In This Section Establishing Enteral Nutrition
In This SectionPotentially Better Practices#10. Enteral feeding begins with oralcolostrum care started shortly after birth.32#11. Start with minimal enteral nutrition(trophic feeds, gut priming) initiated onday of life 1 or 2, unless there are clearcontraindications.33#12. Follow a standard definition of feedingintolerance.35#13. Give enteral feeds by intermittentbolus or continuously by gastric route, andless commonly by transpyloric route.37Establishing EnteralNutritionIntroductionNICUs should standardize feeding management based on best availableevidence. The introduction of enteral feeding for the VLBW infanthas changed dramatically over the past few decades. The greatest trendshave been driving the earliest start of feeding with oral colostrum care(OCC), standardizing feeding advancement and maximizing use ofhuman milk. These feeding process changes have promoted trophicchanges in the intestine along with immunologic protection of thehost. We are only beginning to understand that such early primingmay favorably alter the gut microbiome to confer positive benefits tothe infant.#14. Enteral feeding advancement ratesshould be linear and specified in the feedingguideline.38#15. Fortification should be establishedbefore full enteral feedings are reached.39#16. Enteral feeds should be advancedand concentrated until they are providingadequate nutrition to sustain optimalgrowth along an infant’s growth curve.40Tools# 8. Example: Infant Feeding NG TubeProtocol42# 9. Example: Residuals & FeedingIntolerance Protocol46#10. Example: Neonatal Feeding Protocol47#11. Example: Neonatal Feeding Protocol49#12. Example: Feeding Flow ChartReferences5051Nutritional Support of the Very Low Birth Weight InfantA CPQCC Quality Improvement Toolkit31
POTENTIALLY BETTER PRACTICE #10Enteral feeding begins with oral colostrum care (OCC) startedshortly after birth.Background, Rationale, and Goals Studies have shown that OCC can reduce sepsis,improve weight gain, and reduced length of stay.1-9The benefit of oral colostrum care is mostlyimmunologic in nature with the introductionof immune cells, immunoglobulins, otherimmunoprotective agents in milk, naturalprobiotics and prebiotics.10Quality Improvement: Outcome/Process Measures OCC guidelines/protocol available?% of target population (e.g. VLBW infants)receiving OCCAge (in hours) of 1st OCCRecommendations, Guidelines andAlgorithms Develop a protocol for delivery of oral colostrumcare including volume, timing, duration andmethod of collection and delivery.Encourage mothers to express colostrum within 1hr after delivery in the delivery room or recoveryroom after cesarean section.Nutritional Support of the Very Low Birth Weight InfantA CPQCC Quality Improvement Toolkit32
POTENTIALLY BETTER PRACTICE #11Enteral feeding begins with the introduction of trophic enteral feedsinitiated on day of life 1 or 2, unless there are clear contraindications suchas current or recent exposure of the bowel to hypoxia, severe anemia,hypotension, or congenital anomalies precluding immediate feeding (e.g.omphalocele or gastroschisis).Background, Rationale, and Goals 33The fetal gastrointestinal tract is continuallyexposed to large volumes of swallowed amnioticfluid, absorbing fluid and some nutrition,performing rudimentary peristalsis, and formingmeconium.Trophic feeding can stimulate gut maturation,hormone release, and motility. Early introductionof feeds shortens the time to full feeds and todischarge without an increase in NEC whereaswithholding of feeds puts the gut at risk forinfection and delayed maturation includingimmune protection.11Early feeding accelerates mature intestinal motilitypatterns.12Early introduction of feeding results in less seriousinfections in low birth weight infants.13There are no contraindications to initiating orfeeding with an umbilical artery catheter (UAC).14The impact of feeding in the presence of a PDAor during the treatment for a PDA closure(indomethacin, ibuprofen, acetaminophen) hasnot been shown to add further risk for bowelcomplications such as NEC or spontaneousintestinal perforation (SIP). 15-17The risk of SIP associated with the concomitantuse of indomethacin and steroids needs to berecognized and feeding held as a precaution in thisscenario. Meta-analyses of trials of non-steroidalanti-inflammatory agents alone for PDA closurehave not affected NEC rates. 