Transcript Overview

Post-discharge nutrition for high risk infants
Steven A. Abrams, MD
Professor of Pediatrics
Baylor College of Medicine
[email protected]
Disclosure Information
In the past 12 months, I have had the following financial relationships
with the manufacturer of any commercial products and/or providers
of commercial services discussed in this CME activity:
Receives research funding from Mead-Johnson.
I do not intent to discuss an unapproved/investigative use of a commercial
product/device in my presentation.
Objectives

Discuss how to evaluate and promote growth in
premature infants after hospital discharge.
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Evaluate current research and recommendations
regarding use of nutrient-enriched feedings for
premature infants post-discharge.
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Understand nutritional options in special case
situations of intestinal failure, chronic lung disease
and other nutritional limitations after hospital
discharge.
Failure to Thrive Case Study #1
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Former 30 4/7 week female
Infant was discharged home around 36 weeks PMA with
the following feeding plan:
 Breastfeeding 4 times per day and 4 bottles of
EBM + transitional formula = 27 kcal/oz
Now 40 3/7 wks PMA admitted with FTT
Failure to Thrive Case Study #1
Birth
Anthros
Birth
Percentiles
D/C #1
Gest Age: 30 4/7
PMA: 37 5/7
Weight
1280 g
10-50th %ile
1982 g
Length
39 cm
10-50th %ile
n/a
FOC
26 cm
3-10th %ile
n/a
Readmit
Readmit
Percentiles
PMA: 40 3/7
Weight
2040 g
<3rd %ile
Length
46 cm
<3rd %ile
33.2 cm
<3rd %ile
FOC
D/C #1
Percentiles
<3rd %ile
Failure to Thrive Case Study #1
 Mother reported:
 Baby breastfed for approximately 10-20 minutes, 4 times
per day
 Taking 30-60 mL of the 4 bottle feeds of EBM +
transitional formula = 27 kcal/oz (proper mixing was
verified).
 Calculated calorie concentration is probably
overestimated
 Mother reported that when she pumps she is only getting 0.51.5 ounces per breast. During her baby’s first hospitalization
she was getting up to 3 ounces per breast.
 Overall probably receiving about 100-120 mL/kg/d
Failure to Thrive Case Study #1
 Intervention: 4 bottles of EBM and 4 bottles of powder
transitional formula mixed to 24 kcal/oz.
 Infant began taking > 200 mL/kg/day
 Weights during admission
 Day 1: 2.04 kg
 Day 2: 2.135 kg
 Day 3: 2.2 kg
Failure to Thrive Case Study #1
Readmit
D/C
Birth
Weight
D/C
Failure to Thrive Case Study #1: Take
home
 Often breastfeeding is often not well established at
discharge. One or two days of one or two bedside
attempts at nursing is not enough to assure adequacy.
 Ineffective breastfeeding and limited pumping can
decrease volume and lead to FTT.
 If a few formula feeds are given, need to ensure mom is
pumping regularly and has good milk volume.
 Careful growth measurements needed after discharge.
 Many moms will benefit from established plan to contact
lactation support services after discharge.
Failure to Thrive Case Study #2
 Former 27 week BB discharged home on amino acid
based formula.
 Per mother she was told that this formula was used
because it is high in protein and good for premature
infants (no reported history of bloody stools, feeding
intolerance).
 ER admission at 45 1/7 PMA for cough (weight obtained)
 Admitted at 47 4/7 PMA for FTT
Failure to Thrive Case Study #2
 Mother reports that infant:
 Drinks 4 ounces of formula every 3 hours
 7 dirty diapers on average
 Mother reports that formula mixing was changed from 2
scoops:4 oz water to 1 scoop formula: 4 oz water (half
strength or 10 kcal/oz) at the recommendation of her
pediatrician about 2-4 weeks prior to admission.
 Mom had received multiple mixing lessons at PCP office. She
missed last week’s appointment.
 PCP office and parents both believe the other initiated the
improper change in mixing.
Failure to Thrive Case Study #2
Readmit
Half-Strength
Formula
ER
D/C
Birth
Weight
D/C
Failure to Thrive Case Study #2:
Intervention and summary
 Intervention:
 Change from 4 oz half-strength amino acid based
formula every 3 hours to transitional formula 22
kcal/oz ad lib.
 In the first 24 hours of admission infant took 264
mL/kg/day of formula and gained 160 grams.
 Combination of specialized formulas and novel mixing
instructions can be a problem.
 High cost might have led mom to try to over-dilute?
Up to 15% of families may do this.
 Written instructions are crucial.
Planning for discharge
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Transition to home feeding plan at least 3 days before
discharge
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Weight gain should be demonstrated over 3 days,
not “can go home if gains weight overnight”
Training for family in special feeds/techniques
 Especially mixing powder formula
 Written instructions are best
 Consider 24 hour pre-discharge care by parents
Purchase nutritional products as needed
 Infant formulas: Identify stores with formula
 Multivitamins and iron
 Other equipment such as feeding tubes
Oral feeding before discharge
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Breast-feeding (if planned) as much as possible
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Arrange lactation support as needed for post-discharge.
Use ad lib feeds when possible
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If not, be very clear about ranges of feedings and timing
range for feeds.
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Transition if possible to more physiological feeding
schedule. Does the baby need to eat every 3 hours?
Why? Give family a plan for spacing feeds during night.
Decision making: What to feed at home?
Premature, especially VLBW infants have unique
nutritional needs that continue after hospital discharge.
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Nutrient deficits accumulate during hospitalization.
Human milk feedings extremely important, but nutrient
intake may be limited in some cases.
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Ongoing health issues, BPD, reflux, neurological
impairments will affect feeding choices, strategies.
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Why do premature infants exhibit suboptimal
nutrition at discharge?
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Born with low nutrient stores
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Often fluid restricted (BPD, PDA)
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Glucose and lipid intolerance may have limited provision
of adequate IV nutrition
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Inadequate oral intake due to immature p.o. feeding
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Suspension of feedings for procedures, sepsis, feeding
intolerance
Protein deficit:
develops rapidly
during hospitalization
Denne and Poindexter, Sem Perinatol 2007
Dusick et al, Sem Perinatol 2003
Post-discharge formula-feeding: Use of
Transitional formulas

