feeding neonates with surgical problems

Nottingham Neonatal Service Clinical Guideline D10

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Title: Feeding Neonates with Surgical Problems

Version: 2 Ratification Date: March 2012 (circulated November 2012) Review Date: December 2014 Approval: Nottingham Neonatal Service Clinical Guideline Group April 2012 Author: Chris Jarvis, Brian Davies, Helen Budge Job Title: Specialist Neonatal Dietitian, Consultant Paediatric Surgeon, Consultant

Neonatologist Consultation: Neonatal Service Staff and Clinical Guideline Meeting Guideline Contact Chris Jarvis, Specialist Neonatal Dietitian c/o Stephanie Tyrrell, Nottingham

Neonatal Service [email protected] Distribution: Nottingham Neonatal Service, Neonatal Intensive Care Units Target audience: Staff of the Nottingham Neonatal Service Patients to whom this applies:

Patients of the Nottingham Neonatal Service who fit the inclusion criteria of the guideline below

Key Words: necrotising enterocolitis, stoma, milk, bowel atresias, feeding Risk Managed: Suboptimal perioperative nutrition and necrotising enterocolitis Evidence used: The contemporary evidence base has been used to develop this guideline.

References to studies utilised in the preparation of this guideline are given at its end.

Clinical guidelines are guidelines only. The interpretation and application of clinical guidelines remain the responsibility of the individual clinician. If in doubt, contact a senior colleague. Caution is advised when using guidelines after the review date. This guideline has been registered with the Nottingham University Hospitals NHS Trust.

1. Background

Nutrition & growth are vital to the quality of outcomes following neonatal surgery. Breast milk is believed to be the best form of enteral nutrition for babies. The incidence of necrotising enterocolitis (NEC) is considerably less in babies breast fed or fed with expressed breast milk (EBM).[1] Mothers of preterm babies or babies expected to have surgical problems should be actively encouraged to express milk as necessary and progress to breast feeding.

Our approach to introducing and advancing feeds (Nottingham Neonatal Service Guideline D3) and the choice of milk when breast milk is unavailable (Nottingham Neonatal Service Guideline D4), serve as the basis for this guideline and a summary of these is given as Appendix 1. Poor nutritional intakes which result from the use of low protein and energy, or diluted, feeds can be avoided by the use of the most appropriate milk and appropriate parenteral nutrition (PN) (as detailed in Nottingham Neonatal Service Guideline D6).

This guideline (Nottingham Neonatal Service Guideline D10) offers guidance on choice of milk, feeding regimen and management of specific surgical conditions. Appendices 2 and 3 contain additional useful information on the comparable content of available milks.

Breast-feeding/EBM should be encouraged in all babies,

especially premature babies and babies with surgical problems.

Those with antenatally detected conditions will already have been counselled to this effect if time allowed before delivery


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Summary of enteral feeding decision making for small or preterm surgical babies

(


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2. Choice of enteral feed for surgical babies in NICU (Appendices 2 and 3)

Breast-feeding/EBM should be encouraged in all babies -

especially premature babies and babies with surgical problems.

2.1 Special circumstances influencing choice of enteral feed for surgical babies in NICU

Occasionally, in some abdominal surgical conditions, feeding with breast milk may need to be temporarily suspended. Parents should be consulted and mothers supported to maintain lactation by expressing and freezing breast milk for future use. Frequency of expression should not be reduced even though breast milk is not currently being fed to the baby or future supply may be affected. The decision to feed with a milk-substitute where maternal breast milk is available should only be made following review by Consultant Paediatric Surgeon and Attending Consultant Neonatologist. The Neonatal Dietitian should be consulted. Certain considerations may be necessary for some babies with surgical conditions of the bowel:

- Lactose tolerance

Whilst breast milk contains lactose, it is unlikely that lactose intolerance will be clinically significant in the majority of babies, although it is a theoretical possibility in injured or shortened bowel. Therefore, breast milk or a lactose containing formula may be tried in the first instance and reviewed closely. If lactose intolerance is thought to be a significant issue, the use of a minimal lactose formula containing glucose polymer (Pepti-Junior) may be necessary after review by Consultant Paediatric Surgeon and Attending Consultant Neonatologist. Advice should also be sought from the Neonatal Dietitian.

