NEONATAL CLINICAL PRACTICE GUIDELINE

Transcription

1 NEONATAL CLINICAL PRACTICE GUIDELINE Approval Date: January 2015 Approved by: Neonatal Patient Care Teams, HSC & SBH Child Health Standards Committee Pages: 1 of 9 Supercedes: HSC # SBH# PURPOSE AND INTENT: 1.1 To provide a process for management of all enteral nutrition and supplements for preterm and high risk infants in neonatal units. Note: All recommendations are approximate guidelines only and practitioners must take in to account individual patient characteristics and situation. Concerns regarding appropriate treatment must be discussed with the attending neonatologist. 2.0 PRACTICE OUTCOME 2.1 To provide optimum nutrition and minimize risk for disease among newborn infants. 3.0 GUIDELINES Initial Enteral Feeds 3.1 Initiate enteral feeding or minimal enteral feeding (MEF) for all infants within hours of birth unless there are contraindications to feeding. For infants >1250 gram birthweight >29 weeks, proceed direction to the feeding schedules in APPENDIX A. For infants with birthweight greater than 2000 g, determine nutrition based on assessment of infant s history, condition and tolerance of feeds, start feeds at and advance Feed every 3 or 4 hours depending on individual assessment of the infant. 3.2 Initiate the following MEF protocol for all infants <1250 gram birthweight / <29 weeks gestational age: Use expressed breast milk, donor breast milk (see guideline) or appropriate premature formula if none available. Feed 1 ml/kg every 2 hours calculated on the baby s birthweight. Do not measure pre-feed gastric residuals. Continue MEF for at least hours. After that advance feedings according to the feeding protocols in APPENDIX A. Include MEF volumes in the cumulative fluids total, but not in the total fluid intake as they are a fluid gift. Continue to administer intravenous fluids at the full rate. 3.3 Continue the MEF protocol even when the following are present as they are NOT contraindications to MEF: Umbilical catheters Intrauterine growth restriction Inotropic or nitric oxide support In utero reversal of end-diastolic flow Decreased bowel gas seen on an abdominal x-ray Treatment for Patent Ductus Arteriosus (PDA) 3.4 Discontinue or delay MEF if any of the following occur: Infant is receiving two or more inotropes. Infant has a serum lactate of 3 mmol/litre.(after 24 hours of age) Infant is diagnosed with Necrotizing Enterocolitis (NEC) - see Appendix B Infant has suspected or confirmed bowel obstruction. Note: Unless NEC or bowel obstruction confirmed, resume MEF within 24 hours.

2 2 of When reinstituting MEF after an interruption, continue the remainder of the MEF protocol for total duration of 3-5 days including the days before the interruption prior to increasing feeds according to the protocols in APPENDIX C. 3.6 Initiate oral immune therapy (OIT) using expressed breast milk within the first 6 hours of life for all infants <29 weeks and/or <1250 gram birthweight if the mother is pumping. See OIT guideline for details. Advancing Enteral Nutrition 3.7 Determine feeding volumes and frequencies according to the protocols in Appendix A. Determine vitamin and iron supplementation according to the chart in Appendix C. For infants >2000 grams determine feeding plan based on assessment of condition and tolerance of feeds. For compromised or high risk infants, start feeds at 5 ml and increase 1-2 ml per feeding or as ordered by physician/nurse practitioner. 3.8 When advancing enteral feeding volumes, decrease intravenous fluids as appropriate to meet daily fluid requirements (TFI). Note: Minimal enteral feeds (MEF) are not considered part of the total fluid requirements. 3.9 Consider fortification of breast milk and supplementation of vitamins and minerals when enteral intake is greater than 75 to meet estimated nutritional requirements When the infant s history or condition places them at a higher risk for developing necrotizing enterocolitis, consider advancing feeds at a slower rate than the protocol provides For infants with a confirmed patent ductus arteriosus receiving medical treatment continue feeding plan including advancing feeds as planned For infants with an umbilical arterial catheter continue to feed enterally, irrespective of where the line is placed (high or low). Infants with an umbilical venous catheter can be fed enterally if the tip of the catheter is located above the diaphragm and the catheter has not been used for any type of exchange transfusion 3.13 Assess feeding tolerance with each feed as feeds progress based on clinical assessment. Volume of gastric residuals aspirated before the feeding of up to 50% of the previous feed may be normal and not constitute any risk for or indication of illness. Perform a complete clinical and physical examination when feeding intolerance is suspected before making a decision regarding interruption of feeding. Continue to monitor the baby s condition closely When writing NPO orders on the Physician Order Sheet include the reason and patient assessment information in the Integrated Progress Notes. 4.0 PRIMARY AUTHORS Registered Dietitians: Sharla Fast & Jeremy Amman, HSC, Kari MacLellan SBH Clinical Nurse Specialist: Doris Sawatzky-Dickson, Health Sciences Centre Dr. John Baier, Assistant Medical Director, NICU HSC 5.0 REFERENCES 5.1 American Dietetic Association Pediatric Nutrition Practice Group (2009). ADA Pocket Guide to: Neonatal Nutrition. 5.2 Bellander, M., D. Ley, et al. (2003). Tolerance to early human milk feeding is not compromised by indomethacin in preterm infants with persistent ductus arteriosus. Acta Paediatrica, 92(9): Berseth, C. L. (2005). Feeding strategies and necrotizing enterocolitis. Current Opinion in Pediatrics 17(2):

