III. FLUID, ELECTROLYTE & NUTIRTION
MANAGEMENT
IN THE NEONATAL ICU
o Standard IV Fluid Orders
o Guidelines for Initiation and Advancement of Parenteral
Nutrition in the NICU
o Starter TPN Information
o TPN Macro/Micronutrient Needs
o Lab Monitoring Guidelines for Parenteral Nutrition
o Enteral Feeding Guidelines
o TPN Weaning, Enteral Nutrition Initiation & Advancement
o Milk/formula Feeding Options
o Milk & Formula Selection
o Lab Monitoring Guidelines for Enteral Nutrition
o
o
o
o
Assessing Growth in the NICU
Nutrition Therapies for Common NICU Disorders
Vitamin and Fe Supplementation Guidelines
References
STANDARD FLUID ORDERS
(all fluids should be ordered daily)
UAC fluids: ½ NS with 0.25 units of heparin/mL @ 0.8 ml/hr (minimum rate)
*If an infant is hypernatremic, consider changing to D5W with 0.25 units heparin/mL @ 0.8
mL/hr. (Note: it is difficult to obtain accurate glucose measurements from UAC line if
D5W infusing).
Peripheral arterial line fluids: ½ NS with 1 unit heparin/mL and 12 mg Papaverine/100
ml at 0.8 mL/hr.
On admission use starter TPN if infant will be NPO more than 24 hours.




Starter TPN contains D10W with 3 grams of amino acids/kg and 0.54 mEq/kg of
calcium.
Run the starter TPN at the patient’s weight in kg x 1.5
o For example: 500 grams = 0.75 ml/hr
o Provides a GIR of 2.5 mg/kg/min
Piggyback D10W or D12.5W to make up the remainder of the needed fluids.
On day of life #2, when TPN is being ordered, remember to discontinue the
starter TPN and the piggyback fluids.
Standard pre-op and post-op IVF for infants with normal hydration and electrolyte balance:
D10W ¼ NS @ ~100-120 ml/kg/day.
If TPN/maintenance fluids will be running at a rate >2 mL/hr, omit the heparin.
As a general rule, for the first week of life use the infant’s birth weight for all fluid
calculations. On day of life #8 begin using the infant’s daily weight. During rounds and
sign-outs, specify what weight is being used for calculations.
GUIDELINES FOR INITIATION AND ADVANCEMENT OF
PARENTERAL NUTRITION IN THE NICU
Introduction:
Early aggressive nutrition in premature infants has been shown to improve growth
outcomes, neurodevelopment and resistance to infection. Timely intervention with TPN
begins with the provision of glucose as soon as possible after birth, amino acids
within 12 hours and intravenous lipids within 24 hours.
Goal:
 To minimize the interruption of nutrient delivery and prevent catabolism, especially
in premature infants with limited nutritional reserves.

Aggressive use of amino acids to prevent “metabolic shock” that would trigger
endogenous glucose production and catabolism. Amino acids stimulate insulin
secretion to improve glucose tolerance.

To attempt to achieve intrauterine growth and nutrient accretion rates in preterm
infants.

To optimize nutritional status to help both term and preterm infants resist the
effects of trauma and disease and improve overall morbidity rates and responses to
medical and surgical therapy.

To define minimal and maximal acceptable intakes.
This document and the following best practices are based on a review of current literature, recommended
evidence-based better practices and recently revised advisable intakes on protein and energy for pre-term
and term infants. Please see a list of reviews, studies and references at the end of the document
to support the following recommendations.
STARTER TPN
Rationale: Newborn infants who do not receive protein have negative nitrogen balance
and lose up to 1% of their protein stores daily. Catabolism is a particular problem of the
very low birth weight infant who may have minimal nutritional reserves. Additionally,
recent studies have indicated that when there is a shortage of amino acids, insulin levels
fall, resulting in hyperglycemia and hyperkalemia. Parenteral intakes of 1.5 grams/kg/day
of protein appear to be sufficient to prevent catabolism in newborn infants, and to maintain
normal serum glucose and potassium levels.
Target Patient:
 Newly admitted patients <1500 grams
 Newly admitted patients 1500-1800 grams who are NPO for 24 hours
 Term infants NPO >1-2 days or complex surgical patients.
Recipe:
Central & Peripheral Lines: D10W (Dextrose 10g/100mL) + 8.25 g/100mL Neonatal
amino acids + 1.5 mEq/100mL Calcium Gluconate
Procedure:
Run @ 1.5 mL/kg/hour
 For example: Birth weight of 500 grams = run at 0.75 ml/hr
 This volume provides 36 ml/kg/day of fluid, a GIR of 2.5 mg/kg/min, 3
g/kg/day of protein and 0.54 mEq/kg/day calcium
Order Writing for Starter TPN:







