Neonatal Feeding and Fluid Guideline
Jinja Regional Referral Hospital
Background
The incidence of LBW is 14.3% in Africa, with little variation across the region as a whole.
When babies are small or born preterm, there is an increased risk of feeding difficulties for
the newborn. This can be due to immature/ absent sucking reflexes in the baby or
secondary to many neonatal conditions including infections and congenital abnormalities.
This guideline is attended for use by healthcare staff caring for neonates at Jinja Regional
Referral Hospital; it is not intended for wider distribution to other healthcare facilities
where the ability to follow these guidelines may be restricted.
Introduction
There is strong and consistent evidence that feeding mother’s own milk to pre-term infants
of any gestation is associated with a lower incidence of infections and necrotising
enterocolitis, as well as improved neurodevelopmental outcome as compared with formula
feeding.
When giving feeding advice to a mother about her baby, it is important that exclusive
breastfeeding for the first six months of the child’s life is advocated wherever possible, in
accordance with the WHO advice.
What to do when there is no/ reduced breast milk supply
Supporting and educating the mother about breastfeeding is the best way to ensure that
the mother’s milk supply is optimal for the baby’s nutritional requirements.
Health workers should be able to explain and demonstrate good breast-feeding positions in
order to help establish breastfeeding as early as possible (see figure below).
•
Baby's whole body toward mother
•
Chest to chest
•
Touch baby’s upper lip with nipple, when opens mouth wide, pull baby onto the
breast
•
Holding breast for support
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•
Mouth should cover not just the nipple but as much of the areola (the darker part
surrounding it) as possible
Figure 1. Attachment of baby at mother’s breast
Short term feeding alternatives include cup feeding expressed breast milk or inserting a
nasogastric tube.
If alternative feeding methods are used, mothers should be encouraged to continue to
spend as much time as possible with their baby, ideally in the Kangaroo care position in
order to facilitate bonding and stimulate mother’s milk supply.
If babies are <1.0 kg at birth, they will not be able to suck effectively enough to get an
adequate supply of milk. These babies should have an NG tube inserted when feeding is due
to start in order to ensure that they get adequate nutrition (please see appendix on ‘How to
insert an NG tube’). Babies <1.5kg are also more likely to experience feeding difficulties and
should have a graduated introduction of milk.
You MUST ensure that the mother’s nutritional intake is adequate enough to produce a
good supply of breast milk. A mother that is malnourished will not be able to produce
enough breastmilk and both the baby and the mother’s health will be at risk.
Traffic lights system
All babies can be categorised into green, yellow or red groups. When a neonate is admitted
to special care unit, please ensure they are placed into correct feeding plan as per this
guideline.
Green
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-
Birth weight >1.5kg
No evidence significant infection
No congenital abnormalities identified
No delayed passage of meconium (if known)
No vomiting or per rectal blood.
Breastfeed as normal or give expressed breast milk by cup at
daily requirements. No iv fluids required unless feeding fails.
Yellow
-
Birth weight 1.0-1.5kg or >1.5kg with significant infection
Known antenatal absent/reversed end-diastolic flow
Milky vomiting ONLY
Do not feed for at least first 24 hours. Give 10% dextrose at 60ml/kg/day, then 80ml/kg/day
on day 2 if required. Electrolytes need to be added to fluids from day 3 onwards.
Gradual introduction of feeds following initial period of intravenous fluids only as per figure
C (feed requirements for VLBW infants).
Red
-
Birth weight <1.0kg
Bilious vomiting
Delayed passage of meconium
Per rectal bleeding
Abdominal distension with visible bowel loops/ colour change
DO NOT FEED for 48 hours.
Begin feeding at 24ml/kg/day, then 48ml/kg/day, then 72 ml/kg/day, then 96ml/kg/day,
then 120ml/kg/day, then 150ml/kg/day, then 165ml/kg/day, then 180ml/kg day.
