Enteral nutrition in NICU

2. Agenda
• Indications , Contraindications
• Nutritive , Non-Nutritive
• Oral , Ryle
• Breast , Formula
• HMF , Vits
• Tolerance , intolerance
• Medical , Non-Medical

4. Introduction
• Nutritional support can be given enteral ,
parenteral or a combination of both methods.
• Whenever it is safe & tolerable , enteral feeding is
the natural & preferred route
of nutrition as the structural & functional
integrity of the GIT is dependent upon the
provision of enteral feeding.

5. Introduction
• Providing appropriate nutritional support remains a
significant challenge in neonates especially those
with health problems.
• PT , especially ELBW < 1 kg require special attention
because of several problems , which are specific to
them as immaturity of GIT , inability to suck , swallow
, ↑ risk of illnesses that may interfere with adequate
enteral feeding (e.g., NEC , RD$ , PDA , Apnea , …..).

6. Introduction
• Seriously ill neonates do not feed well & often
will not tolerate feeding.
• a change in feeding pattern is often an early
sign of a problem in neonates.
• These neonates must be managed carefully
parenterally “IVF , TPN” until stabilization.

8. Indications Contraindications
Int sounds present No
Abd dist No present
Respiratory status stable Unstable
B.P stable Unstable
Lytes stable Unstable

9. Local Contraindications
• NEC
• I.O
• perforation
• paralytic ileus

10. Systemic Contraindications
• Severe RD  have ↑Risk of aspiration
RR < 60/minute  Oral feeding
RR 60 : 80/minute  Ryle feeding
RR > 80/minute  maintained NPO with
Parenteral nutrition “IV fluids , TPN”

11. Systemic Contraindications
• Shock , severe ↓ B.P , Hemodynamic instability ,
use of inotropes
• Hypoxia , Perinatal depression , Acidosis , Apgar
score of 5 at 5 minutes , Seizures
• Sepsis
• PDA , ttt with Indomethacin for PDA
 Shock , Hypoxia , ….  ischemic injury to the GIT
that  require 3 days or more for recovery before
feedings can be attempted.

14. Non-Nutritive Feeding
• = trophic feeding
• = gut-priming
• = Hypocaloric feeding
• = Minimal Enteral Nutrition “MEN”
• = feeding very small amounts not for nutrient
delivery But for induction of gut maturation 
trophic effect on the gut mucosa.

15. Advantages of Non-Nutritive Feeding
• ↑ GIT motility , ↑ GIT hormones , enzymes
secretion
• ↑ feeding tolerance , earlier progression to
full enteral feeding  transition to Nutritive
feeding
• ↓ days on parenteral nutrition “IVF , TPN”
• earlier disharge & ↓ hospitalization days.
• ↓ incidence of sepsis , cholestasis

16. Indications of Non-Nutritive Feeding
• ELBW < 1 kg.
• Neonates who have been NPO for > 1 week.
• Neonates recovering from NEC.
• N.B.: M.V , UAC (per se) is not a
contraindication for initiation of Non-Nutritive
feedings.

17. Strategy of Non-Nutritive Feeding
• use colostrum , breast milk , formula “full
strength”
• N.B.: EBM is the preferred milk for Non-
Nutritive feeding by Ryle feeding

19. Advantages of Nutritive Feeding
• = Standard feeding
• = supply the required nutrients , calories to
achieve the expected growth , ↑ B.W , bone
mineralization

20. • within the 1st week of life  the expected daily ↓ in
B.W
 FT 5 : 10% of their B.W
 PT 10 : 15% of their B.W
• after 1st week of life  the expected daily ↑ in B.W
 FT 20 : 30 gm/day
 PT 15 : 20 gm/day

22. Calories of Nutritive Feeding
• > 1,5 kg  100 : 140 “120” kcal/kg/day
• 1 : 1,5 kg  120 : 160 “140” kcal/kg/day
• < 1 kg  140 : 180 “160” kcal/kg/day
• PT have limited total body energy stores  need
higher calories
• Neonates with severe illness e.g., sepsis , BPD ,
…..  need higher calories

23. Intervals of Nutritive Feeding
• Neonates < 1,5 kg  Q2 hrs
• Neonates > 1,5 kg  Q3 hrs

24. Starts of Nutritive Feeding
• Start feeding as soon as it is medically possible.
• Evaluate the ability to feed the baby daily.
• For stable , larger PT > 1,5 kg  the 1st feeding may
be given within the 1st day of life.
• For unstable , smaller PT < 1,5 kg  the 1st feeding
may be given within first 3 days of life with the
objective of reaching full enteral feeding in 3 weeks.

