Document Control - North Devon District Hospital...2018/10/04 · LBW - Low birth weight

Enteral Nutrition for Neonates Guideline

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Document Control

Title

Enteral Nutrition for Neonates on SCBU Guideline

Author

Author’s job title Senior Neonatal Staff Nurse and Educator

Directorate Unplanned Care

Department Special Care Baby Unit

Version Date

Issued Status Comment / Changes / Approval

0.1 Jan 2014 Draft Initial version for consultation

0.2 May 2016

Draft Revised following comments from stakeholders

0.3 Aug 2016

Draft Feeding pathway revised.

2.0 Dec 2016

Draft Updated following comments from Dr Selter. Feeding pathway revised again.

2.1 Feb 2017

Draft Formatting changes and comments from Liz Mills.

2.1 Mar 2017

Final Approved by Paediatric Speciality Team.

2.2 May 2017

Revised Amendments to include ‘Day 0’ and tidy ‘contents’.

2.3 June 2018

Revised Amendments to ensure in line with BFI guidance.

2.4 Oct 2018

Revised Amendment – to express ideally within 2 hours not 6.

Main Contact Special Care Baby Unit North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB

Tel: Direct Dial – 01271 322610 Tel: Internal – Email:

Lead Director Director of Paediatrics

Document Class Guideline

Target Audience All Staff working with newborn infants

Distribution List SCU Staff Medical Staff

Distribution Method Trust’s internal website (Bob)

Superseded Documents None

Issue Date March 2017

Review Date March 2020

Review Cycle Three years

Consulted with the following stakeholders: (list all)

SCU nursing team Paediatric Consultants

Contact responsible for implementation and monitoring compliance: Staff Nurse



Midwifery team Paediatric pharmacist Dietetics team

Education/training will be provided by: Neonatal Staff Nurses and preceptors

Approval and Review Process

Paediatric Speciality Team

Ratified by Trust Board?

No

Local Archive Reference G:\SCBU Local Path \Policies and Guidelines Filename Feeding Guideline

Policy categories for Trust’s internal website (Bob) Neonates

Tags for Trust’s internal website (Bob) Enteral feeding, expressed breast milk, EBM, Formula, supplements, fortifier, centile, nutrition, thrive, growth, development, NEC, Neontates, new born feeding



CONTENTS

Document Control........................................................................................................................ 1

2. Purpose ................................................................................................................................ 4

3. Definitions............................................................................................................................ 4

4. Responsibilities .................................................................................................................... 5

Role of Neonatal multidisciplinary team ........................................................................................ 6

5. General principles of enteral nutrition................................................................................... 6

Growth ............................................................................................................................................ 7

Growth monitoring ......................................................................................................................... 7

6. Types of milk and uses .......................................................................................................... 8

Breast milk ...................................................................................................................................... 8

Donor breast milk ........................................................................................................................... 9

Breast milk fortification .................................................................................................................. 9

Formula ......................................................................................................................................... 10

7. Risk factors requiring individualized feeding plans following discussion with the Consultant Paediatrician .............................................................................................................................. 11

Assessing feed tolerance .............................................................................................................. 11

8. SCU Feeding Pathway ......................................................................................................... 11

9. Discharge ........................................................................................................................... 14

10. Monitoring Compliance with and the Effectiveness of the Guideline .................................... 14

Standards/ Key Performance Indicators ....................................................................................... 14

Process for Implementation and Monitoring Compliance and Effectiveness .............................. 14

11. References ......................................................................................................................... 15

12. Associated Documentation ................................................................................................. 16



1. Purpose

1.1. The following general principles can be applied in order to improve the growth and development of infants on the Special Care Unit (SCU), by

1.2. This guideline applies to all babies on the Neonatal Unit. Non-compliance with this guideline may be for valid clinical reasons only. The reason for non-compliance must be documented clearly in the patient’s notes.

1.3. The policy applies to all staff involved in care of infants on the neonatal unit, postnatal ward (if applicable) and paediatric ward (if applicable).

