Questions about managing NICU babies

SteveNNP, MSN, NP · Sep 1, 2008

1) For premies, when do you start feeding them? Day 2 or 3? I know that if you feed them starting day 1, they can get NEC. In the meantime, do you start TPN? Or is TPN only if the baby is going many days without eating? What kind of IVF do you like to use? D10W + NS or 1/2 NS, + KCL, + Ca?

- Starting feeds on day 1 has nothing to do with NEC. Feeds are started based on a host of factors. Gestational age, delivery course/complications, diagnoses, lines, therapies, labs...... if the baby is getting feeds, but not enough to grow, they are usually supplemented with IV D10% until custom TPN is ordered. Where I work, we have standard TPN formulations (MP-micro, LP-large preemie, G- term, C- cardiac) which we start as needed.

When you start to feed premies, do you have to slowly advance it, or do you just immediately give them feeds that would have them at 100 kcal/kg/day?

- You have to slowly advance as tolerated. You would NEVER start at full feeds. No baby, term, preterm, etc. EVER starts at full feeds straight out of the gate.

2) How much spit up do you tolerate before you decide that either medication or NG tube needs to be used? Do you not care as long as they arent aspirating, brady, apneic, choking, and gaining weight appropriately?

NG tubes are not placed for spitting up. If the baby is determined to be refluxing, either by observation, swallow study, upper GI series etc, meds or surgery may be indicated. The occasional new-onset spit may be treated simply by thickening feeds or backing off on the amount.

3) Do all/most premies get OG/NG even if they have no feeding/airway issues?

-No

4) How do you adjust feed schedule if the baby is on a vent?

- Vented babies, if fed at all, are usually on continuous feeds via GT/OG/NG

5) How much weight is a baby supposed to gain each day? Like 10g or so?

- We like to see at least a 10 gram weight gain every day

6) When you start human milk fortifier? Only if the baby has had several days of BM with poor weight gain? Or does every premie get HMF regardless of their weight gain?

It depends. Here we start adding HMF to breastmilk when the baby is taking a volume greater than 20cc/kg/d. Most preemies get the breastmilk fortified, not only for calories, but added vitamins and minerals. Rarely do term non-cardiac babies get fortifier.

7) All these babies are supposed to lose weight for at least the first week regardless of what you feed them, correct?

- The first 3-4 days they can be expect to lose 10-15% of their birthweight.

8) What do you use ECMO for besides PPHN?

- in the OR during cardiac surgery. Mainly PPHN. Occasionally cardiac issues.

Sweeper933 · Sep 1, 2008

Pretty much the same answers as Steve - except for our babies on the vent. If they're eating, they get the same feeding schedule as other babies... which is every 3 hours. All feeds are given as a bolus through their NG / OG tube.

texas2007, BSN, RN · Sep 1, 2008

1) For premies, when do you start feeding them?
I'm not sure when they start feeding. Some wait a few days, others start on day 2. Of course if they have green funk coming out of the OG they aren't going to be eating until that clears up.
When you start to feed premies, do you have to slowly advance it, or do you just immediately give them feeds that would have them at 100 kcal/kg/day?
2) We start at 20 kcal/kg/day and work from there.
3) Do all/most premies get OG/NG even if they have no feeding/airway issues?
On the bigger preemies we keep them NPO for a day or two just to observe so they will have an OG/NG to vent or gravity during this time. If they do well on feeds, they will DC the OG/NG in a few days.
4) How do you adjust feed schedule if the baby is on a vent?
Unless they are NPO, it's Q3 just like everybody else.
5) How much weight is a baby supposed to gain each day? Like 10g or so?
I believe we aim for an avg of 30 g/day.
6) When you start human milk fortifier? Only if the baby has had several days of BM with poor weight gain? Or does every premie get HMF regardless of their weight gain?
I have no idea how they decide when to advance but we start out with 20 cal BM or formula, supplemented with TPN/IL, then move to 24 cal after a while (maybe 2-3 weeks) And if they need to gain a lot of weight like dialysis kids or fluid restrictions, ostomy or very poor weight gain they'll advance to 27 cal. Haven't seen 30 cal at this place but I know they do it.
7) All these babies are supposed to lose weight for at least the first week regardless of what you feed them, correct?
YES
8) What do you use ECMO for besides PPHN?