Formulas have nutrient contents that are mostly midrange between term and preterm formulas
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About 10 studies in infants < 1800 g BW
 Most
show growth benefits in at least a subgroup
 Large
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Evidence strongest for:
 Males

safety margin in use of these formulas
< 1250g BW
Other findings
 Increased
 No
bone mineral content
effect on neuro-development (small studies?)
Carver 2001
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N = 125, Birthweight < 1800g
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Term formula or transitional formula (22kcal/oz) to 12
months PMA
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Significant benefits:
 Weight,
 Head
 But
length, head circumference (6 months)
circumference (12 months)
only in those BW < 1250g
 Other
studies suggest some benefit 1250-1800 g BW
Carver JD, Pediatrics 2001, 107,683-9.
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Studies very heterogeneous
Did not have access to original data
Data synthesis limited
The available data do not provide strong evidence that
feeding preterm infants following hospital discharge with
nutrient-enriched formula compared with standard term
formula affects growth rates or development up to 18
months post-term.
This remains controversial. What is “strong evidence”
compared to just plain evidence? 18 months is not
likely long enough to show this benefit.
Cochrane Database Syst Rev. 2007 (and again in 2012)
Recommendations for using transitional
(post-discharge) formulas
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Transition to these formulas from 24 kcal/oz preterm formula if
< 1500 -1800 g BW at about 2.0 kg
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May delay if serum alk phos > 600 IU/dL or BPD with fluid
restriction.
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Preterm formulas are available for home use but difficult to
obtain/expensive and may have excess of some nutrients,
esp. Vitamin A (for > 3 kg infants) and minerals.
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Usually transition to these formulas when ready to be fed
“ad lib”.
Preterm infants over 1800 g at birth?
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Minimal research and outcome data
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These formulas are often more expensive for government
payment sources (WIC) and may be slightly more
expensive for families.
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Long-term use or use in late preterm babies can lead to
excessive weight gain.
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No good guidance
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Some use for infants > 1800 g BW but use of routine
formulas is also acceptable.
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We do not encourage their use in infants > 2.2-2.4 kg or
34 0/7 weeks unless has other conditions.
Not generally recommended for most
former preterms
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Soy formulas
Lactose-free formulas
Partially hydrolyzed casein formulas without clear evidence of
protein intolerance
Amino acid based formula except intestinal failure patients or
protein intolerance not responsive to partial hydrolyzed casein
Reflux/spitting thickened formulas
Non-pasteurized donor milk
Goat milk, almond milk, etc
Early introduction of solid foods
Long-term risk of obesity?
 Faster
weight gain (upward percentile crossing for weight) in
infancy is associated with a greater risk of long-term obesity
and possibly cardiovascular disease
rapid and more complete “catch up” in preterm infants
fed with the nutrient-enriched formula (preterm formula), is not
associated with altered adiposity.(Cooke et al, Pediatr
Research 2010).
 More
 SGA
fullterm infants are an area of controversy. Feed for brain
or long-term cardiovascular health? (Singhal et al, AJCN 2010)
 Be
cautious of over-use of high energy dense formulas after
discharge.
Current recommendation is to target catch-up in preterm
infants, but to be more cautious in SGA fullterm infants
Thickeners
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“The Food and Drug Administration (FDA) wants parents,
caregivers and health care professionals to be aware that
infants of any age may face an increased risk of developing a
life-threatening condition if fed a thickening product called
SimplyThick.” (Xanthan gum).
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“Since May 2011….has identified 22 infants who developed
necrotizing enterocolitis (NEC).” Seven of those infants died.
One was a full-term infant.
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In May 2011, FDA advised against feeding SimplyThick to
infants born before 37 weeks gestation.
J Pediatr 2012;161:354-6 and
http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm256250.ht
Thickeners
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Uncertain when it might be “safe” to use thickeners.
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Company says “SimplyThick® thickener is NOT intended for
use with preterm or infants under 12 months of age. Or
children under the age of 12 years with a history of NEC.”
(http://www.simplythick.com/, accessed July 2013).
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We do not use any commercial thickeners in high risk infants.
Alternatives?
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Rice cereal
 Safe
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but often does not work very well
Others including Carob bean flour
 Inadequately
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tested
Carefully paced feeding is usually best
Breast feeding post-discharge
Nutrients limited in human milk for
preterm infants
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Protein: Need extra to continue to resolve deficit and
to support catch-up growth
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Minerals: Especially calcium, phosphorus, iron and
zinc
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Vitamins: Especially Vitamin D
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Unless mom receiving very high dose (6400 IU/d)
Vitamin D supplementation, there is negligible
Vitamin D in human milk.
Energy: Primarily limited by feeding volume, also
caloric density
Supporting human milk feeding after
discharge
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Several studies have shown human milk-fed infants grow
more slowly than formula-fed preterm infants after d/c.