1.4. Implementation of this policy will ensure that:

The use of breast milk is optimised Increases in the number of babies receiving breastmilk Increases in breastfeeding initiation rates Increases in the number of babies who are discharged home breastfeeding or

breastmilk feeding Recommended nutrient intake is achieved Postnatal growth and body composition approximating foetal growth is

achieved The risk of nutritional deficiency states such as late anaemia of prematurity or

metabolic bone disease is reduced The risk of feeding related morbidities including NEC is reduced Long term neurodevelopmental outcomes are improved Increases in the proportion of mothers who chose to formula feed reporting

that they have received proactive support to formula feed as safely as possible in line with Department of Health guidance

Improvements in parents’ experiences of care

2. Definitions

2.1. ABCD – Apnoea, Bradycardia, Colour change, Desaturations

2.2. Birth weight - is the first weight of the newborn obtained after birth (ideally within one hour of delivery).

2.3. LBW - Low birth weight <2500 g.

2.4. VLBW - Very low birth weight <1500 g.

2.5. ELBW - Extremely low birth weight <1000 g.

2.6. Working weight - The baby’s actual weight is used when calculating nutrient requirements, unless the actual weight is lower than the birth weight in which case birth weight should be used.



2.7. BMF – Breast milk fortifier

2.8. Bolus feeds – Milk given at intermittent intervals

2.9. Continuous feeding – Milk given continuously via nasogastric tube driven by oral syringe pump

2.10. Corrected age – Chronological age reduced by the number of weeks born before 40 week gestation

2.11. EBM – Expressed Breast milk

2.12. IUGR - Intrauterine Growth Restriction

2.13. NEC – Necrotising enterocolitis

2.14. NG – Nasogastric

2.15. Preterm - < 37 completed week’s gestation

2.16. SCBU - Special Care Baby Unit

2.17. SIFT – Speed of increasing milk feeds study

2.18. Term – 37 or more completed weeks gestation

3. Responsibilities

3.1. The Paediatric Speciality Team will be responsible for agreeing and ratifying this guideline.

3.2. Northern Devon Healthcare Trust is committed to:

Providing the highest standard of care to support parents with a baby on the neonatal unit to feed their baby and build strong and loving parent-infant relationships. This is in recognition of the profound importance of early relationships to future health and wellbeing, and the significant contribution that breastfeeding makes to good physical and emotional health outcomes for children and mothers.

Ensuring that all care is mother and family centred, non-judgmental and that parents’ decisions are supported and respected.

Working together across disciplines and organisations to improve parents’ experiences of care.

3.3. As part of this commitment the service will ensure that:



All new staff are familiarised with the Newborn Infant Feeding policy on commencement of employment.

All staff receive training to enable them to implement the policy as appropriate to their role. New staff receive this training within six months of commencement of employment.

The International Code of Marketing of Breastmilk Substitutes is implemented throughout the Trust.

All documentation fully supports the implementation of these standards.

Parents’ experiences of care will be listened to through: regular audit using the Baby Friendly Initiative audit tool, parents’ experience surveys e.g. Care Quality Commission, Bliss Baby Charter audit tool etc., Trust feedback forms.

Role of Neonatal multidisciplinary team

3.4. The Neonatal multidisciplinary team will be responsible for ensuring that this guideline is followed.

For episodes where non-compliance with this guideline is agreed, this should be documented in the patient’s case notes.

Episodes of deviation from the guideline need to be documented in the notes.

4. General principles of enteral nutrition

Feeding is a crucial part of the development of the newborn.

All babies, once born should start enteral feeds unless there is a clear and documented reason not to.

The best milk for the baby is mother’s own breast milk, we therefore promote the use of mother’s own breast milk when feeding her baby and aim to enable the progression to full breastfeeding on discharge.

Babies who are <35 weeks or too immature to suckle are usually fed enterally via oro-gastric or naso-gastric tube, or may be offered a cup feed if deemed appropriate (see NDHT Cupfeeding guidance).

Evidence suggests that bolus feeding may be physiologically beneficial as it promotes a surge of gut hormones, but continuous feeding may be implemented for infants who are not tolerating bolus feeds. Continuous feeds may use less energy and improve weight gain. (If using continuous feeds the syringe should be tilted so as the fat should be given first and the tubing and milk changed every four hours.)



Normally an infant should weigh at least 1.5 kgs before going from 2 to 3 hourly feeds, and 2.5 kgs before moving to 4 hourly feeds (Contrera, 2008), but decisions may be made and documented on an individual basis according to condition.

Growth

4.1. Intrauterine growth rate (~15g/kg/day) is the most commonly used and accepted standard for preterm growth, but it is difficult to achieve in practice (Tsang et al., 2006).

