section: f clinical practice procedure - synova … · the md and adjust iv rate according to...

Section: F

Manual: Clinical Practice Procedure Procedure No.: CP-F-11 Approved By: VP & CNO, Nursing Services

Subject: NICU Nurse-Directed Feeding Advancement

Effective Date: 3/13 Revised Date: 10/13 Reviewed Date: 10/13

Key Words: Weight-Based Feeding, Very Low Birthweight, Extremely Low Birthweight,, Residuals, Nurse-Directed,

Cross References: NP-G-1 gastric Tubes- Gavage and Gastric Decompression PURPOSE:

1. To provide a standardized method for initiating and advancing enteral feedings for infants in the NICU, including the Extremely Low Birth Weight (ELBW) infants, the Very Low Birth Weight (VLBW) infants as well as any NICU patient that would benefit from a standardized feeding advancement.

2. To provide guidelines for nurse directed systematic feeding advancement in NICU patients. 3. To reach ultimate goal of reducing the prevalence of extrauterine growth failure and therefore

improving neuro-cognitive outcomes in the VLBW population. CRITICAL ELEMENTS:

by has started pumping breast milk, especially utilizing hand expression and

grams and less than 32 weeks gestation will receive mother’s breast milk or

fant refuse the use of Donor breast milk, consult MD/NNP. transition to

. .

QUPMENT LIST -Directed Feeding Advancement Worksheet based on infant’s weight

1. Ensure mother of bacollection of colostrum in tiny tubes within the first 6 hours after delivery and continue every 3 hours thereafter.

2. All infants < 1500 Donor breast milk.

a) If parents of in3. Once infant reaches 32 weeks corrected gestational age, MD/NNP may consider

Similac Special Care 24 cal on a per patient basis, if MBM insufficient to meet volume needs. 4. If mother of baby is not planning on breast feeding, is ill and unable to pump or has initiated

pumping but not acquired any milk, RN/MD/NNP to obtain consent to use Donor Breast Milk5. Check breast milk freezer to ensure adequate volume of Donor Breast Milk is available for use

E

• NICU – Nurse• NICU-Continuation of Nurse-Directed Feeding Protocol Worksheet (Q2H or Q3H)

PROCEDURE KEY POINTS

1. Infants less than 1500 grams a.) When infant is less than 1500 grams, hemodynamically

ms

stable and within the first 48 hours of life, including day of life 1, MD/NNP will initiate Nurse-Directed Feeding Advancement Protocol.

2. Infants greater than 1500 gra 0 gramsa.) When infants greater than 150 , MD/NNP will

and advance by

begin enteral feeds in one of three ways: 1. On Demand feeding schedule 2. Begin at 30 ml/kg/day on Day 1

30 ml/kg/day until full feeds (150 ml/kg/day) are

http://www.cpmc.org/�

reached at Day of feeds 5. 3. Begin the >1250 gram feeding advancement. This

b.)

o Nursing Protocol NP-G-1 gastric

sidual amount and document. rotocol,

e

structions for using NICU-Nurse-Directed Feeding

750gms, 751-1000 gms :

may be an option when the MD/NNP would like the infant to start with trophic feeds.

RN will perform full abdominal/gastrointestinalassessment

c.) RN will refer tTubes- Gavage and Gastric Decompression for NG/OG placement.

d.) Determine ree.) After MD/NNP inputs order to start feeding p

RN will obtain the NICU – Nurse-Directed Feeding Advancement Worksheet that correlates with thpatient’s birth weight.

InAdvancement Worksheet: 1. For weight categories < )

d in

lume is 1 ml per feed for <

a) *Days 1-4 are trophic feeds; weight is not factoreon days 1-4.

b) The feeding vo 750 gms (see

arting on day 4 or 5

e) Feed”

od.

