Nutrition for Neonates Undergoing Surgery for CHD — Initiate Enteral Feeds — Clinical Pathway: Inpatient

Nutrition for Neonates with Congenital Heart Disease Clinical Pathway — CICU

Initiate Enteral Feeds

After assessing feeding readiness, use this information to guide initiation of enteral feeds. Determine type, route and rate and volume and advance while monitoring tolerance to goal of 150 mL/kg/day.

Readiness Assessment includes:

  • Adequate cardiac output
  • Stable hemodynamics, weaning inotropic support
  • Stable rhythm or stable arrhythmia
  • No clinical seizure activity for > 12 hours
  • No signs/symptoms of NEC or gut ischemia

Step 1

Determine Type of Feed Human milk or donor milk preferred, based on mother’s feeding plan
If human milk is not available or parent preference is to use formula:
≥ 37 weeks – Enfamil Infant 20 cal/oz, Good Start Gentle 20 cal/oz, Similac Advance 20 cal/oz
≥ 35 to < 37 weeks – Enfamil Enfacare 22 cal/oz, Similac Expert Care NeoSure 22 cal/oz

Step 2

Determine Route

BOLUS

PO + NG

 Demonstrating oral feeding readiness based on these guidelines:
  • On ≤ 2 L NC
  • Resp rate < 70 breaths per minute
  • Demonstrating feeding cues:
    • Awake/alert
    • Rooting
    • Sucking on pacifier
    • Hands to mouth
Document feeding cues in EPIC Intake Flowsheet.

CONTINUOUS

NG or ND

If ND cannot be placed at the bedside, may attempt continuous NG feeds and consider IR placement of post-pyloric ND tube.

 Does not demonstrate oral feeding readiness as listed above.
Conditions that require post-pyloric feeds:
  • Congenital GI anomalies
  • Known gastroparesis
  • Severe GERD
  • High-aspiration risk
  • Ileus

Step 3

Determine Appropriate Rate and Advance
  Continuous (NG or ND) Bolus (PO + NG) Goal
Normal Advance
  • ≥ 3 days of age
  • < 3 kg
    • Initiate at 1 mL/hr
    • Advance by 1 mL/hr q 6 hr to goal
  • ≥ 3 kg
    • Initiate at 2 mL/hr
    • Advance by 2 mL/hr q 6 hr to goal
  • Initiate at 15 mL q 3 hr
  • Advance by 5 mL q 6 hr to goal
  • Add in the diet order comments the dot phrase .cardiacpoadlib
  • Advance to goal of
    150 mL/kg/day
Slow Advance
  • < 37 weeks gestation
  • < 3 days of age
  • Ready to advance from
      NPO or trophic feeds
  • < 3 kg
    • Initiate at 1 mL/hr
    • Advance by 1 mL/hr q 12 hr to goal
  • ≥ 3 kg
    • Initiate at 1 mL/hr
    • Advance by 1 mL/hr q 6 hr to goal
  • Initiate at 5 mL q 3 hr
  • Advance by 5 mL q 6 hr to goal
  • Add in the diet order comments the dot phrase .cardiacpoadlib

Advancing (or Titrating) PN While Advancing Enteral Nutrition:

  • When enteral feeds are initiated, any enteral volume administered may exceed the intravenous TFL of 100 mL/kg/day up to 130 mL/kg/day prior to weaning PN.
  • Continue IV lipids until enteral caloric intake ≥ 100 kcal/kg/day.
  • Once goal enteral nutrition achieved, discontinue TFL order.
  • Discuss/evaluate TFL order daily.

Advancing to Goal Calories

  • Goal volume of 150 mL/kg/day will provide minimum requirement of 100 kcal/kg/day.
  • Once goal volume is reached, assess growth and determine further caloric goals with dietitian. Infants may require a further increase in volume, hindmilk and/or fortification (See Fortification Guidelines).

Nursing Documentation of Enteral Calories (kcal/kg/day):

  • In EPIC Intake Flowsheet, choose “add rows” and search “kcal”. Then choose “Caloric intake past 24 hours.”
  • For every feed amount that is documented in EPIC, also document the calorie per ounce so that EPIC can accurately calculate the enteral intake (kcal/kg) received.
  • The total enteral kcal/kg/day will automatically appear in the CICU and CCU rounding tools. Read the 6 a.m. value when presenting daily intake on rounds.