Day 1- no feed, iv 10% dextrose only at 60ml/kg/day
Day 2- no feed, iv 10% dextrose only at 80ml/kg/day
Day 3- EBM 24ml/kg/day + remainder of fluids (76ml/kg/day) as iv 10% dextrose and ringers
lactate
Day 4- 48ml/kg/day
Day 5- 72ml/kg/day
Day 6- 96ml/kg/day
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Day 7- 120ml/kg/day
Day 8- 150ml/kg/ day
Day 9- 165ml/kg/day
Day 10- 180ml/kg/day
Initiate appropriate antibiotic coverage if bowel obstruction or necrotising enterocolitis
suspected (ampicillin, gentamicin and metronidazole). Remember to insert an NG tube and
place on free drainage to relieve intra-abdominal pressure if bowel obstruction or NEC
(necrotising entercolitis) suspected.
Feed requirement
Term babies and babies >1.5kg weight should initiate breastfeeding as soon as possible, providing
they are not unwell.
Babies should gain about 10g / kg of body weight every day after the first 7 days of life. If they are
not, check that the right amount of feed is being given.
Weight should be checked on admission, then at 3 days, 5 days, 7 days and twice weekly thereafter.
Normal birthweight = > 2.5kg
Low birth weight = 1.5- 2.5kg
Very low birthweight = 1.0- 1.5 kg
Extremely low birthweight = <1.0 kg
If there are any concerns about the hydration status of the baby i.e. very sick, appears dehydrated or
suspected cardiac failure (heart murmur, peripheral oedema, oxygen requirement, tachypnoea) then
weigh baby DAILY.
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When to start feeds
For babies with a birth weight > 1.5kg, without any congenital anomalies, breastfeeding should be
initiated as soon as possible.
Babies in the ‘red’ category i.e. birth weight less than 1.0kg should not receive feeds for the first 48
hours following delivery; they should be started on intravenous 10% dextrose
Which fluid to use
Figure 2. Composition of intravenous fluids (per L)
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10% dextrose
Given to babies that are at risk of hypoglycaemia and used for those requiring maintenance fluids in
the first 48 hours of life. Babies should NOT be given fluids containing electrolytes in the first 48
hours.
Ringer’s Lactate
Given to babies for rehydration and help with maintaining normal electrolytes. Contains sodium and
potassium and best used in combination with some 10% dextrose if on IV fluids from day 3 of life.
½ DS (Darrow’s solution)
Contains half the sodium and twice the potassium of ringer’s lactate. Can be used in combination
with 10% dextrose to maintain normal electrolytes in babies from day 3 of life.
Normal saline
Can be given to babies requiring resuscitation or to replace losses from abnormal bowels e.g.
gastroschisis or exomphalos. It should not be used for maintaining the fluid requirements of babies
that are not feeding as it contains too much sodium.
25% and 50% dextrose
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Should NEVER be given to neonates. If you are concerned that a baby is hypoglycaemic, give 5ml/kg
of dextrose 10%
Rehydration of dehydrated newborns
Newborns can get dehydrated quickly if adequate feed or fluids are not administered.
However, it can be normal for term babies of normal birth weight (>2.5kg) to take up to 72
hours to establish breastfeeding.
If the baby is passing urine and stool regularly and does not appear clinically dehydrated or
lethargic- there is no indication to give intravenous fluids.
Signs of dehydration in newborns
1)
2)
3)
4)
5)
6)
Decreased urine output
Weight loss
Prolonged skin pinch
Dry mucous membranes
Sleepy or unable to feed
Sunken fontanelle
Treating dehydration
Weigh the baby- this is the most accurate assessment of dehydration in a newborn due to
their high water content.
Give up to 20ml/kg as a fluid bolus for severe dehydration and ensure that hypoglycaemia is
corrected.
Fluid regimes after day 3 of life should include some attempt to correct electrolyte
imbalances as well as maintain normal glucose levels.
Aim to correct their dehydration slowly over the next 48 hours. The best way to rehydrate a
baby is using mother’s breast milk.
If possible, monitor the serum electrolytes.
HOW TO CALCULATE FLUID REQUIREMENTS
Age of baby (days), then refer to table re: feeding requirements on day 1-7 life.
Number of ml/kg required x birth weight = total number of mls of fluid/ day (24 hours)
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To calculate the number of mls required at each feed, divide the total number of mls of fluid
required in 24 hours by 12 (to get 2 hourly feed amounts) OR by 8 (to get 3 hourly feed
amounts).