. The amount to feed will be carried over into the “Amount to

3. essment has deemed infant safe to feed,

ee

ull Abdominal Assessment will

s,

nd

,

eding period,

the Nurse-

h

the first day of enteral

NOTE: If infant has a weight loss, the feeding calculation shou

.

specify which weight

xample: The infant weighs 835 grams on the

1st day of enteral feeding e feeding volume will be 1 ml

•

Addendum A) and 751-1000 gms (See Addendum B) c) For the trophic feeding days (see above for weight

categories), only fill in the date. d) After the trophic feeding period (st

depending on weight category), the bedside nurse will:1. Fill in the date next to the appropriate day

l

2. Fill in the weight of the infant in kilograms 3. Calculate the amount to feed by multiplying the to be used.

weight in kilograms by the specified numerical factor and rounding to the nearest whole number. Please see example below.

The “numerical factor” used in the “Amount tocalculation is derived by dividing the approximate ml/kg/day by the number of feeds in a 24 hour peri

2

Feed” column. After clinical assthe RN will use independent verification process to double check mathematical calculation and amount to fwith second RN.

d e

Finclude: auscultate bowel sounds; observe for presence of bowel loopdiscoloration of abdomen, repeated episodes of emesis; new onset of residuals; palpate for tenderness asoftness; compare abdominal girth withlast measurement; note frequency and quality of stool; note any changes in clinical status, i.e., changes in HR, BPRR, oxygen requirements, or increase inapnea and bradycardia. • NOTE: For Trophic Fe

RN does not need to report residualsto MD/NNP unless bilious, bloody or other clinical concern.

• NOTE: The infant startsDirected Feeding Advancement Protocol in a group based on birtweight. The infant will remain in thisweight group for as long as they are on the protocol. MD may change birth weight group for different advancement.

• NOTE: Day 1 isfeedings; it does not always correspond with day of life.

•

d be based on the last weight prior to weight loss

• NOTE: If > 10% weight gain since previous weight, call physician to

E•

Th(see trophic feeding above)

The infant will receive 1ml every 6 hours.

The infant weighs 934 grams on the5th day of enteral feeding

The feeding volume will be 0.934 x 2.5 = 2.34

The infant will receive 2 ml very 2 hours.

4. RN will feed this volume to the patient according to the

rtifier on the day

00 and feeds

dule and reached their

MD/NNP will determine whether the continuation of

H from Q2H and feeding

t reaches 1250 grams, MD/NNP will ess of

to

aches 120 ml/kg/day, RN should f

til

en

g

NOTE: Even if infant did not start feeds on day 1 until 1800, the feedings will still advance at 0800 on

frequency stated in “Frequency” column. 5. RN will obtain order for adding Protein Fo

designated on the NICU – Nurse-Directed Feeding Advancement Worksheet (signified in grey).

6. “Amount to feed” will be calculated daily at 08increased at next scheduled feed.

7. Once infant has completed the schegoal volume of feeding, the feedings need to be continually advanced using the NICU-Continuation of Nurse-DirectedFeeding Protocol Worksheet specific to weight category of infant. a) The

d

feeds will be on a Q2H (See Addendum E) or Q3H schedule (see Addendum F)

b) When feeds transitioned to Q3via gavage, run feeds over 1 hr, and reduce time as tolerated.

c) When infantransition to the Q3H Continuation sheet, regardlinfant’s birth weight. If infant reaches 1250 gms before reaching 160 ml/kg/day, infant will continue on Q2H feeds (complete Advancement sheet) until transition continuation sheet, at which point MD/NNP will change to Q3H feeds.

d) Once the infant reconsider discussing with MD/NNP discontinuation ocentral line. Pt is fed via orogastric/nasogatric tube unpt is 32 weeks CGA, at which time the RN may initiate the Infant- Driven Feeding scale (IDFP) and when appropriate MD/NNP will place order for Infant DrivFeedings. Refer to NP-F-10 Feeding Protocol: Infant Driven Feeding Scale-NICU. (IDFP and VLBW FeedinAdvancement Protocol will be concurrent orders.)

•

ay 2.

NURSING CONSIDERATIONS: 1. Colostrum swabs may still be used, but will remain

d or

attending MD/NNP to evaluate if

bdomen

ol iduals >50% of feeding volume

e. temp instability,

Manageme0% of feeding volume), re-feed

completely separate from the NICU – Nurse-DirecteFeeding Protocol. MD/NNP will write separate orders fcolostrums swabs.