18,19Nutritional Support of the Very Low Birth Weight InfantA CPQCC Quality Improvement ToolkitRecommendations, Guidelines andAlgorithmsEnteral feeding practices should be listed as policy orguideline and available in each NICU specifying thefollowing aspects: Delivery of oral colostrum care including volume,timing, duration and method of collection anddelivery Early initiation of feedings for eligible infants withtype of feeding (full strength mother’s milk, heattreated donor human milk, formula only underrare conditions for VLBW infants) Stopping or holding rules for cardiorespiratoryinstability Details of feeding volume advancement Definition of feeding intolerance Timing of fortification steps Timing of introduction of vitamins and iron Rules for volume and concentration of feeds forinfants who are not growing optimallyQuality and Process Improvement Creation and implementation of OCC guidelinesDevelopment of feeding guidelines with timingof nutritional interventions. (see example: tion of feeding guidelines into EMR
Outcome/Process Measures Initial feeding type (Mother’s own milk, donorhuman milk, formula)Feeding protocol completed (with/without breaks)(Y/N)DOL full enteral feeds achieved (140 mL/kg/dayor more)DOL when birthweight regainedDays on parenteral nutritionPercentage of infants on any enteral nutrition by24, 48, 72 hours of life (Refer to Tool #5)Nutritional Support of the Very Low Birth Weight InfantA CPQCC Quality Improvement Toolkit34
POTENTIALLY BETTER PRACTICE #12NICUs should develop standard definitions of feeding intolerance, withspecific reference to actions/inactions based on gastric residual volumes,changes in abdominal signs and the presence of bloody stools.Background, Rationale, and Goals 35Enteral feedings of VLBW infants are frequentlystopped, or feeding advances held, based onconcerns for feeding intolerance.The definition of feeding intolerance is highlyvariable but may include the presence andquality (normal, yellow, green, blood-tinged) ofgastric residuals, emesis, abdominal distensionor tenderness, the presence of heme-positive orabnormal-appearing stools, the presence, absenceor quality of bowel sounds, or any combinationthereof. 20,21As all of these clinical phenomena may occur ina healthy premature infant tolerating feedings, itis important to put these findings into a clinicalcontext that is understood by nursing andphysician staff.22Measurement of abdominal girth may be disruptiveor stressful to the infant and may not addsignificantly to the clinical assessment of abdominaldistension or tenderness.In one study, when feeding intolerance wasmore clearly defined, nutritional outcomes weredramatically improved.23Gastric residuals reflect the immature dysmotilityof the premature gut and are very common in thefirst few weeks of life.The gastric residual alone is neither a sensitive norspecific indicator of bowel injury and should notsolely dictate stopping or advancing enteral feeds.24Gastric residuals may be present prior to NECbut may be more helpful in combination withother signs of early NEC (abdominal distensionNutritional Support of the Very Low Birth Weight InfantA CPQCC Quality Improvement Toolkit or tenderness, bloody stools, apnea, temperatureinstability) in making the diagnosis of NEC.25Not checking gastric residual volumes before eachfeed was associated with faster attainment of fullfeeding without increasing risk of NEC.26Many NICUs have now moved away fromchecking gastric residuals based on the lack ofspecificity of checking gastric residuals.If gastric residuals are checked, one should becautious about using residuals as the sole reason tocompletely stop enteral feedings.There are few justifications for discarding gastricresiduals as fluids, electrolytes and nutrition maybe lost.Recommendations, Guidelines andAlgorithms Team based definition of feeding intoleranceintegrated into feeding algorithmRefer to TOOL #8 on page 42 and TOOL #9on page 46 for examples of feeding protocols withinstructions for feeding intolerance/residuals. Education for staff regarding the new definition,clinical context and potential practice changes
Quality and Process ImprovementOutcome/Process Measures Number of feeding interruptionsReasons for withholding feedings should bedocumented in the progress notes and discussedon rounds.Nutritional Support of the Very Low Birth Weight InfantA CPQCC Quality Improvement Toolkit36