Example
1.4 kg baby- requires iv maintenance fluids from birth.
Should receive 60ml/kg/day for day 1. Will require 10% dextrose only.
60 x 1.4 = 84 mls
84 mls fluid needed in 24 hours, plan for 2 hourly feeds.
84/12 = 7 mls fluid required every 2 hours (see prescription below).
Always record how much fluid has been given to a baby and sign the chart, writing the
date and time fluid was given.
Babies can become overloaded and oedematous if too much fluid is given, the child is septic
or the child has an underlying cardiac condition.
Signs of fluid overload
-
Excessive weight gain
Periorbital or genital oedema
Oxygen requirement
Tachypnoea
Harsh sounding heart murmur
If you are concerned that a baby is fluid overloaded or has signs of cardiac failure, ensure
that fluids are appropriately reduced and consider the use of a diuretic (1mg/kg of
furosemide iv or po). Ideally, their renal function should be tested.
When reducing fluids, ensure that the baby is monitored closely for signs of hypoglycaemia.
Hypoglycaemia
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Hypoglycaemia in the newborn is defined as a blood glucose of < 2.6mmol/L.
Babies that do not feed are at risk of hypoglycaemia and if there is any concern that a baby is
hypoglycaemic, treatment should be given.
If you do not have a glucometer to measure the blood glucose, there are some clinical signs that you
can look for in order to determine if a baby has a low blood sugar.
These include:
-
sleepiness or lethargy
convulsions
jitters (shaking movements of arms and legs that stop when you hold affected limb)
High risk babies include
-
Preterm babies
Infant of a diabetic mother
Babies with severe sepsis/ meningitis
Treatment options include
a) immediate feed (breast/cup/NG)
b) 5ml/kg bolus of iv 10% dextrose
Be aware that treating with dextrose once is unlikely to fix the feeding difficulties immediately,
therefore a clear feed and fluid plan should be made for the next few hours after treating
hypoglycaemia, to ensure it does not recur.
Vitamins and Mineral Supplementation
All preterm and low birth weight babies should receive nutritional supplementation with Grovit
drops 0.3ml once daily for at least 14 days.
Each 0.3ml Grovit contains 2500iu vitamin A, 200iu vitamin D, vitamin B1 0.5mg, Vitamin B2 0.2mg,
vitamin C 25mg, nicotinamide 2.5mg.
Ferrous fumurate (sytron) supplementation should start from 8 weeks age for the next 12 weeks in
any baby that is preterm or has a birth weight <2kg. Dose = 2.5ml once daily.
SPECIAL CIRCUMSTANCES
A) Necrotising Enterocolitis
If a baby develops bilious vomiting, significant abdominal distension or passes blood per rectumSTOP FEEDS IMMEDIATELY. This baby may have NEC (necrotising enterocolitis). Feeds should be
stopped for at least 48 hours, with clear explanation to the mother about the concerns.
Insert an NG tube and allow free drainage of abdominal contents.
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Arrange an abdominal x-ray- look for signs of intramural gas, thickened bowel loops or intestinal
perforation.
Treat the baby with triple intravenous antibiotics: ampicillin, gentamicin and metronidazole
Consider treating with iv vitamin K 1mg if blood per rectum.
B) SURGICAL PROBLEMS
Cleft lip & palate
Babies with an isolated cleft lip should be able to breastfeed normally. The baby should be offered
an early breastfeed straight away.
Babies with cleft palates can sometimes struggle to breast feed and may need to use alternative
methods. Mothers should express breast milk and feed the child with a cup and spoon.
This should be tried cautiously under supervision from nursing or midwifery staff, to ensure the baby
does not choke or aspirate milk.
Mothers should be advised that the baby should sleep on it’s side with a rolled up blanket behind
the back in order to prevent accidental aspiration whilst sleeping.
Early referral to a centre that can assess the defect for repair is essential i.e. Mbale Regional Referral
Hospital or Mulago Hospital, Kampala.
