TEAM C SURVIVAL GUIDE: Answer to Question #3

3.       Another one of your patients has recently graduated to room 1.  He is an ex 27 week male who was ventilator dependent in the past, but is now thriving on room air with only occasional episodes of apnea.  He is on caffeine for his apnea, and as far as feeds are concerned, is on a standard formulation of Enfamil Premie (24kcal/oz) at 30cc q3h.  You need to increase his daily caloric intake so he will be big enough to go home.  How can you increase the calories without increasing total fluid?  How many kcal/kg/day is he getting now?  

First, calculate how many calories your patient is getting now:

30cc Q3h= 30cc x 8 feeds/day = 240 cc/day

1oz = 30 cc

24 kcal/oz x 1 oz/30cc = 0.8 kcal/cc

0.8 kcal/cc x 240 cc = 192 kcal/day

divide by the weight

192kcal/d ÷ 2kg = 96kcal/kg/day

Now concentrate to 27kcal/oz:

as above: 

240cc/d x 27kcal/30cc = 216kcal/d

now divide by weight

216kcal/d ÷ 2kg = 108kcal/kg/d

Now add MCT oil to the 27kcal/oz formula. This is usually added at 1-2cc/d divided BID. Start your patient at 0.5cc BID, for 1cc/d.

MCT oil = 8kcal/cc

1cc/d x 8kcal/cc = 8kcal/d

divide by weight

8kcal/d ÷ 2kg = 4kcal/kg/d

Add to above calculation for calories from formula

108kcal/d + 4kcal/kg/d = 112kcal/kg/d

Now, suppose your patient is breastfeeding (Breast milk (BM) = 20kcal/oz). This will not give him adequate calories, protein, or minerals for the weight gain we want. So, you can add a caloric supplement to the breastmilk, human milk fortifier (HMF). You can start by adding this at a ratio of BM:HMF 1:50 (1 package to 50 cc’s). This will give your patient 22kcal/oz (see chart in blue book). 

As above:

240 cc/d x 22 kcal/30cc = 176 kcal/d

divide by weight

176 kcal/d ÷ 2 kg = 88 kcal/kg/d.

You can slowly increase the BM:HMF concentration (i.e., 1:25) until achieving the desired kcal/kg/d.