- Fat absorption

Fat may be affected in some conditions (cholestatic jaundice, short bowel and/or high stoma). Breast milk and normal formulas contain long chain triglycerides which are dependent upon bile salt emulsification for absorption. Where bile salt metabolism is thought to be substantially impaired, a formula containing medium chain triglycerides (MCT) (such as Pepti-Junior) may be beneficial. As the provision of long chain polyunsaturates (LCPs), naturally present in breast milk, may also be important, all the formulas recommended are supplemented with LCPs.

- Protein tolerance

Breast milk contains readily absorbed whole protein and is usually well tolerated. In the occasional circumstances when protein intolerance becomes a feature of short bowel and high stomas, a hydrolysed protein formula may be beneficial.

Pepti-Junior (12.8%) is a hydrolysed protein formula designed for infants born at term but can be modified for preterm infants to 15% to more closely meet increased requirements - see section 3.1.2

Aptamil Pepti 1 (13.6%) is a hydrolysed protein formula that we plan to use for babies with gastroschisis due to the better palatability while not needing MCT and the low lactose levels provided by Pepti-Junior. It can also be enriched (16% solution) for infants born preterm see section 3.1.2

Neocate LCP is an amino acid containing term formula that is very rarely required, but may be useful where partially hydrolysed formulas have failed.

None of the above formulas meet the nutritional requirements of preterm infants nor are they available as ready to feed preparations. However, there is currently no suitable product in the UK so enriched versions of Aptamil Pepti 1 or Pepti-Junior provide the best option.

3. Enteral feeding in specific surgical conditions

PN should be considered early and used to avoid periods of suboptimal nutrition. The stepwise approach to introducing milk outlined in Appendix 1 serves as a good starting point and guide. However, for conditions such as NEC and gastroschisis it may be necessary to progress more slowly. This can be done by daily review of feeding strategy by the Attending Consultant Neonatologist and Consultant Paediatric Surgeon.

The proportion of the intestine remaining should be clearly documented by the surgical team in the operation notes as length of small intestine remaining is a major factor in the likelihood of weaning PN and establishing full enteral nutrition. [2] Where possible an estimate of the amount of small intestine remaining should be documented as this will be used as a predictor of feed choice. (see 3.1.1). This should be recorded in the surgical notes as cm resected and remaining and the approximate proportion or percentage remaining. The presence of the ileocaecal valve, although not necessarily a predictor of ultimate enteral tolerance [3], may be a factor and is important in preventing bacterial overgrowth so should also be documented. However, as the length of intestine remaining can only be an estimate, clinical assessment (including weight gain, hydration, electrolytes, stool frequency and size) must be taken into account.


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3.1 Enteral Feeding following NEC

In NEC requiring surgery, commencing feeds depends on operative findings and clinical condition post-surgery:-

- if there is no residual disease or no proximal disease between the stomach and the stoma and a good post-operative recovery, feeds can be commenced from the 7

th post-operative day with EBM where at

all possible.

- in conservatively managed NEC (without surgery), or where there is residual disease and/or clinical evidence of ongoing NEC at operation, the baby will require 10 days nil by mouth (NBM) from operation (if undertaken) to allow recovery before a joint decision regarding commencing feeds is made between the Consultant Paediatric Surgeon and Attending Consultant Neonatologist. Feeds should be commenced with EBM where possible. Antibiotics are needed for this 10-day period (Nottingham Neonatal Service Guideline C1).

These differences in the length of NBM recommended in NEC above relate to the presence or removal of diseased intestine which will come into contact with the milk.

Starting feeds post-surgery or following medical management of NEC after surgical opinion, will be a combined decision between the Attending Consultant Paediatric Surgeon and Attending Consultant Neonatologist which will be assessed daily with clear guidance given. Modifications to this guidance should only be made where change to clinical condition or tolerance occurs between the daily reviews.

3.1.1 Choice of feed (see Summary Algorithm Page 2)

EBM is the milk of first choice

When EBM is unavailable the following can be used as a guide:

- in babies where birthweight


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3.2 Stomas

Babies may have stomas sited for a variety of reasons including congenital obstruction and NEC. Those infants with of healthy small intestine between mouth and stoma, so called low stomas, should usually be managed according to the standard enteral feeding guideline (Nottingham Neonatal Guidelines D3, D4).

3.2.1 Managing babies with jejunal/ high ileal stomas (50ml/kg/day are usually excessive.

3.2.3 Intravenous Replacement Fluids

Replacement of fluid losses should be considered in infants with high stoma losses and a guide will be suggested by the Consultant Paediatric Surgeon and Attending Consultant Neonatologist.

