Amount and frequency:
• Generally there should be guidance from the institution you are working in as to the rate for giving fluids in a premature infant. Pre-set guidelines are useful to avoid mistakes due to the fragility of small neonates and the tiny amounts involved. The fluid requirements for a premie are higher than for term neonates. There are many different protocols to follow, and so this would be a suggestion:
| Milk intake (mls/ kg/ d) | Alternative protocol (mls/kg/d) |
Day 1 | 80 | 60 |
Day 2 | 100 | 90 |
Day 3 | 120 | 120 |
Day 4 | 140 | 150 |
Day 5 | 160 | 150 |
e.g. a 1.1kg neonate should have 80ml/kg/d on day 1, which would be – (1.1kg x 80ml) divided by 12 (for 12 feeds per day if 2 hourly feeds, or divided by 8 if 3 hourly feeds) = 7 ml of milk every 2 hours
• You should monitor blood sugars (pre-feed) to ensure the neonate is getting what they need
• Also temperature should be monitored as these premies get very cold, which will cause their blood sugars to drop (which is why Kangaroo Mother is so vital!)
• Normally I would try to feed the small babies as often as possible. Ideally every 1-2 hours. 1 hour is not usually practical, so I aim for every 2 hours, which is much more practical. It can be disastrous if they miss feeds as will drop their blood sugars very quickly since they have so few fat reserves.
• There are very useful guidelines to follow in the WHO resource: http://apps.who.int/iris/bitstream/10665/43206/1/9241546700.pdf (see page 51 onwards).
• There is also some background research here: http://apps.who.int/iris/bitstream/10665/43602/1/9789241595094_eng.pdf
Recipe:
• In an ideal situation, breast milk / wet-nurse would be best; however this is not always possible.
• Next best would be premature formula milk (better outcomes than term formula).
• There is some information on En-Net regarding use of SDMT: http://www.ennonline.net/fex/37/diluted which is worth a look at.
• I have used SDMT previously, when we did not have formula available, and where there were no other alternatives. There will be a risk of NEC (necrotising enterocolitis) so feeds needs to be carefully introduced and the baby watched for any signs of NEC (distended tender abdomen, blood in the stool, vomiting, temperature instability, etc.).
• SDMT formula: there are couple of formulas for preparing SDTM, this one is taken from MSF guidelines that are available online http://files.ennonline.net/attachments/799/protocol-for-newborns-and-infants-2008-final-english.pdf (see page 14)
• There are also some useful guidelines on increasing milk production and feeding infants in emergencies here: http://www.unhcr.org/45f6cc4e2.pdf
Maternal Feeds:
• Previously when I’ve worked in programmes where the mothers themselves are very malnourished, I’ve supplemented their feeds with the standard SP 100, and encouraged them to eat a varied diet (as much as possible), as well as giving them multivitamins / checking they’re not anaemic (if at all possible)
• The most important thing is adequate fluid intake, especially in hot climates. (Be aware of the risks of hyponatraemia – low sodium – in a hot climate, which I have seen, so important to encourage them to not drink litres and litres of pure water due to the lack of electrolytes but have a varied diet and varied fluids)
• Some centres recommend supplementation with medications such as domperidone and metoclopramide to be given to the mother, to increase breast milk production. In some countries this is routinely prescribed to the mothers, in other countries not so. The evidence base is mixed.
• The importance of Kangaroo Mother as has been pointed out already cannot be underplayed in terms of increasing breastmilk production, helping the baby to learn to breastfeed, once they are stable and not sick.
If you would like some further background reading on premature / LBW babies, this is one of my favourites: http://apps.who.int/iris/bitstream/10665/44864/1/9789241503433_eng.pdf?ua=1. It outlines many useful strategies to get further resources and how to focus on the best outcomes for these small babies.