2. Hold feeds and ask infant has any of the following:

a) Distended abdomen b) Tense and/or tender ac) Persistent visible loops d) Vomiting e) Bloody stof) Persistent resg) New onset of large residuals h) Bilious residuals if new i) Deterioration in status, i.

tachycardia, increased apnea

nt of Residuals: 1. For small residuals (<2

and proceed without subtracting from the feeding

volume. 2. For large isolated residuals (>20% and <50% of feeding

to

rate (for infants with IV+PO u

als >

MD Changes to Feeding Advancement ires an MD/NNP

st be

must place an

for longer than 24 st

ement

NICU – Nurse-Directed Feeding Advancement

o initiate feeds with

very

.

with feedings outside the realm of this

efer to NICU – Nurse-Directed Feeding

NOTE: The RN will mix probiotic with a inimu

x

volume), re-feed but subtract residual from feeding volume. After 3 feedings of large residuals, notify MDsee how to proceed.

3. DO NOT adjust the IVorders) after you obtain just 1 large residual. IF yoobtain 3 or more large residuals in a row, please notifythe MD and adjust IV rate according to IV+PO.

4. For infants who continue to have repeated residu50% of feeds and are unable to advance on feeds, RN will notify MD/NNP for possible discontinuation of protocol and change to continuous feeds.

1. Any change in feeding protocol requorder. This includes a HOLD on feeding orders. a) If feed is held >24 hours, a HOLD order mu

placed by MD/NNP. b) When feeds resume, MD/NNP

order to resume feeds, indicating which day on which to resume feeds. RN will obtain new feeding schedule worksheet and resume feeds on day indicated by MD/NNP order.

2. If patient incurs a HOLD in feeding hours and then resumes feedings, a new schedule mube obtained, with an order from the MD/NNP indicating what day on the schedule to resume feeds.

3. If infant reaches 1250 grams while on theAdvancement sheet, complete the Advancsheet and then move to the Q3H Continuation sheet.

4. Refer to Worksheet and NICU- Continuation of Nurse-Directed Feeding Advancement Worksheet for guidelines on when to call MD/NNP.

5. Every effort should be made tmother’s breast milk. If mother is actively working on pumping, but is still not producing enough, please discuss use of donor breast milk with MD/NNP and obtain consent for use if necessary.

6. Probiotic use will continue during the protocol and eeffort will be made to start probiotic use in the first 48 hours of life. MD/NNP order is required to start probiotics

7. For infants with special circumstances, i.e. fluid restrictions, MD/NNP will continue to have the option ofproceeding protocol.

8. Notify MD if no stool in over 24 hours. MD may order glycerin suppositories.

RAdvancement Worksheet and NICU- Continuation of Nurse-Directed Feeding Advancement Worksheet for guidelines on when to call MD/NNP. •

m m of 3 ml sterile water and administer to patient until there is a volume of breast milk adequate to mithe probiotic. When the volume of breast milk is adequate for mixing

probiotic, RN will use breast milk instead of sterile water to administer probiotic.

cted Feeding Advancement Worksheet and NICU- Continuation of Nurse-Directed

ing on day 4 or 5, depending on weight category), and amount to feed

On Nurses Flow Sheet: encement of the NICU Nurse-Directed Feeding Protocol for patient in narrative and

unt, color, and whether it was re-fed or discarded

rmed, document feeding volume on the NICU I/O , communicate to MD/NNP what your IV rate will be

R.

1. N/MD/NNP will obtain consent for use of Donor Breast Milk from legal guardian of infant upon

ever obtains consent) will give parent information sheet on use of Donor Breast

DOCUMENTATION On NICU – Nurse-DireFeeding Advancement Worksheet.

1. Document date, weight (startfor that day (starting on day 4 or 5, depending on weight category), derived from calculation on worksheet.

1. Document commmiscellaneous column

2. Document residual, amo3. Document amount of feeding and frequency 4. Document any reasons to notify MD/NNP 5. rfoDaily at 0800 after feeding calculation is pe

Flowsheet in EHR and if patient has IV+POchanged to and document this rate change in the EHR. MD/NNP will change IV rate order in EH

Donor Breast Milk Consent Radmission to NICU.

