Nutrition, Fluid and Electrolytes

Feeding Advancement Protocol

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Fluid Management

Initial total fluid guide

• Term: 60-80 ml/kg/day
• Preterm ≥ GA 28 weeks: 80 ml/kg/day
• Preterm < GA 28 weeeks: 90-100 ml/kg/day

Glucose infusion rate (GIR)

Formula 1:

$mg/kg/min\ =\ \displaystyle \frac{(\%\ Dextrose)\ \times\ total\ fluid\ (ml/kg/day)}{144}$

Formula 2:

$mg/kg/min\ =\ \displaystyle \frac{(\%\ Dextrose)\ \times\ hourly\ rate\ (ml/hr)}{6\ \times\ weight}$

Custom fluid builder (Not TPN)

Order code: 66686 Order name: IV Fluid Composer Adjustable Neonatal IV Continuous

Line KVO rates

NICU Line KVO Rates Quick Reference (NICU CNS, sent to Pharmacy, October 2026).

Line	Minimum KVO rate	ELBW / ELGAN minimum
PICC (single or double lumen)	1 mL/hr	—
UVC (single or double lumen)	0.5–1 mL/hr	0.3 mL/hr
UAC	0.5–1 mL/hr	—
PAL	1 mL/hr	0.5 mL/hr

Standard KVO solution — all NICU lines (UVC, UAC, PICC, PAL)

½ Na-Acetate with heparin 0.5 units/mL to infuse at 1 mL/hr

Heparin reminder — central lines

• Fluid must be heparinized at a minimum of 0.5 units/mL.
• Rate < 1 mL/hr → increase heparin to 1 unit/mL.

Alprostadil (Prostin) minimum rate

Central line 1 mL/hr · Peripheral line 2 mL/hr

Non-central infusions

Max osmolality 900–1,000 with Neonatology collaboration

ELBW: extremely low birth weight (< 1,000 g); ELGAN: extremely low gestational age newborn (< 28 weeks); PICC: peripherally inserted central venous catheter; UVC: umbilical venous catheter; UAC: umbilical arterial catheter; PAL: peripheral arterial line.

Total Parenteral Nutrition (TPN)

“Standard” concentration

“Standard” concentration is the default concentration for pharmacy

“Standard” concentration	Na	K	Ca	Phos	Mg
Peripheral	30mEq/L	20mEq/L	9mEq/L	9mmol/L	4mEq/L
Central	30mEq/L	20mEq/L	25mEq/L	12.5mmol/L	4mEq/L
Goal range	135-145mEq/L	3-6mEq/L	8.5-11 mg/dL	5-8 mg/dL	1.7-2.8mg/dL

Monitoring

• Consider frequent monitoring electrolytes, Ca, Phos, and Mg while on TPN for > 50% of total fluid.

Hyperkalemia

Treatment

• Albuterol
  • 0.4mg/kg/dose med nebulizer q2hrs.
  • 1 unit dose vial = 3mL = 2.5mg.
• Calcium gluconate
• Lasix
• Insulin

Hypokalemia

Treatment

KCl 0.5mEq/kg over 2 hrs

Guide for Selenium Adjustment

Goal for total selenium intake

• ~7–8 mcg/kg/day (TPN + enteral)

Prolacta +6 (Higher Selenium Contribution)

• Preterm EBM + Prolacta +6 (4.5 mcg selenium per 100 mL)

Enteral Feeds (mL/kg/day)	Enteral Se (mcg/kg/day)	TPN Se (mcg/kg/day)	Total Se (mcg/kg/day)
60	2.7	5.0	7.7
80	3.6	4.0	7.6
100	4.5	3.0	7.5
120	5.4	2.0	7.4

Enfamil HMF (Standard Protein) – Lower Selenium Contribution

• 22 kcal/oz (2.2 mcg selenium per 100 mL)

Enteral Feeds (mL/kg/day)	Enteral Se (mcg/kg/day)
60	1.32
80	1.76
100	2.20

• 24 kcal/oz (2.0 mcg selenium per 100 mL)

Enteral Feeds (mL/kg/day)	Enteral Se (mcg/kg/day)
80	1.60
100	2.00
120	2.40

Assumptions: Preterm EBM used for calculations. Enteral selenium values exclude TPN.

Postnatal Enteral Nutrition and Growth

Feeding Advancement Protocol

The NICU Feeding Advancement Calculator.mht file should only be opened using Microsoft Edge browser for the App to be active.

