at Risk Neonates
Providing adequate nutritional support to
babies with problems is a challenge.
Nutritional support can be accomplished
enterally or parentraly , or as a combination of
both. Enteral feeding is the natural and
preferred route of nutrition whenever it is safe
The sick or At – Risk Infant
Changes in feeding are often an early sign of
neonatal problems for example, feeding
problems may be an early sign of infection.
Most seriously sick babies do not feed well
and often will not tolerate tube feeding. These
infants must be managed carefully with IV
fluids until bowel function and renal output
Infants who have experienced shock or
asphyxia may have Ischemic injury to the
intestine that will require 2-3 days or more for
recovery before small feedings can be
attempted, even when their general status is
stable. Premature infants require special
attention, because they have difficulty sucking
and swallowing adequate volume and
calories, and may be deficient in intestinal
enzymes and absorption.
Feeding can be initiated for the sick or at risk
infant once physical findings have
normalized. Determination of the type of milk
to be used is the first step. Breastmilk is the
preferred diet, providing sufficient protein,
fat, carbohydrates, and water for normal
It is important to remember that milk from
mothers who have delivered a premature
baby is different from the milk of term
mothers, and it should be used. Formulas
with greater than the standard 0.67 cal / ml
can be made from concentrated formula or
powder; 0.80 cal / ml formula is tolerated by
Hospital needs to determine what type of
formulas to stock.
Most infants including the preterm tolerate
standard 67 cal /100 ml milk – based
formulas, and for reasons of cost and
availability these are recommended. Certain
clinical situations, including the small
preterm infant, may necessitate special
formulas and nutritional additives.
TYPES OF FEEDING
A. Trophic Feeding (Gut priming, non-
Definition: Small amounts of early enternal
feeding in infants who can not tolerate
regular nutritive feeding.
Indications: This feeding strategy is mainly
– Extremely low birth weight premature infants
(birth weight 1000 grams)
– Term infants with mild instability (such as
sepsis) can also benefit from trophic feeding.
– Umbilical artery catheter in place.
– Before starting trophic feeding ensure that the
• Has active bowel sounds
• Does not have abdominal distension
• Has stable blood pressure
• Has stable respiratory status (may be on ventilator)
– Contraindications to trophic feeds are the
same as those for very early feeding.
– Start in the second or third day of life using
breast milk or ½ strength ( ½ ST.) formula.
Start with 1 cc every 6 hours and advance
slowly not to exceed a total of 15-20 cc/kg/day
within one to two weeks of life depending on
the infant’s birth weight.
* Breast milk full strength can be used instead of
– Day of life # 1-2
– Day of life # 3-4
• ½ St. Premature Formula 1cc every 6 hours
– Day of life # 5-6
• ½ St. Premature Formula 1cc every 4 hours
– Day of life # 7-8
• Full St. Premature Formula 1cc every 4 hours
• Advantages: Gut priming has been shown
– Preserve Gl motility
– Promote Gl hormones, and enzyme secretion
– Reduce the need for parenteral nutrition
– Reduce the direct bilirubin level
B. Nutritive Feeding
– The goal of nutritive feeding is to supply the
required nutrients and calories to achieve the
expected weight gain. Matching intrauterine
growth for current size and gestational age is
the ultimate goal. Neonates loss almost 10% of
their birth weight within the first week of life.
Following this drop of weight, the expected
daily weight gain varies from 20 to 30
grams/day according to the gestational age. The
caloric requirement to achieve this growth is
120 K calories/kg/day.
ROUTES OF FEEDING
A. Gastric feeds
• Indications: It can be used in infants who
are unable to nipple feed such as:
– Premature infants < 32 weeks gestation
– Infants with neurological impairment
– Infants with residual respiratory distress
• Procedure: Orogastric or nasogastric tube
can be used
– Use a polyethylene tube number 5 or 8 French
– Turn the infant’s head to the side and measure
the length from the xyphoid to ear lobe and
then to the nose
– Mark that length on the feeding tube using a
small piece of tape
– Pass the tube through the nose or mouth with
the neck in the flexed position
– Inject air through the tube while auscultation
the stomach for bubbling gently aspirate stoned
content then give 1-3 c.c. after.
