How much is he DRINKING???

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Wait…. I thought this was a pediatric blog…Yes; we are talking about the little neonate that comes to the Emergency Room that is vomiting “all his feeds” as per the mother. You are a little confused as the baby has doubled his weight in 30 days and does look well hydrated. You ask the mother about the feeds and she is frantic and nervous. You are able to extract that the 30 day old baby has been feeding about 4 ounces of formula every 2 hours in addition to breast milk… The mother is convinced that she is not producing adequate breast milk. She supports the belief with the fact that the baby continues to cry after she pulls him away from the breast..

Common scenario in the ER, which highlights the importance of knowing the truth behind infant and newborn feeding patters… You thought you didn’t need it as you are an ED resident …not a pediatric one right??? You are getting ready to order blood work, do a bedside ultrasound and order an official one as the pediatric radiologist is in house!!! You are trying to get an intravenous access, which is difficult to obtain…You pause, look at the smiling baby with a perfectly normal exam and wonder in your head if the baby is simply being over fed.. Good assessment of the feeding status in newborns can help alleviate misdiagnosis, parent anxiety and unnecessary interventions in the emergency room.

Newborns feed every two to three hours. The calorie requirement in newborns is about 90 to 100 calories/kg/day. The best way to estimate adequate feeds in newborns is weight gain and urine output. Adequate weight gain is about 15 to 20 grams per day. Newborns regain their birth weight by 10 to 14 days of life. They usually double their birth weight by 5 months of age and triple it by one year. Newborns should have a wet diaper every two to three hours during the first few months of life. Breast milk and most conventional formula provide 20 Calories per ounce (30 cc) of formula. If you do the math right you could estimate the calorie requirement and volume of feeds for a new born throughout the day. This would approximate volume per feed if the baby feeds every two to three hours!!!!!

Let us use an example:

Calorie requirement in a 3 kg weight baby = 3 x 100 = 300 Calories

1 ounce of formula/ breast milk = 20 Calories

15 ounces would equate 300 calories

No of feeds in the day (approx.) = 8(Feeds every three hours),

Volume per feed = 15/8 = 1.8 ounce!!!!!

Wow that was a lot of math!!! It is actually pretty simple, requires less time than getting iv access or an official US and eliminates the anxiety associated with guessing. It is important to identify and educate mothers that may be over feeding. Babies, who are overfed, vomit and get irritable. It is important to estimate the volume and frequency of feeds in any baby that presents to the emergency department with vomiting. Overfeeding can be the sole cause of vomiting in well appearing, otherwise healthy babies. Vomiting in the newborn poses a diagnostic challenge and can be the cause of a clinical dilemma!!!! It can include a number of life threatening and critical causes. Red flags or ominous signs include green or bilious vomiting, weight loss, excessive irritability, inconsolable cry, dehydration, vomiting of the entire feed and or other signs of an acute abdomen on exam including distension and rigidity. Good history and a detailed exam can cue to the diagnosis of these ominous signs.

History about newborn feeding with a detailed exam is essential to an accurate diagnosis. Nutritional requirement and feeding cues in babies demand attention and time… Good counseling of the mother and education of feeding practices can help establish better patient compliance and understanding of the problem. It is always important to counsel mothers to continue to breast feed and the mantra that “breast is best” is not a myth. Emergency room physicians should have an understanding of newborn feeding patterns and use objective measures to determine what and how much is he actually drinking!!

By,

Virteeka Sinha

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