Energy and protein are the two major nutrients that affect growth, and so a key goal of nutritional management is to facilitate adequate delivery of both.

Accelerated growth in preterm infants should be avoided by not giving energy intakes over the infant’s requirements (Tsang et al., 2006). Therefore, only increase volumes beyond 150 mls/kg/day if indicated by weight gain. Also ensure the infant is receiving the correct milk for gestation when giving formula.

Preterm infants have higher nutrient requirements than term infants. Most preterm infants weighing less than 1500g will require Parenteral Nutrition to meet their requirements while enteral feeds are introduced and increased to their target volume (Tsang et al., 2006).

Growth monitoring

4.2. UK WHO Growth Centile Charts are used to monitor weight, all preterm infants should have ‘corrected’ gestational age

Infants should be weighed twice a week on Mondays and Thursdays, and weights should be checked by a second member or staff.

Document weight and head circumference on:

Admission and twice weekly on the UK-WHO centile charts Fluid chart (to calculate fluid requirements) Nursing care plan Handover sheet Badger data collection Baby red health care record

Indicators of inadequate growth are:

Weight loss (other than when diuresis is expected, or within the first week of life)

Drop in centiles on WHO growth chart Weight gain at less than an average target of 15g/kg/day

Serum sodium, potassium, phosphorus, calcium, urea and creatinine, CRP, Haemoglobin in infants less than 34 weeks gestation should be monitored weekly, or 2 weekly in stable babies, for nutritional assessment.



Infants between 35-36 weeks gestation may have bloods monitored on an individual basis as required.

5. Types of milk and uses

Breast milk

5.1. Breast milk is the feed of choice for all babies, especially preterm infants. All pregnant women and new mothers are given information to make an informed choice about the way in which they will feed their baby and are supported to express and feed their baby with their breast milk even if they have decided not to breastfeed.

5.2. The benefits of human milk for preterm infants are well documented and have been summarised below:

immune protection – resulting in lower rates of sepsis and NEC superior nutrient bioavailability compared to formula (fatty acids are better

absorbed from human milk due to both the structure of the milk fat globule and the presence of bile salt stimulated lipase)

improved feed tolerance neurodevelopmental advantages compared to formula fed infants better long-term health outcomes

5.3. Enabling babies to receive breastmilk and to breastfeed:

This service recognises the importance of breastmilk for babies’ survival and health.

Therefore, this service will ensure that: A mother’s own breastmilk is always the first choice of feed for her baby Mothers have a discussion regarding the importance of their breastmilk for

their preterm or ill baby as soon as is appropriate A suitable environment conducive to effective expression is created Mothers have access to effective breast pumps and equipment Mothers are enabled to express breastmilk for their baby, including support to:

o Express as early as possible after birth (ideally within two hours) o Learn how to express effectively, including by hand and by pump o Learn how to use pump equipment and store milk safely [Breastmilk SOP] o Express frequently (at least eight times in 24 hours, including once at

night) especially in the first two to three weeks following delivery, in order to optimise long-term milk supply

o Overcome expressing difficulties where necessary, for example if less than 750ml in 24 hours is expressed by day 10

o Stay close to their baby (when possible) when expressing milk o Use their milk for mouth care when their baby is not tolerating oral feeds,

and later to tempt their baby to feed



A formal review of expressing is undertaken a minimum of four times in the first two weeks to support optimum expressing and milk supply (this expressing assessment form is in all admission careplans to SCBU- it should be carried out once within the first 24hours, D1, D3 and D5).

Mothers receive care that supports the transition to breastfeeding, including support to:

o Recognise and respond to feeding cues o Use skin-to-skin contact to encourage instinctive feeding behaviour

[Developmental Care Guidelines] o Position and attach their baby for breastfeeding o Recognise effective feeding o Overcome challenges when needed

Mothers are provided with details of voluntary support for breastfeeding which they can choose to access at any time during their baby’s stay.

Mothers are supported through the transition to discharge home from hospital, including having the opportunity to stay overnight/for extended periods to support the development of mothers’ confidence and modified responsive feeding.3

Mothers are provided with information about all available sources of support before they are transferred home.

Donor breast milk

5.4. Donor Breast milk is available for ‘high-risk’ infants that fit the criteria, for example those who are very low-birth weight or premature (see NDHT Donor Breast Milk guidelines).