Commonly, this may be an instruction such as losses greater than 30ml/kg/day should be replaced with an equal volume of IV fluids. However, the actual decision to replace stoma losses should consider the need in that individual infant so that intravenous replacement of small volumes does not occur.

For example:- 1) Under the standing order of losses greater than 30ml/kg/day should be replaced with an equal

volume of intravenous fluids, stoma losses of 35ml/kg/day would lead to an additional 5ml/kg/day intravenous fluid which is unlikely to be clinically indicated.

2) A baby on full enteral feeds in a significant positive fluid balance is unlikely to need replacement.

IV fluids replacement would usually be made using 0.9% NaCl with 10mmol KCl in 500ml. Where infants are receiving PN an increase in nutrition would be achieved by replacing with the aqueous solution. This should be a consultant decision based on the nutritional needs with neonatal dietitian advice if available.

3.2.4 Urinary Electrolyte Measurement

Where stoma losses of 20ml/kg/day do occur, urinary electrolytes should be measured weekly.

A low urine sodium (


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3.2.5 Recycling stoma losses

There are case reports to suggest that collecting losses from a proximal stoma and repassing them into the distal mucous fistula is beneficial in terms of stimulating mucosal growth, preventing atrophy of the bowel and increased nutrient and electrolyte absorption thereby reducing need for PN which may reduce risk of cholestatic jaundice. [5, 6] This practice will be requested by the surgeon if required and detailed guidance given. The surgical team should do at least the first three attempts before requesting that the NICU nursing staff take this on. The fluid replaced into the distal stoma must not be recorded as stoma loss on the fluid balance charts as this will risk double counting and the baby receiving unnecessary additional fluids.

3.2.6 Loperamide

As the feed volume increases in a baby with high volume stoma losses, loperamide may be considered in order to inhibit intestinal secretion. [7] Loperamide binds to the opiate receptor in the gut wall, reducing propulsive peristalsis and increasing intestinal transit time, as well as increasing tone of the anal sphincter.[8]

The need for loperamide should be made as a joint decision between the Consultant Paediatric Surgeon and the Attending Consultant Neonatologist. When it is indicated, loperamide (1mg/ml as sugar-free, sorbitol-free version manufactured as a special product in pharmacy) should be commenced at 400 micrograms/kg/day (100 micrograms/kg/dose 4 times a day), given 30 minutes before feeds where possible. As changes in loperamide dose take a little time to result in altered stool volumes, dosage should be reviewed no more than twice per week. Where stoma losses remain excessive on review, it is recommended that total daily dose of loperamide should usually be increased as below.

DAILY Loperamide dose QDS Loperamide dose

400 micrograms/kg/day = 100 micrograms/kg/dose



Allow 3-4days between increases for loperamide to have an effect

The maximum dose of loperamide is unknown but for chronic diarrhoea in infants 1m-1y a total daily dose of 2mg/kg/day may occasionally be required (BNF for Children). (500micrograms/kg/dose 4 times per day)

Loperamide should be used with caution in severe hepatic impairment discuss with Attending Consultant Neonatologist and Neonatal Pharmacist.

Following stoma closure where a good length of bowel remains, loperamide should not be required and, therefore, it should be discontinued after stoma closure. However, if there are significant losses with feeding following stoma closure, reintroduction of loperamide may be considered by the Consultant Paediatric Surgeon and Attending Consultant Neonatologist.

3.2.7 Stoma Closure

All decisions to close a stoma early will be made by the Consultant Paediatric Surgeon and Attending Consultant Neonatologist. Factors which are considered are whether there is a useful length of unused intestine and any existing problems related to the stoma (poor growth, electrolyte disturbances, prolapse, retraction, stenosis or skin excoriation).

If the infant is growing well and there are no problems, or there is very little extra intestinal length to be gained, a decision for late closure will usually be made.


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3.3 Gastroschisis

In babies with gastroschisis, there is a risk of NEC as bowel motility returns. Many of these babies seem to tolerate standard formula milks poorly. [9]

Therefore, EBM is the milk of first choice and breast-feeding should be strongly encouraged antenatally and actively supported postnatally.