POTENTIALLY BETTER PRACTICE #13Enteral feeds can be given by bolus or continuously by gastric route andless commonly by transpyloric route.Background, Rationale, and Goals 37VLBW infants require tube feedings before they aremature enough to safely suck and swallow.The two primary methods of tube feeding are bolusor continuous.Delivery route options are orogastric, nasogastric,or through a gastrostomy tube, and gastric versustranspyloric.Milk feedings given by intermittent bolus gavagemethod may be more physiologic because theypromote the cyclical surges of gut hormones seenin normal term infants and adults.27A Cochrane analysis concluded that infants fed bythe continuous tube method took longer to reachfull feeds, but there was no significant difference insomatic growth, days to discharge, or the incidenceof NEC.28A “slow” bolus feeding given over a longer timeinterval, such as 30-120 minutes, results in a returnof motility and improved tolerance.29Delivery of tube feedings into the stomach elicitsthe associated physiologic stimulation and digestiveprocesses.It is undetermined if bolus vs continuous feeding isbetter for GERD.30Transpyloric (e.g. nasojejunal or NJ) feeds must becontinuous and are not recommended for routineuse in preterm infants, as no benefit was foundand are associated with a greater incidence ofgastrointestinal disturbance and death.31Transpyloric feeding has the potential benefit ofdelivering feeds past the pylorus when concernsarise for significant GERD and/or aspiration riskNutritional Support of the Very Low Birth Weight InfantA CPQCC Quality Improvement Toolkit and/or moderate to severe CLD.Fats in human milk are of lower density than otheraqueous components and will therefore rise andseparate.If a syringe is horizontal, fat may float to the topand therefore will be the last fluid emptied into thetubing, resulting in variable fat administration ratesand causing some of the highest caloric feed tonever reach the baby.32-34Recommendations, Guidelines andAlgorithms NICU feeding guideline should specify bolus vscontinuous and if continuous is chosen greaterattention to the following is required to minimizenutrient loss. Orienting feeding syringes vertical and directedup using the thinnest tubing and the shortesttravel distance from pump to infant willdecrease fat loss. Ensuring that any residual milk is purged withair or small amount of water.Quality and Process Improvement Record route of feedingEnsure that transpyloric feeding have definedindications and guidelines to offset riskDefine rules and timeline for need for gastrostomytubeOutcome/Process Measures Route of feeding
POTENTIALLY BETTER PRACTICE #14Enteral feeding advancement rates should be linear and specified inthe feeding guidelines.Background, Rationale, and Goals The lack of a feeding guideline introduces morevariability in feeding rate and may increase risk ofgut morbidities.The feeding rate of advancement has been shownto have a wide range of tolerance (20-35 mL/kg/day) and is not a major determining factor forintestinal complications such as NEC. 35There is a wide range of feeding rates that are usedby NICUs around the world.Slower feeding protocols (8-10 mL/kg/day) inELBW have been associated with negligible NECrates. 36,37Faster rates of feeding are associated with improvedweight gain, reduced PN days and line relatedcomplications.Quality and Process Improvement Define rates of feeding advancement in feedingguidelines specified by birthweightRefer to TOOL # 10 on page 47, TOOL #11 onpage 49 and y/NEWBORN/NICU/SPIN/Pages/default.aspx. Automate process of calculations and/or embedadvancement algorithm in EMR.Outcome/Process Measures Day of life started the feeding guidelinesDay of life completion of the feeding guidelineswith/without breaksNutritional Support of the Very Low Birth Weight InfantA CPQCC Quality Improvement Toolkit38
POTENTIALLY BETTER PRACTICE #15Fortification should be established before full feeds are reached.Background, Rationale, and Goals 39Early fortification of human milk minimizes thenutritional gap that occurs in the transition fromparenteral to enteral nutrition. Fortification ofbreastmilk should be initiated well before a fullfeeding volume is reached.38There is no clear evidence when it is safe tointroduce fortification of human milk duringfeeding advancement. However, protocols haveincreasingly used earlier fortification steps beforefull feeding volume has been reached, includingsome starting as early as 40 mL/kg/day withoutevidence of intestinal complications.22,39-41Ascertain the increase in osmolality with theaddition of fortifiers does not exceed significantlevels of risk that were associated with NEC.40,42There are now decided advantages to using liquidhuman milk fortifiers due to ease of use and bettermixing. The available liquid bovine-based fortifierscontain higher protein content that is beneficialfor the ELBW infant and are void of intact bovineprotein.43,44National standards have long recommended thatpowdered infant formulas no longer be used in