Management -SWEET

Cold stress causes an increases oxygen and glucose consumption as the infant tries to generate heat which can lead to hypoglycaemia & worsen any hypoxia

Target Blood Sugar Levels: Strive to keep blood glucose levels above 2.6 mmol/L to prevent hypoglycaemic complications (refer to local guidelines)

Confirm Low Blood Sugar: Any initial low blood sugar readings should be validated generally through a laboratory result or a reliable blood gas machine to ensure accuracy.

Frequent Monitoring: For infants with blood sugar levels below 2.6 mmol/L, recheck glucose levels hourly until they stabilise. Continuous monitoring will help in early identification and management of recurrent hypoglycaemia (refer to local guidelines)

Signs of Poor Perfusion: Be vigilant for clinical signs of poor perfusion, such as lethargy, hypotonia, or feeding difficulties, which may indicate severe hypoglycaemia or other complications

Fluid volumes & concentrations of dextrose need to be carefully titrated to maintain blood glucose within normal range.

Feeding Protocols:

• For well infants, avoid intravenous (IV) dextrose unless the blood sugar is critically low (below 1.5 mmol/L).
• For infants identified as at risk (e.g., premature, small for gestational age), initiate feeds as soon as possible or administer a 10% dextrose infusion early on.
• Limit the volume of feeds or IV fluids to no more than 90 mL/kg on the first day of life for premature or small-for-gestational-age infants. If blood sugar levels remain

Consultation for Persistent Issues: If higher concentrations of dextrose (greater than 10%) are required to maintain normothermia or if hypoglycaemia persists despite appropriate management, the infant should be reviewed by the endocrine team for further assessment and possible investigations into underlying causes.

Anticipatory Care: Identify infants at risk early (e.g., those with a history of maternal diabetes, intrauterine growth restriction, or those born prematurely) to implement proactive measures, including early feeding and monitoring protocols. If unstable, medical team may consider increasing a higher dextrose concentration or as per local policy.

If the infant is hypoxic, they are forced to rely more on anaerobic metabolism, rapidly depleting glucose stores leading to hypoglycaemia 

Hypoxia also reduces peripheral perfusion, impairing thermoregulation and predisposing the infant to cold stress –hypothermia

Nil by mouth versus oral feeding: already compromised infant (increased WOB) does not need to concentrate on digesting milk in addition to breathing with impaired respiratory status.

A full stomach will push up on the diaphragm, which can exacerbate work of breathing.

Medical team may order IVT 60mg/kg/day starting dose to provided adequate calories for an already compromised infant

Blood sugars-4-6 hourly depending on initial reading or as per local policy

Premature neonates often have underdeveloped sucking and swallowing reflexes, making it difficult for them to take suck feeds.

They also have higher energy needs (calorie requirements) to ensure and are at risk of dehydration and malnutrition if not managed carefully

Parenteral Nutrition (PN): Initially, may require IV nutrition to provide adequate caloric and fluid intake until they can tolerate enteral feedings. Commencing rate 60 mls/kg /day

Enteral Feeding: Once the infant can tolerate (haemodynamically stable), small amounts of expressed breast milk (or formula) can be introduced via a nasogastric or orogastric tube.

Breast Milk: Breastfeeding is encouraged as it provides essential nutrients, immunity, and growth factors. Expressed breast milk should be given if the infant cannot directly breastfeed.

Fortification of Milk: often require milk fortifiers to meet their increased nutritional demands, especially for growth and bone development.

Monitoring Growth and Intake: Regular weight checks and monitoring fluid balance are essential to ensure appropriate growth and avoid complications such as dehydration or overfeeding.

Adequate nutrition is essential for the treatment of neonatal jaundice, as maintaining hydration by either parental (if unable to tolerate milk feeds) or enteral feeding (via NGT, breast of bottle) can help promote gut motility and the elimination of bilirubin through urine and stool.

Monitor Hydration: Monitor the infant for signs of dehydration, such as dry mucous membranes or reduced urine output. Ensure that the infant is receiving adequate fluids to stay hydrated, fluids may be increased by medical team at the commencement of phototherapy to avoid complications of dehydration

Feeding intolerance in neonates, especially in preterm or critically ill infants, is a common and challenging issue. It refers to the inability of a neonate to tolerate enteral feedings, leading to signs of distress such as vomiting, abdominal distension, or signs of discomfort. This condition is often seen in preterm infants or those with underlying medical conditions like necrotizing enterocolitis (NEC), gastroesophageal reflux (GOR), gastrointestinal immaturity, or infections.

Managing nutrition is critical for neonates with feeding intolerance. Careful assessment and adjustments to feeding protocols are necessary to prevent worsening of symptoms and support the infant’s growth and development.

Assess and Monitor Feeding Tolerance: Carefully monitor for signs of intolerance, such as abdominal distension, vomiting, lethargy, or changes in bowel movements. These signs may indicate an issue with the current feeding regimen or gastrointestinal function.

Gradual Introduction of Feedings: In cases of suspected feeding intolerance, gradually introduce enteral feeding, starting with small volumes (e.g., trophic feeds) to assess gastrointestinal tolerance. Slowly increase the volume and concentration as tolerated.

Consider the Type of Feeding:

If the infant is unable to tolerate breast milk or formula feeds, consider alternative feeding methods such as parenteral nutrition (PN), which can provide nutrients intravenously while allowing the gut to rest.

Use fortified breast milk or specialized preterm infant formula if additional calories or nutrients are needed for growth.

Management of Feeding Intolerance – 

 Initial Steps:

• • Conduct a focused physical exam.
  • Insert a nasogastric or orogastric tube for decompression before other diagnostic or therapeutic actions.
  • Establish Intravenous access for fluids, electrolytes, and nutrition.

Stabilisation and Diagnosis:

• • Stabilise the infant hemodynamically.
  • Perform abdominal imaging to determine the need for surgical intervention.

Treatment:

• • Gastric decompression and nil by mouth (NBO).
  • Parenteral nutrition, fluid, and electrolyte balance.
  • Thermoregulation
  • Positioning to enable visualisation
  • Intravenous antibiotics
  • Parental support.

Nil by mouth versus oral feeding: already compromised infant does not need to concentrate on digesting milk

IVT 60mg/kg/day starting dose to provided adequate calories for an already compromised infant.

Fluid & Electrolyte Balance: Strict FBC must be maintained, fluid intake and urine output must be measured.

Hypoglycaemia may occur due to increased metabolic demands or hyperglycaemia related to stress therefore regular BSL monitoring. BSL 4-6 hours

Adequate nutrition is critical in managing NAS, as infants may have difficulty with feeding due to irritability, poor suck-swallow coordination, or vomiting.

Assess Feeding: Monitor the infant’s ability to feed, including the suck and swallow reflexes. Infants with NAS may have difficulty feeding, and some may require Nasogastric tube feeding if they are unable to feed effectively.

Monitor hydration status closely by assessing skin turgor, fontanelles, and urine output. Dehydration can exacerbate NAS symptoms.