If EBM is unavailable:

- babies whose birth weight was >2kg, 13.6% Aptamil Pepti 1 should be used. Once thriving at home, a standard formula can usually be introduced. This will be agreed at surgical review

- babies whose birth weight was


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3.8 Meconium ileus

These babies require consultation with the CF team for consideration of pancreatic supplementation (Nottingham Neonatal Service Guideline F4).

4. Assessing Feed Tolerance

Feed tolerance is assessed using a number of factors including vomiting; quantity and type of aspirate; consistency, volume and frequency of stool or stoma loss; weight gain and growth. Detailed nursing and medical recording is essential for informed decision making. For many infants, standard recording is adequate for decisions on progressing feeds. Where feed tolerance is poor and variable such as found with high stomas, a summary flow chart of these parameters can be useful and should be completed as part of the daily medical review where this is requested by the medical and surgical team (Appendix 4).

4.1 Aspirates

High volume aspirates are common following gastrointestinal surgery and feeds will not be started until these have settled, though early trophic feeding is beneficial. Guidance will be given daily on proportion of aspirate to be replaced and this may differ from the advice in Guideline D3 due to the surgical condition and its potentially altered anatomy.

The volume of aspirate that is relevant will be dependent on the volume of feed given so instructions will be given to stop or reduce feeds or continue and replace the aspirate itself according to the following guide:

if aspirate 30% of intake) and if the gastric pH is


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5. Guidance for discharge Once established on enteral feeding and ready for discharge from hospital, the choice of feed will depend on clinical need. Where EBM is available and mother still intends to breastfeed, every effort should be made to establish breast feeding with or without supplements. The Neonatal Dietitian will advise as required. Fresh EBM should be used in preference to frozen where available. Where infants are no longer receiving breast milk, those tolerating whole protein formulas should be changed to Nutriprem 2 or term formula as per existing guidelines on feeding post discharge (Nottingham Neonatal Service Guideline D9) unless specialised formulas are required. Infants with birth weight 2kg Breast-feeding or Term formula where breast milk is not available

Infants who will not tolerate the appropriate formula above may need to be discharged on a specialised formula and must be referred to the Neonatal Dietitian for advice. Babies with gastroschisis who are not receiving maternal breast milk should be discharged on a hydrolysed protein formula such as Aptamil Pepti 1 until good growth is assured at outpatient surgical review. Where specialised formulas such as Aptamil Pepti 1, which have been designed to meet the needs of term infants, are required for preterm infants, the concentration is likely to need increasing. This will require the advice of, and ongoing review from, the Neonatal Dietitian.

Infants requiring loperamide at discharge should continue to receive the same preparation as used in hospital providing 1mg/ml rather than the proprietary product routinely available in the community (Imodium 0.2mg/ml) which, as a result of its concentration requires 5x the volume to achieve the same dose and contains sorbitol which may result in osmotic diarrhoea. This should be made clear on the prescription at discharge and the NICU Pharmacist will advise as necessary.

REFERENCES 1. Lucas, A. and T. Cole, Breast milk and neonatal necrotising enterocolitis.Lancet, 1990. 336(8730): p. 1519-23. 2. Andorsky, D.J., et al., Nutritional and other postoperative management of neonates with short bowel syndrome correlates with clinical outcomes. J Pediatr, 2001. 139(1): p. 27-33. 3. Kocoshis, S., Evolving concepts and improving prospects for neonates with short bowel syndrome. The Journal of Pediatrics, 2001. 139(1): p. 5-7. 4. Parker, P., S. S, and G. H, A controlled comparison of continuous versus intermittent feeding in the treatment of infants with intestinal disease. Journal of Pediatrics, 1981. 99(3): p. 360-4. 5. Wong, K.K., et al., Mucous fistula refeeding in premature neonates with enterostomies. JPGN, 2004. 39(1): p. 43-5. 6. Richardson, L., S. Banerjee, and H. Rabe, What is the evidence on the practice of mucous fistula refeeding in neonates with short bowel syndrome? J Pediatr Gastroenterol Nut, 2006. 43(2): p. 267 7. Moriarty, K., et al., Nufenoxole,inhibits fluid secretion in the human jejunum. Gut, 1985. 26: p. 75-80. 8. eMC Loperamide - pharmacodynamic properties - http://www.medicines.org.uk/emc/medicine/17607/SPC/. 2010. 9. Jayanthi, S., et al., Necrotizing enterocolitis after gastroschisis repair: a preventable complication? Journal of Pediatric Surgery, 1998. 33(5): p. 705-7.

