptation.13,15,16,18,22
2. Human milk is the preferred feeding for all infants.1-3,5,6,12,15,18,22-24 (Class I, LOE A)
2.1. Use maternal human milk if available and is not contraindicated. (Class I, LOE A)
It is suggested to use colostrum first, followed by transitional milk then mature
milk.
2.2. All infants with birth weight <2000 g are eligible for use of donor human
milk.2,12,15,22,24,25(Class I, LOE A)
2.2.1. For multiple births: if at least one multiple’s birth weight is < 2000 g, all
multiples will be eligible for donor human milk.
2.2.2. Additional criteria for donor human milk includes:
2.2.2.1. History of NEC or other GI anomalies
2.2.2.2. Congenital heart disease
2.2.2.3. Post-surgical nutrition (PDA ligation, bowel surgery, etc.)
2.2.2.4. Significant feeding intolerance
2.2.2.5. Malabsorption syndromes
2.2.2.6. Failure to thrive
2.2.2.7. Absent or insufficient lactation
2.2.2.8. Immunodeficiency disorders
2.2.2.9. Illness in mother requiring temporary interruption of breastfeeding
2.2.2.10. Other indications per clinician’s discretion. Must consult RD for
infants > 2 kg to ensure appropriate usage.
2.2.3. Those who are ELBW and/or born at 23-26 weeks gestation should use
preterm donor milk as available for the first 4 weeks of life.
2.2.4. Length of time that donor human milk will be used is to be determined by
the medical team
2.2.4.1. Once the infant has reached 34 weeks PMA, weaning from donor
milk should be considered.
2.2.4.2. Weaning off donor human milk should occur at least 1 week prior to
discharge. (Class I, LOE C)
2.2.4.3. When weaning off donor human milk, it is recommended to add 1-2
formula feedings per day until fully transitioned off donor human
milk.
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2.3. Use appropriate infant formula for those patients who do not have sufficient
supply of human milk available, do not qualify for donor human milk, or do not
have consent signed for use of donor human milk.2,12,17,26
2.3.1. All infants <2000 g birth weight should use preterm formula when human
milk is not available. (Class I, LOE B)
2.3.2. Initiate using full strength formula since dilution of formula has not been
shown to reduce incidence of NEC and only decreases total nutrient
intake. (Class IIa, LOE C)
2.3.3. It is suggested to use protein hydrolysate or elemental formula for those
with short bowel syndrome or for post-surgical nutrition when human milk
(maternal or donor) is not available in order to decrease duration of
PN.14,16,23,27 (Class I, LOE B)
2.3.4. The use of soy formulas is contraindicated for premature neonates due to
poor calcium and phosphate availability.2 (Class III, LOE B)
3. Advancement of Enteral Nutrition
3.1. Advance EN by 10-30 mL/kg/day depending on birth weight, gestational age,
and medical status to an initial EN goal volume of 150-160 mL/kg/day. See
appropriate EN feeding pathway for further feeding advancement details
(Tables 1-4).1-5,12,28 (Class I, LOE A)
3.2. Total fluid orders will be determined daily with the medical team. This will
include all IV fluids, medications, and EN unless otherwise specified.
3.3. It is recommended to discontinue IV fat emulsion when EN has reached 80-100
mL/kg/day and discontinue PN when EN has reached 120-140 mL/kg/day in
order to decrease risk of growth failure while transitioning to full EN.3,29 (Class IIa,
LOE C)
3.4. For surgical neonates on continuous feedings, begin transition to bolus
feedings every 3 hours once goal volume has been achieved. (Class IIa, LOE C)
4. Fortification of Human Milk2,3,5,9,12,29 (Class I, LOE B)
4.1. Fortification of human milk is recommended for all infants born <32 weeks
gestation and for some born between 32-26 weeks gestation.
4.2. Fortification of human milk will occur at 100-120 mL fluid/kg/day using the
appropriate fortifier.
4.3. Prolacta is a human milk-based fortifier that should be used for those born with
birth weight <1250g.24,30
4.3.1. Additional qualifiers for Prolacta include:
4.3.1.1. History of NEC and the patient is unable to tolerate cow’s milk-
based fortifiers
4.3.1.2. Impaired blood flow to the GI tract, such as congenital heart
disease
4.3.1.3. Intolerance to formula or cow’s milk-based human milk fortifier
4.3.1.4. Consult with RD when Prolacta is being considered for those
>1250g birth weight
4.3.2. Consider transitioning off Prolacta after 4 weeks of exclusive human milk
diet or when >34 weeks PMA.
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4.3.3. Start fortification with Prolact+4 and advance as needed to support
growth.
4.4. Similac HMF is a cow’s milk-based, liquid, human milk fortifier that should be
used for those born with birth weight between 1250-2000 g to support growth.
4.4.1. Fortify to 22 kcal/oz for 24 hours. If the patient tolerates, advance to 24
kcal/oz for 24 hours prior to advancing feeding volume.
4.5. Fortification with a liquid protein modulator should be considered for the
following:29,31
4.5.1. To meet a protein goal of at least 3-4 g/kg/day and protein-to-energy
ration of 3.0 – 3.5 g/100 kcal.
4.5.2. Supplementing with additional protein is suggested when:
4.5.2.1. BUN is <8 mg/dL
4.5.2.2. Growth failure
4.5.2.3. Weight-for-age crossing to <10th percentile
4.5.2.4. Patients < 2kg: weight gain < 10-15 g/kg/d
4.5.2.5. Patients > 2kg: weight gain < 20 g/d
4.5.2.6. Head circumference and linear growth < 0.8 cm/week
4.5.3. When initiating protein supplementation, start at < 0.5 g/kg/day liquid
protein for 24-hours. Advance to 1 g/kg/day as the patient tolerates.