theNICU (CDC, FDA, ADA).Liquid human milk fortifiers are preferred overpowder to prevent incomplete mixing difficulties,separation of milk components, while minimizingcontamination risk.The use of donor human milk based HMF hasbeen shown to further reduce infant morbiditiessuch as NEC and reduce days on parenteralnutrition.45-47 There are retrospective datasuggestive of other morbidity reductions includingsepsis, ROP, CLD.48Nutritional Support of the Very Low Birth Weight InfantA CPQCC Quality Improvement Toolkit Modern NICU milk preparation has advancedto the point that quality control processes arerequired to provide the best quality human milkderivatives.49-52 The collection, storage and handlingof human milk with fortification preparation hasbecome more complex. The most efficient and safeway to manage all the milk preparations each dayis to streamline these processes and in particularreduce the number of handlers or preparers so thatquality control can occur. The other importantcontrol element is to have a clean area that can be aconsistent workspace for the preparation area.Quality and Process Improvement Advocate for a dedicated milk preparation roomand technician to standardize mixing and optimizethe quality of milk handling. This requires botha commitment for appropriate clean space anddedicated personnel for milk preparation.Define a standard time for starting fortifiers in thefeeding advancementChoose a fortifier that provides the best growthoutcomes with the lowest morbidities for yourinfantsIdentify balancing measures such as intestinalcomplicationsOutcome/Process Measures Age or volume of feeds when fortifier startedDays on PNDOL Full Feeds (140 mL/kg/day based on BW)Number of feeding intolerance eventsNECSIP
POTENTIALLY BETTER PRACTICE #16Enteral feeds should be advanced and concentrated until they areproviding adequate nutrition to sustain optimal growth along an infant’sgrowth curvesBackground, Rationale, and Goals The goal of enteral feedings is to provide optimalnutrition and growth and replace the need forparenteral nutrition.The advancement of volume is the first approach todelivering nutrients.Delivery of volumes between 150 to 200 mL/kg/day can often be given without significant adverseeffects.53 Some growth restricted infants maydemand even more volumes.Feeding volume should be increased until theinfant shows signs that gut capacity has beenreached, then kept at that volume through dailyadjustment of the feeding volume for weightgain.38,54Increased milk intakes were associated withincreased daily weight gains and a greater weightat 35 weeks, but no difference in any growthparameter at 1 year or difference in morbidity.53There are no standardized upper limits of volumehowever some preterm infants with significantlung disease may experience challenges and requirefurther fortification instead.Since human milk nutrient content is so variable,infants that are not growing optimally with peakvolume and 24 kcal/oz fortification will requirefurther fortification. Restricting feeding volumeuntil a weight plateau has been identified is themost common cause of growth delay.55Although fortification of human milk beyond24 kcal/oz has not been well evaluated it isincreasingly coming into practice.A proactive versus a reactive approach to growthwith daily nutrition and growth assessments isfavored to prevent repeated protracted poor growthperformance. Feeding prescriptions should be adjusted accordingto daily weights and not weekly weights.Customized fortification may be required for someinfants who are not growing as targeted. Theseinfants may have differences in nutrient intake due tothe variability of their mother’s milk, with the use ofdonor milk or have energy expenditure higher thanexpected.Increases in volume or caloric density are possibleto meet the greater needs of the infant. Some haveadvocated an adjustable approach to fortificationbased on growth and low BUN levels less than 9 mg/dL as a trigger for adding greater nutrient densitywith more fortification.56Additional fortification can be in the form of protein,formula or concentrate remembering that protein isthe key to optimizing growth.There are also emerging technologies available thatcan measure macronutrient content in humanmilk samples down to a few milliliter volumes.57-60These data may be helpful in growing infantssince there is such variability in human milksamples between mothers whereby some milk maycontain significantly less protein and fat that willnot optimally support growth even with HMFs.However, these devices have not yet been approvedby the FDA to support clinical decision makingfor selectively fortifying human milk in a targetedmanner. More clinical data are required, along withmore defined workflow and approval from FDA,before targeting fortification using human milkanalyzers can be used clinically.Nutritional Support of the Very Low Birth Weight InfantA CPQCC Quality Improvement Toolkit40
