Chapter 4:


Student Author: Kira Düsterwald

Specialist Advisor: Dr Farhaad Khan

Illustration showing paediatrician lying inside bowl of pasta, looking very full but still eating

This chapter covers the following topics:



Breast milk should be the exclusive food for infants in the first six months of life. The World Health Organisation’s (WHO’s) Baby-Friendly Hospital Initiative encourages breastfeeding (see related image here) at all baby-friendly hospitals and has published a ten-step guideline to promote and support breastfeeding at these facilities.


Practical advice

One must educate the mother antenatally about the advantages of breastfeeding and the technique, so that she knows how she will feed after delivery. The baby should latch over the whole areola, not just the nipple. The nurse on duty may help the mother with the latching technique.

The initial feed, colostrum, is very nutritious and, if possible, should be given within half an hour of birth. Early breastfeeding also stimulates prolactin and oxytocin and helps to promote uterine tone.

Breastfeeding should be done on demand and the infant allowed to drink from one breast until it is empty before moving on to the other breast. Breasts should be alternated at the start of each feed. Initially the baby will have small but frequent feeds, but over time this pattern will change. Neonates need to be fed at least three-hourly.

Mothers can also express the breast milk and this may be done using their hands. The infant should be fed this expressed milk with a cup rather than a teat. Pretoria pasteurisation/flash heating is the process of heat-treating breast milk so that it is safer for babies to drink in the case of maternal HIV. Expressed milk can be stored in a clean container with a tight lid:

If the mother is worried about the amount of food that the infant is receiving, one can educate her on the signs of correct feeding:

Common Problems

Common problems during breastfeeding include:

Feeding Principles for the Preterm or Sick Neonate

The aim when feeding any neonate should be to maintain a growth rate similar to the intrauterine rate for the same gestational age, and to reach developmental goals for corrected gestational age. Premature and sick neonates struggle to meet their nutritional requirements through demand breastfeeding for the following reasons:

For these reasons, high-risk infants may need supplemental feeds, which can be given as enteral feeds or intravenously (parenteral feeds). There is a push by some to give as much volume enterally as is possible, if the baby tolerates oral cup or naso/oro-gastric feeds i.e. does not vomit and has a soft abdomen etc. This is an area of debate as the benefits of enteral feeds also come with the disadvantage of higher rates of necrotising enterocolitis in formula-fed infants. Expressed breast milk, if available, is used preferentially.

The mother should be encouraged to express after every feed or 8–10 times daily. The first bit of breast milk, the colostrum, is especially beneficial. However, waiting for colostrum should not delay feeding, as hypoglycaemia should be avoided in neonates. Very sick babies might require IV 10% dextrose solution within 30 minutes of birth. Donor breast milk can also be used.

Calculating Feeds in Sick and Premature Neonates

In general, the total daily fluid intake (TFI) is calculated in units of mL per kg per day and then split over routes of administration depending on how sick the infant is – IV (parenteral) and oral feeds. The neonate’s highest weight achieved is used for the TFI. See Table 4.1 below for daily requirements. One is encouraged to memorise the first column for infants over 2 kg.

The TFI amount should be increased daily by 10–20 mL/kg/day, taking into consideration the new weight and age of the baby but making sure not to increase too fast as the neonate may not tolerate large volumes. The child can be switched to full enteral feeds when they comprise >80% of the split. In premature neonates, TFI is often increased up to 160–180 mL/kg/day.

Table 4.1: TFI by Weight
>2000 g 1500–1999 g 1000–1499 g <1000 g
Day 1 60 mL/kg/day 70 80 90
Day 2 75 80 90 100
Day 3 100 110 120 130
Day 4 125 130 140 150
Day 5+ 150 mL/kg/day Titrate mL/kg/day to growth from this point onwards – not an exact science. Observe how infant feeds and tolerates increments. If growing well (average 15 g/day over 3 days), maintain TFI NEVER increase TFI above 200 mL/kg/day without consultant input

For enteral feeds, try to substitute some of the formula volume for expressed breast milk if the infant is too young to suck effectively. Blood glucose should be regularly checked (three hourly) and maintained within 2.6–7.0 mmol/L. Urgently treat hypoglycaemia with additional feeds and manage hyperglycaemia by switching to 5% glucose-containing fluids.

Table 4.2: Notes on and Examples of TFI Calculations


  • Term infants may feed three hourly or on demand
  • Pre-terms should, at first, feed orally, two hourly (as far as they can tolerate)
  • In general, give full parenteral feeds for infants <1500 g (except for colostrum) with gradual introduction of enteral feeds starting at 24 mL/kg/day and increasing by 36 mL/kg daily via orogastric tube (this is a good route for all infants <34 weeks)
  • Give IV maintenance of 10% dextrose solution (also known as neonatalyte) at approx. 1 mL/kg/hour. However, neonates <1000 g need 5% dextrose water for the first 36-48 hours
  • Feeds should be increased (by 10–15 mL/kg/day) for infants receiving conventional phototherapy
  • One can substitute a “feed” for a breastfeeding session. 100 mL of breast milk has 67 kcal, while 100 mL pre-term formula has 85–87 kcal
  • Premature infants lose up to 15% of their weight from water loss in the first week (term infants lose about 10%)

Example: Write up feeds for a 2000 g 34-week prem with presumed neonatal sepsis on day 1 of life. What are her feeds on day 5, when she weighs 1800 g, and her sepsis has resolved?