Also see South West Neonatal Network Donor Breast Milk guideline

Breast milk fortification

5.5. Breast milk alone might not meet the needs of babies born < 1500g, so in these cases fortifier is recommended. Breast milk fortifiers have been shown to lead to short term improvements in weight, length, and head circumference (BLISS, 2010).

Fortifier may be offered to:

All babies born at gestation under 34 weeks and birth weight of less than 1.5kg

Babies born less than 34 weeks with 1.5 – 2kg birth weight with wavering growth

Other considerations for use of fortifier:

They should be tolerating feeds of at least 150ml/kg (preferably 180ml/kg if fortification is being considered necessary) for at least 24 hours.



Babies must be receiving at least half of their total feeds (mls/kg/day) as breast milk to commence on fortifier, and it should be discontinued if breast milk becomes less than half of their total volume.

Babies with Urea of <4mmol/l and falling may need fortifier. In the majority of babies serum urea drops over the first 2 weeks and it has been shown that once it drops below 1.6 mmol/l babies are receiving less than 3g/kg human milk protein. To avoid protein deficiency it is therefore advised that once urea is <4mmol/l and falling additional protein is needed.

Babies with birth weight over 2 kg are unlikely to need breast milk fortifier.

The is some evidence that use of fortifier may increase the osmolarity of breastmilk , particularly when added to cold breastmilk. Therefore, fortifier should be added to warmed breastmilk where possible.

Fortifier should not be added when breast milk is mixed with formula at any given feed (BLISS, 2010).

Formula

5.6. Where EBM is not available for preterm infants, preterm formula should be used (if donor EBM criteria are not fulfilled).

Nutriprem 1 and Nutriprem 2 are designed to meet the nutritional requirements of the preterm infants between 150 – 180 ml/kg.

On SCBU infants born before 37 weeks will only start on Nutriprem 1 or 2 where EBM / DBM is unavailable. Use Nutriprem 1 if < 2kgs, and Nutriprem 2 if ≥ 2kgs. Individual circumstances should be considered, for example, a 35 week gestation infant who is born over 2kgs may not be considered to need Nutriprem 2 and may go straight on to term formula.

Nutriprem 2 is available on prescription for preterm infants from 35 weeks up to 6 months corrected age.

Growth restricted term infants >37 should be offered ordinary term formula (Morley R et al., 2004).

To aid tolerance when changing over milks, do so slowly over time and not suddenly from one formula to another.

The service will ensure that parents who formula feed:

Receive information about how to clean/sterilise equipment and make up a bottle of formula milk

Are able to feed this to their baby using a safe and responsive technique.



6. Risk factors requiring individualized feeding plans following discussion with the Consultant Paediatrician

Assessing feed tolerance

6.1. Infants should be assessed for feed tolerance at the beginning and end of feeds and any concerns are documented and referred to the medical team for review.

Signs of feeding intolerance may include:

Vomiting Gastric aspirate volume > 2 hourly amount Abdominal distension/ increasing abdominal girth Abdominal discolouration, visible loops Unwell baby Rectal bleeding / blood in stools Bilious / bloody aspirates Visible bowel loops/ abdominal distension Blood / watery stools Clinically unstable or acute deterioration Metabolic acidosis / rising lactate, thrombocytopenia Tender firm, shiny abdomen If there are signs of intolerance, feeding should be stopped and infant kept Nil

By Mouth until review by Doctor and individualized feeding plan is made.

6.2. Preterm infants are at increased risk of developing necrotizing enterocolitis (NEC). Signs of NEC may be similar to those of feeding intolerance (above)

7. SCU Feeding Pathway

7.1. Infants will assessed as High, Moderate or Low risk for feeding, using the criteria below. If babies have risk factors that are associated with feeding problems their feeding regimen is adjusted in response.



HIGH

Preterm < 28 weeks at birth

Extremely low birth weight < 1000g

Unstable / hypotensive / on inotropes

Severe IUGR (wt < 2nd centile) < 35 weeks

Absent/ Reversed End Diastolic Flow (AREDF) < 35 weeks

Re-establishment of feeds following NEC or surgical issue

Infants with severe congenital GI malformation e.g. gastroschisis

Perinatal hypoxia/ischaemia with significant organ dysfunction

Feeding protocol for HIGH risk infants Infants in this category will normally require transfer out to a Level 2 or 3 Neonatal Unit. They should have an appropriate feeding plan on return to a Level 1 unit or discuss with consultant.