Mec aspiration, cardiac defects come to mind but I'm sure there's others.

littleneoRN · Sep 1, 2008

Typically, if mom is pumping we try very hard to wait for expressed milk. The when depends on many factors, like Steve said. For a stable preemie we hope to start trophic feeds on maybe day 2-3 of life. Pretty much everyone starts on D10W when they come, and right away the pharmacy starts working on a batch of starter TPN, which is just hyperalimentation, without protein, and no lipids. That is piggybacked with plain D10W at 1 ml/kg/hour. Then, regular TPN with lipids is started in the evening when all our kids' TPN comes up. Occasionally if a baby will only be on fluids briefly or is basically done with TPN, we'll hang D10W with custom added lytes as needed. We pretty much start TPN on any babies

We are pretty tolerant of reflux. Even if they do have associated apnea and bradycardia, it has to be fairly severe for us not to just see if they'll grow out of it. If it is ongoing with associated spells, we will sometimes do tests to see if they're actually aspirating. That would be more concerning. Or we'd be concerned if we were having difficulty establishing weight gain. We don't notice most of the meds making a big difference for most kids, so we don't tend to use them too much. An NG tube won't make a difference, except that it allows you to feed them at a nurse/pump determine speed and you can actually promote reflux if it's too fast. We rarely do true gavage, but we'll slow the pump down if we notice reflux.

3) Do all/most premies get OG/NG even if they have no feeding/airway issues?

No, but we're not very trustworthy of anyone less than about 35 weeks, so often we won't offer bottles and just go straight to NG feedings. They can still work on breastfeeding of course. And most of the those 35 weekers bottle well initially and then end up getting jaundiced and not hungry enough when their volumes go up, so they end up with a tube too.

4) How do you adjust feed schedule if the baby is on a vent?

Um, we don't really adjust them. Most kids on vents are on continuous feeds, but they can still get their full daily feedings as long as they're tolerating them.

5) How much weight is a baby supposed to gain each day? Like 10g or so?

We tend to look for about 10-15 g/kg/day. But we're not too picky if their general trend is growth that matches the growth curve.

6) When you start human milk fortifier? Only if the baby has had several days of BM with poor weight gain? Or does every premie get HMF regardless of their weight gain?

All of our kids less than 35 weeks get some degree of HMF, usually to 24 kcal. Our nutrition protocols call for adding it when the kid is tolerating feedings and is to a certain kcal/kg/day, but I don't remember the exact number. Maybe when they're getting about 80 kcal/kg/day I think. First to 22 kcal, then to 24 kcal, then Beneprotein if needed.

7) All these babies are supposed to lose weight for at least the first week regardless of what you feed them, correct?

Unlike Steve said, we don't typically see weight loss of 10-15%. In our normal healthy term baby, we would see maybe 5-7%, but we start to get concerned for dehydration in the 7-10% range. This is masked a bit anytime we're pumping IV fluids into a new baby because that is not the body's normal state after birth.

8) What do you use ECMO for besides PPHN?

meconium aspiration, pre- and post- op cardiacs if needed, severe heart failure, PPHN (especially with DH kids)

Sweden · Sep 1, 2008

1) For premies, when do you start feeding them? Day 2 or 3? I know that if you feed them starting day 1, they can get NEC. In the meantime, do you start TPN? Or is TPN only if the baby is going many days without eating? What kind of IVF do you like to use? D10W + NS or 1/2 NS, + KCL, + Ca?

- We start feedings within 2-3 hours of birth, D10 and/or TPN is started as soon as possible (if the baby isn´t on full feeds from the start ofcourse).

When you start to feed premies, do you have to slowly advance it, or do you just immediately give them feeds that would have them at 100 kcal/kg/day?