Day 1: TFI = 60 m/kg/day, therefore baby requires 120 mL per day (60 x 2 = 120) in 2 hourly feeds. Thus, she should be given 10 mL per feed (120/12 = 10). Give colostrum if available. Give EBM if available, otherwise use formula. She will likely need cup feeds. If cup feeds are not tolerated, she should be given orogastric tube feeds. If she is very sick or has severe respiratory distress, she will need parenteral feeds.

Day 5: TFI = 150 mL/kg/day, therefore baby requires 300 mL per day (150 x 2 = 300; use her highest-ever weight, i.e. birth weight, rather than her current weight). This should be given in 2 hourly feeds of 25 mL per feed (300/12 =25). Give EBM if available, otherwise continue PreNAN®, Similac® or equivalent. Assess the mother’s breastfeeding technique and the baby’s suck to determine when to transition to breastfeeding.


One should work with a dietician, especially regarding formula and availability. Breast milk fortifier should be given to infants <2000 g, once s/he is on full feeds i.e. 150 mL/kg/day. This supplement is usually called FM85 and 0.5–1g is added depending on feed volume. It should NOT be added to formula, only expressed breastmilk. Medium chain triglycerides may be given if there has been inadequate weight gain.

When the neonate has been switched to only enteral feeds, s/he should also be started on multivitamin drops until mixed feeding is well established (including breast milk).

Iron (ferrous gluconate/Ferrodrops®) should be given from one month old until the neonate is weaned as there is a high risk of anaemia in pre-term babies (have low iron stores).

One should also check phosphate and ALP levels in infants <32 weeks and VLBW infants. Abnormal serum sodium can be an indicator of poor intake / inadequate fluid management.

Solid Food

It should be introduced when the child is six months old. Small amounts of solid food should be given, starting with cereals (see image here), puréed fruits and vegetables. There should be a gradual progression to a mixed diet and breastfeeding continued for as long as possible (WHO recommends two years).

If there is a family history of food allergy:


Fluid requirements in paediatrics fall under four main categories – resuscitation, rehydration, maintenance and replacement of ongoing losses.


Resuscitation fluids are indicated for the child in shock (an emergency). The following signs may be used to recognise the shocked child:

It may be difficult to identify these signs in a malnourished child.

Table 4.3: Types of Shock

Recall that there are four types of shock:

  • Hypovolaemic:
    • Large volume e.g. acute gastroenteritis (AGE), burns, sepsis, abdominal pathology
    • Low volume e.g. myocarditis, severe acute malnutrition (SAM), drowning, diabetic ketoacidosis (DKA), traumatic brain injury (TBI), status epilepticus, toxins
  • Cardiogenic
  • Distributive:
    • Septic
    • Anaphylactic
    • Neurogenic
  • Obstructive


The correction efforts for hypovolaemia should have the same focus as any resuscitation situation:

The patient’s response to treatment should then be reassessed. If s/he is still shocked, give more fluid boluses and administer ceftriaxone (80 mg/kg stat to cover for possible sepsis). If after 15–20 minutes, the patient has still not improved, contact one’s regional hospital to discuss further management and, if necessary, contact the flying squad to discuss transfer.

If the child is transferred to a provincial hospital, s/he may be started on inotropes (dopamine 10 𝜇g/kg/min) and admitted to PICU.

Table 4.4: Management of the Malnourished Child with Shock


Severely malnourished children have a high risk of mortality if they are given too much IV fluid because they are more likely to become fluid overloaded. Thus, IV fluid must be carefully titrated because it may not reverse the shock if too little is given, may be life-saving if the correct amount is given or may be life-threatening if given in excess.

The approach to shock is initially the same as in the non-malnourished. Once perfusion is restored, the child should be switched to enteral fluids and rehydrated over 24 hours (see treatment section below).

If fluid overload develops then all fluids must be stopped and the child urgently discussed with a senior clinician; see related image here.


Evaluate the child’s hydration status by assessing the characteristics laid out in the table below.

