NICU Case Study

ERIN KIESER
Dietitian’s Role in
the NICU
Provide evidenced-based, individualized nutrition care

Develop, evaluate, & modify nutrition care plans & document

interventions

Participate in teaching rounds and patient care conferences

Make referrals to the community

Instruct patient families

Follow up care after hospital discharge

Follow feeding difficulties after discharge from the NICU

Provide education to other health professionals

Participate in research projects

NICU Team
Neonatologist

Respiratory Therapist

Therapies (PT, OT, ST)

Dietitian

Lactation Consultant

Social Workers
 Terms and Definitions
Low Birth Weight (LBW) < 2500 grams
Very Low Birth Weight (VLBW) < 1500 grams
Extremely Low Birth Weight (ELBW) < 1000 grams

Preterm (premature) Gestational age < 37 weeks

Term Gestational age 37-42 weeks
Postterm Gestational age > 42 weeks

Small for gestational age (SGA) < 10th percentile birth weight for gestational age
Appropriate for gestational age (AGA) 10th-90th percentile birth weight for gestational
age
Large for gestational age (LGA) > 90th percentile birth weight for gestational age
 Assessment Date: 2/19/21
Gender: Female

Case Study Age: DOL #7

DOB: 2/12/21 8:59AM (34w6d GA)
Assessment: Well preterm baby at risk for sepsis plan to admit to
SCN.
Nutrition Assessment
DOL #7
Anthropometric Assessment
Current Weight: 2.344 kg (30.38%)
Birth Weight: 2.48 kg (64.05%)
Current Length: 76.07%
Current Head Circumference: 68.01%
Weight Trend: was trending up but currently down 6 g from
yesterday. +4 gm 3 day average weight gain
 Weight
Weight
2.5
2.48 2.48

2.45

2.4
Weight in Kilograms

2.36
2.35 2.34
2.35
2.33
2.32

2.3

2.25

2.2
1 2 3 4 5 6 7

DOL
Anthropometric Expected initial postnatal weight loss between 8 and 15%
Interpretation
Fenton chart Wt loss for the first 4-6 days of life

Birth wt usually regained by 2-3 wks

Expected length gain ~0.9 cm/week

Expected head circumference gain ~0.9 cm/week

Wt Assessment: LBW, AGA

Biochemical Assessment

Lab Value Reference Range

Hgb 17.2 g/dL 13.4 – 20.0 g/dL
Hematocrit 49.3% 39.6 – 57.2%
Glucose 41 mg/dL 40-120 mg/dL
Calcium (H) 5.3 mg/dL 4.8 – 5.2 mg/dL
Potassium 5.1 mmol/L 3.5 – 5.3 mmol/L
Sodium 137 mmol/L 135 – 148 mmol/L
Clinical Assessment
Gender: Female
Age: 35w6d PMA
DOB: 2/12/21
Age at Birth: 34w6d
Apgar Scores: 8 (1 minute), 9 (5 minutes)
Assessment: Delivered via C-section d/t arm presentation after PPROM and trial of labor.
Mother 19 years old G1P0. Hx of depression and anxiety. +THC on drug screen. S/p magnesium
for pre-eclampsia. Azithromycin, penicillin, and cefazolin for unknown GBS status. During labor,
pt’s arm felt during cervical check resulting in C-Section. Right arm appeared edematous after
delivery but moved spontaneously. Neonatology consulted d/t hand presentation.
 Vital Signs at Birth
Vital Sign Value Reference Range

Blood Pressure 67 / 45 mmHg 60-90 / 20-60 mmHg

Pulse 132 bpm 120 – 160 bpm

Temperature (!) 36.7*C 36 – 36.5*C

Respiratory Rate 45 breaths/minute 40 – 60 breaths/minute

Spo2 100% > 89%

Late Preterm Babies
10.02% birth rate in the United States in 2018
Higher readmission rates
Increased financial burden

Mean Cost of initial hospitalization:

