Transitioning Newborns from NICU to Home

Feeding

Breast Milk

Benefits

• Optimal food for almost all infants regardless of gestational age.
• Has been shown to improve subsequent mental development in term/preterm infants as well as provide enhanced protection against infection.
• Premature infants with BW<1800-2000g are supplemented with human milk fortifier while hospitalized to provide adequate calories, protein, and nutrients for growth and development.
• Human milk fortifier is not recommended after discharge.
• Mothers of premature babies produce milk with significantly higher concentrations of lipids, proteins, sodium chloride, iron, anti-infective properties (e.g., IgA), and neuroprotective properties for approximately 4-6 weeks following birth.
• Nutritional composition of breast milk varies greatly among mothers.

Recommendations

• Slow feeding and easy fatigue are common problems after discharge.
• Feed on demand every 1.5-3 hours; preterm infants may require a schedule for feedings (e.g., every 3 hours).
• If supplementation is required at discharge due to prematurity, poor growth, inadequate volume intake, or fluid restriction:
  • 2-4 feedings per day with premature transitional formula (22kcal/oz), and remainder as breastfeeding (preferred method), or—
  • Add premature transitional formula powder (Enfamil EnfaCare Lipil 22 or Similac NeoSure 22) to expressed breast milk to make 24-30 kcal/oz (call dietitian for recommendations and recipe).
• Infants <34 weeks or BW<1800g should receive a multivitamin (1mL/day) and an iron supplement (2 mg/kg/day) for the first year of life (can be given as 1mL of MVI with Fe).
• All term breastfeeding infants should receive Vitamin D (400 IU/day) as 1mL of MVI.
• Infants who have birthweight <1500g and are discharged on unfortified human milk may be at risk for nutritional insufficiency (growth failure and metabolic bone disease).
  • Evaluate at 2-4 weeks post-discharge and as needed thereafter: weight, length, FOC, serum phosphorous and alkaline phosphatase activity.
  • If poor growth or abnormal laboratory results, recommend neonatal dietitian consult to assess need for supplementation or further evaluation.

Growth Outcomes

• Very low-birthweight infants fed human milk initially have slower early growth, but have improved Bayley mental developmental index scores.
• Early catch-up growth for length (<9 months) and head circumference (<4 months).

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Feeding Tubes

Types of Devices

• Nasogastric (NG) tube: non-weighted, polyurethane tube for use more than 10 days.
• Gastrostomy tube: tube protrudes from anterior abdominal wall; most common initial gastrostomy device.
• Button/skin-level gastrostomy: access device that is flush to the skin.
  • Mushroom tip: mushroom or wing-tip portion to secure the tube to the stomach wall.
  • Balloon tip: port on external portion of catheter to inflate or deflate the balloon securing the tube to the stomach wall.

Care

• Recommend management with consultation from GI and pediatric surgery.
• Check NG tube position by aspiration of gastric fluid before each feeding, or if child has been retching/vomiting/coughing.
• NG or G-tube/button care:
  • Assess skin around tube site for redness and skin breakdown with every feeding.
  • Use ordinary soap and water to clean around the tube site to prevent build-up of debris.
  • Keep the tube open for a short time after feedings, to allow infant to "burp."
  • Flush tube with water before and after feedings or medications to prevent occlusion.
  • Check external tube length daily to make sure tube has not migrated, and adjust as needed.
• Check G-button balloon volume 1-2 times per week, and re-inflate as needed to initial volume.
• Button devices typically last several months; replace when the valve fails and/or the tube leaks.

Complications

• NG tubes:
  • Easily displaced.
  • Risk of malplacement/pulmonary aspiration.
  • Gastric or esophageal trauma during placement.
• Gastrostomies:
  • Granulation tissue (67%).
    • Bleeding (28%).
    • Pain (65%).
    • Requiring silver nitrate (56%).
  • Broken or leaky tube (56%).
  • Dressing needed on a regular basis to control drainage (60%).
  • Stomal infection requiring antibiotics (45%).
  • Drainage of pus or clear fluid from the stoma (82%).
  • Leakage of tube feed at least 1-2 times per month (49%), daily (25%).

Troubleshooting

Table adapted from Khair J, Br J Community Nurs 2003;8(3):116-126.

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Formula Feedings

We recommend breastfeeding for all infants when possible.  However, when breastfeeding is unavailable or undesired, the following formula recommendations apply.

