Neonatal Nutrition Guideline

 

 Reviewed by Barbara Cormack

July 2010, updated Sept 2010

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All babies <37 weeks or a birthweight <1500 g: Initiation of amino acid and lipid within 12 hours of birth

Infants ≤1000g: Standard IVN solutions composition

Starter solution from Day 0 at 30 ml/kg.day and lipid at 1 g/kg.day via central venous line or umbilical venous catheter providing 2 g/kg.day protein.

Over the next few days P100 (amino acid and dextrose solution) increases to a maximum of 96 ml/kg.day, providing 4 g/kg.day protein.

Infants >1000g or infants ≤1000g without central venous access:

P100 from Day 0 (51 ml/kg.day providing 2 g/kg.day protein)

Over the next few days P100 increases to a maximum of 90 ml/kg.day, providing 3.8 g/kg.day protein. Additional fluid is given as lipid and 10% dextrose

Recommended volumes for babies <37weeks           Fluid calculator

 

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Fluid ml/kg.day

60

75

90

105

120

150

180

Lipid

1 g/kg.day

2 g/kg.day

3 g/kg.day (continue 3g/day lipid until the day IVN finishes or don't order lipid on the day P100 will finish)

Enteral Nutrition - If born at <32 weeks OR birthweight <1800g

Reasons to withhold feeds

Bile stained aspirates only (see Withholding Feeds Guideline )

Start enteral feeds

Within 24 hours of birth (can wait up to 72 hours for breastmilk)

Feed type 1st choice

Expressed breastmilk (EBM)
 If breastmilk not available   Feeds started with Preterm formula

Starting volume,

feeding route and frequency

Begin 1 ml bolus feeds 2 – 6 hourly (as extra fluid) via nasogastric or orogastric tube and increase as tolerated until 1 ml 2 hourly.  
Feed volume then increased by 1 ml, every 8 to 24 hours (included in fluid allowance) 

Recommended daily increase    

20 – 35 ml/kg.d per 24 hrs

Full feed volume

180 ml/kg.day  - Increase to 200 ml/kg if not growing well  

Breastmilk fortifier added

If born at <32 weeks OR birthweight <1800g

Add breastmilk fortifier when feed volume reaches 5 ml per feed

If breastmilk not available

Feeds started with preterm formula

Iron supplementation

Started 4 weeks after birth. Starting dose 3 mg/kg.day elemental iron (0.5ml/kg.day). Dose increased to 6 mg/kg.day if iron-deficient.

Vitadol C

A higher dose of Vitadol C is needed to meet the 2009 ESPGHAN recommended nutrient intake for Vitamin D 

 Vitamin and iron supplements should be continued till the infant is well established on a balanced diet of solids.

1.       Start  Vitadol C 0.2 ml twice per day  for all babies on ≥150 ml/kg/day of any oral feed when having at least 8 ml per feed (because vitamin and mineral supplements substantially increase the osmolality of a feed)

2.       Vitadol C continues at this dose while on breastmilk fortifier or preterm formula then reduce Vitadol C to 0.2 ml once per day when weight reaches 1500 g

3.       Babies on all other feeds (e.g. unfortified EBM, term or hydrolysed formula, which have much lower levels of vitamins and minerals)
or fluid restricted to <150 ml/kg/day need individual assessment of vitamin D intake to prescribe Vitadol C   

Other nutrients e.g. folic acid

Not given routinely

Post discharge formula

May be recommended if born at <33 weeks, not breastfed and post term

On discharge

Vitadol C to 0.3ml once per day

Ferrous sulphate 3mg/kg.day elemental iron (0.5ml/kg.day)

Vitamin and iron supplements should be continued till the infant is well established on a balanced diet of solids

At any time if growth is inadequate, consider referral to dietitian


Additional Notes:
  • Some infants with a gestation at birth ≥32 weeks and birthweight ≥1800g may require fortifier or preterm formula for growth.
  • Some infants who are demand feeding will take volumes in excess of 200ml/kg/day of expressed breast milk or term formula.
  • Iron (ferrous sulphate) should be commenced at 4 weeks of age in eligible infants.
    • Usual starting dose 3mg/kg/day of elemental iron (0.5ml/kg/day) but increase dose to 6mg/kg/day in iron-deficient infants.
    • Infants receiving treatment with erythropoietin require iron supplementation on commencement.
  • Iron and/or vitamins may be commenced in some infants who do not fit the above criteria. These may include:
    • Infants at risk of nutritional deficiency, for example – malabsorptive diseases, long term parenteral nutrition, fluid restriction (<160ml/kg/day), gastrointestinal tract losses, and infants of mothers who are known to have or are at risk of nutritional deficiencies.
    • Babies at high-risk of iron deficiency.
  • Note that a small number of infants who do not fulfil the criteria above for iron supplementation may nevertheless develop iron deficiency anaemia within the first few months of life.  A FBC and iron studies should be undertaken to confirm the diagnosis, and supplementation should be instituted.

 

On Discharge

References

1 Tsang RC, Uauy R, Koletzko B, Zlotkin SH. Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines 2ed. Cincinnati:  Digital Education Publishing, Inc., 2005.
2 Agostoni C, Buonocore G, Carnielli V, De Curtis M, Darmaun D, Decsi T, et al. Enteral Nutrient Supply for Preterm Infants:  Commentary From the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition Committee on Nutrition. J Pediatr  Gastroenterol Nutr 2009.