MODERATE

Preterm 28 – 31 +6 weeks, otherwise well

Very Low Birth Weight 1000 – 1500g

Moderate IUGR (wt< 9th centile,<35/40)

Baby on inotropes, ibuprofen/ indomethacin or dexamethasone

Illness or congenital anomaly which may compromise feeding

Symptomatic Polycythaemia

Baby receiving respiratory support e.g. NCPAP, Optiflow

Feeding protocol for MODERATE risk infants Step 1 will be followed for the first 24 hours of feeding. Feeds can commence as soon as possible if baby otherwise stable. Please use EBM if available. If no EBM (or not sufficient quantity) try to give colostrum first, before commencing formula. Colostrum should be given even if the baby is NBM

STEP 1

Weight (Kg) Start at (HOURLY)

Increase 1 hourly feed volume by:

Start at (2 HOURLY)

Increase 2 hourly feed volume by:

1.0 – 1.200 kg 1 ml 0.5 mls 6 hourly 2 mls 1 ml 6 hourly

1.201 – 1.600 kg 1.5ml 1 ml every 12 hours

3 ml 2 ml every 12 hours

1.601 – 2.000 kg 2 ml 1 ml every 8 hours 4 ml 2 ml every 8 hours

2.001 – 2.400 kg 2.5 ml 1 ml every 6 hours 5 ml 2ml every 6 hours

2.401 kg and above

3 ml 1.5 ml every 8 hours

6 ml 3 ml every 8 hours

Step 2: After the first 24 hours of feeding if tolerating well, increase volume by 30mls/kg each day (as tolerated). If not tolerated well – to discuss with paediatrician for individualized plan.

Preference should be given to 2 hourly feeding as soon as tolerated.



If giving colostrum ‘ad hoc’, these trophic feeds should be additional to any intravenous maintenance fluids. Once feeds reach Step 1 (ie. 1ml hourly or 2ml 2hourly) this amount should be reduced from the intravenous fluids given. The increase in volume by 30mls/kg each day should be an increase in milk volume where possible, not intravenous fluids.

LOW

All other babies not fulfilling above categories

Feeding protocol for LOW risk infants

Step 1

Commence milk feeds at 60 ml/kg/day supplemented by IV fluids if necessary. Feed 2 – 3 hourly.

Step 2

Increase feeds by 15 mls/kg/day as tolerated until at volume of 150 mls/kg/day, or 180mls/kg/day if preterm and deemed necessary.

Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9

Term 60 75 90 105 120

135 150 150 150 150

Preterm 60 75 90 105 120 135 150 160

(if needed)

170

(if needed)

180

(if needed)

If an infant is IUGR or hypoglycaemic, consider starting on 75mls/kg/day on Day 0 and then increasing at 15mls/kg/day.

If on IV fluids for more than 24 hours please see Paediatric Infusions policy.



8. Discharge

Infants born at less than 35 weeks and who are not breast fed may require supplementary feeding at discharge. They should be transferred onto Nutriprem 2 once they are over 2 kg and weight gain is satisfactory.

Nutriprem 2 is available on prescription for preterm infants from 35 weeks to 6 months corrected age.

Growth restricted term infants should be offered normal term formulas in the absence of mother’s breast milk.

9. Monitoring Compliance with and the Effectiveness of the Guideline

Standards/ Key Performance Indicators

9.1. Key performance indicators Special Care Unit use:

BAPM recommendations Neonatal Network recommendations Nice Neonatal Quality Standards NHS Toolkit for High Quality Neonatal Services (2009) National Neonatal Audit Programme NHS Standard Contract for Neonatal Critical Care Baby Friendly Neonatal standards (2012)

Process for Implementation and Monitoring Compliance and Effectiveness

9.2. Staff are informed of new documentation. There is an expectation that staff are responsible to keep updated on any improvements to practice and deliver care accordingly. Data is collected by use of Badger data base and via Vermont Oxford Network and can be used to generate output for clinical and operational benchmarking.

Monitoring of implementation, effectiveness and compliance with these guidelines will be the responsibility of the Staff in the Special Care Unit. Where deviation is found, it must have been documented in the patient’s medical notes, reviewed by the medical team and reported by Datix.



Any incidents will be investigated and actions plans made. Learning will be discussed at ward and Paediatric Team meetings.. Further discussion and reviews may occur at Directorate meetings, Maternity Patient Safety and Governance meetings. Learning and action plans are cascaded at these meetings and improvements implemented. Key findings and learning points will be disseminated to relevant staff.