34 weeks gestation: $18,617
36 weeks gestation: $15,864
>37 weeks gestation: $12,305
Late Preterm Outcomes
LONG TERM NEURODEVELOPMENT
SHORT TERM CLINICAL OUTCOMES
OUTCOMES
Respiratory Cognitive delays
Hyperbilirubinemia Speech delay
Feeding difficulty Cerebral palsy
Hypoglycemia ADHD
Temperature instability and cold stress Autism
Immunological response and sepsis T2DM, asthma, mental health disorders
Apgar Scores
A: activity
P: pulse
G: grimace
A: appearance
R: respiration

Score of 7-10: Ideal

Score of 4-6: Abnormal
Score of 0-3: Low
Hx Mother
Marital status: single (living with partner)
Financial resource strain: somewhat hard
Food insecurity: no worry or inability
Smoking: never smoker
Alcohol/drug abuse: not currently
Estimated delivery date: 3/20/21
Prenatal labs: blood type (A+), RPR (nonreactive), Rubella
(immune), HIV (negative), Hepatits B sAg (netagive), GBS
unknown
Notes: no antenatal steroid doses. Taking prenatal vitamin
before admit
 Marijuana use During Pregnancy
THC crosses the placenta and is present in breast milk Adverse Effects:
Limitations to existing literature
Fetal growth
Two reviews and consensus document with conflicting data:
Preterm birth
Connor- association only between heavy marijuana use and low birth
weight and preterm birth. No association with NICU admission Stillbirth
Gunn- association between prenatal marijuana use and anemia, low
birth weight, and higher odds of NICU admission. No association with Congenital anomalies
preterm birth, congenital birth defects
Neonatal morbidity
National Academy of Sciences- insufficient evidence to support or
refute association between marijuana use and later childhood NICU admission
outcomes of cognition and academic achievement. Relationship
between abnormal fetal growth and maternal marijuana use Long term neurological events
Marijuana use &
Breastfeeding
Reyes-Perez & associates (2005): 0.8% of mother’s dose per
kilogram expressed in breastmilk
Baker & associates (2018): 2.5% of maternal dose
Bioavailability in neonates is unknown
Time dependent concentration of THC in breastmilk is largely
unknown
ACOG and the American Academy of Pediatrics recommend
that women refrain from using cannabis while lactating
Dietary Intake Assessment
NGT placed 2/12/21 d/t lack of feeding cues
Primary Feeding: EBM
Secondary Feeding: Enfamil Enfacare 22 (E22)
Feeding Rate: 50 ml q3h
Nippling: 27%
No emesis x 24 hours
SLP following
Assessment: Initially had some emesis with NG feeds, switched to feeds with pump over 45
minutes. Cueing occasionally and shuts down quickly when oral feeds attempted. Now tolerating
oral/NG feeding. Stool and urine output noted in EMR.
Lactation Consultant
Offer support and breastfeeding advice
2/13/21: mom reports that baby is getting bottles at this
point, but she would like to feed baby at breast. Mother’s BF
goal to provide BM for 1 year in whatever way the baby will
take, mom would like to try at the breast
2/16/21: mother decides to switch to formula
2/17/21: per nurse mother pumped and brought in 2 bottles
of breastmilk
SLP: Oral Feeding Assessment
Consulted d/t slow feeding associated with preterm birth
2/13/21: Baby showing limited feeding cues per RN. Baby having emesis therefore gavage fed
from pump over 45 minutes
2/15/21: oral reflexes of rooting, suck/swallow, phasic bite, lateral tongue immediate, 2-4 sucks
in a row. Infant with decreased coordination of SSB resulting in decreased tolerance of slow flow
nipple
2/16/21: baby with no feeding cues and small desat. Recommend feeds via NG unless actively
sucking on pacifier/rooting
2/17/21: infant po feeding about every other feed
 Intake Chart 2/18/21
350

300

250

200

150

100

50

0
NG Intake Oral Intake

EBM E22
Diet Hx 2/18/21: EBM/E22
EBM—EXPRESSED BREAST MILK E22—ENFAMIL ENFACARE

Total Intake from I/O Chart: 246 ml Total Intake from I/O Chart: 114 ml
20 kcals/oz (0.67 kcals/ml) 22 kcals/oz (0.73 kcals/ml)
246 ml x 0.67 kcals/ml = 164.82 kcals 114 ml x 0.73 kcals/ml = 83.22 kcals