2. RN will place this signed consent in the section of the patient worksheet labeled “Consents.” RN/MD/NNP (whomMilk.

SUPPO1. E ely Low Birth Weight (ELBW):

RTIVE DATA: xtrem Birth weight less than 1000 grams

ght (VLBW):2. Very Low Birth Wei Birth weight less than 1500 grams tiniest infants (<1000

mference <10%.

h

e ciated with prolonged TPN

ol for feeding VLBW infants. d eight Potentially Better

care units and was able to gth of cedure

d

in trophic feedings of <10-20 ml/kg/day of breast milk or Donor Breast Milk during lish feeding protocols for VLBW infants. Benefits

3. “Extrauterine growth retardation” is very common in VLBW infants. In the grams) 30-50% are discharged with a weight, length and head circu

4. Early and adequate nutrition: a) Decreases the incidence of late onset sepsis and NEC b) Improves overall growtc) Improves cognitive outcomes d) Improves feeding tolerance) Decreases complications asso

5. Rationale for a standardized protoca) The Vermont Oxford Network “Got Milk” initiative introduce

Practices (PBPs) in three participating neonatal intensive demonstrate an improvement in the nutritional intake and growth with decreased lenstay and related costs for very low birth weight (VLBW) infants. This standardized proseeks to implement the PBPs that could be expected to lead to improved nutrient intake angrowth.

b) Potentially Better practices (PBPs) i. Beg

the first 3 days of life and estabinclude:

• Promote gut maturation • Prevent mucosal atrophy • Decrease hyperbilirubinemia and osteopenia • Increase feeding tolerance

ii. Management of feeding tolerance/intolerance can be improved with the development of an algorithm for managing residuals

g/day.

re infants.

iii. VLBW infants should receive expressed breast milk fortified with protein powder beyond human milk fortifier to achieve delivery of a minimum of 4 gm/k

iv. Consistent systematic advancement of enteral feedings by 10-20 ml/kg/day once trophic feedings have been established enhances the growth and outcomes of prematu

c.) Clear guidelines for when to hold feeds, restart feeds and troubleshoot makes care more uniform and results in fewer long periods of “NPO.”

Author(s): Michelle Rhein, RN, MSN, RNC; Jenny Charles, MPH, RD, CNSC; 10/13 Reviewed by: Kathy Lewis, MD Approved: Terri Slagle, MD; Cathy Leon, RN, BSN, BC-NE, MBA 10/13, Jessica Eads RN MSN MPHD. Revised by: Michelle Rhein, RN, MSN, RNC; Jenny Charles, RD; 10/13 References: Fallon, E.M., Nehra, D., Potemkin, A.K., Gura, K.M., Simpser, E.,Compher, C., American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), Puder, M. (2012). A.S.P.E.N. Clinical Guidelines: Nutrition support of neonatal patients at risk for necrotizing enterocolitis. Journal of Parenteral and Enteral Nutrition, 36(5), 506-523. Hay, W. (2009). Strategies for feeding the preterm infant. Neonatology, 94(4), 245–254. Kuzma-Reily, B., Duenas, M., Greecher, C., Kimberlin, L., Mujsce, D., Miller, D. Walker, D. (2003). Evaluation, development, and implementation of potentially better practices in neonatal intensive care nutrition. Pediatrics, 111, e461-470. Ziegler, E., Thureen, P., Carlson, S. (2002). Aggressive nutrition of the very low birth weight infant. Clinics in Perinatology, 29, 225-

ADDENDUM A NICU Nurse-Directed Feeding Advancement Protocol

< 750 grams Feeding Route: All gavage unless otherwise specified by MD/NNP or IDFP is ordered.