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Few interventions have been studied in breastfed infants.
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An evolving area
Former preterms who are breastfed drop %iles on growth
curve. May lead to stopping breast feeding.
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Slow(er) growth may or may not be harmful.
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Infants discharged with a subnormal weight-for-age are at
increased risk for long term growth failure
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Such infants should receive a special post-discharge formula
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The human milk they consume should be supplemented, for
example with a human milk fortifier.
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Frequently done in Europe but US practitioners prefer not to
add powder and substitute some feedings for formula. Also,
HMF is not easy to obtain at home and is expensive.
J Pediatr Gastroenterol Nutr. 2006 May;42(5):596-603.
Fortification of human milk post-discharge
No significant effect seen for
development but very small sample
size (Aimone et al, JPGN 2009).
Some studies show no effect
Avg. BW about 1300 g,30 weeks
PMA, some over 2 kg. No effect of
home fortification in a study in
Denmark. However, bigger babies
than we might use in research.
Zachariassen et al., Pediatrics 2011;127;e995.
Not enough
data for
conclusions
Young L, et al. Cochrane Database of Systematic Reviews 2013, Issue 2. Art.
No.: CD004866.
Fortification of breast milk at home?
 No
ideal product available for consumers
 Significant
disruption of breast-feeding dyad
 Accurate
measurement of milk volume?
 Accurate
measurement of amount of fortificant?
 Bacterial
contamination potential for powders
 Effect
of fortificant on absorption and other nutritional
factors from HM
Safety of powder fortifiers or formula
 All
US formula manufacturers recommend against use of
powder infant formula in at-risk patients (VLBW,
immunocompromised) and NICU settings unless no
alternative is available.
 Risk
of E. sakazakii (now Cronobacter sakazakii) in babies
fed powder. About 50 such cases in last 30-40 years,
including several recently.
 High-risk
period may extend past hospitalization
“Complementary” formula feeds
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Relatively less interruption of breast-feeding
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No concerns about sterility if use liquid formulas.
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Small but definite benefit for nutrient intake.
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Our usual current approach
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5-6 feedings/day of breast-milk or breast-feeding
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2-3 feedings/day of transitional formula
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Re-evaluate need for formula at 48-52 weeks PMA
If mother does not wish to use any formula, can follow baby
closely for growth, serum total alk phos activity post-discharge.
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Individualize
for infants needing fluid restriction or with poor
growth history.
Growth monitoring
 Should
monitor weight, length and FOC using current
growth curve data and length board. Use gender-specific
WHO curves when possible.
 Recognition
that some drop-off, especially in weight %iles
will occur in breast-fed preterms.
 Drop
in length %iles is not desirable.
 Monitor
 Bone
for excessive weight gain or weight/length.
catch-up is usual in first 2-3 months after d/c.
 Do
not routinely check alk phos unless < 1500 g
birthweight AND not receiving any supplement to HM.
 Smallest
infants have poorer catch-up.
Growth Parameters
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> 2000 g bodyweight
 Goal
is 20 – 30 g/day averaged over a week
Length
and FOC should be plotted and monitored weekly.
TWO people are needed to measure length properly using a
length board.
 Length
 FOC
goal: 0.8 – 1.2 cm/wk
goal: 0.8-1.0 cm/wk
Fenton growth
curves (22-50 wk
PMA)
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New gender specific
Fenton curves
(Fenton T, Kim JH.
BMC Pediatrics 2013)
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Curves equal the
WHO Growth
Standards at 50
weeks
Is the baby growing?
Plot
with Fenton curves to 50 weeks, then CDC/ WHO curves.
Day-to-day
weight changes don’t mean much.
Variation
in scales, IV, tubes in/out of baby, stool, urine or
feeding before weights affect day-to-day weights.
If
a feeding change is made, it takes at least 3 days to evaluate
its effects.
Not
necessary to keep a baby in the hospital who is feeding
well an extra day to “see if s/he gains weight overnight.”
Long-term
outcomes are likely more related to length and FOC
growth than weight gain.
Example: 27 week
infant with moderate
BPD, full feeds
Easy to do, but this isn’t accurate
http://www.topendsports.com/testing/tests/height-baby.htm
http://www.quickmedical.com/seca/pediatrics/210.html
Closer, but still not quite right
Lesotho, Africa
2012
Bingo!! It takes two people to do this
http://www.nursing-help.com/2011/07/growthmeasurement-and-procedures.html
Post-discharge: How long to continue
transitional formula or complementary feeds?
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One guidance is to stop at 4-6 mo corrected age if all
growth parameters are > 25%ile (Bhatia, J Perinatol 2005).
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If not gaining excessive weight, then continuing until 9
mo CGA is reasonable.
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Emphasis should be on monitoring length, FOC
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AAP suggests “weight for length maintained above the
25%ile.”
Rarely wish to stop at less than 48 weeks PMA as 40-48
weeks are critical catch-up time period (Adamkin, J
Perinatol 2006).
Iron
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Iron status should be monitored: Recommend both serum
ferritin and CBC.
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Preterm infants and those < 2500 g birthweight should be
supplemented with iron at time of hospital discharge or at 6 to 8
weeks postnatal age.
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Iron intake of 2-4 mg/kg/day, higher range of this in smallest
infants.
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For formula-fed infants, may need small supplement to achieve
at least 3 mg/kg/day, can be combined with vitamin D.