10. Schulman, R., et al., Early feeding, feeding tolerance, and lactase activity in preterm infants Journal of Paediatrics, 1998. 133(5): p. 645-649. 11. Vanderhoof, J.A., et al., Effect of high percentage medium-chain triglyceride diet on mucosal adaptation following massive bowel resection in rats. J Parenter Enteral Nutr, 1984. 8(6): p. 685-9. 12. Kollman, K.A., E.L. Lien, and J.A. Vanderhoof, Dietary lipids influence intestinal adaptation after massive bowel resection. J Pediatr Gastroenterol Nutr, 1999. 28(1): p. 41-5. 13. Innis, S.M., Perinatal biochemistry and physiology of lcp's. J Pediatr, 2003. 143(4 Suppl): p. S1-8. 14. Silk, D.B., et al., Use of peptides rather than amino acids in "elemental" diets. JPEN, 1980. 4(6): p. 548-53. 15. Ksiazyk, J., et al., Hydrolyzed v nonhydrolyzed protein in short bowel syndrome in children. JPGN, 2002. 35(5):p615-8.

16. Abdelhamid, A.E., et al., In Vitro Cow's Milk Protein-Specific Inflammatory and Regulatory Cytokine Responses in Preterm Infants With Necrotizing Enterocolitis and Sepsis. Pediatric Research, 2011. 69(2): p. 165-169 17. Vanderhoof, JA et al, Hydrolyzed v nonhydrolyzed protein in short bowel syndrome in children.JPGN 2004.38(1):p 107 18. Bines, J., D. Francis, and D. Hill, Reducing parenteral requirement in children with short bowel syndrome: impact of an amino acid-based complete infant formula. J Pediatr Gastroenterol Nutr, 1998. 26(2): p. 123-8. 19. Fenton, T. and J. Belik, Routine handling of milk fed to preterm infants can significantly increase osmolality. Journal of Pediatric Gastroenterology & Nutrition, 2002. 35(3): p. 298-302.


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APPENDIX 1: Current Approach to At Risk Premature Non-Surgical Babies (Guideline D3)

Starting feeds 2 hourly bolus feeds are preferred regimen

Patient condition First feed advice

>30 weeks and well Start 2 hourly bolus feeds from birth, at step 2 or 3. Some babies will tolerate full feeds immediately and this can be tried in those 32/40 and above.

23-30 weeks and well Start feeds in first 24 hours and review at 24 hours

If on Inotropes (any gestation)

Delay starting feeds


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APPENDIX 2: Issues to consider when deciding on a feed

1. Lactose: Pepti-Junior is clinically lactose free, whereas EBM, Aptamil Pepti 1, term and preterm formulas contain lactose. Breast milk confers significant advantages. Therefore, although transient lactose intolerance may occur following any gut trauma and EBM has all the CHO as lactose, breast milk would still be our first feed of choice. Lactase activity increases 5 fold throughout the last trimester, is increased by early feeding and is thought to be inducible by the presence of lactose. [10] The presence of lactose if tolerated, would optimise the appropriate gut micro flora. However, if breast milk is not tolerated, the presence of undigested CHO in the bowel could in theory predispose to necrotising enterocolitis. Although low lactose feeds appear to have been used automatically in short bowel syndrome (SBS) in published studies, whether this is intentional or just because semi-elemental/elemental feeds nearly always contain a reduction in lactose is unknown.

2. MCT: EBM and Nutriprem 1 are not sources of MCT, Pepti-Junior has 50% of fat as MCT. Although MCT is said to be more easily absorbed, animal studies suggest that it is probably less beneficial than LCT, especially LCPs, in promoting mucosal adaptation. [11, 12]. A source of MCT may be beneficial in babies with conjugated jaundice which is often present in some infants requiring gut surgery due to need for long term PN. However, infants growing well on breast milk or standard formulas should not be changed routinely.

3. LCPs: long chain polyunsaturated fats are thought to be essential for normal brain and retinal development in LBW infants who do not have the maturity of enzyme function to produce them from essential fatty acids. [13] and are known to be major trophic factors in short bowel. [12] They are naturally present in EBM and added to Nutriprem 1 & 2, Aptamil Pepti 1, Pepti-Junior and Neocate.