Page ___ of ___

Day Date Weight (Kg)

Daily Wt (Kg) X factor = Amt to Feed (ml/feed)

Amount to feed

Frequency Approx. ml/kg/day

1* N/A N/A 1 Q6hr N/A 2* N/A N/A 1 Q6hr N/A 3* N/A N/A 1 Q3hr N/A 4* N/A N/A 1 Q3hr N/A Feeding Advancement 5 _________kg X 2.5= Q2hr 30 6 _________kg X 3.3= Q2hr 40 7 _________kg X 4.2= Q2hr 50 8 _________kg X 5= Q2hr 60 9 _________kg X 5.8= Q2hr 70 10 _________kg X 6.7= Q2hr 80 Fortify to 22 cal/ounce (1 packet HMF/50 ml)11 _________kg X 6.7= Q2hr 80 12 _________kg X 7.5= Q2hr 100 Fortify to 24 cal/ounce (1 packet HMF/25 ml)13 _________kg X 8.3= Q2hr 100 14 _________kg X 9.2= Q2hr 120* 15 _________kg X 11.7= Q2hr 140 Add protein fortifier (1 ml to 50 ml FMBM 24)16 _________kg X 13.3= Q2hr 160 Instructions for Using this Form: 1.) Fill in date and current weight (in Kg).

2.) Calculate amount to feed using calculation above. Round to nearest whole number.

3.) Use independent verification process to verify amount to feed with

second RN.

For RN: For MD/NNP:

Calculate feeds daily at 0800 and begin with next scheduled feeding Do NOT withhold feedings in premature baby if:

Notify MD/NNP if: 1.) PDA or Indocin

1.) Onset large residuals >50 % of feeding 2.) Low Apgar scores

2.) Bilious residuals if new 3.) Green residuals

3.) Abdominal distension 4.) Umbilical lines

4.) Bloody stool 5.) CPAP

5.) Deterioration in status. E.g. temp instability, 6.) Low dose dopamine

tachycardia, increased apnea 7. ) Residuals <50%

6.) If no stool in over 24 hrs. MAKE NPO IF: 1.) High dose pressors >5 mcg/kg/min

7.) If weight change > 10% 2.) Bloody stool until evaluated

*For Trophic Feeds (Days 1‐4): 3.) Onset severe apnea until stabilized

RN does not need to report residuals to MD 4.) Severe abdominal distension

unless bilious, bloody or other clinical concern.

Probiotic Use: 1.) Start within first 48 hours of feeds. 2.) Mix with minimum 3 ml sterile water until adequate breast milk volume available

*At 120 ml/kg/day, RN to discuss with MD/NNP discontinuation of central line Use of BBM: Reassess need for continued use at 32 weeks CGA or 1500 gms. May transition to preemie formula at this time per MD/NNP discretion

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ADDENDUM B

NICU Nurse-Directed Feeding Advancement Protocol 751 – 1000 grams

Feeding Route: All gavage unless otherwise specified by MD/NNP or IDFP is ordered

Day Date Weight (Kg)

Daily Wt in Kg X factor = Amt to feed (ml/feed)

Amount to feed


1* N/A N/A 1 Q6hr N/A 2* N/A N/A 1 Q6hr N/A 3* N/A N/A 1 Q3hr N/A 4* N/A N/A 1 Q3hr N/A Feeding Advancement 5 ________kg X 2.5= Q2hr 30 6 ________kg X 3.3= Q2hr 40 7 ________kg X 5= Q2hr 60 8 ________kg X 6.7= Q2hr 80 Fortify to 22 cal/ounce (1 packet HMF/50 ml) 9 ________kg X 6.7= Q2hr 80 10 ________kg X 8.3= Q2hr 100 Fortify to 24 cal/ounce (1 packet HMF/25 ml) 11 ________kg X 10= Q2hr 120* 12 ________kg X 11.7= Q2hr 140 Add protein fortifier (1 ml to 50 ml FMBM 24) 13 ________kg X 13.3= Q2hr 160 Instructions for Using this Form: 1.) Fill in date and current weight (in Kg).


3.) Use independent verification process to verify amount to feed with

second RN.

For RN: For MD/NNP: Calculate feeds daily at 0800 and begin with next scheduled feeding

Do NOT withhold feedings in premature baby if:






5.) Deterioration in status. E.g. temp instability, 6.) Low dose dopamine

tachycardia, increased apnea 7. ) Residuals <50%






Probiotic Use: 1.) Start within first 48 hours of feeds. 2.) Mix with minimum 3 ml sterile water until adequate breast milk volume available

*At 120 ml/kg/day, RN to discuss with MD/NNP discontinuation of central line Use of BBM: Reassess need for continued use at 32 weeks CGA or 1500 gms. May transition to preemie formula at this time per MD/NNP discretion

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ADDENDUM C NICU Nurse-Directed Feeding Advancement Protocol 1001-1250 grams

Feeding Route: All gavage unless otherwise specified by MD/NNP or IDFP is ordered

Instructions for Using this Form: 1.) Fill in date and current weight (in Kg).