Growth goal

• Weight gain by 15-20 g/kg/day
• Length increase by 0.8-1 cm/week
• Head circumference increase by 0.8-1 cm/week
• Weight/length/head circumference to follow growth chart curve

Nutrition intake goal

• Calories: 120-130 KCal/kg/day
• Protein: 3.0-3.5 g/kg/day [Link]
• Fluids: 120-180 ml/kg/day

Nutrition survelleince

• Obtain Na, Phos, ALP, BUN, every Monday once full enteral feeds achieved

ESPGHAN Guidelines Links

ESPGHAN: European Society for Paediatric Gastroenterology, Hepatology and Nutrition

Parenteral Nutrition

Last update in 2018:
https://espghan.info/published-guidelines/

• Fluid and electrolytes [Link]
• Energy [Link]
• Carbohydrates [Link]
• Amino acids [Link]
• Lipids [Link]
• Calcium, phosphorous and magnesium [Link]
• Iron and minerals [Link]
• Vitamins [Link]
• Venous access [Link]

Enteral Nutrition

Last update in 2022:
https://www.espghan.org/knowledge-center/publications/Nutrition/2022-enteral-nutrition

• Position paper [Download]

Oral Care with Colostrum

Target population

Infants of any GA admitted to the NICU < 72 hrs of age who cannot be orally fed safely

Order oral care on admission

Place a PERFORM ORAL CARE order

• Frequency: 3 TIMES A DAY
• Comments: Please provide oral care with colostrum while not orally fed. After each care, please document under Shift NICU / Hygiene / Oral Care with Colostrum

Documentation

Use the dot-phrase .oralcare to pull nursing documentation of oral care into daily progress note, or alternatively, document manually.

Donor Breast Milk

Eligibility criteria

GA < 32 weeks or BW < 1,500g

Consent

Physician to consent parents verbally, and place proper documentation in the daily progress note.

dotPhrase

Prolacta Prolact+ H²MF Products

Eligibility criteria

• GA < 32 weeks or BW < 1,500g
  Remember to update the feeding advancement protocol to reflect Prolacta use as indicated

Protocol

• Use Prolacta instead of HMF when fortifying milk for infants who meet criteria for Prolacta.
• Start at 26 KCal (Prolact +6 H²MF).
• Increase calories per nutritionist recommendations and at rounding neonatologist’s discretion based on the infant’s clinical condition.

QI Project on Prolact+ H²MF cost

• Process measure
  • Use Postnatal growth charts to determine fortificationp plan beyond 26KCal/oz
• Outcome measure
  • cost of Prolact+ H²MF product
• Balance measure
  • Length of stay
  • BPD
  • ROP

Prolacta Cream

Eligibility criteria

When using Prolacta Prolac+ H²MF
Note: not to be used before breast milk fortification

Indication

Either of the following:

1. Overcome fat absorption by gavage tube - feeding rate-dependent
2. Overcome low fat content in mother’s milk

Usage

Route

1. Administer by itself through gavage tube before fortified milk
2. Mix with fortified milk

Volume

Dedepding on the fortified milk feeding volume, three ratios can be used:

• 3mL Cream per 100mL fortified milk - increase calculated calories by 2.4 KCal/oz
• 4mL Cream per 100mL fortified milk - increase calculated calories by 3.1 KCal/oz
• 5mL Cream per 100mL fortified milk - increase calculated calories by 3.9 KCal/oz

Possible combinations

Regimen	Details
1	20kcal milk
2	Cream before milk + 26kcal milk
3	Cream before milk + 26kcal milk mixed with cream
4	Cream before milk + 28kcal milk
5	Cream before milk + 28kcal milk mixed with cream
6	Cream before milk + 30kcal milk
7	Cream before milk + 30kcal milk mixed with cream

Feeding order

Use the .NICUCREAM dot-phrase in the comment field to indicate administration route and volume:

Example:
Please give ***mL of Prolacta Cream followed by ***mL of EBM/DBM with Prolacta +6.
Please add ***mL of Prolacta Cream to 100mL of fortified milk.

Fortified milk (mL)	4mL cream per 100mL milk (mL)	5mL cream per 100mL milk (mL)	6mL cream per 100mL milk (mL)
5	0.2	0.3	0.3
6	0.2	0.3	0.4
7	0.3	0.3	0.4
8	0.3	0.4	0.5
9	0.4	0.5	0.5
10	0.4	0.5	0.6
11	0.4	0.6	0.7
12	0.5	0.6	0.7
13	0.5	0.7	0.8
14	0.6	0.7	0.8
15	0.6	0.8	0.9
16	0.6	0.8	1.0
17	0.7	0.9	1.1
18	0.7	0.9	1.1
19	0.8	1.0	1.1
20	0.8	1.0	1.1
21	0.8	1.1	1.3
22	0.9	1.1	1.3
23	0.9	1.2	1.4
24	1.0	1.2	1.4
25	1.0	1.3	1.5
26	1.0	1.3	1.6
27	1.1	1.4	1.6
28	1.1	1.4	1.7
29	1.2	1.5	1.7
30	1.2	1.5	1.8
31	1.2	1.6	1.9
32	1.3	1.6	1.9
33	1.3	1.7	2.0
34	1.4	1.7	2.0
35	1.4	1.8	2.1
36	1.4	1.8	2.2
37	1.5	1.9	2.2
38	1.5	1.9	2.3
39	1.6	2.0	2.3
40	1.6	2.0	2.4
41	1.6	2.1	2.5
42	1.7	2.1	2.5
43	1.7	2.2	2.6
44	1.8	2.2	2.6
45	1.8	2.3	2.7
46	1.8	2.3	2.8
47	1.9	2.4	2.8
48	1.9	2.4	2.9
49	2.0	2.5	2.9
50	2.0	2.5	3.0
51	2.0	2.6	3.1
52	2.1	2.6	3.1
53	2.1	2.7	3.2
54	2.2	2.7	3.2
55	2.2	2.8	3.3
56	2.2	2.8	3.4
57	2.3	2.9	3.4
58	2.3	2.9	3.5
59	2.4	3.0	3.5
60	2.4	3.0	3.6

Probiotics (Evivo)

NTrainer Use Regional Guidelines

Workflow overview

NTrainer workflow for infants at risk for feeding difficulty.