164.82 kcals (EBM) + 83.22 kcals (E22) = 248.04 kcals/day

248.04 kcals/day / 2.48 kg = 100 kcals/kg/day
 Nutrient Per kg per Nutrient Per kg per
day day
Fluid (ml) 135-200 Calcium 120-140
Recommended (mg)

Nutrient Intakes Energy (kcal) 110-135 Phosphate

(mg)
60-90

for Preterm Protein (g) 3.5-4.5 Vitamin D 800-1000

Infants from (IU)
ESPGHAN Fat (g) 4.8-6.6 Vitamin A 1300-3300
(IU)
Carbohydrate 11.6-13.2 Iron (mg) 2-3
(g)
Preterm Feeding Environment
Impaired developmental and metabolic outcomes
Smaller/less mature brains compared to term infants
Immature sucking, swallowing, breathing coordination and
gut motility are immature
Insufficient hepatic glycogen stores
Excessive weight loss
Delayed supply of mother’s breastmilk
 Infant Formula Indication
Mother’s Milk All babies, except HIV in the mother, active use of alcohol, or non
compatible medications
Medolac Donor Milk All babies whose parent’s choice of feeding is exclusive breastmilk—used
until mother’s supply is established

Feeding Choice Enfacare 22cal Formula Late preterm babies over 1800g at birth.—cow’s milk based with added
protein, P, and Ca

Hierarchy for Enfamil Premature 24cal

Formula
Late preterm and preterm babies below 1800g at birth—cow’s milk based
with added protein, P, and Ca

Preterm Infants Enfamil Newborn

Premium 20cal Formula
Term babies—cow’s milk based

Enfamil GentleEase 20cal Term babies—cow’s milk based, gentler in digestion. Babies suffering from
GI issues d/t neonatal abstinence syndrome or frequent emesis not d/t
Formula
1. EBM Prosobee Soy 20cal
volume issues
Term babies when babies when cow’s milk protein not tolerated or when
parental choice is a vegan feed
Formula
Enfamil AR 20cal Formula Term babies with regurgitation problems usually caused by reflux—cow’s

2. Donor BM Nutramigen 20cal Formula

milk based
Term babies with intolerance to cow’s milk protein. Hydrolyzed cow’s milk
protein based
Elecare/Neocate 20cal Term babies with multiple food allergies who cannot tolerate hydrolyzed
Formula formula—amino-acid based formula

3. Formula Human Milk Fortifier Preterm babies under 1500g at birth—used to fortify human milk with extra
protein, P, and Ca
 Advantages of Feeding Breast Milk Enterally
• Better feeding tolerance
• Lower risk of NEC, sepsis, and late onset sepsis
Overall • Reduced hospital LOS and risk of rehospitalization

Microvascular • Protective role in preventing retinopathy of prematurity

• Lower risk of HTN and atherosclerosis late in life
Cardiovascular • Improved left/right ventricular end diastolic volume index and stroke
volume index, and beneficial long term cardiovascular outcomes
Bone Health • Significant increase in whole-body bone area and bone mineral content
• Improved neurological development in later years
• Significantly higher IQ in later years
• Improved mental and psychomotor development
Neurological • Significant improvement in white matter microstructure
• Increased receptive language at 3 years and verbal/nonverbal IQ at 7
years

Kumar et al., 2017

Nutrition Intervention
and Goals
Calculating Goal Volume
Currently receiving 246 ml BM and 114 ml E22
BM goal volume:
120 kcals/kg x 2.48 kg = 297.6 kcals x 1 ml/0.67 kcals = 444 ml / 8 feedings = 55 ml q3h
E22 goal volume:
120 kcals/kg x 2.48 kg = 297.6 kcals x 1 ml/0.73 kcals = 407 ml /8 feedings = 50 ml q3h
55 ml + 50 ml = 105/2 = 53 ml q3h
Intervention:
Enfamil Enfacare 22 and expressed breast milk at 53 ml q3h will provide ~120 kcals/kg/day