On admission, 7 days a week, 24 hours per day for target patients
A TPN order is not needed
Check glucose 4 hours after starting
Another maintenance fluid will always need to be ordered to maintain an adequate
glucose infusion rate and fluid intake
Start regular TPN the next scheduled interval and order 3 – 3.5 grams of amino
acids per kg per day (2.5-3 g/kg/day for term infants).
Do not discontinue the starter TPN if the baby is hyperglycemic or hyperkalemic as it
may make the situation worse. Consider changing the piggyback maintenance fluids
to decrease the dextrose delivery.
You cannot adjust the contents of Starter TPN
TPN Macronutrients:
Initiation and Advancement Guidelines
Premature
Infant < 32 –
36 weeks, >
1000 grams
DOL: 0
Premature
Infant < 32
weeks,
<
1000 grams
Initiation
Dextrose (GIR)
Amino Acids
Lipids
a
Non-Protein Calories
4 – 6 mg/kg/min
3 – 3.5 g/kg/d
1 – 2 mg/kg/min
e
0.5 - 1g/kg/d
1 g/kg/d
0.5 - 1g/kg/d
≤ 12 mg/kg/min
c
4 g/kg/d
3-3.5 g/kg/d
d
60 – 70 kcals/kg/d
85 – 95 kcals/kg/d
50 – 60 kcals/kg/d
70 – 80 kcals/kg/d
90-100 kcals/kg/d
Dextrose
4 – 6 mg/kg/min
1 – 2 mg/kg/min
Amino Acids
3 – 3.5 g/kg/d
Total Calories
Lipids
a
Non-Protein Calories
Total Calories
Amino Acids
Lipids
a
Non-Protein Calories
Total Calories
40 -50 kcals/kg/d
Goal
b
Dextrose
Term Infant,
> 37 weeks
Advancement
e
≤ 12 mg/kg/min
c
3.5 g/kg/d
1 g/kg/d
0.5 - 1g/kg/d
3 g/kg/d
d
b
60 – 70 kcals/kg/d
85 – 95 kcals/kg/d
50 – 60 kcals/kg/d
70 – 80 kcals/kg/d
90-100 kcals/kg/d
6 – 8 mg/kg/min
2 – 3 mg/kg/min
40 -50 kcals/kg/d
2 – 3 g/kg/d
e
0.5 - 1g/kg/d
2 g/kg/d
40 – 50 kcals/kg/d
0.5 - 1g/kg/d
b
50 – 60 kcals/kg/d
≤ 12 mg/kg/min
c
2.5 – 3 g/kg/d
2.5 – 3 g/kg/d
d
50 – 60 kcals/kg/d
70 – 80 kcals/kg/d
60 – 70 kcals/kg/d
80 – 90 kcals/kg/d
Goal is to supply ~25 calories per gram of protein. Use a combination of glucose and lipid as the
energy source. Non-protein calories are used to calculate energy needs in the NICU.
Feeding summaries do not include protein calories from TPN.
a
Minimum calorie and amino acid intake for “zero balance” (i.e. not catabolic) can be achieved with
40 - 50 kcals/kg/day (basal metabolic energy needs) and 1.5 g/kg/d protein. Note: a GIR of 6 - 8
mg/kg/min with 1 g/kg lipids will provide ~40 - 50 non-protein kcal/k/d in ELBW infants.
b
Do not exceed the maximal oxidative glucose capacity of 12.5 mg/kg/min or 18 g/kg/d of
carbohydrate (for cholestatic jaundice keep around 15 g/kg/d of carbohydrate).
Usual maximum concentration: 12.5% peripheral route, 25% central route.
c
Fluid restricted (≤150 ml/kg/d), growth compromised patients limited by peripheral access may
require lipid infusion as high as 4 g/kg/d. However, this should not routinely be the end goal of
intravenous lipids.
*To prevent essential fatty acid deficiency, provide a minimum of 0.5 g/kg/d of
intravenous lipids.
d
There is no evidence that gradually increasing amino acid intake improves “tolerance” to amino
acids. Order 3 – 3.5 g/kg/d amino acids with the first regular TPN following starter
TPN.
e
f
Use starter TPN for term infants made NPO for >1-2 days or complex surgical patients
TPN Guidelines: Micronutrients, etc.