Table 4.5: Features of Mild-to-Moderate and Severe Dehydration
5% Dehydrated (Mild-to-Moderate) 50 mL/kg loss 10% Dehydrated (Severe) 100 mL/kg loss (>2 of the signs below)
Body weight loss 5–10% >10%
Eyes Sunken Sunken
Thirst Increased and drinking regularly Drinking poorly
Activity Restless/irritable Lethargic
Skin turgor (pinch) Normal (raised for <2 seconds) Decreased (stays raised for >2 seconds)
Mucous membranes Dry Dry
Tears Normal/slightly reduced Absent
Urine output Oliguric Oliguric or anuric
Anterior fontanelle Normal Sunken
Shock No signs May have signs if very severe – use resuscitation algorithm

One should also evaluate nutritional status – assess the patient for SAM as it is commonly associated with AGE.


Admission criteria for the dehydrated child are:

Rapid Rehydration

Otherwise healthy children should be rapidly rehydrated via the gut. Enteral rehydration should be performed whenever possible. IV and IO lines are only for patients who are shocked or have failed oral therapy, since there is greater danger of fluid overload, among other concerns. A nasogastric tube can be used, especially in patients whose airways are at risk e.g. very lethargic children, severely dehydrated children who refuse to or are unable to drink. The estimated hydration status assessment shown above is important as one does not want to give too much fluid (such that the child cannot tolerate it and becomes fluid overloaded) nor too little fluid (such that the rehydration is ineffective). One may adjust the amount of rehydration fluid given if need be e.g. if the child is not responding after a few hours or does not tolerate the volume of feeds/fluids.

Table 4.6: Rehydration of Mild-to-Moderate and Severe Dehydration
Mild-to-moderate Dehydration Severe Dehydration
  • Give ORS at a rate of 10–12,5 mL/kg/hour for 4–6 hours (one is aiming to replace the 50 mL/kg loss i.e. 10 mL/kg/hour for 5 hours)
  • Breastfeed if tolerated, but initially continue ORS feeds if the child is usually formula-fed
  • Replace ongoing losses with ORS
  • Resume age-appropriate diet once rehydrating
  • Give ORS at a rate of 20–25 mL/kg/hour for 4–6 hours (one is aiming to replace the 100 mL/kg loss i.e. 20 mL/kg/hour for 5 hours)
  • Breastfeed if tolerated, but initially continue ORS feeds if the child is usually formula-fed
  • Replace ongoing losses with ORS
  • Resume age-appropriate diet once rehydrating

If the child is not tolerating oral fluids, ½ Darrows dextrose (DD) may be given IV. However, in the child who is vomiting, one should give rehydration fluid (0,45% normal saline and 5% dextrose) with added potassium (20 mmol/L), as this is most appropriate.

Slow Rehydration

Rapid rehydration should be avoided in certain sick children. These children include those with:

Instead one should rehydrate these children over 24–48 hours, using the same amounts as above over the longer period i.e. 100 mL/kg/day for severe and 50 mL/kg/day for mild-moderate cases (see hydration formula recommended by UNICEF here).


Maintenance fluid requirements are calculated as follows for children less than 60 kg, and added to the above rehydration prescription if necessary:

Table 4.7: Maintenance Fluids
All ages Can get fluids by breastfeeding on demand, replacing the below
<3 months old 150 mL/kg/day
3 months – 1 year 120 mL/kg/day
>1 year
  • 1–10 kg: 100 mL/kg/day for 1st 10 kgs
  • 10–20 kg: 50 mL/kg/day for 2nd 10 kgs
  • For every kg >20 kg: 25 mL/kg/day

Maintenance fluids for children >1 year old can be remembered using the 4:2:1 rule: 4 x every kg in the first 10 kg, 2 x every kg in the next 10 kg, and 1 x every kg thereafter (i.e. >20 kg). The sum of these amounts gives you the hourly maintenance fluid requirement. If this sum is multiplied by 25, one will get the daily total.

Example: A 24 kg child needs 64 mL/hour (10x4 + 10x2 + 4x1) and 1600 mL/day (24x25). That can be distributed as nasogastric feeds at a rate of 67 mL per hour.

If maintenance is to be given intravenously only, one must choose an age-appropriate dextrose-containing solution e.g. neonatalyte (10% dextrose) in neonates and small infants; maintelyte (5% dextrose) in older children. These solutions are usually mildly hypotonic and often equivalents can be made up by adding the desired dextrose concentration to a crystalloid.

For small children and infants, total daily fluid intake should be carefully tallied, considering all supplemental fluids, including any dilutants for medications. These additional fluids should be considered part of fluid provision and, therefore, subtracted from the maintenance amount (see hospitalized child with Intravenous Fluids here).

The child should be weighed six-hourly to objectively assess gains or losses.

Ongoing losses

Ongoing losses should be calculated for continuous losses (usually stools but sometimes vomits). These can be counted precisely, using an estimate of 5–10 mL/kg/stool. These feeds can be given immediately after stools if stool passage is measured e.g. in a high-care setting where monitoring, care and staff is plentiful.

Often such precision is impossible, and ongoing losses are assumed to be 20–30 mL/kg/day if the bout of acute gastroenteritis is known to be ongoing. This amount can be added to the daily fluid requirements for rehydration and maintenance.