Feeding Regimen | Recommended Supplementation |
|---|---|
Preterm Infants | |
Human milk fortified with HMF | BW <2500 g: Iron (2 mg/kg/d) beginning after age 2 weeks until age 1 year BW >2500 g: No recommendation for higher iron needs for this group |
Unfortified human milk | All: Multivitamin (1 mL/d) BW <2500 g: Iron (2 mg/kg/d) beginning after age 2 weeks until age 1 year BW >2500 g: No recommendation for higher iron needs for this group |
Premature iron-fortified formula | None indicated |
Premature iron-fortified transitional formula | None indicated |
Term iron-fortified formula (weight <3 kg) | Multivitamin (1 mL/d) until weight >3 kg |
Term Infants | |
Human milk exclusively | Iron (1 mg/kg/d) starting at age 4–6 months Triple vitamin (A, D, C) at 1 mL/d within the first few days of life |
Term iron-fortified formula (weight >3kg) | Not indicated |
- Galactosemia in an infant
- Active maternal illegal drug use
- Active, untreated maternal tuberculosis (The mother should be separated from her infant, expressing milk for the baby to be fed via bottle. After treatment has begun and the mother is allowed to be with her infant, she can resume breastfeeding.)
- Maternal HIV infection (in developed countries), maternal HTLV type I or II infection
- Active HSV lesions on the breast; feeding can be continued on the unaffected breast
- Maternal use of certain radioactive isotopes, cancer chemotherapy agents, and a small number of other medications (see below)
- Extensive list of dangerous and safe drugs in breastfeeding: American Academy of Pediatrics Policy Statement in Pediatrics 2001;108(3):776 and at LactMed http://toxnet.nlm.nih.gov.easyaccess2.lib.cuhk.edu.hk
- Nurse at least 8 to 12 times a day or every 1 to 3 hours for the first week(s) of breastfeeding.
- Have no more than one 4-hour sleep period in 24 hours during the first week of breastfeeding.
Location | Temperature | Duration | Comments |
|---|---|---|---|
Countertop | ≤77°F (≤25°C) | 6–8 h | Cover all containers and keep as cool as possible; likelihood of contamination ↑ without refrigeration |
Insulated cooler bag | 5°-39°F (-15°–4°C) | 24 h | Keep ice packs in contact with milk container at all times |
Refrigerator | 39°F (4°C) | 5 d | Store milk in back of refrigerator |
Freezer | |||
Freezer portion of refrigerator | 5°F (-15°C) | 2 weeks | Store milk in back of freezer; over time, the lipids in milk degrade |
Freezer portion of refrigerator with separate doors | 0°F (-18°C) | 3–6 mo | |
Upright deep freezer | -4°F (-20°C) | 6–12 mo | |
Birth–4 mo | Age 4–6 mo | Age 6–8 mo | Age 8–10 mo | Age 10–12 mo | |
|---|---|---|---|---|---|
Breast milk and/or infant formula | 8–12 feedings 2–6 oz/feed 18–32 oz/d | 4–6 feedings 4–6 oz/feed 27–45 oz/d | 3–5 feedings 6–8 oz/feed 24–32 oz/d | 3–4 feedings 7–8 oz/feed 24–32 oz/d | 3–4 feedings 24–32 oz/d |
Cereal, bread, and starches | None | None | 2–3 servings Iron-fortified baby cereal, soft cooked breads, cereals, starches | 2–3 servings Iron-fortified baby cereal, soft cooked breads, cereals, starches | 4 servings (1 serving = 1–2 Tbsp) iron-fortified baby cereal, soft cooked breads, cereals, starches |
Fruits and vegetables | None | None | Begin to offer plain cooked, mashed, or strained baby foods (vegetables and fruits) Avoid combination meat and vegetable dinners 2–4 oz of 100% fruit juice in a cup only | 2–3 servings (1 serving = 1–2 Tbsp) soft, cut, and mashed vegetables and fruits 3–4 oz of 100% fruit juice in a cup only | 4 servings (1 serving = 2–3 Tbsp) of vegetables and fruits 3–4 oz of 100% fruit juice in a cup only |