Quality and Process Improvement Provide education to all caregivers on nutritional planningand assessment including proactive strategies to preventgrowth falteringDefine volume practices and decision rules in feedingguidelines being usedDefine normal growth velocity targets based on growthchartsAutomate calculations of feeding volumes and caloriesOutcome/Process Measures 41Anthropomorphic growth metricsCurrent Z relative to birth Z for growth metricsNutritional Support of the Very Low Birth Weight InfantA CPQCC Quality Improvement Toolkit
TOOL #8EXAMPLE: Infant Feeding Nasogastric Tube ProtocolTitle:Feeding Nasogastric Tube: Infant[ x ] Policy [ x ] Procedure [ ] Guideline [ ] OtherPatient Population:[ ] High Risk OB/Labor, Delivery and Recovery [ ] Post-partum[ ] Low Risk Infant [ x ] High Risk InfantUnit(s) Affected:[ ] L&D/BC/Antepartum [ x ] NICU [ ] PostpartumAncillary Services:[ ] Pharmacy [ ] Nutrition [ ] Respiratory [ ] Social Work [ ] LactationEffective Date:Revision/ReviewDate(s):POLICY STATEMENT/SCOPE: N/ARELATED POLICIES: N/ADEFINITIONS: N/APOLICY1. Multidisciplinary collaboration will determine need for gavage feeding, and the type of nutrient, volume,frequency, plan for advancement and administration of gavage feedings.2. Gavage feeding is indicated for infants requiring endotracheal intubation and infants with immature, weak,or absent suck, swallow, or gag reflex.3. Only enteral products will be used to minimize risk of parenteral/enteral misadministration.4. Prolonged oral gastric or nasogastric feedings may cause adverse oral stimulation and promote GERD andproblems of oral aversion.5. Feeding intolerance is frequently the first sign of illness.6. Feedings will be held and the licensed medical provider be notified immediately if there are any negativeabdominal findings, bilious or hemorrhagic residuals or evidence of feeding intolerance.7. Non-bilious formula or breastmilk residuals can be re-fed after notifying the medical provider (see below).8. Type of nutrient (e.g. breastmilk, formula, and fortifiers) will be documented at each feeding interval.9. Feeding tube insertion is considered a stressful and moderately painful procedure (comparable to the painof a heelstick). There is also evidence to suggest that the insertion of a feeding tube alters the cerebral bloodflow in premature infants. Minimizing insertions will assist in minimizing exposure to pain and discomfort.(Wallace, 2014)10. Bacterial contamination with pathogens is a documented problem with feeding tubes. While there isinconsistent evidence to suggest this may lead to an increased risk of feeding intolerance and NEC, it may beprudent to treat feedings, feeding tubes and all of the associated tubes in an aseptic manner in an attempt tominimize nosocomial contamination. (Wallace, 2014)Nutritional Support of the Very Low Birth Weight InfantA CPQCC Quality Improvement Toolkit42
11. Venting of feeding tubes after feedings should be done after feeding has infused in order to prevent gaseousdistention of abdomen.12. For infants on nasal IMV or nasal CPAP the abdomen needs to be vented with an open 8 FR feeding tube.PROCEDURES AND RESPONSIBILITIESProcedure for insertion of NG or OG tube:1. Assess infant to determine need for indwelling vs. intermittent gavage tube.a. Polyurethane indwelling feeding tubes (long term) should be used if an infant requires gavage feedingsfor 24 hours. These tubes do not harden over time and can be left in place for up to 30 days.b. Polyvinyl chloride (PVC) tubes (short term) harden with time when exposed to the acidic environmentof the stomach and should only be used for a single feeding or left in place 1-3 days. PVC feeding tubeshave been implicated with tissue perforation (Wallace 2014).2. Determine appropriate type and size of feeding tube.a. 16 or 20 inch feeding tubes are preferred over 36 inch feeding tubes in order to minimize the lossnutrients in tubing.b. If needed for decompression or venting, an 8fr will be more effective than a 5fr.3. If an infant without a feeding tube needs to be gavaged after nippling part of a feeding, a rest period must begiven before a feeding tube is passed.4. Position infant for assessment/placement.5. If placing a nasal feeding tube, use measuring tape to measure from the nose to