Gastrointestinal and Nutrition
Feeding and nutrition
Human milk is first choice; donor milk is used for VLBW infants when maternal milk is unavailable. Fortify human milk to 22-24 kcal/oz for preterm infants. Start trophic feeds 10-20 mL/kg/day and advance 15-30 mL/kg/day as tolerated; target 150-180 mL/kg/day. Preterm energy needs are about 110-135 kcal/kg/day with protein 3.5-4.5 g/kg/day.
Necrotizing enterocolitis
Bell staging: stage I suspected, stage II definite with pneumatosis, stage III advanced with perforation or systemic instability. Signs include feeding intolerance, bilious emesis, abdominal distention, bloody stool, and lethargy. Management: stop feeds, nasogastric decompression, blood culture, CBC, lactate, abdominal radiograph, and broad-spectrum antibiotics; surgery for perforation. Human milk and standardized feeding protocols reduce risk.
Surgical and structural problems
Bilious emesis in a newborn is malrotation and volvulus until proven otherwise; obtain an urgent upper GI series. Pyloric stenosis presents at 3-6 weeks with projectile nonbilious vomiting and a palpable olive. Hirschsprung disease causes delayed meconium and distention; diagnose with rectal biopsy.
Worked example
A 30-week infant on day 12 receiving 150 mL/kg/day develops a grossly bloody stool, distention, and lethargy. Reasoning: stop feeds, decompress, obtain radiograph looking for pneumatosis, send cultures, and start ampicillin, gentamicin, and metronidazole. Consult surgery early.
Traps
- Attributing bilious emesis to sepsis alone and delaying imaging.
- Advancing feeds despite recurrent emesis and distention.
- Missing that probiotics are not uniformly recommended or FDA-approved.