25. Volumes of Nutritive Feeding
• 140 : 160 “150” ml/kg/day

26. Example of FeedingDays
NPO1 , 2
1 ml Q6 hrs3
1 ml Q4 hrs4
1 ml Q3 hrs5
1 : 2 ml/kg/feed Q 2 : 3After then
10 : 20 ml/kg/dayMax trophic
↑ 10 : 20 ml/kg/dayDaily ↑
as enteral volumes are ↑  the rate of any Parenteral “IVF , TPN” is ↓
accordingly  so that the total daily fluid volume remains the same.
transition to nutritive feeding with continuous monitoring of feeding
tolerance to avoid complications as any evidence of feeding intolerance e.g,
abd dist , residuals , NEC

27. PT
Bad
FT
Good
10
ml/kg/day
20
ml/kg/day
Max Trophic
Daily ↑

28. When Enteral Feeds Reach
60 ml/kg/day stop Ca
120 ml/kg/day stop IVF
add Tonics
150ml/kg/day add Fe

29. Rule of 20
• 10 : 20 ml/kg/day  Max trophic feeding
• 10 : 20 ml/kg/day  Normal daily feed ↑
• 20 ml/kg/feed  Normal feed
• 10 : 20 : 30 ml/kg/feed  stop Ca
 stop IVF , add Tonics
 add Fe
• 15 : 20 : 30 gm/day  Normal daily B.W ↑

31. Oral
“Breast or Bottle”
Ryle
“Gastric or Transpyloric”
GA “weeks” > 34 < 34
Coordinated Reflex
“suck-swallow-breathe”
present No
RD No present
Maxillofacial abnormalities No present
Neurological impairment
e.g., seizures , hypotonia , coma
No present

33. Ryle Feeding
• unable to feed oral
• Types :
• Nasal/oral “Start”
 Nasal are used > oral
 since oral has difficult fixation.
• Gastric/Transpyloric “End”
 Gastric are used > Transpyloric
 since > Transpyloric has special indications.

34. Good Position of The Ryle
Gastric Transpyloric
Air bubbling present No
Air aspirated present No
Aspirate Acidic Alkaline
Aspirate Non bilious bilious
Not good position do not feed
 But do not wait
 unsuccessful
 repeat the whole procedure
do not feed
 But wait for 4 hrs.
 unsuccessful
 repeat the whole procedure

35. Bolus Feeding
• = gavage
• = by gravity
• PT > 1 kg can generally tolerate bolus feeding up to full
feeds.
• start with bolus feeding divided Q 2 : 3 hrs over 10 : 20
minutes (by gravity) , not to be injected by a syringe.
• If feeding intolerance occurs , the time over which a
feeding is given is to be lengthened by infusion for 30 :
120 minutes.

36. Infusion Feeding
• = drip
• = continous
• Indications :
• ↑ risk of aspiration (e.g., severe GERD , delayed gastric emptying).
• May be routinely used in ELBW < 1 kg
• in transpyloric method
• Procedure :
• Use an automated pump.
• The pump rate is set as ml/hr

37. Bolus vs. Infusion Feeding
• With gastric ryle  we can use bolus or infusion
• But with transpyloric ryle  we use infusion only
• Bolus feeding is more physiologic & can promote
better gut growth
• Infusion feeding results in better energy
retention & body growth

39. Transition to Oral Feeding
“Breast , Bottle”
• NNS may facilitate the ryle to oral feeding
transition.
• PT who practices NNS on their mothers’
emptied breasts after EBM or a pacifier during
bolus feeds  gain more weight , have faster
gut transit-time , can be discharged from the
hospital earlier.

40. Transition to Oral Feeding
“Breast , Bottle”
• Oral feedings should begin slowly at :
 1 feeding/day  then
 3 feedings/day  then
 every other feeding  then
 finally to full oral feedings.

41. Transition to Oral Feeding
“Breast , Bottle”
• too rapid change to oral feeding may result in
weight loss , because the neonates tires with
feeding & is unable to take a sufficient amount
of food.
• Scheduling oral feedings for parent visits
enables them to actively participate in their
neonate’s care.

42. Aspiration

45. Advantages of Breast Milk
• ↑ GIT function “digestion , absorption ,
lactase enzyme activity  more rapid gastric
emptying  ↓ in intestinal permeability
• ↑ immunity
• ↑ neurodevelopmental outcomes
• ↑ maternal psychological well-being

46. Advantages of Breast Milk
• The ideal enteral diet for normal growth for all
neonates providing :
• sufficient Calories , Ptns , fats , CHOs ,
micronutrients , vitamins , minerals , water

47. Advantages of Breast Milk
• PT breast milk is the milk of choice for all PT.
• Compared with FT breast milk , PT breast milk has :
 higher levels of Calories , Ptns , fats , fatty acids ,
nitrogen , vitamins , minerals (Na , Cl , Mg).
 higher levels of immune factors , including cells , Igs,
other anti-inflammatory elements than FT breast
milk.