the mid- earlobe to a pointhalfway between the xiphoid process and the umbilicus. If placing an oral feeding tube, measure from themouth to the mid-earlobe to a point halfway between the xiphoid process and the umbilicus.6. Put on gloves.7. Pass the feeding tube through the mouth or nose into the stomach. If placing the tube nasally, lubricate thetip with sterile water or saline before insertion.8. Verify correct tube placement:a. Inject 0.25-0.5mL of air into tube and auscultate over stomach. NOTE: Auscultation of air over thestomach can be unreliable and DOES NOT assure the tip of the tube is in the stomach.b. Aspirate residual from tube and verify gastric contents (color, consistency, and amount).c. While the x-ray is not a practical tool for routine assessment in the neonatal population, it does presentthe most accurate picture of placement. When x-rays are obtained for other purposes the tube insertiondepth should be recorded and the tip location should be noted and tracked.d. Carefully track and record the position of the feeding tube each time it is used. Compare cm mark tomeasurement described in step 5 above.9. Secure feeding tube to infant’s face. Document cm mark (at nare or lip), characteristics of aspirate, and thedate and time of insertion on the EMR.43Nutritional Support of the Very Low Birth Weight InfantA CPQCC Quality Improvement Toolkit
Procedure for feeding/administering medication with NG or OG tube:1. Verify correct position of the feeding tube with methods listed in step 8 above. Also note cm mark at nare orlip. Document this in the EMR.2.3.4.5.Assess abdomen for bowel sounds, softness, girth, and color.In the absence of a UAC/UVC, abdominal girth is to be measured at the level of umbilicus.In the presence of a UAC/UVC, abdominal girth is to be measured directly above the level of the umbilicus.Hold feeding and notify licensed medical provider ASAP for positive abdominal findings (such as: emesis,diarrhea/watery stools, loops of bowel, abdominal distention, increased girth, firmness, tenderness,discoloration of abdomen, decreased or absent bowel sounds, and/or heme positive ( ) stools.6. Document the amount, color, and consistency of residual or aspirate.7. If non-bilious/non-hemorrhagic, residuals 50% notify licensed medical provider of the amount and if thereare any signs of feeding intolerance. Decision will be made whether to subtract the amount from the totalfeeding volume from the next feed.8. If non-bilious/non-hemorrhagic, residuals 50% should be returned and the total feeding volume given (ifthere are no other signs of feeding intolerance).9. Feeding should be held for any sign of feeding intolerance and the licensed medical provider notified.10. Residuals should not be checked if feedings are continuous.11. Methods of administration:a. Syringe pump: Use syringe pump for ongoing or established intermittent or continuous feedings.b. Hand controlled: Slowly administer feeding with syringe over 15-30 minutes for a full feeding volume.Observe infant for intolerance of rate of administration.c. Gravity controlled: Attach syringe barrel without plunger to the feeding tube. Fill the barrel withfeeding, control rate of administration by lowering or elevating the syringe. Observe infant forintolerance of rate of administration.d. Continuous feedings: Syringe and tubing will be changed every 3 hours.12. If using intermittent feeding tube, pinch off and remove quickly after feeding complete. Use new tube witheach feeding.13. After administration of feeding or medication, flush indwelling tubes with 0.5-1 mL of sterile water.14. Venting of feeding tubes after feedings should be done after feeding has infused in order to prevent gaseousdistention of abdomen. Venting of feeding tubes should be continuous on all infants on nasal IMV, nasalCPAP, and high flow NC 2 L.a. A 10mL Gavifeed venting syringe (see picture below) should be attached to feeding tube betweenfeedings. Gravifeed syringe should have end cap open to minimize resistance. Please place the syringe ona diaper or 4x4 to avoid spills.b. An 8 fr feeding tube will vent more effectively than a 5 fr feeding tube.15. To facilitate gastric emptying, consider positioning infant prone or on the right side with head of bedelevated. If infant meets criteria for black to sleep positioning, need MD order for prone or HOB elevated.Nutritional Support of the Very Low Birth Weight InfantA CPQCC Quality Improvement Toolkit44