3 3 of Canadian Pediatric Society. (2013). Vitamin D supplementation: Recommendations for Canadian mothers and infants. Position Statement. Accessed at September 12, Gallo S, Comeau K, Vanstone C, Agellon S, Sharma A, Jones G, L'Abbé M, Khamessan A, Rodd C, Weiler H. (2013). Effect of different dosages of oral vitamin D supplementation on vitamin D status in healthy, breastfed infants: a randomized trial. JAMA. 309(17). P Gianluca, T., P. Annalisa, et al. (2009). Minimal enteral feeding reduces the risk of sepsis in feed-intolerant very low birth weight newborns. Acta Pædiatrica, 98(1): Huffman S et al. (2004) Methods for confirming feeding tube placement: Application of research in practice. Pediatric Nursing; 30(1): Jeon GW, Jung YJ, Koh SY, Lee YK, Kim KA, Shin SM, Kim SS, Shim JW, Chang YS, Park WS. (2011).Preterm infants fed nutrient-enriched formula until 6 months show improved growth and development. Pediatrics International. 53(5). P Karagol BS, Zenciroglu A, Okumus N, Polin RA. (2013). Randomized controlled trial of slow vs rapid enteral feeding advancements on the clinical outcomes of preterm infants with birth weight g. Journal of Parenteral and Enteral Nutrition. 37(2). P Lau C, Smith EO. (2012) Interventions to improve the oral feeding performance of preterm infants. Acta Paediatrica. 101(7). P. e Leaf A, Dorling J, Kempley S, McCormick K, Mannix P, Linsell L, Juszczak E, Brocklehurst P; Abnormal Doppler Enteral Prescription Trial Collaborative Group. (2012) Early or delayed enteral feeding for preterm growth-restricted infants: a randomized trial. Pediatrics. 129(5):p. e Lucas, A., S. R. Bloom, et al. (1986). Gut Hormones and 'Minimal Enteral Feeding'. Acta Paediatrica, 75(5): McCain GC, Del Moral T, Duncan RC, Fontaine JL, Pino LD. (2012). Transition from gavage to nipple feeding for preterm infants with bronchopulmonary dysplasia. Nursing Research, 61(6), p McClure, R. J. and S. J. Newell (1999). Randomised controlled trial of trophic feeding and gut motility. Arch Dis Child Fetal Neonatal Ed,80(1): F National Patient Safety Agency (2005). Reducing the harm caused by misplaced gastric feeding tubes in babies under the care of neonatal units Pérez LA, Pradilla GL, Díaz G, Bayter SM. (2011). Necrotizing enterocolitis among preterm newborns with early feeding. Biomedica, 31(4): Roggero P, Giannì ML, Orsi A, Amato O, Piemontese P, Liotto N, Morlacchi L, Taroni F, Garavaglia E, Bracco B, Agosti M, Mosca F. Implementation of nutritional strategies decreases postnatal growth restriction in preterm infants (2012). PLoS One. 7(12):e Terrin G., Passariello A., Canani R.B., Manguso F., Paludetto R., Cascioli C. (2009) Minimal enteral feeding reduces the risk of sepsis in feed-intolerant very low birth weight newborns. Acta Paediatrica. 98: Winnipeg Regional Health Authority (2008). Child Health Pediatric Enteral and Parenteral Nutrition Handbook Ziegler EE, Nelson SE, Jeter JM. (2009).Iron supplementation of breastfed infants from an early age. American Journal of Clinical Nutrition. 89(2). P

4 4 of 9 APPENDIX A FEEDING SCHEDULE FOR INFANTS: g TPN basic + Lipid MEF MEF * consider protocol feeds or MEF * HMF 1pkg /50 ml EBM Vitamin supplements FEEDING SCHEDULE FOR INFANTS: g TPN basic + Lipid MEF MEF * consider protocol feeds or MEF * HMF 1pkg /50 ml EBM Vitamin supplements FEEDING SCHEDULE FOR INFANTS: g TPN basic + Lipid MEF MEF * consider protocol feeds or MEF * HMF 1pkg /50 ml EBM Vitamin supplements