Order TPN daily by 14:00 to ensure delivery by 20:00
Determine total daily fluids and subtract out other IV fluids, supplemental enteral nutrition and IV fat emulsion volume to
determine TPN fluid volume.
Cycled TPN should be tapered unless a dextrose solution is running while the TPN is off. Consider checking a serum
glucose concentration 1 hour after the TPN is off to ensure cycled TPN rate is tolerated.

Macronutrients (Protein, Dextrose and Lipids)
Dextrose:
Maximum concentration peripherally = 12%; Central 25%
Maintain glucose infusion rate (GIR) < 12 mg/kg/min for optimal glucose utilization
GIR (mg/kg/min) = (% dextrose X rate in mL/hr ÷ 6 ÷ (wt in kg))
Protein:
Begin with 3 g/kg/day and advance to goal of 3.5-4 g/kg/day
Never begin with < 3g/kg/day since this is the amount delivered in Starter TPN
Lipids:
0.5-1 g/kg/day is needed to prevent essential fatty acid deficiency (can develop within 72 hours after birth)
Advance lipids by 0.5-1 g/kg/day to maximum of 3-3.5 g/kg/day
Consider serum triglyceride level if infused greater than 0.15 g/kg/hr (0.75 mL/kg/hr), or if the patient is septic
Consider decreasing lipids if serum triglyceride is greater than 200 mg/dL or Direct Bili is > 2 mg/dL
Calcium & Phosphorus
● Ideal ratio of Calcium (mEq): Phosphorus (mMol) is 2-2.5:1 for best absorption of both nutrients
● Mineral wasting can be caused by a Ca:Phos ratio less than 1.6 mEq:1 mmol
● Always attempt to maximize these nutrients for premature infants if able
Goal: 3 mEq/kg/day Calcium and 1.5 mmol/kg/day Phosphorus (MAX= 4mEq/kg Calcium & 2 mmol/kg Phos)
● If unable to reach goals due to precipitation, consider the addition of cysteine to the TPN solution to increase the solubility
Phosphorus is given as NaPhos or KPhos- you will not be able to meet phosphorus goal if there are insufficient amounts of these nutrients in the TPN
Electrolytes, Vitamins, Minerals & Trace Elements
Sodium/Potassium: Adjust amounts in TPN based on lab values
Magnesium:
Consider exogenous maternal tocolytic as a source in the initial days of TPN
Magnesium depletion may precipitate refractory hypokalemia and hypocalcemia
Standard Multivitamins:
2 mL/kg/day (maximum dose of 5 mL/day) of Pediatric MVI
Pediatric MVI contains 40 mcg/mL of Vitamin K
If Vitamin K is ordered, it will be in addition to the standard multivitamin dose
Standard Trace Elements (in 0.2mL/kg):
Pediatric
20 mcg/kg Copper
6 mcg/kg Manganese
0.2 mcg/kg Chromium
100 mcg/kg Zinc
< 3 kg
20 mcg/kg Copper
1 mcg/kg Manganese
0.2 mcg/kg Chromium
400 mcg/kg Zinc
3-6 kg
20 mcg/kg Copper
1 mcg/kg Manganese
0.2 mcg/kg Chromium
250 mcg/kg Zinc
Omit the manganese and chromium in TPN solutions if an infant has severe hepatic disease (e.g. Direct Bili >2mg/dL) or is on long-term TPN
Continue to provide standard copper for these patients and monitor blood concentrations if there is a concern for toxicity
Consider a decreased dose or elimination of chromium and selenium (see below) with severe renal disease
Consider extra Zinc if increased ostomy output, diarrhea or significant NG suction
Other Additives:
.
Cysteine:
Carnitine:
Iron Dextran:
Selenium:
If unable to meet calcium and phosphorus goals due to precipitation in the TPN, consider adding 30 mg of
cysteine per gram of protein in the TPN. This reduces the pH and increases the solubility of calcium/phos.
Monitor acid/base balance if added.
For optimal lipid utilization, consider adding 5-10 mg/kg/day in patients on TPN greater than 2-4 weeks.
Do not add until lipids are initiated. Discontinue when lipids are not given.
Only consider in patients greater than 2 months of age on chronic TPN and unable to provide enteral iron
Consider in patients maintained on TPN for 1 month or with severe GI issues. Do not give selenium if N
creatinine level is >1. Normal dose = 1.5-4.5 mcg/kg/day; max 30 mcg/day.
LAB MONITORING GUIDELINES FOR PARENTERAL
NUTRITION IN THE NICU
>1 week of TPN
and clinically stable
< 1 week of TPN
Electrolytes**
Ca, Mg, Phos
Glucose
BUN/Cr
Bilirubin (T/D)
Triglycerides
Prealbumin
Daily
2x/week
Daily
Daily-2x/week
2x/week
As lipids advance
----
2x/week
1x/week
Every other day
1-2x/week
1x/week
1x/week
Alk Phos
AST/ALT
-------
Every other week if inadequate calcium/phos in TPN
Every other week if unable to maximize protein in TPN
1x/month