4. Hydrolysed protein: Whole proteins are found in EBM, Nutriprem 1 & 2. Hydrolysed protein as peptides are found in breast milk fortifier (BMF), Aptamil Pepti 1 and Pepti-Junior. The degree of hydrolysis is different, with chain length of peptides decreasing from BMF>Aptamil Pepti 1>Pepti-Junior and Neocate LCP containing protein as amino acids the most basic form of protein. Although it may seem logical that the further protein is hydrolysed the more readily it will be absorbed, there is contradictory published evidence and it is likely that whole protein may be as well utilised [14, 15]. The further a protein is hydrolysed, the greater the osmotic effect, so lactose is usually replaced with glucose polymer to help reduce osmolality of the final product. Whilst it has been postulated that cows milk protein may have a role in the development of NEC and sepsis [16] and that dietary antigen sensitisation may have a role in promoting or sustaining inflammation in both [17], evidence in support of this is awaited.

There is a retrospective review in neonates with SBS which supports the use of EBM or fully elemental formulas (amino acids, rather than peptides) in reducing duration of parenteral nutrition (PN) [2]. However, semi-elemental formulas may also help in decreasing peak bilirubin concentration. There is also a suggestion that amino acids may be of benefit in SBS as they eliminated the need for PN in a small number of children with SBS in whom peptide formulas had been unsuccessful [18].

5. Nutritional profile: Currently available hydrolysed protein/amino acid based formulas in the UK do not meet the nutritional requirements of preterm infants even if fed at large volumes, which are unlikely to be tolerated in SBS. Although a higher concentration can be used, this still does not meet the specific nutritional needs of preterm infants, though is the best option at present. None of these formulas are available as ready to feed preparations so carry the risk of variable composition due to reconstitution from powder. This may be critical to infants with malabsorption, so care should be taken when making up feeds to ensure greatest accuracy.


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APPENDIX 3: Table of nutritional comparison of feeds that may be considered in surgical patients

Per 100ml Feed

Unfortified EBM

(term/mature preterm)

Fortified EBM (term/mature

preterm)

Nutriprem 1 Aptamil Pepti 1 13.6% ~16%

Pepti-Junior 12.8% ~15%

Neocate LCP

Nutriprem 2

Protein g 1.3 (estimate) 2.5 (estimate) 2.6 1.6 1.9 1.8 2.1 1.8 2.0

Degree of Hydrolysis

Whole protein

Whole protein + peptides

$

Whole protein

*peptides *peptides amino acids Whole protein

Fat g 4.2 4.2 3.9 3.5 4.1 3.5 4.1 3.4 4.0

% Fat as MCT - - 8% 3% 50% MCT 5% MCT 9%

LCPs Yes Yes Yes Yes Yes Yes Yes

CHO g 7.4 10.2 8.4 7.1 8.3 6.8 8.0 7.2 7.4

% Lactose 100% 72% 56% 41% Aptamil Pepti 1 > Pepti Junior


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Appendix 4 14 Day Summary Chart for Feed Tolerance in Infants with Surgical Stomas

Date

Weight (kg)

Total fluids (ml/kg/d)

P N

PN (ml/kg/d)

E N T E R A L

Type of milk

Volume & Frequency

Amount (ml/kg/d)

O U T P U T

Stoma output (ml/kg/d)

No. of vomits

IV replacement* (ml/kg/d)

Na S T A T U S

Serum Na (mmol/l)

Urine Na (mmol/l)

PN - Na intake (mmol/kg/d)

Na Supp (mmol/kg/d)

Total Na intake (mmol/kg/d)

N O T E S

IV replacement will generally be with 0.9% NaCl with 10mmol KCl in 500ml. Where infants are receiving PN an increase in nutrition would be achieved by replacing with the aqueous solution. This should be a consultant decision based on nutritional needs with neonatal dietitian advice if available.

1. Milk, preferably EBM should be increased according to individual tolerance using rates in the NICU Yellow Regimen (Appendix 1) as a maximum 2. Where feed intolerance is suspected or likely, decisions on fluid replacement, feed advancement, need for Na supplements, loperamide, etc should be made

based on the previous days tolerance using table below. Changes should not necessarily be made daily as the infant may need longer than this to adjust to a change. This table should be completed daily by the doctor performing the daily review to allow informed decisions to be made on the Consultant Ward Round

Patient Name: Date of Birth: Hospital Number:

NHS Number:

(attach label)

feeding neonates with surgical problems

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