Criteria for initiating NTrainer therapy

All criteria for the infant’s gestational age group must be met:

• For infants ≤ 30 weeks at birth:
  • Start training as early as 30 0/7 weeks PMA
  • Medically Stable (not on continuous vasopressor medications or invasive ventilator support, if on CPAP, or HFNC Fi0₂ ≤ 40%)
  • Tolerating enteral feed in previous 48 hours
  • Tolerating non-nutritive sucking with minimal bradycardic and desaturation events
• For infants > 30 weeks at birth:
  • Care team’s concern for the baby’s nipple feeding skills development
  • Medically Stable (not on invasive ventilator support, if on CPAP, or HFNC Fi0₂ ≤ 40%)

Assessment

• All initial assessments are performed by OT/PT.
  • OT/PT will place instructions at bedside when nursing and/or family are able to initiate therapy.
• For infants ≤ 30 weeks at birth:
  • Initial assessment at 30 weeks PMA.
  • If at 30 weeks PMA infant experiences cardiorespiratory event that does not resolve with removing the appliance, repeat assessment at 31 weeks PMA.
• For infants > 30 weeks at birth:
  • Timing of initial assessment based on OT/PT evaluation
• Ongoing assessments for all infants: 1-2/week until full PO feeding

Therapy

• Choose NTrainer length of therapy based on OT evaluation:
• Standard therapy mode will be used for all therapy sessions
  • NTrainer (Standard program): If PMA < 33 weeks, gavage feeding via pump for at least 20 minutes. Do not attempt to nipple feed until the next feeding.
  • Pre-Oral NTrainer (Standard program for one 3-minute cycle then progress to nipple feeding): Pt recommend to transition, If PMA > 33 weeks, Readiness Score < 3 on Infant-Driven Feeding Scale (see Appendix A) and nippling ≥ 1/3 volume in the previous feeding.
• Perform training: 2 times/day (try once per shift):
  • Done by OT/PT, bedside nurses, or parents
• Length of NTraining:
  • Initiate training for two weeks
  • Continue training until PO ≥ 75% of feedings and cueing and nippling each feed with a well-coordinated suck

Usage

• For all infants born at GA ≤ 32 weeks, start upon enteral feeds initiation, discontinue when reaching 34 weeks PMA.

Breastfeeding and Bonding Education Material

Medications and medical procedures while you are Breastfeeding

MOST medications, medical procedures, and imaging studies DO NOT require you to stop breastfeeding or even temporarily discard your breast milk.

Imaging procedures. Some of the more common imaging procedures and their relative risks:

• X-rays, ultrasound, mammograms, CT scans, and MRIs. Radiation from these tests will not affect your breasts or breast milk.
• Aspiration and breast biopsy procedures. These do not typically affect your breast milk.

Contrast agents for imaging procedures. A small amount of contrast could be excreted into your breast milk (American College of Radiologists- 2021). Since this amount is so small, the available data suggests that it is safe to continue breastfeeding. Oral barium is sometimes used as a contrast agent. Because barium is not absorbed, it will not go into your breast milk.

If you are worried about any potential effects to your child, you may wish to stop breastfeeding for 12 to 24 hours from the time of contrast use. Discard breast milk from both breasts during that time. You may use a breast pump before your procedure, so you have milk to feed your child during the 24 hours after the exam.

Radiation for breast cancer treatment. Radiation can damage breast tissue and decrease milk production. This effect is usually permanent. However, lactation will not be affected on the breast that does not receive radiation. If you have radiation, your child can breastfeed on the other breast.

Surgery with anesthesia. Anesthetic drugs appear in low levels in breast milk. You should continue breastfeeding as soon as possible after surgery (American Society of Anesthesiologists, 2019).

If you temporarily stop breastfeeding, use a breast pump regularly. This helps you keep your milk supply and return to breastfeeding easily, when appropriate.

Ultimately, the decision to temporarily stop breastfeeding is yours.

THC Use During Breastfeeding

Consultation

Consult all moms with a known history of THC use during or prior to pregnancy, or if toxicology screen is positive for THC, that there is unknown effect of THC on the developing brains, so THC use is strongly discouraged while moms are providing breast milk.

Documentation

Document the following in the Nutrition section of the daily progress note:

Mom verbally agreed to not use any THC products while breast feeding due to neurodevelopmental risks for her newborn