Meats and other protein | None | None | Begin to offer plain well-cooked, soft, finely cut, or pureed meats | Begin to offer well-cooked, soft, finely cut, or pureed meats, cheese, and casseroles | 1–2 oz/d of soft, finely cut or chopped meat or other protein |
Food Groups and Number of Daily Servings | Age 12–23 months | Age 2–3 years | Age 4–6 years | Age 7–8 years |
|---|---|---|---|---|
Milk and Milk Products Low-fat or fat-free milk or milk products only for age ≥2 yr; for children <2 yr, use whole milk or milk products | 2 cups/d | 2 cups/d | 2–3 cups/d | 2–3 cups/d |
1 cup equivalent = 1 cup milk or yogurt, 1½ oz natural cheese, 2 oz processed cheese, 1/3 cup shredded cheese | ||||
Meats and Protein Foods | 1½ oz/d | 2–4 oz/d | 3-5 oz/d | 4-5 oz/d |
1 oz equivalent = 1 oz beef, poultry, or fish;, ¼ cup cooked beans; 1 egg; 1 Tbsp peanut butter*; ½ oz nuts* | ||||
Breads, Cereals, and Starches Whole-grain breads, infant or cooked cereals, rice, pasta, ready-to-eat cereals | 2 oz/d | 3–5 oz/d | 4–5 oz/d | 4–5 oz/d |
1 oz equivalent = 1 slice whole-grain bread; ½ cup cooked cereal, rice, or pasta; 1 cup dry cereal | ||||
Fruits One source of vitamin C daily (citrus, strawberries) and one source of vitamin A every other day (dark green and yellow fruits, melons) | 1 cup/d | 1–1½ cup/d | 1–1½ cup/d | 1½ cup/d |
1 cup equivalent = 1 cup fruit or 100% fruit juice (limit to 4–6 oz/d), ½ cup dried fruit | ||||
Vegetables One source of vitamin C daily (broccoli, tomatoes) and one source of vitamin A every other day (spinach, sweet potato, squash) | ¾ cup/d | 1–1½ cup/d | 1½-2 cups/d | 1½–2½ cups/d |
1 cup equivalent = 1 cup raw or cooked vegetables or vegetable juice, 2 cups raw leafy greens | ||||
Fats and Oils Margarine, butter, oils | Do not limit | 3 servings/d | 4–5 servings/d | 4–5 servings/d |
1 serving equivalent = 1 tsp oil, margarine, butter, or mayonnaise, 1 Tbsp salad dressing, sour cream, or light mayonnaise | ||||
Miscellaneous Desserts, sweets, soft drinks, candy, jams, jelly | Use sparingly | |||
Food Groups and # of Daily Servings | Age 9–13 years | Age 14–18 years |
|---|---|---|
Milk and Milk Products Low fat or fat free milk or milk products ONLY FOR AGE ≥ 2 yrs; <2 yrs, use WHOLE MILK OR MILK PRODUCTS | 3 cups/d | 3 cups/d |
1 cup equivalent = 1 cup milk or yogurt, 1½ oz natural cheese, 2 oz processed cheese, 1/3 cup shredded cheese | ||
Meats and Protein Foods | 5 oz/d | 5–6 oz/d |
1 oz equivalent = 1 oz beef, poultry, or fish; ¼ cup cooked beans; 1 egg; 1 Tbsp peanut butter; ½ oz nuts | ||
Breads/Cereals/Starches Whole-grain breads, infant or cooked cereals, rice, pasta, ready-to-eat cereals | 5–6 oz/d | 6–7 oz/d |
1 oz equivalent = 1 slice whole-grain bread; ½ cup cooked cereal, rice, or pasta; 1 cup dry cereal | ||
Fruits One source of vitamin C daily (citrus, strawberries) and one source of vitamin A every other day (dark green and yellow fruits, melons) | 1½ cup/d | 1½–2 cups/d |
1 cup equivalent = 1 cup fruit or 100% fruit juice (limit to 4–6 oz/d), ½ cup dried fruit | ||
Vegetables One source of vitamin C daily (broccoli, tomatoes) and 1 source of vitamin A every other day (spinach, sweet potato, squash) | 2–2½ cups/d | 2½–3 cups/d |
1 cup equivalent = 1 cup raw or cooked vegetables or vegetable juice, 2 cups raw leafy greens | ||
Fats and Oils Margarine, butter, oils | 5–6 servings/d | 6–7 servings/d |
1 serving equivalent = 1 tsp oil, margarine, butter, or mayonnaise; 1 Tbsp salad dressing, sour cream, or light mayonnaise | ||
Miscellaneous Desserts, sweets, soft drinks, candy, jams, jelly | Use sparingly | |
- The benefits of trophic feedings has been well established.
