ENTERAL FEEDING

Breast-milk or formula?

When to start feeding?

How to progress the volume?

 BREAST-MILK OR FORMULA?

 Breast-milk (20 kkal/oz, 290-300 mOsm/L)

 Standard Formula (20 kkal/oz, 300 mOsm/L)

 Premature Formula
 20 kkal/oz, 280-300 mOsm/L

 24 kkal/oz, 280-300 mOsm/L

 COMPONENT OF PREMATURE HUMAN-MILK

Premature Human-Milk Matur

Component Nutritional
Human-
(unit/kg/day) First Second Third Needs
Milk
Week Week Week
Energi (kkal) 120 120 120 120 120
Volume (mL) 180 180 180 190 150
Protein (g) 3,9 3,4 2,8 2,4 3,5
Natrium 4 2,7 1,8 2 3,5
(mEq)
Kalsium (mg) 53 46 42 47 160-200
Phosfor (mg) 25 27 23 26 80-100

Schanler RJ. Clin Perinatol 1995;22:207-22

 Practical recommendation for enteral
feeding
Initiate on the first day of life (10-20
mL/kg/day)
Advance 10-20 mL/kg/day
Do not dilute formula
Do not advance in unstable patients
Contraindication : intestinal ischaemia

Navarro-Psihas S. IPOKRaTES Seminar in Philipine, 2010

 Feeding Guidelines in relatively stable infants
Weight Initial Feed Intervals min Volume of Frequency of
(gram) Volume (mL) (hrs) increments max increments (hrs)
(mL)
< 750 0,5 – 1 1-2 0,5-1  24

750-1000 1 2 1-2 12-24

1000-1500 1-2 2 1-2  24

1500-2000 2-3 2-3 2-4  12

2000-2500 4-5 3 3-5 8

> 2500 10 3-4 7-10 6

Sumber: Chessex P, VanAerde JEE. Nutrition and feeding, Residents

handbook of neonatology, 1999.
 FORTIFIED HUMAN MILK FOR PRETERM INFANTS

 Infants born < 34 weeks gestation

 Infants < 1500 grams at birth
 Infants on TPN for > 2 weeks
 Infants who are at high nutritional risk for nutrition
problems after discharge from a NICU
 BENEFITS OF FORTIFICATION OF HUMAN MILK

 Improved weight gain

 Increased linear growth
 Normalization of serum calcium, phosphorus, and
alkaline phosphatase
 Improved protein status
 Increased bone mineralization
 SPECIAL FORMULA

Transitional Formulas (“post-discharge

premature formulas”)
 Transitional formula provide 22 kcal/oz and have higher levels of protein,
calcium, phosphorus, vitamins and other minerals than standard infant
formulas

 Research has shown that premature infants fed these formulas have
improved growth and bone mineralization compared to those fed standard
infant formulas
 Low risk-LBW Infant
•Infant discharge weight > 2000 g
•Birth weight > 1500 g

BF recommendation Formula feeding recommendation

• BF on demand • Offer standard 67 kkcal/100 ml with iron

• Supplement with standard supplementation until 1 year corrected

age
formula if BF insufficient
 Moderate risk-LBW Infant
•Infant discharge weight < 2000 g
•Birth weight > 1500 g

Exclusive BF Formula feeding recommendation

• Provide transitional formula (72
kkcal/100 ml) up to 9 mo

BF recommendations:
• Suppl BF w/ HMF until infant BW 1850-2400 g
• Suppl BF w/ transitional formula
• Alternative: increase caloric density w/ standard formula to 9
mos corrected age or good catch up growth
 High risk-LBW Infant
Category definition:
•Infant discharge < 2000 g
•BW < 1500 g
•History of TPN & diuretics
•Demonstrated poor growth
•Elevated alkaline phosphatase (>500 U/L)

Formula feeding recommendation:

Exclusive BF
BF recommendation:
•Suppl w/ HMF
•Suppl BF w/ transitional formula
•Increase caloric density of BF
w/ standard formula
•Provide a 81 kkcal/100 ml
premature formula until infant
weight 1850-2000 g
•Change to a 72 kcal/100 ml
discharge formula until 9 mo
corrected age
•If catch up growth is achieved
change to standard formula
 Suplementation
Multivitamin
 Multivitamin adequately available in formula
milk or fortified EBM
 Commence on day 5 or when infant is on full
enteral feeds
 Not required after discharge
 …suplementation
Iron
 Babies < 2.5 kg at birth, commence on day 21 if
feeds are fully established  3 mg elemental iron
daily)
 Continue for 6 months after discharge

RWH Reccomendation
 Expected growth rate
 The intrauterine growth rate is 10–20 g/kg/day with
15–20 g/kg/day the desired goal.
 Once the infant reaches 2000–2500 g a rate of 20–30
g/day is frequently used.
 A growth rate of approximately 0.9 cm/week is the
goal for both length and head circumference

Anderson DM, Clin Perinatol, 2002

 Growth Chart
Tanis Fenton 2003

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