48. Advantages of Breast Milk
• fats & caloric content of hindmilk > foremilk.
• Researchers recommend that the hindmilk
fraction of EBM to be predominantly used for
feeding of PT.

49. EBM
• prepared daily & stored as following :

50. EBM
• For ELBW , the milk should be stored in small
amounts for thawing , warming of small
feeding volumes in order to minimize wasting
the maternal milk supply.

52. Cow’s Milk
• has been designed to mimic human milk
• adequate to meet the nutritional & physiologic
needs of neonates with an intact GIT
• provides Ptns with appropriate protein/Calories ratio
for normal growth & normal fluid requirements.
• PT formula contains higher Ptns , calories , vitamins ,
minerals Ca/PO4 ratio , lytes sufficient for the normal
growth of the PT.

53. New Formula “Prebiotics , Probiotics”
• Prebiotics : HMO
• Probiotics : Bacteria
Comfort

54. HCF
• when feeding volumes can not be tolerated e.g.,
• GIT problems
• fluid intake must be limited e.g., BPD , HF , renal
failure
• IUGR/SGA
• caloric delivery & nutritional support can be
maintained by ↑ the caloric contents of feedings.

55. HCF
• This can be done by adding to the formula or
breast milk :
• CHO : glucose polymers “starch”
• Fats : microlipids , MCTs oil “corn oil”
• Ptns : HMF or
HCF

56. Special Formula
• designed for special diseases e.g.,
• CMPA
• Lactose intolerance
• malabsorption syndromes
• IEMs
• NEC
• Surgical

57. Old Concept “CMA”
Formula Similarity to
Cow’s milk
Price kcal/oz kcal/ml
GOat 80% expensive 12 0.42
Soy 60% expensive 10 0.35
Oat 0% expensive 15 0.50
Rice 0% expensive 14 0.47
Coconut 0% expensive 6.5 0.22
Almond 0% expensive 5 0.17

58. • Plant formulas are not appropriate for PT
because of the :
• poorer quality of Ptns
• lower Ca , Zn

59. New Concept “CMPA”
Formula Ptn Size in ȡ Price kcal/oz kcal/ml
PH “HA” 5000 expensive 20 0.67
EH “CMA” 2500 expensive 20 0.67
AA Zero Very expensive 21 0.70

60. Dilution
• All = Cup / 30
• Any S = Cup / 60

61. Calories Calculation
• = Total daily amount in ml X Fixed kcal in 1 ml
B.W
• = kcal/kg/day

62. Formula kcal/oz kcal/ml
FT 20 0.67
PT 24 0.81
PDF 22 0.74
HCF 30 1

63. Example of Ready Calculated Calories
B.W “Kg” > 1,5 1 : 1,5 < 1
Range kCal/kg/day 100 : 140 120 : 160 140 : 180
Target kCal/kg/day 120 140 160
ml/kg/day
FT 0.67 180 208 240
AA 0.70 172 200 228
PDF 0.74 164 188 216
PT 0.81 152 176 200
HCF 1 120 140 160

65. Feeding Supplements
• PT feeding EBM only should be started on vitamins or
HMF supplement as soon as they are receiving full
enteral nutrition.
• PT feeding PT formula only do not routinely require
additional vitamins
• any supplementation will depend on Labs checked
regularly :
• serum Hb , Fe levels
• serum Ca , Po4 , ALP levels

66. Feeding Supplements Assessment

67. PT Formula
• Start with FT formula
↑ to volume 100 ml/kg/day “near to stop IVF”
• Change to PT formula
↑ to volume 150 ml/kg/day “full”
contine on it until the B.W 2,5 kg.
• Discharge on PDF
contine on it until the age 12 months.

68. HMF
• HMF is added to the EBM to ↑ Calories , Ptns ,
vitamins , minerals (Ca , Po4 , Zn , Cu) to a level that is
more appropriate for PT.
• once PT is tolerating 100 ml/kg/day of EBM “near to
stop IVF”  fortify with 1 packet HMF/50 ml EBM
• once PT is tolerating 150 ml/kg/day of EBM “full” 
fortify with 1 packet HMF/25 ml EBM
• contine on it until the B.W 2,5 kg.