- Some are full feeds right away (usually GA > 30 weeks), others advance their feedings as soon as they tolerate it.

2) How much spit up do you tolerate before you decide that either medication or NG tube needs to be used? Do you not care as long as they arent aspirating, brady, apneic, choking, and gaining weight appropriately?

- We tolerate spit up as long as the baby otherwise is doing ok and gaining weight (spit up is ok, puking all the time isn´t). Medications for gastric reflux is really uncommon, we don´t see much gastric problems.

3) Do all/most premies get OG/NG even if they have no feeding/airway issues?

- No, we try to avoid OG/NG tubes if it´s not absolutely necessary.

4) How do you adjust feed schedule if the baby is on a vent?

- Vented patients are fed the same way as all others (bolus fed every 2 hours). The ventilator is not a considered much of a factor when deciding feeding.

5) How much weight is a baby supposed to gain each day? Like 10g or so?

- That entirely depends on the baby (GA, condition, current weight and so on).

6) When you start human milk fortifier? Only if the baby has had several days of BM with poor weight gain? Or does every premie get HMF regardless of their weight gain?

- HMF is usually started after about 2-4 weeks if he/she isn´t gaining enough weight on just breastmilk (we can go up to 220 ml/kg/day depending on baby´s condition).

7) All these babies are supposed to lose weight for at least the first week regardless of what you feed them, correct?

- All babies loose weight, we try to keep it

:nurse: Anna

platon20 · Sep 1, 2008

Thanks guys, more questions:

1) Doc asked me if the baby was on "full feeds." I dont know what that means. Does that mean 120 kcal/kg/day with only PO intake (no TPN or IVF) or are they talking about cc/hr or some other metric?

2) We use a solution called SNAP10 which is an IVF of 10% proteins. How do I calculate how many kcals the kids get from that? How much are they supposed to get?

3) Whats the diff btwn HAL (hyperalimentum) and TPN? Why use one over the other? How do you calculate the caloric intake for HAL and TPN?

4) Some kids have OG tubes and others have NGs. When is one better than the other?

SteveNNP, MSN, NP · Sep 2, 2008

Thanks guys, more questions:
1) Doc asked me if the baby was on "full feeds." I dont know what that means. Does that mean 120 kcal/kg/day with only PO intake (no TPN or IVF) or are they talking about cc/hr or some other metric?
2) We use a solution called SNAP10 which is an IVF of 10% proteins. How do I calculate how many kcals the kids get from that? How much are they supposed to get?
3) Whats the diff btwn HAL (hyperalimentum) and TPN? Why use one over the other? How do you calculate the caloric intake for HAL and TPN?
4) Some kids have OG tubes and others have NGs. When is one better than the other?

Full feeds usually means that the baby is receiving full nutrition from enteral feeds. The kCal and volume depends on the baby.

I am not familiar with SNAP10...I'll have to check it out

Hyperal is TPN fluids alone, TPN used to mean fluids + intralipids, but everyone just refers to the fluids as TPN.

NG vs OG depends on the baby. If he's having trouble breathing, I'm not going to occlude a nare with a tube. If he's trying to bottle feed, I go with an NG, so his mouth and suck are not affected.

TiffyRN, BSN, PhD · Sep 3, 2008

I like Steve's answers. I will add this. I don't know what Snap10 is. But our unit does use something called trophamine until HAL is started, but usually only for smaller kids. All I know is that is has amino acids & glucose, but how much I don't know. A excellent resource for caloric content (or at least nutrient content) would be your friendly pharmacist.

In our unit full feeds is roughly 150-160ml/kg/day. Sometimes IVF's will be stopped before this amount is reached especially if IV access is tough. Generally full feeds mean no IV's will be running.

Generally OG vs. NG has mostly to do with nurse preference and if the child's resp. needs. We have one MD who hates NG's in general. He will pretty much only allow it on kids with no O2, no resp issues at all, and nippling at least 2/3 feeds. Not that it doesn't get retaped when he's off duty!