NICU Nutrition Protocol
NICU Nutrition Protocol
NICU Nutrition Protocol
<1500 g Admission Phase (DOL 0 and Feeding Day 1) ≥ 1500 g Admission Phase (DOL 0 and Feeding Day 1)
• IVF: Start 1st Day TPN and IL (1 g/kg) on admission • IVF: Clear IVF (with Ca if cardiac or IDM)
• TF goal: • TF goal:
o < 750g: 100 ml/kg/day o 1500-1799g: 80 ml/kg/day
o 750-999g: 90 ml/kg/day o 1800-2500g: 70 ml/kg/day
o 1000-1499g: 80 ml/kg/day o >2500g: 60 ml/kg/day
• Access: Central line recommended for < 1250 g • Access: PIV if stable; central line if indicated
• Feeds: Order “EBM if available” on admission; goal • Feeds: Order “EBM if available” on admission; goal
to start by 6-12 hours of life if stable; feeding to start by 6-12 hours of life if stable; feeding
volume based on chart on back volume based on chart on back
• DBM: Get consent if < 1500 OR <34 wks gestation • EBM preferred; SSC if preterm; Sim advanced if term
• Labs: BMP at 24 hours • Labs: BMP at 24 hours
<1500 g Early Advancement (DOL 1-3 & Fdg Day 2-3) ≥ 1500 g Early Advancement (DOL 1-3; Fdg Day 2-3)
• Order routine TPN/IL • Order routine TPN/IL if NPO > 3 days
o Protein: begin at 2.5g/kg (peripheral) or o Protein: begin at 2.5g/kg (peripheral) or 3g/kg
3g/kg (central); advance by 1 g/kg Q day to (central); advance by 1 g/kg Q day to goal of
goal of 4g/kg 4g/kg if preterm or 3.5 g/kg if term
o Dextrose: minimum 7 g/kg/day; advance by 3 o Dextrose: minimum 7 g/kg/day; advance by 3
g/kg/day daily to goal of 18 g/kg/day. Max g/kg/day daily to goal of 18 g/kg/day. Max 20
20 g/kg/day g/kg/day
o Cysteine: hold if base excess more than -6 o Cysteine: hold if base excess more than -6
o No Na & K in TPN for 1st 24 hours; remember o No Na & K in TPN for 1st 24 hours; remember
to count Na in line fluid to count Na in line fluid
o Ca/Phos: Start Ca at 2 (advance by 0.5 q 1-2 o Ca/Phos: Start Ca at 2 (advance by 0.5 q 1-2
days to goal 3); start phos at 1.2 (will need days to goal 3 if preterm or 2.5 if term); start
either Na or K to give; advance by 0.2 Q 1-2 phos at 1.2 (will need either Na or K to give;
days to goal 2); goal Ca:Phos ratio is 1.7:1 advance by 0.2 Q 1-2 days to goal 2); goal
o Mg: consider holding if mom on mg PTD Ca:Phos ratio is 1.7:1
o Ace: Cl ratio: based on labs; 1:1 if no labs o Mg: consider holding if mom on mg PTD
o IL: increase by 1 g/kg daily to goal of 3g/kg o Ace: Cl ratio: based on labs; 1:1 if no labs
• TF goal: Increase by 10 ml/kg/day unless lab o IL: start at 2 g/kg; increase by 1 g/kg daily to
and/or clinical data indicate otherwise goal of 3g/kg
• Access: ck UVC placement Q 2-3 days; consider • TF goal: Increase by 20 ml/kg/day unless lab
PICC and/or clinical data indicate otherwise
• Feeding: Advancement per chart on reverse • Access: ck UVC placement Q 2-3 days if present;
• Labs: Lytes at least twice in first week if < 1500 consider PICC if NPO for extended period
o OK to skip BUN/Cr if no renal concerns; only • Feeding: Advancement per chart on reverse
check trig if on max IL > 1 week • Labs: Lytes as clinically indicated; check mg on DOL
o Check Mg on DOL 3 if held due to mat. mg 3 if held due to mat. mg
<1500 g Cont. Advancement (Fdg Day 4 – Full Fdg) ≥ 1500 g Cont. Advancement (Fdg Day 4 – Full Fdg)
• Continue TPN/IL until reach 100 ml/kg/day; then • Continue TPN/IL until reach 100 ml/kg/day; then
clears clears
o Protein/Dextrose/Ca/Phos/IL: wean per chart o Protein/Dextrose/Ca/Phos/IL: wean per chart
• Access: Check UVC Q 2-3 days; Check PICC placement • Access: Check UVC Q 2-3 days; Check PICC placement
Q 14 days; remove when feeds reach 120 cc/kg/day Q 14 days; remove when feeds reach 120 cc/kg/day
• Feeding/Fortification/Vit D/Fe • Feeding/Fortification/Vit D/Fe
o Feeding advancement per chart below o Feeding advancement per chart below
o Fortify to 22 cal/oz when feeds reach 60 ml/kg/d o Fortify to 22 cal/oz when feeds reach 60 ml/kg/d
then 24 cal/oz the next day then 24 cal/oz the next day if preterm
o Add LP next day after reaching 24 cal/oz (use goal o Add LP next day after reaching 24 cal/oz (use goal
feeding volume when using chart below) feeding volume when using chart below) if
o TF goal 150-160 ml/kg/d for 120-130 kcal/kg/d <1800g
o Aiming for growth velocity of 20-25 g/kg/d o TF goal 150-160 ml/kg/d for 120-130 kcal/kg/d for
o Start Vit D when feeds reach 80 ml/kg/d; if Alk preterms; caloric goal 110 kcal/kg for terms
Phos > 500 then increase to 800 units o Aiming for growth velocity of 20-25 g/kg/d
o Start Fe when on full enteral feeds and 14 days o Start Vit D when feeds reach 80 ml/kg/d
old per chart below o Start Fe when on full enteral feeds and 14 days
o Transition off DBM at 34 weeks old per chart below
• Labs: • Labs:
o If prolonged TPN > 1 month, follow CMP, Dbili, o If prolonged TPN > 1 month, follow CMP, Dbili,
mag, phos, TG weekly mag, phos, TG weekly
o Check lytes after 1-2 days on full BM feeds o 30 Day bone labs NOT needed
o Check bone labs at DOL 30 if < 1500 g. If normal,
do not repeat.
Addition of LP to Feeds (use goal feeding volume when determining LP – even prior to reaching goal)
GOAL feeding HMF HP* STANDARD HMF
volume 22 kcal/oz 24 kcal/oz 22 kcal/oz 24 kcal/oz 26 kcal/oz 28 kcal/oz 30 cal/oz
120mL/kg/day 4.5 ml 3 ml 5 ml 4 ml 3 ml 3 ml 2.5 ml
130mL/kg/day 4 ml 2.5 ml 5 ml 3.5 ml 2.5 ml 2 ml 2 ml
140mL/kg/day 4 ml 2 ml 5 ml 3 ml 2 ml 2 ml 1.5 ml
150mL/kg/day 3.5 ml 1.5 ml 4.5 ml 3 ml 1 ml 1 ml 1 ml
160mL/kg/day 3 ml 1 ml 4 ml 2.5 ml 1 ml 1 ml 0.5 ml
* Use HMF HP for babies with weight <2.5kg and <24kcal/oz; use standard HMF if weight >2.5kg or >24 kcal/oz
Fe Supplementation
< 1800 g > 1800 g
Majority BM feeds 4-5 mg/kg/day 2-3 mg/kg/day
Majority formula feeds 2-2.5 mg/kg/day