This assumes that TPN remains relatively unchanged the first week. With changes, some labs
may need to be checked more frequently. Labs may also need to be checked more frequently
for ELBW or clinically unstable infants.

Serum electrolytes should be monitored at least daily on infants whose IV fluid intake exceeds
40% of total intake.

Magnesium may need to be checked in high risk infants with chronic gastrointestinal losses and
infants born to mothers on high dose Magnesium Sulfate to suppress labor.
Rationale for monitoring patient groups on parenteral nutrition:
 Electrolyte abnormalities are the most common metabolic complication in infants on IV
fluids.
 Premature infants are at risk for hyper and hyponatremia when establishing baseline fluid
and electrolyte needs.
 Indirect bilirubin is used to determine need for phototherapy and/or exchange transfusions.
 Hyperkalemia is frequent in VLBW infants.
 BUN and creatinine help to evaluate renal function, hydration and protein status.
 Micropreemies (birth weights <700 grams) and IUGR infants are at increased risk for altered
electrolytes.
 Infants receiving parenteral nutrition for >2 weeks are at risk for cholestatic jaundice.
 Infants receiving parenteral nutrition for >2 weeks are at risk for developing metabolic bone
disease.
ENTERAL NUTRITION GUIDELINES
Enteral nutrition is the preferred method of nutrient delivery for all infants in the NICU. The goal is
to initiate enteral feeds within a few days of birth. These feeds, known as trophic feeds or minimal
enteral nutrition, will continue for a few days before advancing to aid in GI priming and help avoid
feeding intolerance and necrotizing enterocolitis. For premature infants, hemodynamic instability
often times delays these feeds, and parenteral nutrition must be initiated first and continued as a
supplement until full enteral feedings can be tolerated. *See the following page for TPN weaning and enteral nutrition initiation and advancement guidelines
The majority of nutrient storage occurs in the third trimester, especially fat and glycogen stores,
iron reserves and calcium and phosphorus deposits. The goal of enteral nutrition in the NICU is to
attempt to achieve nutrient accretion rates similar to those infants would receive in utero.
While breast milk is the preferred feeding for all infants in the NICU, it lacks sufficient amounts of
vital nutrients that premature infants need for adequate growth and development. Human milk
fortifier (HMF) is added to breast milk to increase the overall energy, protein, calcium, phosphorus
and electrolyte content. Premature formulas are also available for premature infants when breast
milk is not available and contains similar nutrient profiles to that of fortified breast milk.
 Contraindications to starting enteral feeds:
o
Any condition associated with decreased gut blood flow
o
o
Diastolic intestinal blood flow “steal” secondary to a PDA
Sepsis and/or significant clinical instability
High pressor support