3.) Use independent verification process to verify amount to feed with second RN.

4.) When infant reaches 1250 grams, finish advancement, then choose Q3H continuation sheet.

For RN: For MD/NNP: Calculate feeds daily at 0800 and begin with next scheduled feeding

Do NOT withhold feedings in premature baby if:

Notify MD/NNP if: 1.) PDA or indocin





5.) Deterioration in status. E.g. temp instability, tachycardia, increased apnea

6.) Low dose dopamine

7. ) Residuals <50%






Probiotic Use: 1.) Start within the first 48 hours of feeds. 2.) Mix with minimum 3 ml sterile water until adequate breast milk volume available

*At 110 ml/kg/day, RN to discuss with MD/NNP discontinuation of central line

Use of BBM: Reassess the need for continued use at 32 weeks CGA or 1500 grams. May transition to preemie formula at this time per MD/NNP discretion.

Day Date Weight (kg)

Daily Wt (Kg) X factor = Amt to feed (ml/feed)

Amount to feed


1* N/A N/A 1 Q3hr N/A2* N/A N/A 1 Q3hr N/AFeeding Advancement 3 ___________kg X 2.5 = Q2hr 30 4 ___________kg X 4.2= Q2hr 50 5 ___________kg X 5.8= Q2hr 70 6 ___________kg X 7.5= Q2hr 90 Fortify to 22 cal/ounce (1 packet HMF/50 ml) 7 ___________kg X 7.5= Q2hr 90 8 ___________kg X 9.2= Q2hr 110Fortify to 24 cal/ounce (1 packet HMF/25 ml) 9 ___________kg X 9.2= Q2hr 110*10 ___________ kg X10.8= Q2hr 130Add protein fortifier (1 ml to 50 ml FMBM 24) 11 ___________ kg X13.3= Q2hr 160

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Addendum D NICU Nurse-Directed Feeding Advancement Protocol

>1250 gms Feeding Route: All gavage unless otherwise specified by MD/NNP or IDFP is ordered

Day Date Weight

(Kg) Daily Wt in Kg X factor = Amt to Feed (ml/feed)

Amount to feed


1* N/A N/A 3 Q3hr N/A 2* N/A N/A 4 Q3hr N/A Feeding Advancement 3 ___________kg X 3.8 = Q3hr 30 4 ___________kg X 7.5= Q3hr 60 Fortify to 22 cal/ounce (1 packet HMF/50 ml) 5 ___________kg X 11.3= Q3hr 90 Fortify to 24 cal/ounce (1 packet HMF/25 ml) 6 ___________kg X 15= Q3hr 120* 7 ___________kg X 18.9= Q3hr 150 Add protein fortifier (1 ml to 50 ml FMBM 24) 8 ___________kg X 20= Q3hr 160 Instructions for Using this Form: 1.) Fill in date and current weight (in Kg).


3.) Use independent verification process to verify amount to feed with second RN.

For RN: For MD/NNP:


Notify MD/NNP if: 1.) PDA or indocin





5.) Deterioration in status. E.g. temp instability, tachycardia, 6.) Low dose dopamine

increased apnea 7. ) Residuals <50%






Probiotic Use: 1.) Start within the first 48 hours of feeds if infant >1500 grams 2.) Mix with minimum 3 ml sterile water until adequate breast milk volume available.

*At 120 ml/kg/day, RN to discuss with MD/NNP discontinuation of central line Use of BBM: Reassess need for continued use at 32 weeks CGA or 1500 grams. May transition to preemie formula at this time per MD/NNP discretion.

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Addendum E Continuation of NICU Nurse-Directed Feeding Advancement Protocol Full Feeds Given Q 2 hrs

Weight Groups: <750 grams, 751-1000 grams & 1001-1250 grams All Feeds: FMBM 24 cal with LPF unless ordered otherwise

Instructions for Using this Form:

1.) Fill in date and current weight (in Kg).