Imperforate anus/ meconium ileus
Most newborn babies will pass meconium within 24 hours of birth and all should pass meconium
within 48 hours of delivery. If the passage of meconium is delayed, there may be a structural bowel
abnormality or an obstruction to the passage of meconium within the bowel.
It is important to check that the position of the anus is normal and that the anus is not imperforate
in any child with a history of delayed passage of meconium. If the anus appears normal, an urgent
abdominal x-ray should be arranged for the baby and feeding withheld until any structural problems
have been ruled out.
Exomphalos/ gastroschisis
The feeding and fluid management for these babies is often very difficult, due to the large amount of
fluid being lost to the atmosphere through the exposed bowel wall.
Babies who are born with these congenital abnormalities of the bowel require early assessment by
the surgical team. While awaiting the surgeon’s review, do not feed the baby.
Insert an intravenous cannula and give 10% dextrose fluid at normal requirements + an extra
30ml/kg/day of 0.9% saline, to account for the fluid lost through the exposed bowel wall.
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Insert an NG tube to allow the stomach contents to drain freely and avoid additional pressure on the
abnormal bowel.
Babies with severe infection
Babies with severe infections may not tolerate normal feed volumes if if their gut has no structural
abnormality.
Fighting an infection can lead to reduced gut motility and vomiting, if large volumes of feed are used.
This intolerance to feed will improve as the infection is treated, but the baby may require smaller
volumes of feed for a few days. If this is the case, ensure that intravenous fluids are used to achieve
daily fluid requirements as necessary.
C) Babies born to mothers with HIV
Mothers that are HIV positive during pregnancy should be advised to exclusively breast feed their
babies. The baby should only be offered formula feeding at birth if the supply of baby formula can be
maintained throughout infancy and is AFASS (acceptable, feasible, affordable, sustainable, safe). For
most women delivering at Jinja hospital, this will not be the case.
It is very important to ensure that the mother does not mix feed (i.e. some formula and some
breastmilk) as this has been shown to have an increased risk of transmission of HIV to the baby.
Ensure that no other milk substitutes are given e.g. cow’s milk, as they are deficient in iron and can
affect the neurological development of the baby long-term.
References
1)
2)
3)
4)
5)
Basic paediatric protocols- Kenyan guidelines, revised 2010
Optimal feeding of low-birth-weight infants. Technical review, WHO
Nottingham Neonatal Service guidelines
WHO, pocketbook of Hospital Care for Children, 2009.
Nutritional Unit, Jinja Regional Referral Hospital
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APPENDIX 1: Neonatal Fluid Chart
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APPENDIX 2: Insertion of a nasogastric (NG) tube
1. Select the correct size NG tube (babies will require between a 3Fr and
5Fr size NGT to fit comfortably).
2. Holding the tip against the child’s nose, measure the distance from the
nose to the earlobe, then to the xiphisternum (epigastrium). Mark the
tube at this point.
3. Hold the baby firmly. Lubricate the tip with water and pass directly down
one nostril. The nasal cavity travels straight backwards before curving
down towards the baby’s body, so aim the NG tube directly backwards
from the nose initially when inserting.
4. When the measured distance is reached, secure with tape.
5. Aspirate a small amount of fluid to ensure that the tube is in the correct
place.
If there is any doubt over the position of the NG tube, remove it and start
again. Baby’s will often cough or sneeze as the NG tube is being inserted
but should not change colour. If the colour changes during insertion of the
NG tube, remove it immediately.
Picture taken from WHO Hospital Care for Sick
Children pocketbook, 2009.
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Appendix 3: Flow chart of feeds
Birth weight?
<1kg
1.0-1.5kg
>1.5kg
Baby clinically
well?
Baby clinically
well?
Baby clinically
well?
No
Yes
Yes
No
No
Features of
NEC or bowel
obstruction?
Features of
NEC or bowel
obstruction?
Yes
Yes
Yes
No
No
Persistent milky
vomiting or feed
intolerance, without
features of NEC
RED regime
+
arrange
xray
abdomen,
triple
antibiotics
and NGT
Yes
Follow
RED
regime
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YELLOW
regime
Follow
RED
regime
Follow
YELLOW
regime
No
Breastfeed or
EBM at daily
requirements
GREEN
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