o
Asphyxia, hypoxemia, hypotension, concomitant use of indomethacin/ibuprofen
 Benefits of Trophic Feeds:
o
o
o
o
Stimulates GI tract, promotes GI maturation and improves GI motility
Reduces intestinal permeability
Faster transition to full enteral feeds (less TPN)
Improved mineral absorption and glucose tolerance
 Route:
o
NG or OG, usually through a soft, indwelling tube.
o Breast/bottle attempts may begin once the infant is showing active feeding cues, which
develop around 33-34 weeks.
Enteral Nutrient Requirements
Energy (kcal/kg/day)
Protein (g/kg/day)
Calcium
Phosphorus
Iron (mg/kg/day)
Preterm
Term
120-130
3.5-4.5
100-220 mg/kg/day
60-140 mg/kg/day
100-110
2-3
210 mg/day
100 mg/day
2-4
None needed if iron-containing solids are
introduced at 4-6 months of age
TPN Weaning Schedule
For VLBW Infants
Enteral Feeding Volume
(mL/kg/day)
NPO
Concentration of
Breast Milk/Formula
20
40
60
80
**
100
**
120
140
20
20
20
20/24
20/24
24
24
(kcal/oz)
TPN GIR* (mg/kg/min)
6-12
6-12
6-12
6-10
6-8
6-8
TPN Protein (g/kg)
3.5-4
3.5
3.5
3
2.5
2.5/2
TPN Lipids (g/kg)
TPN Calcium/Phos
3-3.5
3
3
2.5
2
1.5
3/1.5
3/1.5
3/1.5
2.5/1.3
2/1
2/1
90-100
90-100
70
65
50/40
40/25
(mEq/mmol)
TPN Total kcals/kg/day
TPN is typically D/C’d
once infants are @ 120
ml/kg/day. Use IVFs to
meet fluid needs.
Do not give Starter TPN
if feeds are fortifiedthis leads to excessive
protein intake.
*GIR will vary based on glucose levels. The GIR should be adjusted as needed to meet overall
energy goals of 90-100 kcal/kg/day (TPN only) & 100-110 kcal/kg/day (TPN + enteral feeds)
**Fortify feeds to 24 kcal/oz. once the infant is tolerating 80-100 ml/kg/day enterally
Enteral Nutrition Feeding Initiation & Advancement
Birth Weight
(g)
Initiation Rate
(ml/kg/day)
*Continue for
3-5 days
Frequency
Advancement
Rate*
(mL/kg/day)
Goal Volume
(ml/kg/day)
Type of Feeding
20
150
Breast milk**
20
20-30
Q2H or
less
Q2H
Q3H
20
20-40
150
150
Breast Milk**
Breast Milk**
1501-2000
20-40
Q3H
20-40
150
MBM or Preterm
Formula
2001-2500
30-50 or ad lib
with cues
Q3H
150-180
MBM or
Transitional
formula
>2500
50 or ad lib
with cues
Q3H if
scheduled
180
MBM or Term
Formula
<750
10-20
751-1250
1251-1500
30-50
(Neosure/Enfacare)
50
*Advancement rates will vary based on tolerance.
** Breast milk, either Mother’s own or donor milk (with consent), should be the first
feeding for all infants born <1500 grams. Preterm formula would only be given to these
infants if the mother refuses to provide her own milk and does not consent to the use of
donor milk.
MILK/FORMULA OPTIONS IN THE NICU
Breast milk should be the first feeding for all infants in the NICU, unless
contraindicated due to medication use or infections.
 Contraindiations to using breast milk:
o
o
o
o
Infants with galactosemia or some inborn errors of protein metabolism
Mothers with herpes simplex lesions on the breast; with active, untreated tuberculosis, or who are
HIV-positive
Mothers receiving radioactive isotopes, chemotherapeutic agents, and certain medications
Mothers using drugs of abuse
 Donor Breast Milk
o
o
o
Donor breast milk (DBM) is available for all infants born <1500 grams and <34 weeks in our
NICU. The goal is to avoid the use of formula in these infants. DBM allows us to start enteric
feeds as soon as the infant is medically ready, even if the mother’s milk has not come in. It
can also be used to supplement feeds if a mother has a low milk supply.
DBM is continued until the infant reaches 34 weeks and 1500 grams. At this time, the infant
would transition to a premature formula.
Consent must be obtained before administering DBM.
Human Milk Fortifiers: Used to fortify breast milk for infants born <2kg & <35weeks
 Similac HMF & Enfamil HMF (contain bovine proteins)
 Prolacta
o
This is the only human milk-based HMF. Infants with a birth weight <1250 grams qualify for
the use of Prolacta only after 2 failed attempts at the use of powdered HMF. Never order
Prolacta without a discussion with the MD and dietitian.
Premature Formula: For infants born <2kg & <35 weeks if the mother does not provide her own milk
or does not consent to the use of donor milk if the infant is <1500g and/or <34 weeks