Benefits

• Premature transitional formulas have higher contents of protein, minerals, trace elements, and long-chain polyunsaturated fats, as well as providing higher caloric intake (e.g., 22kcal/oz), compared to term formula.
• Increased energy density may be required to optimize growth in the presence of fluid restriction.
• Soy formulas are not recommended for preterm infants due to an increased incidence of osteopenia and poorer protein bioavailability.

Recommendations

• Infants with birth weight <1800g or poor growth history, fluid restriction, or abnormal laboratory indices may be discharged on premature transitional formula until 9 months corrected age.
• Healthy, larger preterm infants may demonstrate catch-up growth more quickly and uncommonly require the use of transitional formula.
• Former very low-birthweight infants should receive formula with arachidonic acid (ARA) and docosahexaenoic acid (DHA).
• Preterm infants on iron fortified premature transitional formula should be given multivitamin (0.5 mL/day) until weight is >5 kg.
• Preterm infants receiving an iron fortified term formula should be given multivitamin (0.5mL/day) until weight is >3 kg.

Growth Outcomes

• Premature infants fed formula supplemented with long-chain polyunsaturated fats (ARA and DHA) have shown improved growth and psychomotor development.
• Transitional formula may result in greater weight gain, linear growth, and bone mineralization than term infant formula.

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Growth

General Growth

• Use growth charts made specifically for premature infants.
• After infant reaches term corrected gestational age, a standard growth chart may be used.
• Use corrected postmenstrual age until 2 years of age.
• Interpretations of catch-up growth vary.  Catch-up growth usually occurs when an infant reaches between 5^th to 10^th percentile on growth chart.  This may not be the goal for all infants, especially those born IUGR or SGA (goal may be to simply follow their own curve below the standardized curves).
  • Catch-up growth minimizes the differences between term and preterm infant, usually by 12-18 months of age, but may continue for up to 5-7 years.
  • Most significant growth occurs between 36-40 weeks postmenstrual age.
  • Attainment of catch-up growth affected by birth weight, gestational age at birth, genetic potential, and continuing morbidity.
• Premature infants who are IUGR or infants who are SGA demonstrate less catch-up growth and higher rates of poor growth.
• Extremely low-birthweight infants commonly demonstrate growth that is close to or below the 5^th percentile; if their growth runs parallel to the normal curve, however, this is usually a healthy growth pattern.
• Otherwise healthy preterm infants first catch up in head circumference, then weight and length.

Weight

• Weight gain of 20-30 g/day is desirable in preterm infants (>2 kg).

Length

• Increases by approximately  1.1 cm/wk until term.
• From term-3 months, 0.75 cm/wk.
• From 3-6 months, 0.5 cm/wk.

Head Circumference

• Head growth is approximately 0.5 cm/wk until 3 months of age.
• From 3-6 months, slows to 0.25 cm/wk.
• Infants with head growth >1.25 cm/wk should be evaluated for hydrocephalus.

Abnormal Growth

• Infants whose growth curve plateaus or growth trajectory falls off, and those who lose weight after discharge or fall below the 5^th percentile warrant further evaluation to assess energy intake.
• Consider consultation with neonatal dietitian, gastroenterologist.

Growth rates of preterm infants through 18 months of age

In Kelly (2006), adapted from Verma, Sridhar, and Spitzer (2003).

Fetal-Infant Growth Chart for Preterm Infants

©2003 Fenton; licensee BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original URL.  http://www.biomedcentral.com/1471-2431/3/13

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Weaning

Description

• The introduction of solid food feedings and the gradual replacement of milk by solid food as the main source of energy and nutrients.
• Shared pleasure in eating and feeding enhances the relationship between infants and their caregivers.
• Signs of readiness for solid foods:
  • Adequate head control.
  • Interest in feedings.
  • Decrease in tongue thrust.
  • Ability to sit with support at 60-90 degrees.

Considerations

• Very low-birthweight infants are at risk for developing aversions to feeding.
  • May have more gagging when initiating solid feeding.
• Water and juices should not be offered prior to 6 months of age.
• Whole milk should be offered at ≥12 months of age.
• Weight gain may be jeopardized by adding poor caloric solid foods in place of breast milk or formula.
• Premature infants may feed more slowly due to weaker global tone, limited energy, and a lack of fully coordinated suck and swallow reflexes and oromotor tone.

Recommendations

• AAP recommends solid foods be introduced at 4-6 months corrected age.
• Use preterm formula milk to liquefy dried cereal foods until 9 months corrected age.
• Introduce rice cereal first, then vegetables or fruits.
• Introduce single-ingredient baby foods one at a time, and continue for 5-7 days before introducing an additional new food.

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