Goals:
1. 120 kcals/kg/day (not met)
2. Appropriate choice of feed to promote growth and development (met)
3. Nippling 100% (not met)
4. Weight gain of 23-32 g/day on average over 3 days (not met)
Monitoring &
Evaluation
1. Caloric intake
2. PO vs. NG intake
3. Breast milk vs. E22 intake
4. Mother’s feeding choice
5. Weight
6. Enteral feeding tolerance
7. Stool and urine output
8. Plan of care
 References
American Academy of Pediatrics. (2015). The apgar score. Pediatrics, 136(4), 819-822. doi: 10.1542/peds.2015-2651
Conner, S. N., Bedell, V., Lipsey, K., Macones, G., Cahill, A. G., & Tuuli, M. G. (2016). Maternal marijuana use and adverse neonatal outcomes. Obstetrics and Gynecology, 128(4), 713-723. doi:
10.1097/AOG.0000000000001649
Embleton, N. D. (2013). Optimal nutrition for preterm infants: Putting the ESPGHAN guidelines into practice. Journal of Neonatal Nursing, 19(4), 130-133. doi: 10.1016/j.jnn.2013.02.002
Fenton, T. R., Geggie, J. H., Warners, J. N., & Tough, S. C. (2000). Nutrition services in Canadian neonatal intensive care: The role of the dietitian. Canadian Journal of Dietetic Practice and Research, 61(4), 172.
Gunn, J. K., Rosales, C. B., Center, K. E., Nuñez, A., Gibson, S. J., Christ, C., & Ehiri, J. E. (2016). Prenatal exposure to cannabis and maternal and child health outcomes: A systematic review and meta-analysis. BMJ open, 6(4),
e009986. https://doi.org/10.1136/bmjopen-2015-009986
Karnati, S., Kollikonda, S., & Abu-Shaweesh, J. (2020). Late preterm infants: Changing trends and continuing challenges. International Journal of Pediatrics & Adolescent Medicine, 7(1), 36–44.
https://doi.org/10.1016/j.ijpam.2020.02.006
Kumar, R. K., Singhal, A., Vaidya, U., Banerjee, S., Anwar, F., & Rao, S. (2017). Optimizing nutrition in preterm low birth weight infants: Consensus summary. Frontiers in Nutrition, 4, 20.
https://doi.org/10.3389/fnut.2017.00020
Martin J.A., Hamilton B.E., Osterman M.J.K. (2018). Births in the United States, 2018 Key findings data from the national vital statistics system.
Morgan, J., Young, L., & McGuire, W. (2014). Delayed introduction of progressive enteral feeds to prevent necrotising enterocolitis in very low birth weight infants. The Cochrane Database of Systematic Reviews, 2014(12),
CD001970. https://doi.org/10.1002/14651858.CD001970.pub5
Moyer-Mileur, L. J. (2007). Anthropometry and laboratory assessment of very low birth weight infants: The most helpful measurements and why. Semin Perinatol, 31, 96-103.
Olsen, I. E., Richardson, D. K., Schmid, C. H., Ausman, L. M., & Dwyer, J. T. (2005). Dietitian involvement in the neonatal intensive care unit: More is better. Journal of the American Dietetic Association, 105(8), 1224-1230.
doi: 10.1016/j.jada.2005.05.012
Sallakh-Niknezhad, A., Bashar-Hashemi, F., Satarzadeh, N., Ghojazadeh, M., & Sahnazarli, G. (2012). Early versus late trophic feeding in very low birth weight preterm infants. Iranian journal of pediatrics, 22(2), 171–176.
Simon, L. V., Hashmi, M. F., & Bragg, B. N. (2021) Apgar score [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470569/
Stanford Children’s Health (2021). The neonatal intensive care unit (NICU). https://www.stanfordchildrens.org/en/topic/default?id=the-neonatal-intensive-care-unit-nicu-90-P02389
Verduci, E., Giannì, M. L., & Di Benedetto, A. (2019). Human milk feeding in preterm infants: What has been done and what is to be done. Nutrients, 12(1), 44. doi: 10.3390/nu12010044