Similac Special Care (SCF): 20 kcal/oz, 24 kcal/oz. High Protein & 30 kcal/oz.
Enfamil Premature Formula: 24 kcal/oz.
Transitional Formula: Used at discharge or for late-preterm infants
 Neosure & Enfacare

These formulas have a nutrient profile that is between premature formula and term formula. When
made as directed on the can, it will make 22 kcal/oz. formula and provide higher amounts of protein,
calcium and phosphorus.
Term Formula: For infants >36weeks and >2500g when breast milk is not available
 Similac: Advance or Similac Sensitive (lactose-free)
o

24 kcal/oz. Similac Advance is available for term, hypoglycemic infants
Enfamil Premium
Specialized Formula: For infants with severe GI issues and/or allergies


Alimentum: semi-elemental formula used for cow’s milk protein intolerance
Neocate/Elecare: Elemental formulas with completely hydrolyzed proteins. This formula
should only be used as a last resort if an infant is unable to tolerate any other feeds.
MILK & FORMULA SELECTION
During Hospital Admission
Gestational Age & Birth Weight
Appropriate Formula (at goal feeds)
24 kcal/oz. BM + HMF (Maternal or Donor if <1500g)
24 kcal/oz. Premature formula
<36 weeks, <2000 gm
>36 weeks and >2500 gm
Unfortified MBM or Term Formula
Borderline (“Late Preterm”)
34-37 weeks, 2000-2500 gm
22-24 kcal/oz. MBM + HMF (based on intake, growth & labs)
Transitional Formula (Neosure or Enfacare)
Consider 22-24 kcal/oz. MBM/HMF or preterm formula
until ~2.5 kg
IUGR, >35 weeks, <3%ile
Approaching Discharge:
 Attempt to transition to the diet regimen the infant will be going home on a few days before
discharge. This will allow us to determine whether or not the infant will be able to meet volume
and weight gain goals on this regimen.
 If the infant is receiving premature formula, transition to a Transitional formula prior to
discharge.
 For infants going home on MBM, continue to use HMF until discharge or until the infant weighs
3.5kg (we are unable to use any other powdered formula in the NICU).
Discharge
MBM & Formula
Gestational Age/Birth Weight
<36 weeks
<2000 gm
“Late Preterm”
34-37 weeks
2000-2500 gm
Breast feeding ALD
+
2-4 bottles of 24 kcal/oz MBM +
Transitional formula
Breast feeding ALD
All Formula
Transitional Formula
22 kcal/oz
*May need 24 kcal/oz. if unable to
meet weight gain goals or discharge
weight is <2kg
2-4 bottles of 22-24 cal/oz MBM
+ Transitional Formula
Consider using Transitional
Formula (22 kcal/oz) until
40 weeks, then term
formula
Breast Feeding ALD
Term Formula
+
*Concentration depends on intake, growth
& labs
>36 weeks
>2500 gm
*IUGR infants may need specialized discharge formula/regimen please consult Dietitian*
Indications for Transitional Formula







<35 weeks
<2000 gm (regardless of GA)
Infants with elevated Alk Phos
Poor weight gains
Poor volumes
IUGR at any age
Growth delays (<10% or <3%)
Length of Time to Continue Transitional Formula
Birth Weight: Duration
 <750 gm = Up to 12 months CGA
 751-1000 gm = Up to 9 months CGA
 1001-1500 gm = Up to 6 months CGA
 1501-2000 gm = Up to 3 months CGA
 2001-2500 gm = 1-3 months CGA if needed
LAB MONITORING GUIDELINES FOR ENTERAL NUTRITION
IN THE NICU

Alkaline Phosphatase, Phosphorus and Prealbumin are considered “nutrition labs”

Begin to check these labs once an infant is off TPN and on full, fortified enteral feeds for
at least 1 week.