2.) Calculate amount to feed using calculation above. Round to nearest whole number. 3.) Use independent verification process to verify amount to feed with second RN. 4.) Change to Q3H Continuation Sheet when infant is 1250 gms.

For RN: For MD/NNP:





3.) Abdominal distension 4.) Umbilical Lines



increased apnea 7.) Residuals <50%


7.) If weight change > 10% 2.) bloody stool until evaluated

*For Trophic Feeds (Days 1‐4): 3.) onset severe apnea until stabilized

RN does not need to report residuals to MD 4.) severe abdominal distension


Probiotic Use: 1.) Start within first 48 hours of feeds. 2.) Mix with minimum 3 ml sterile water until adequate breast milk volume available.

Feeding Route: All gavage unless otherwise specified by MD/NNP or IDFP is ordered Use of BBM: Reassess need for continued use at 32 weeks CGA or 1500 grams. May transition to preemie formula at this time per MD/NNP discretion

Date Weight (kg)

Daily Wt (Kg) x factor = Amt to Feed (ml/feed)

Amount to Feed

Frequency Approx ml/kg/day

_________kg x 13.3= Q2hr 160

_________kg x 13.3= Q2hr 160

_________kg x 13.3= Q2hr 160

_________kg x 13.3= Q2hr 160

_________kg x 13.3= Q2hr 160

_________kg x 13.3= Q2hr 160

_________kg x 13.3= Q2hr 160

_________kg x 13.3= Q2hr 160

_________kg x 13.3= Q2hr 160

_________kg x 13.3= Q2hr 160

_________kg x 13.3= Q2hr 160

_________kg x 13.3= Q2hr 160

_________kg x 13.3= Q2hr 160

_________kg x 13.3= Q2hr 160

_________kg x 13.3= Q2hr 160

_________kg x 13.3= Q2hr 160

_________kg x 13.3= Q2hr 160

_________kg x 13.3= Q2hr 160

_________kg x 13.3= Q2hr 160

_________kg x 13.3= Q2hr 160

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ADDENDUM F Continuation of NICU Nurse-Directed Feeding Advancement Protocol Full Feeds Given Q 3 hrs

Weight Group: >1250 gms or >1250 gms at time of change to continuation sheet All Feeds: FMBM 24 cal with LPF unless ordered otherwise

Instructions for Using this Form:

1.) Fill in date and current weight (in Kg).

2.) Calculate amount to feed using calculation above. Round to nearest whole number. 3.) Use independent verification process to verify amount to feed with second RN.

For RN: For MD/NNP:





3.) Abdominal distension 4.) Umbilical Lines



increased apnea 7.) Residuals <50%


7.) If weight change > 10% 2.) bloody stool until evaluated

*For Trophic Feeds (Days 1‐4): 3.) onset severe apnea until stabilized

RN does not need to report residuals to MD 4.) severe abdominal distension


Probiotic Use: 1.) Start within first 48 hours of feeds. 2.) Mix with minimum 3 ml sterile water until adequate breast milk volume available.

Feeding Route: All gavage unless otherwise specified by MD/NNP or IDFP is ordered Use of BBM: Reassess need for use at 32 weeks CGA or 1500 grams. May transition to preemie formula at this time per MD/NNP discretion

Date Weight (kg)

Daily Wt (Kg) x factor = Amt to Feed (ml/feed)

Amount to Feed

Frequency Approx ml/kg/day

__________kg x 20= Q3hr 160 __________kg x 20= Q3hr 160 __________kg x 20= Q3hr 160 __________kg x 20= Q3hr 160 __________kg x 20= Q3hr 160 __________kg x 20= Q3hr 160 __________kg x 20= Q3hr 160 __________kg x 20= Q3hr 160 __________kg x 20= Q3hr 160 __________kg x 20= Q3hr 160 __________kg x 20= Q3hr 160 __________kg x 20= Q3hr 160 __________kg x 20= Q3hr 160 __________kg x 20= Q3hr 160 __________kg x 20= Q3hr 160 __________kg x 20= Q3hr 160 __________kg x 20= Q3hr 160 __________kg x 20= Q3hr 160 __________kg x 20= Q3hr 160

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