69. Vitamins
• Vitamin E :
 12 IU/kg/day
• Vitamin D :
 AAP recommends 400 IU vitamin D/day for all breast milk-fed
infants not only PT
• Fe :
 Start supplementation at 4 weeks of age once they are tolerating
full enteral feeds
 Give supplemental dose 2 : 4 mg/kg/day
 for a total of 12 months.

70. Vitamins

72. Gastric Wash Before 1st Feed
Results Fate
Clear Start
Yellow Wash with Saline till clear
Bilious Ryle , X ray erect , Surgical
Blood Wash with Saline
Saline + Adrenaline
Konakion
Plasma
PPIs
Antacids , Cold saline is obsolete in NICU

73. Feeding Tolerance

74. Feeding intolerance
• Stop enteral feeding if any of the following
signs are present :
• Abd distension  ↑ of abdominal girth > 2 cm.
• ↑ residual > 30% of a feed
• Vomiting of the whole feed

75. Feeding intolerance
• Bilious gastric residual.
• Watery stool or +ve reducing substances
“Clinitest”
• GIT bleeding or +ve heme in stool “Heme-
guaiac test”
• C/P of NEC.

76. Abdominal Distention
• Abdominal girth is measured before each feed
to document ↑ distention.
• ↑ Abd girth  > 2 cm  escape next feed
• then according 

77. Abdominal Distention
• if the abdomen remains soft , lax , non tender 
maintain a prone position , gentle rectal
stimulation with a glycerin suppository help to
relieve gas & enable stooling.
• Persistent abdominal distention , tender with
palpation , discoloration of the overlying skin 
signs of NEC  abdominal x-ray is indicated

78. Residual
• ↑ residual > 30% of a feed
• < 30%  feed
• 30 : 75%  substract
• > 75%  escape
• the residual it self  if digested  Refeed
if not digested  Discard
• The presence of bile or blood in the residual 
consider NEC  abdominal x-ray is indicated

79. Vomiting
• Vomiting of the whole feed
• Feeding should be stopped if NEC ,
obstruction , metabolic disorders , infection ,
↑ ICT are suspected.

80. Watery Diarrhea
• stool C&S for bacterial , viral pathogens
• stool Clinitest should be performed if the
neonate also appears ill
• In Lactose intolerance , short-term use of a LF
formula or AA formula should result in return
to normal stools.

81. Blood in Stool
• consider NEC
• stop feeding
• abdominal x-ray
• obtain bleeding & clotting profile

82. Apnea , Bradycardia
• result from ↑ vagal stimulation due to feeding
• to ↓ vagal stimulation 

83. Non-Medical ttt of Feeding intolerance
• ↓ feed volume to last tolerated
• ↓ the rate of feeding advance
• ↓ the rate of instillation , allowing the feeding to
flow over a longer period of time more slowly by
the use of smaller Ryle , consider infusion feeds
• Open ryle 1 hr before feed.
• maintain a prone position.

84. Medical ttt of Feeding intolerance
• Simethicone
• glycerin suppository
• Anti GERD “Motilium , Gast-Reg”
• Erythromycin
• HCF
• LF or AA formula

85. NEC
• Risk factors : PT “the most important factor”

86. NEC Risk Factors
↑ ↓
Triad ∆ : Feeding , Infection , Ischemia
HCF EBM
HMF Pre , Pro (boitics)
Infection , Sepsis No
Oral Abx No
Antacids No
UAC , UVC Delayed cord clamp
↓ IVF ↑ IVF
↑ RBCs ↓ RBCs
↓ spO2 < 92 % ↑ spO2 > 92 %
PDA No

87. NEC Risk Factors
• Early initiation of enteral feeding is not
associated with ↑ incidence of NEC.
• Rapid advancement of enteral feeding is
not associated with ↑ incidence of NEC.
• use of HCF have been associated with ↑
incidence of NEC.

88. NEC
• C/P : Distension , Vomiting , Residual ,
Bilious , Bloody stool , Peritonitis
• Lab = Triad ∆ : ↓Na , ↓ PLT , Metabolic
acidosis
• X ray : 4 Airs

89. NEC

90. NEC
• Bell Stages :
1. Clinical only
2. Clinical + X ray (A , B)
3. Clinical + X ray + Critical (A , B)
• ttt : NPO , TPN
Plasma , Dopa 5 “obsolete in NICU”
G-ve Abx , anti-anaerobes Abx
Surgery

92. • if there is any doubt about how well a neonate
is tolerating feeding , it is best to stop feeding
, evaluate the neonate , discuss the case with
a senior staff member.

93. Summary
• Indications , Contraindications
• Nutritive , Non-Nutritive
• Oral , Ryle
• Breast , Formula
• HMF , Vits
• Tolerance , intolerance
• Medical , Non-Medical

94. Thank You