The theory behind not checking these while on TPN is that calcium, phosphorus and protein should
always be maximized in TPN solutions for preterm infants

These labs are followed every other week until stable x2

Alk Phos & Phosphorus measure bone mineralization
 Always check these 2 labs together- elevations in alk phos can also come from periods of
rapid bone growth as well as hepatic issues

Prealbumin measures protein stores

Lab
Alk Phos
Check a BUN in place of prealbumin for infants receiving steroids. A BUN <5mg/dL
indicates a need for additional protein.
Goal
<400 u/L
Prealbumin
>10 mg/dL
Phosphorus
4.5-6.5 mg/dL
Considerations
Up to 600 u/L is acceptable if the
infant is growing well as this may
reflect rapid bone growth
Falsely elevated with steroid use
May be low with an elevated CRP
May see levels up to 8 mg/dL in
premature infants
Possible Interventions
Increase calcium/phosphorus intake,
decrease use of calcium wasting meds
(diuretics), increase vitamin D
Begin protein supplementation
Maximize amount in TPN or consult RD
about supplementation if on enteral
feeds
Other Labs:
 Electrolytes
o Monitor for infants receiving diuretics and/or electrolyte supplements
 Hemoglobin/retic %
o Check approximately every 2 weeks once an infant is stable
o If low, adjust iron supplement if needed. May also be transfused based on the level
 Direct Bilirubin
o Monitor weekly for infants with cholestasis or on TPN >2 weeks. Continue to
monitor this lab until level is <1mg/dL.
 Trace elements
o Certain trace elements may need to be monitored, especially for infants with
significant GI losses. The NICU dietitian can help you determine which nutrients are
at risk for malabsorption and may need supplementation.
The RD will post a list of patients needing nutrition labs in the workroom at the end of
each week- nutrition labs are checked every Monday for IC patients.
ASSESSING GROWTH IN THE NICU

The Fenton growth chart is used to assess the length, weight and OFC for
premature infants in the NICU from 22 weeks to 50 weeks gestational age

The WHO growth chart is used for term infants
Growth Goals:
Measurement
Weight
Length
OFC
Goals
15-20 grams/kg/day (<2kg)
25-35 grams/day (>2kg)
1 cm/week
0.7-1 cm/week
Frequency of
Measurement
Daily
Weekly
Weekly
Factors that may inhibit adequate growth:

Inadequate protein intake
o


80% of inadequate growth is related to inadequate protein intake
Inadequate or excessive energy intake
Increased energy expenditure
o
CHF, severe sepsis, increased WOB, BPD, wean from isolette (temperature control)



Malabsorption
Medications- steroids, diuretics
Use of continuous drip feeds with breast milk

Electrolyte/acid-base imbalance
o
Breast milk fat adheres to the feeding tube, reducing the overall concentration of feeds
Interventions for poor growth:

Calculate intake of energy and protein to ensure the infant’s needs are being met
(minimum of 120 kcal/kg/day and 3.5 grams of protein/kg/day)






Maximize protein intake by adding a protein supplement
Increase feeding volume
Consult Dietitian about increasing the concentration of feeds
Correct low sodium and chloride levels
Transition to bolus feeds if administering breast milk continuously
Return to isolette or resume oxygen if infant demonstrates temperature instability or
increased work of breathing
NUTIRITON THERAPIES FOR COMMON NICU DISORDERS
Osteopenia of Prematurity: Metabolic bone disease

Cause: Lack of calcium and phosphorus in bones (up to 80% of skeletal mineralization occurs in the
3rd trimester)


Defined by: Alkaline Phosphatase value >900 u/L and Phosphorus <4 mg/dL
Treatment:
o Parenteral:

o
Maximize the calcium and phosphorus in the TPN solution. Make sure the Ca:Phos
ratio is 2-2.5:1. If unable to maximize these nutrients, add cysteine to the TPN
solution.