- Enteral nutrition helps maintain normal gut flora and immunity.
- A wide range of commercially available formulas have made it significantly easier to ensure adequate nutrition for children with virtually any impairment of intestinal function.
- May be the primary method of delivering nutrition or may be used as an adjunct with parenteral nutrition.
- The gut should always be used if at all clinically possible.
- Impaired ability to achieve adequate caloric or nutrient intake (because of any reason, including neurologic impairment, children with any disorder requiring increased caloric intake, disorders of GI motility).
- Impaired ability of the GI tract to normally digest and absorb nutrients may require specialized formulas.
- Failure to thrive associated with chronic disease is the most common indication for enteral nutrition support in the pediatric population.
Site | Delivery Route | Indications | Complications |
|---|---|---|---|
Stomach | Orogastric or nasogastric |
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Gastrostomy |
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Transpyloric |
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Type | Indications | Advantages | Disadvantages |
|---|---|---|---|
Bolus or intermittent feeds* |
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Continuous feeds |
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Problem | Prevention or Intervention |
|---|---|
Diarrhea or abdominal cramping |
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Vomiting or nausea |
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Hyperglycemia |
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Constipation |
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Gastric retention of formula |
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Clogged feeding tube |
|
- For infants >1800 g and >34 wk gestation: Human milk or term formula indicated for all infants >1800 g and 34 wk (at a goal volume of 180 mL/kg/d)
- For infants <1800 g and <34 wk gestation: Human milk with human milk fortifier or preterm formula
- Premature transitional formula with iron indicated for premature infants postdischarge with birth weight <1800 g
- Consider higher caloric formulas in infants with congenital heart disease (in whom fluid must often be restricted). Avoid caloric supplementation with simple fats or carbohydrates (eg, corn oil supplement)
Total parenteral nutrition (TPN) is complete IV nutrition that bypasses the GI tract. TPN is used to provide carbohydrates, protein, lipids, vitamins, and minerals.
TPN in Ten: A Step By Step Guide
1. Calculate the IV fluid (IVF) requirement for the patient based on weight.
Fluid requirements for neonates (in mL/kg/d)
Birthweight (g) | Days 1–2 | Day 3 | Day 5 and Beyond |
|---|---|---|---|
< 1000 | 100 mL/kg/d | 140 mL/kg/d | 150 mL/kg/d |
1001–1500 | 80–100 | 100–120 | 150 |
>1501 | 65–80 | 100 | 150 |
For children beyond the neonatal period
- The total goal fluids must be tailored to address individual clinical requirements (eg, children with increased fluid losses from any source; children in renal failure or other fluid overload states).
- For patients <10 kg, approximately 100 mL/kg/d is considered minimum maintenance.
- For patients >10 kg, use BSA × 1600 mL/m2/d to calculate maintenance fluid (See chapter 1 for BSA calculations).
2. Calculate the total energy required for the patient.
- Use the table below to calculate the daily energy requirement.
- For children with increased caloric requirement, you can multiply by a “stress factor;” see the table below.
Age | Total Energy DRI (kcal/kg/d)* |
|---|---|
Preterm† | 110–130 kcal/kg/d enterally 90–100 kcal/kg/d parenterally |
0–3 mo | 102 |
4–6 mo | 82 |
7–12 mo | 80 |
13–35 mo | 82 |
3 yr | 85 |
4 yr | 70 |
5–6 yr | 65 |
7–8 yr | 60 |
Boys 9–13 yr | 47 |
Boys 14–18 yr | 38 |
Boys >18 yr | 36 |
Girls 9–13 yr | 40 |
Girls 14–18 yr | 32 |
Girls >18 yr | 34 |
Alternatively, stress factors can be used in conjunction with an estimation of resting energy expenditure such as the Schofield method or WHO; they should not be used with the DRIs above.