16. A pacifier should be offered with gavage feedings for non-nutritive sucking if infant is awake and interested.17. All feedings containing breast milk or any additives should have the syringe with a 90 degree angle, tip/tubing pointing up to maximize fat and nutrient delivery.18. Document the type of nutrient and volume of feeding, residuals and emesis in the EMR record.ATTACHMENTSAttachment 1: Images of available cathetersFORMS/PARENT HANDOUTSNoneRESOURCES/REFERENCESCharney, P., Malone, A. (2013) Academy of Nutrition and Dietetics Pocket Guide to Enteral Nutrition (2nd ed.)Chicago, Ill: American Dietetic AssociationEllett, M., Cohen, M., Perkins, S., Smith, C., Lane, K., Austin, J. (2011) Predicting the Insertion Length for Gastric Tube Placement in Neonates. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 40 (4) 412-421.Gardner, S.L., Carter, B.S., Enzman-Hines, M., Hernandez, & J.A. (2016). Merenstein & Gardner’s Handbook ofNeonatal Intensive Care. (8th ed.) St. Louis. Mosby Elsevier.Verklan, M., & Walden, M. (2015) Core Curriculum for Neonatal Intensive Care Nursing. (5th ed.) St. Louis.Saunders.Wallace, T., Steward, D. (2014). Gastric Tube Use and Care in the NICU. Newborn and Infant Nursing Reviews,14(3), 103-108. http://dx.doi.org/10.1053/j.nainr.2014.06.011 The JointCommission Tubing Misconnections – A persistent and potentially deadly occurrence, Sentinel Event Alert, Issue36, Apr. 3, 2006.45Nutritional Support of the Very Low Birth Weight InfantA CPQCC Quality Improvement Toolkit
TOOL #9EXAMPLE: Residuals & Feeding Intolerance ProtocolUse if residuals are checked routinely.Check residuals with all NG feedings. Check residuals before restarting continuous feeds off greater than orequal to 1 hour. Residuals on continuous feeds with no break are not checked; follow P&P for continuousfeeds.Disregard:1. Residual volume of less than 2ml regardless of infant’s feeding volume.2. Residual volume of less than 50% of feeding volumes (if there are no additional signs of feeding intoleranceand the clinical evaluation is normal.)3
Slower feeding protocols (8-10 mL/kg/day) in ELBW have been associated with negligible NEC rates. 36,37 Faster rates of feeding are associated with improved weight gain, reduced PN days and line related complications. Quality and Process Improvement Define rates of feeding advancement in feeding guidelines specified by birthweight
Product Criteria The enteral nutrition product requested on an authorization must be on the List of Enteral Nutrition Products and the beneficiary must meet the medical criteria for the specific product category and, if applicable, product-specific criteria. Products are listed in one or more of the followi
of a non-feeding tube device being connected to a feeding tube port. All enteral access devices, including feeding tubes, administration sets and enteral syringes will be impacted by these changes. The New ENFit Connector Provides a way to reduce the risk of enteral tube feeding misco
Drug Interactions with Enteral Nutrition (general use) Guidance regarding enteral administration of medicines and interactions between medicines and enteral feeds, including feeding breaks General points: This list is not exhaustive - contact ward pharmacist, practice pharmacist or Medicines Information (01355 584879 or medicines.information .
hati lebih dianjurkan daripada pemberian nutrisi parenteral karena pemberian nutrisi enteral mempercepat membaiknya keseimbangan nitrogen dan berkurangnya infeksi. Penambahan prebiotik dan probiotik dalam nutrisi enteral pasca-operasi juga dapat menurunkan laju infeksi dibandingkan dengan pemberian nutrisi enteral saja. 5.
Myriam Herrero Álvarez, Rafael Galera Martínez y María del Carmen Rivero de la Rosa Capítulo 14 Nutrición enteral en el paciente oncológico 161 Ana Moráis López, Pedro Cortés Mora y Rafael Galera Martínez Capítulo 15 Nutrición enteral en el niño con enfermedad renal crónica
receiving prepyloric gastric feeds and no cases were observed in the 19 patients receiving post-pyloric feeds through a jejunal tube. To avoid continuous alkalinization and intragastric Gram-negative growth associated with enteral feeding, intermittent enteral nutrition was compared with con-tinuous enteral nutrition in one trial [28]. Five of
Kangaroo 924 Pump Set Enteral, feeding, 500 ml bag, 30/case. Kendall #772025 058854 Each Kangaroo Joey Mini BackPack Bag for Kangaroo Joey feeding pump, fits Joey 500 ml or 1000 ml set, 14"H x 10"W x 4"D, black. Covidien #770025 063333 Each Enteral Pump Accessories Cassettes Medication, for use with Cadd
Enteral feeding supply allowances (B4034, B4035, and B4036) include all supplies, other than the feeding tube and nutrients, required for the administration of enteral nutrients to the beneficiary for one day