If phosphorus is significantly low, consider adjusting the Ca:Phos ratio to 1:1 until
phosphorus levels correct, then return to the 2:1 ratio
Enteral:



Decrease the use of calcium wasting medications (diuretics).
Consult Dietitian about adjusting the fortification of feeds or beginning calcium
and/or phosphorus supplementation (may only need phosphorus).
Begin or increase Vitamin D supplementation.
Cholestasis: Interruption in the excretion of bile flow



Cause: Intra/extrahepatic obstruction. In the NICU, typically from prolonged use of TPN
Defined by: Direct Bilirubin >2 mg/dL
Treatment:
o Begin enteral feeds or attempt to discontinue TPN if able
o Parenterally:


Omit the manganese and chromium from TPN solution
Limit the lipid content of TPN solution (may need to increase the GIR in order to still
meet energy needs)
o Enterally:


Consider beginning Ursodiol (Actigall) and fat-soluble vitamins
May need to consider feeds higher in Medium Chain Triglycerides

MCTs do not require bile salts for digestion/absorption
Anemia of Prematurity: Lack of red blood cells due to early birth



Cause: Inadequate iron stores (iron is stored in the 3rd trimester)
Defined by: Low hemoglobin/hematocrit levels
Treatment:
o
o
o
Transfusions may be necessary
Limit blood drawing for labs
Begin iron supplementation once an infant is at least 2 weeks old and on full, fortified enteral
feeds.
Goal from feeds + supplement= 4 mg/kg/day (BW <1500g)

Infants on all formula feeds or breast milk fortified with Enfamil HMF will already be receiving 2
mg/kg/day, so the supplement should provide the other 2 mg/kg/day.

Infants on breast milk fortified with Similac HMF or Prolacta will need an iron supplement that
provides 3.5-4 mg/kg/day (these HMFs contain little to no iron).
VITAMIN & IRON SUPPLEMENTATION GUIDELINES
Human milk fortifiers and premature formulas contain nutrients meant to meet the increased needs
of premature infants. With the exception of iron and vitamin D, most vitamin and mineral needs will
be met if an infant is on full, fortified enteral feeds. Your dietitian will also be able to help you
calculate the nutrient needs of your infant to assess their need for supplementation.
Iron supplementation during hospitalization:
Feeding Regimen
Iron Supplementation (mg/kg/day)
Birth Weight <1.5kg
Birth Weight >1.5kg
2
2
4
3
None
None
Formula
MBM + EHMF
MBM + SHMF or Prolacta
MBM + formula (1:1)
2
1
Iron supplementation is started when full enteral feedings are tolerated and the infant is at least 2 weeks old. EHMF
and formulas provide ~2 mg Fe/kg/d with the exception of SHMF. This amount has already been subtracted in the
guidelines listed above.
Even though MBM contains iron that is well absorbed, it is a small amount and is usually not included when
determining iron supplementation needs. Iron should not exceed 6 mg/kg/day (formula and supplement combined).
IDM and IUGR infants are at increased risk for low iron stores, so their Fe requirement may be more than the usual
amount for their birth weight. These infants should be assessed and monitored on an individual basis.
Vitamin D Supplementation:


All infants born <34 weeks should receive an additional 400 IUs of vitamin D per day on
DOL 1. This is done regardless of NPO status, with the exception of major GI complications.
Vitamin D may be increased as needed based on lab values measuring osteopenia.
Discharge Supplementation:
Term
Preterm
Feeding Regimen
MBM or Formula
Formula
Fortified MBM
Vitamin Supplement
1mL/day D-Vi-Sol
0.5mL/day Tri-vi-sol or D-vi-sol
1mL/day Poly-vi-sol with iron
D-vi-sol= 400 IUs Vitamin D/1mL
Tri-vi-sol= Vitamins A, C & D
Poly-vi-sol= Vitamins A, C, D, E & B complex; 1mL with iron= 10mg Fe
Re-evaluate vitamin and iron supplementation requirements as needed based on MBM/formula intake and lab values for Fe status.
Infants should continue vitamins with Fe as long as they are receiving predominantly MBM (<1000 ml of formula per day).
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