Consensus Clinical Guidelines for Late Preterm Infant (LPI) Feeding

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UCSF NCNC (Northern California Neonatology Consortium) 

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Table of Contents

• LPI Supplemental Feeding Guidelines
• Vitamins & Nutritional Supplements
• REFERENCES
• ADDENDUM 1: NUTRIENT ANALYSIS
• ADDENDUM 2: FEEDING & SUPPLEMENTATION SELECTION

Goal

• Encourage and support human milk feeding with goal of exclusive breastfeeding for all LPIs.
• Avoid co-morbidities of LPI associated with inadequate feeding.
• Provide adequate intake of calories, protein and micronutrients to achieve optimal growth.

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Criteria for Use of LPI Feeding Guideline

• Infants born at 34 0/7 to 36 6/7 weeks gestational age (GA)
• Absence of severe congenital anomaly, need for critical care intervention, or contraindication for enteral feeding
• Absence of contraindication for use of maternal breast milk (MBM)

Support for Breastfeeding

• Skin-to-Skin: Provide opportunity for skin-to-skin time after birth in all late preterm infants who are clinically stable and maternal post-partum status permits. Encourage first breastfeeding attempt within first hour after birth if possible.
  • Resource-intensive but many maternal & neonatal benefits (e.g. neonatal glucose stability)
• Lactation Consultation: Should be offered to ALL mothers of late preterm infants.
  • Encourage breastfeeding attempts q 2-3 hours (8-12 times / 24 hour period), for 15-20 minutes / session
  • Mothers may skip a few breastfeeding / pumping sessions per 24 hour period in order to obtain sufficient rest
• Milk Expression: Educate & encourage mothers to hand express or pump at least 8 times / 24 hour period, for 10-20 minutes / session
  • All LPIs (34-36 weeks): initiate milk expression within 4 hours after birth
• Assessment of Breast Milk Transfer (for infants receiving supplementation):
  • Latch scoring / subjective nursing and lactation assessment of breastfeeding success
  • After day 3 (or when mother's volume of milk has increased / mother's breasts are softened after feedings), consider weighing diapered infant before and after breastfeeding + subtract transfer amount from the total supplemental feeding guideline for that day
• Assessment of Hydration Status: daily weights, weighing / counting diapers, clinical assessment
• Duration of Supplementation: Supplementation of breastfeeding is needed until LPI can feed effectively, empty mother's breasts, mothers' milk is abundant, and infant is maintaining/gaining weight (lactation specialists may assist with defining "successful / effective breastfeeding")

LPI Nutritional Needs / Goals

• Estimated Needs:
  • 34-36 weeks: 120 kcal/kg/day; 3.1 g protein/kg/day
  • 37-38 weeks: 115 kcal/kg/day; 2.5 g protein/kg/day
  • < 3kg: 120-130 kcal/kg/day; >3 g protein/kg/day
  • > 3 kg: 110-120 kcal/kg/day; >2 g protein/kg/day
• Expected Weight Gain (after diuresis):
  • >2kg or 34-38 weeks: 30-35 g/day
  • 0-3 months CGA: 25-35 g/day
  • 3-6 months CGA: 15-20 g/day
  • *For specific goals per baby, see http://peditools.org/index.html

NOTE: For CATCH-UP GROWTH, increase expected weight gain, energy and protein goals by 10-20%

LPI Supplemental Feeding Guidelines

NOTE: an individual infant may be considered in a higher or lower gestational age feeding category based on provider assessment of infant's maturity and clinical status or based on maternal post-partum status

1. Stellwagon, L and Boies E. CPQCC Care and Management of the Late Preterm Infant Toolkit: Section IV: Nutrition and Feeding of the Late Preterm Infant February 2013.
2. Lubow et al. Am J Obstet Gynecol 2009;20(5):e30-33.
3. Vachharajani & Dawson 2009;48(4):383-388.

NOTE: an individual infant may be considered in a higher or lower gestational age feeding category based on provider assessment of infant's maturity and clinical status or based on maternal post-partum status

NOTE: an individual infant may be considered in a higher or lower gestational age feeding category based on provider assessment of infant's maturity and clinical status or based on maternal post-partum status

*The reason for the difference in calories between MBM and formula for 36 week infants is that formula is premixed to 22 kcal, however if fortifying breastmilk it is probably only worth it to do so if you fortify to 24 kcal.

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Vitamins & Nutritional Supplements

Vitamins / supplements may be started in nursery, at discharge, or as outpatient by 2 weeks of age

Note: 1 ml Poly-vi-sol with iron contains 10 mg iron and no vitamin B12; it is not recommended for an infant of a vegan breastfeeding mother. In addition, it has too much iron for an infant weighing less than 5kg.

*We are discharging the patient on infant multivitamin 1ml q day. Note to pediatrician: After infant reaches 3.5kg, he or she should be switched to Vitamin D 400 IU daily. By 2 months, if not fully formula fed, the infant should also have an iron supplement to provide 10mg daily in their diet.

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References

Stellwagon, L and Boies E. CPQCC Care and Management of the Late Preterm Infant Toolkit: Section IV: Nutrition and Feeding of the Late Preterm Infant February 2013

National Perinatal Association Multidisciplinary Guidelines for Care of the Late Preterm Infant

SFGH Late Preterm Infant Feeding Guidelines and Algorithm

Bhatia J et al. Selected Macro/Micronutrient Needs of the Routine Preterm Infant J Pediatr 2013;162:S48-55.

Lapillonne A et al. Nutritional Recommendations for the Late-Preterm Infant and the Preterm Infant after Hospital Discharge J Pediatr 2013;162:S90-100.

Danner E et al. Weight Velocity in Infants and Children Nutr Clin Pract 2009 24:76-79.

Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes-Adequate Intake for Infants 0-6 months; Washington DC: National Academy Press,1997-2002.

Brandt I et al. Catch-up Growth of Supine Length/Height of VLBW, SGA Preterm Infants to Adulthood J Pediatr 2005;147:662-8.

Groh-Wargo, S, Thompson, M and Hovasi Cox, J Pocket Guide to Neonatal Nutrition, 2nd Ed. Chicago, IL: Academy of Nutrition and Dietetics, 2016.

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ADDENDUM 1: Nutrient Analysis

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ADDENDUM 2: Feeding & Supplementation Selection

UCSF Multi-Site Neonatology Collaboration. Originated 03/2014. Revised 6/2014, 10/2014, 03/2018.
Approved by UCSF ICN Patient Safety Committee: 7/2018
Approved by UCSF Pharmacy and Therapeutics Committee: 8/2018

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