Fever | 12% for each degree >37°C |
Cardiac failure | 1.15–1.25 |
Major surgery | 1.20–1.30 |
Sepsis | 1.40–1.50 |
Catch-up growth | 1.50–3.00 |
Burns | 1.50–2.00 |
- Calculation of basal metabolic rate or resting energy expenditure by the Schofield method:
Basal Metabolic Rate (kcal/d)* | ||
|---|---|---|
Male | Female | |
0–3 yr | (0.167 × wt) + (15.174 × ht) – 617.6 | (16.252 × wt) + (10.232 × ht) – 413.5 |
3–10 yr | (19.59 × wt) + (1.303 × ht) + 414.9 | (16.969 × wt) + (1.618 × ht) + 371.2 |
10–18 yr | (16.25 × wt) + (1.372 × ht) + 515.5 | (8.365 × wt) + (4.65 × ht) + 200 |
>18 yr | (15.057 × wt) (1.004 × ht) + 705.8 | (13.623 × wt) + (2.83 × ht) + 98.2 |
3. Calculate the required protein.
Age | Protein DRI (g/kg/d) |
|---|---|
Preterm infants* | Start at 1.5–2.0 and advance as tolerated to goal (3.5 parenterally or 3.5–4.0 enterally) |
0–3 mo | 1.52 |
4–6 mo | 1.52 |
7–12 mo | 1.20 |
13–35 mo | 1.05 |
3 yr | 1.05 |
4 yr | 0.95 |
5–6 yr | 0.95 |
7–8 yr | 0.95 |
Boys 9–13 yr | 0.95 |
Boys 14–18 yr | 0.85 |
Boys >18 yr | 0.80 |
Girls 9–13 yr | 0.95 |
Girls 14–18 yr | 0.85 |
Girls >18 yr | 0.80 |
4. Calculate lipids and the rate for lipids.
- The usual infusion formulation is 20% lipid emulsion.
- Fat should be approximately 30% of calories.
- Minimum of 5% of calories as fat to avoid essential fatty acid deficiency
- Maximum of 60% of calories as fat to avoid ketosis
- Energy from fat = Total energy (kcal/d) × 0.3
- Minimum of 5% of calories as fat to avoid essential fatty acid deficiency
- The rate of the lipid is calculated by:
- [Energy from fat (kcal/d)]/[2 kcal/mL] = mL/d of lipid (Divide by 24 to get the hourly rate.)
- Example: Patient who requires 2000 kcal/d:
- 2000 × 0.3 = 600 kcal is energy from fat
- [600 kcal/d]/[2 kcal/mL] = 300 mL/d of lipid
- (300 mL/d of lipid)/(24 h) = 12.5 mL/h of lipid
- 2000 × 0.3 = 600 kcal is energy from fat
- Prematurity or concern for lipid intolerance: Begin with 1 g/kg/d (5 mL/kg/d) and advance by 1 g/kg/d (5 mL/kg/d) daily until energy needs from lipids are met and lipid tolerance is achieved. Check serial measurement of serum triglyceride level as indicated. Goal: 15 mL/kg/d (=3 g/kg/d) for neonates and up to 20 mL/kg/d (4 g/kg/d) for older infants, children, and adolsecents.
5. Calculate the solution strength of carbohydrates and amino acids and their rate.
- 70% of calories should come from dextrose and protein.
- Energy from dextrose and amino acid (kcal/d) = Total energy (kcal/d) × 0.7
- Restrict dextrose to maximum 12.5% and amino acids to maximum of 3% if infusing through a peripheral IV line (This is our practice at Texas Children’s Hospital. Most institutions will use a osmolality limit for use in a peripheral line; the AAP recommends no more than 900 mOsm.)
- If concerns of glucose tolerance (ie, extreme low birth weight), initiate at a GIR of 4.5 to 6.0 mg/kg/min.
- Do not exceed 4 g protein/kg/d.
- The amino acids, dextrose, electrolytes, minerals, and vitamins are all in one solution.
- Prematurity: 5% dextrose if <25 to 26 wk gestation and <1000 g; 10% dextrose if >25 to 26 wk gestation and >1000 g.
- This is for the starter TPN only (for DOL 1 and 2); the standard solution is 12.5% dextrose, but it can be adjusted depending on the infant’s glucose tolerance.
- After the final concentration of carbohydrates and amino acids has been determined (in %), the table below can be used for verifying that the solution will provide adequate caloric supply over 24-h period.