4.6. It is recommended to not advance feeding volume on the same day that human
milk is being fortified.
5. Feeding Intolerance2,3,12,32-34 (See Feeding Intolerance Algorithm) (Class IIb, LOE B)
Do not check gastric residual volumes (GRV) when feeding volume is < 40
ml/kg/day. Once feeding volume is >40 ml/kg/day, check GRV q 3 hours unless MD
order not to check.
6. Oral Feedings2,12
6.1. Recommend ordering a speech therapy consult for initiation and advancement
of oral feedings.
6.2. Begin oral feedings as clinically able and based on patient’s gestational age and
maturity.
6.3. For neonates (both surgical and non-surgical) waiting for EN initiation, use
human milk for oral stimulation only unless otherwise specified.
6.4. Once patient is taking >50% goal volume through oral intake, consider transition
to cue-based oral feeding schedule.
7. Vitamin and Mineral Supplementation2,11,12,35
7.1. Start vitamin and/or mineral supplementation on preterm infants when on full
feeds and at least 2 weeks of age. (See to Table 5: Vitamin and Mineral
Supplementation).
7.2. Adjust iron supplementation as follows:
7.2.1. If on erythropoietin aim to supplement with 4-6 mg /kg/day
7.2.2. Iron supplements should be discontinued for 2 weeks post PRBC
transfusion for all infants
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Table 5: Vitamin and Mineral Supplementation
Feeding Solution Vitamin D Iron
Human Milk + Prolacta 1 mL peds multivitamin solution 2-4 mg/kg iron
Human Milk + Similac HMF
<150 mL/d – 400 IU vitamin D
>150 mL/d – 200 IU vitamin D
>300 mL/d – No vitamin D
2-4 mg/kg iron
Similac Special Care <300 mL/day – 200 IU vitamin D >300 mL/day – No supplementation
SSC 24 at 330 mL/d = 4.8 mg
iron
Neosure
<400 mL/day – 400 IU vitamin D
>400 mL/day – 200 IU vitamin D
>800 mL/day – No supplementation
Term Formula
<500 mL/day – 400 IU vitamin D
>500 mL/day – 200 IU vitamin D
>1 L/day – No supplementation
Human Milk, Unfortified 400 IU vitamin D
8. Dosing Weight
8.1. Use patient’s birth weight as dosing weight until birth weight is regained.
8.2. After the patient has regained birth weight, adjust 1-2 times per week to support
growth.
UW Health Implementation
Potential Benefits:
1. Improved growth outcomes
2. Improved feeding tolerance
3. Earlier achievement of full EN
4. Fewer days on PN
5. Reduce incidence of morbidities associated with prematurity such as
necrotizing enterocolitis (NEC).
6. Uniform approach to EN among practitioners and allows opportunity for research and
data collection.
Potential Harms: NA
Plan/ Tools
1. Guideline will be housed on U-Connect in a dedicated location for Clinical Practice
Guidelines.
2. Release of the guideline will be advertised in the Clinical Knowledge Management
Corner within the Best Practice Newsletter.
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3. Links to the guideline will be created within appropriate Health Link or equivalent
tools including:
ξ IP – Intensive Care – Neonatal – Admission [5028]
ξ IP – Whole Body Cooling/Therapeutic Hypothermia – Neonatal – Admission [4746]
ξ NICU Diet Order
Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach
for most patients. It is not intended to replace a clinician’s judgment or to establish a
protocol for all patients. It is understood that some patients will not fit the clinical
condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
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Copyright © 2014 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2014CCKM@uwhealth.org

IF ONE OR MORE OF THE FOLLOWING:
ξ Large GRV*
ξ Large volume or bilious emesis, hematemesis
ξ Visible blood in stool
ξ > 40 ml/kg/day or > 50% increase in end stool output
ξ Worsening abdominal distension
Feeding Intolerance Algorithm
EVALUATE/
PHYSICAL EXAM
NORMAL
EXAM
SICK BABY/
CONCERNING
EXAM
CHECK
ξ Check feeding tube
placement
ξ Place in prone position or
right lateral positioning
ξ Check stool frequency
NOTIFY
ξ Neonatology attending
ξ Pediatric surgeon
FEED
ξ Return GRV. Proceed with
scheduled feeding without
subtracting residual from total.
ξ If excessive stool output, return
to previously tolerated rate for
24-48 hours
EXCCESSIVE STOOL
ξ Re-evaluate
ξ Consider:
- Intermittent on a pump (30 minutes- 2 hours)
- Change in feeding solution
PERSISTENT LARGE GRV
ξ Re-evaluate
ξ Consider:
- ABD X-ray
- Glycerin enema if no evidence of anatomical
obstruction or NEC
- UGI obstruction
*Large GRV Definition:
> 50% entire feed or 3 hour
feeding volume if continuous
OR
Marked or persistent increase
from usual
Last revised/reviewed: 09/2014
For changes, contact CCKM.
Enteral Nutrition – Neonatal – Inpatient
Guideline
Do not check gastric residual volumes (GRV) when feeding volume is < 40 ml/kg/day.
Once feeding volume is > 40 ml/kg/day, check GRV every 3 hours unless MD order
specifies not to check
Copyright © 201 4University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2014CCKM@uwhealth.org