We provide formula-fed infants ½ ml MVI with iron until
about 3 kg.
Lab testing post-discharge

There is no need for any routine lab testing in most preterm
infants after discharge except iron status.
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Consider checking total alk phos activity at 40-48 weeks PMA
if last alk phos was > 600 IU/L OR history of rickets OR < 1250
g BW and exclusive HM feeding.
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No need for routine vitamin D (serum 25-OHD) testing if
receiving appropriate dietary intake of at least 400 IU/day.
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If discharged with conjugated bilirubin > 0.3 mg/dL, this should
be followed. It is not uncommon for TPN cholestasis to persist
for several months.
Summary
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LBW infants often exhibit suboptimal nutrition at discharge
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Transitional (22 kcal/oz) formulas are recommended for
premature infants with birth weight <1800g
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Continue until 4-6 mo corrected age or until all growth
parameters are >25%ile. Do not usually stop < 48 wks PMA.
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Common strategy for baby < 1500-1800 g BW whose mother
has breast milk available for use or is breast-feeding:
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5-6 feedings/day of breast-milk or breast-feeding
2-3 feedings/day of transitional formula
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If discharged on transitional formula: consider ½ mL of MVI
with iron for total of 3 mg/kg/d iron and 400 IU/d vitamin D.

If discharged on ANY human milk: 1 mL MVI with iron.
That’s the End….
[email protected]