Neonatal Services requires that compliance with this policy is audited. Audit results will be reported to the [head of service and head of division] and an action plan will be agreed by Infant Nutrition Steering Group to address any areas of non-compliance that have been identified.

Monitoring outcomes

Outcomes will be monitored by:

monitoring breastmilk feeding rates

monitoring breastfeeding rates

Outcomes will be reported to: Head of service / head of division and Infant Nutrition Steering Group

10. References

Agostoni C, Buonocore G, Carnielli VP, De Curtis M, Darmaun D, Desci T,

Domellöf M, Embleton ND, Fusch C, Genzel-Boroviczeny O, Goulet O,

KalhanSC, Kolacek S, koletzko B, Lapillonne A, Mihatsch W, Moreno L, Neu J,

Poindexter B, Puntis J, Putet G, Rigo J, Riskin A, Salle B, Sauer P, Shamir R,

Szajewska H, Thureen P, Turck D, van Goudoever JB, Ziegler EE, (2010) Enteral

Nutrition supply for preterm infants: Commentary from the European society

for Paediatric Gastroenterology, Hepatology and Nutrition committee.

(ESPGHAN). Journal of Paediatric Gastroenterology and Nutrition 50 1-9

Cobb BA, Et al (2004) Gastric residuals and their relationship to necrotizing

enterocolitis in very low birth weight infants. Pediatrics, Jan;113 (1pt1) :50-3

Contrera, P. (2008) 929 feeding guidelines clinical practice guideline for the

management of feeding in monash Newborn.

De Curtis M, Pieltain C, Rigo J, (????) Effect of fortification on the osmolality of

human milk. Journal of the Medical Association of Thailand. 89/9: 1400-3

Dsilna A, Et al (2005) Continuous feeding promotes gastrointestinal tolerance

and growth in very low birth weight infants. Pediatrics 147 (1) :43-9

GOSH (2014).[on-line] Enteral nutrition for the preterm infant.

http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/enteral-

nutrition-for-the-preterm-infant/ http://www.gosh.nhs.uk/health-

professionals/clinical-guidelines/enteral-nutrition-for-the-preterm-infant/

(accessed 25/8/14)



Enteral feeding on the Neonatal Unit, Southern West Midlands Newborn

Network, Jan 2012

Guidelines for making up special feeds for infants and children in hospital.

(2007) Food Standards Agency

Jones E, King C, (2005) Feeding and Nutrition in the preterm infant. Edinburgh:

Elsevier Churchill Livingstone.

Kamitsuka MD, Horton MK, Williams MA (2000) The incidence of necrotizing

enterocolitis after introducing standardized feeding schedules for infants

between 1250g and 2500g and less than 35 weeks of gestation. Paediatrics Vol

105 No.2 Feb 379-384

King C, Bell S, (2010) BLISS Briefing document on breast Milk Fortifier

Morley R, Fewtrell MS, Abbott R, Stephenson T, MacFadyen U, Lucas A, (2004)

Neurodevelopment in children born small for gestational age: A randomized

Trial of Nutrient Enriched versus standard formula and compassion with a

reference breast fed group. Pediatrics; 113 (3) :515-21

Nutrition care pathway (2013) East of England perinatal network and the NEC

care bundle expert working group

Owen, B and Cherian, S (2008) Cardiff and the Vale neonatal Services, Enteral

feeding guidelines for the infant

Scientific Advisory Committee on Nutrition. Dietary Reference values for

energy SCAN, London, 2011

Tsang RC, Lucas A, Uauy R, Zlotkin S. (2006) Nutritional needs of the preterm

infant: scientific basis and practical guidelines. Baltimore: Williams & Wilkins.

UNICEF & WHO 2004 Low Birthweight: Country, Regional and Global

Estimates. Copy available

athttp://www.unicef.org/publications/index_24840.html.

UNICEF (2012) Baby Friendly Initiative Neonatal standards

11. Associated Documentation

NDHT Newborn Infant Feeding Guideline

NDHT Donor breast milk guideline

NDHT Nasogastric Tube and Medicine Administration for Paediatric SOP

NDHT Paediatric Infusions policy.

NDHT Expressed Breastmilk Handling SOP

Developmental Care Guidelines