5 5 of 9 FEEDING SCHEDULE FOR INFANTS: g TPN basic + Lipid MEF MEF * consider protocol feeds or MEF * HMF 1pkg /50 ml EBM Vitamin supplements FEEDING SCHEDULE FOR INFANTS: g TPN basic + Lipid MEF MEF * consider protocol feeds or MEF * HMF 1pkg /50 ml EBM Vitamin supplements FEEDING SCHEDULE FOR INFANTS: g Recommendations Day TPN basic + Lipid HMF 1pkg /50 ml EBM Vitamin supplements

6 6 of 9 FEEDING SCHEDULE FOR INFANTS: g Recommendations Day HMF 1pkg /50 ml EBM Vitamin supplements HMF 1 pkg/25 ml EBM Discontinue all intravenous fluids when feeds at FEEDING SCHEDULE FOR INFANTS: g Recommendations Day HMF 1pkg /50 ml EBM Vitamin supplements HMF 1 pkg/25 ml EBM Discontinue all intravenous fluids when feeds at

7 7 of 9 Appendix B Modified Bell s Staging Criteria for Necrotizing Enterocolitis 1A Suspect NEC 1B Suspect NEC 2A Definite NEC 2B Definite NEC 3A Advanced NEC 3B Advanced NEC Systemic Intestinal Radiologic Elevated pre-gavage residuals, mild abdominal distention, emesis, heme positive stools temperature instability, apnea bradycardia, lethargy same as IA gross bleeding per rectum same as IA same as IA same as IIA plus mild metabolic acidosis, mild thrombocytopenia same as IIB plus hypotension, severe apnea, neutropenia, DIC, combined respiratory and metabolic acidosis same as IA plus possible abdominal tenderness or absence of bowel sounds same as IIA plus definite abdominal tenderness, possible abdominal cellulitis or right lower quadrant mass same as IIB plus signs of generalized peritonitis, marked tenderness Normal or intestinal dilation, mild ileus intestinal dilation, ileus, pneumatosis intestinalis same as II A plus portal vein gas or possible ascites same as IIB plus definite ascites same as IIIA same as IIIA same as IIB plus pneumoperitoneum

8 8 of 9 Neonatal Iron Supplementation Algorithm APPENDIX C Vitamin and Iron Supplementation Born < 35 weeks and are now 4 weeks old feeding Premature formula or HMF Check: - HgB - Absolute Reticulocyte count - Ferritin Ferritin less than 35 ng/ml (Falsely negative in sepsis) Yes No Supplement 4-6 mg elemental iron/kg/d No supplementation HgB, reticulocytes, ferritin q2 weeks until HgB increasing or discharge HgB, reticulocytes, ferritin q2 weeks until HgB increasing or discharge At Hospital Discharge At Hospital Discharge Iron deficiency anemia Adequate iron status Supplement 4-6 mg elemental iron/kg/d Supplement 2-4 mg elemental iron/kg/d

9 9 of 9 In-Patient Recommendations: Feeding Premature Formula with Iron or Human Milk Fortifier Weight (g) Dose Elemental Iron Standard (2-4 mg/kg/d) Therapeutic (4-6 mg/kg/d) less than 2000 N/A 3.75 mg once daily N/A 7.5 mg once daily 3500 N/A 7.5 mg twice daily In-Patient and Discharge Recommendations Mostly Breastmilk: Feeding > 50% EBM (+/- Fortification) Weight (g) Dose Elemental Iron Standard (2-4 mg/kg/d) Therapeutic (4-6 mg/kg/d) mg once daily 7.5 mg twice daily mg twice daily 7.5 mg three times daily In-Patient and Discharge Recommendations Mostly Community Available Formula: Feeding > 50% Formula Weight (g) Dose Elemental Iron Standard (2-4 mg/kg/d) Therapeutic (4-6 mg/kg/d) mg once daily 7.5 mg once daily mg once daily 7.5 mg twice daily Vitamin A, D and C The table below shows the recommended daily supplementation for infants based on the type of nutritional intake they are receiving. The intention is for an infant to receive no more than 1000 International Units (IU) of Vitamin D per day. Gestational Age at Birth 35 weeks Breast Milk Formula +/- Some Human Milk Fortifier Breast Milk 400 Internaltional Units Vit D 1 ml Pediavit 1 ml Pediavit 800 International Units Vit D less than 35 weeks 400 International Units Vit D 1 ml Pediavit Continue Vitamin D indefinitely When consuming > 1L/day or >6.4kg (of any feeding regimen) discontinue Pediavit and if consuming breastmilk exclusively, add Vitamin D 400 International Units PO OD. Folic Acid 50 mcg until 1500 g All Infants with BW < 1500 g Notes: 1. Dietitian to assess vitamin intake and supplement accordingly. 2. Trademark products may be replaced with generic or other products which have the same dosages.