B. Transpyloric feeds
– Infants with severe reflux or delayed gastric
– May be routinely used in ELBW infants (<
– Insert Orogastric (OG) tube as described earlier
– Measure transpyloric (TP) tube 10cm longer
than the OG tube
– Turn patient onto right side (with left hip up)
– Insert air through OG tube to distend the
• 10 ml for infants < 1000 grams
• 15-20 ml for infants > 1000 grams
– Insert transpyloric tube
– Wait 10-20 minutes with infant on right side,
and aspirate through TP tube gently
– The TP tube is considered in good position if
• Aspirate is bilious
• Aspirate is alkaline
• No air is aspirated
–If not in good position, leave the TP tube open
and OG tube closed for up to 4 hours or until
–If unsuccessful within 4 hours repeat the
procedure all over again
Transpyloric tube has to be flexible not to stiffen in
the jejunum. Stylistic or polyurethane tubes are
suitable for transpyloric feed.
METHODS OF FEEDING
A. Gavage (bolus) feeding:
Premature infant weight > 1000 grams can
generally tolerate gavage feeding up to full
Feeding is to be introduced by gravity not to
be injected by a syringe
Feeding is introduced every 3 hours
Measure gastric residuals before each feed
B. Continuous drip feeding:
It is indicated in infants with severe
gastroesphageal reflux and the ELBW infants
Use an automated pump for that purpose
Set the pump rate at the desired hourly rate
Gavage feeding is more physiology and can
promote better gut growth than continuous feeding.
Continuous feeding has better energy retention and
growth rate. Several studies in 1998, favored bolus
feeds over continuous feeds. It is advisable to reserve
continuous feeds only for premature infants with
ELBW (<1000 grams) and those with
gastroesophageal reflux. With gastric feeds, you
can use gavage or continuous techniques. With
transpyloric feeds use only continuous technique.
TYPES OF MILK
A. Human Milk
Whenever available mother’s own preterm
breast milk is the feeding of choice for
The potential advantages of breast milk over
formulas include gastrointestinal, respiratory,
allergy-immunology, neurological and
Breast milk has suboptimal concentration of
Ca, P, and protein for the growing premature
infant. Powdered premature formula may be
used to supplement breast milk.
Mothers should be oriented with the proper
use of breast pump with the cleaning
instructions for the breast and the container.
Nursery staff should be experienced to
answer mother’s questions.
Major contraindication to the use of breast
milk are maternal HIV, advanced TB and the
use of chemotherapy or radioactive agents.
• Premature Formula:
• Indicated for premature infants < 2000 grams.
• Contain higher calcium and phosphorus ratio and
higher protein & calories enough for the premature
infant to grow.
• At 36-40 weeks post-conceptual age, formula with
iron should be started.
• Premature formula should be continued until
weight is 3kg and serum alkaline phosphates level
is less than 300 and albumin is at least 3.0.
– Multivitamins should be supplemented to premature
infants feeding either regular formula or breast milk
when the baby is on full enteral feeds.
– Vitamin E should be supplemented (25 IU/kg/day) to
premature < 32 weeks.
– Serum level should be checked in all premature infants
on exclusive enteral feeding (without TPN)
– Ca and P are needed for premature infants on exclusive
breast milk (if Human Milk Fortifier is unavailable).
Serum Ca, P and Alkaline phosphates may be checked
regularly to determine any need for supplementation.
The schedule for a formula-fed 30 weeks (1.2
kg) premature infant should be as follow:
–Start with premature formula such as SC or PE.
–Once on full feed check the need for Vitamin E.
–At 36 weeks corrected age (6 weeks postnatal):
Switch to premature formula with iron.
– At 3000 grams: Switch to regular formula if
serum Alkaline phosphates and Albumin are
normal. Start multivitamins, iron, Calcium,
– At 4 months corrected age (6 ½ months
postnatal): Switch to regular formula with iron.
Continue the multivitamins.