Feeding special care babies

Question 1

What are the nutritional problems of LBW babies?

Answer 1

• GREATER ENERGY AND FLUID REQUIREMENTS
• LIMITED NUTRIENT STORES
• PHYSIOLOGICAL IMMATURITY

Question 2

Why is there greater energy and fluid requirements with LBW babies?

Answer 2

• Fluid balance is related to fluid intake, protein and mineral content of the diet, metabolic and ventilation rates, urinary losses, loss in stools and insensible losses.
• Adequate fluid balance is essential for cell growth. LBW infants require 80-200ml/Kg/day.
• The high requirements are due to greater urinary and insensible losses and higher metabolic rates. Treatments such as phototherapy add to fluid loss.
• Requirements are even higher for VLBW infants as they lose considerable amounts of fluid through their more permeable skin

Question 3

Why are there greater energy requirements with LBW babies?

Answer 3

• Poor heat regulation can mean far higher calorie requirements if infants are not nursed in an environment which maintains optimum body temperature.
• Routine nursing care can increase the newborn’s energy requirements by as much as 10% (Whyte et al 1985, cited in Darby and Loughead 1996)
• Sick infants have higher requirements for both energy and fluid

Question 4

Why are there limited nutrient stores with LBW babies?

Answer 4

• Limited stores of glycogen and fat are frequently consumed during labour and delivery.
• Preterm infants haemoglobin is generally lower than full term baby and lower iron stores + loss from frequent blood sampling. Faster growth depletes iron stores. Preterm formulae are supplemented with iron, breast fed infants require supplements
• Vit E stores are low in prems supplementation may be recommended research controversies ? Helps prevent retinopathy, IVH ? Makes more likely NEC and sepsis
• 2/3rds of transplacental transport and storage of calcium and phosphorous occurs during 3rd trimester therefore infants born before 34 weeks lack necessary stores.
• Vit D stores laid down in 3rd trimester and may be low particularly if mothers stores were low.
• Preterm infants require at least twice as much calcium and phosphorous than in breast milk and therefore generally need supplementation to prevent rickets •Before Low Birth Weight Formulas VLBW infants suffered from osteopenia - difficult ventilator weaning, growth retardation and bone fractures during routine care. Metabolic bone disease was frequently seen as fractures of ribs on X-ray

Question 5

How does physiological immaturity of the gastrointestinal system affect the newborn?

Answer 5

Sucking and swallowing
Regurgitation
Small gastric volume
Slow gastric emptying
Low motility

Question 6

How does physiological immaturity of the gastrointestinal system cause malabsorption in the newborn?

Answer 6

–Developmental lactase deficiency (34 weeks only 1/3 lactase activity of full term) Can absorb other disaccharides as well as full term.
–Short chain glucose polymers are digested easily therefore preterm formulae have <50% lactose and rest of carbohydrate is sucrose or glucose polymers
–Prone to fat malabsorption because of limited lipase activity, low bile salts production and limited bile salts recycling

Question 7

Physiological immaturity

Answer 7

• Altered protein metabolism–Reduced ability to synthesize and excrete urea–Protein intake for LBW controversial 3.5-4g/kg/day–LBW babies cannot make Taurine or Cystine so these must be provided in diet
• Urinary system –reduced excretion of urea, inability to concentrate urine, sodium and water loss
• Liver immaturity –Increased risk of jaundice–Reduced ability to metabolize nutrient

Question 8

Nutritional care of VLBW babies

Answer 8

NUTRITIONAL CARE OF VLBW BABIES•Immediately after birth–Special attention to - glucose homeostasis fluid and electrolyte balance•Within 2 or 3 days–Parenteral nutrition until tolerating sufficient enteral feeds–Growing knowledge -> better formulae–Amount increased slowly over 8 days–Fats infused separately

Question 9

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Answer 9

NUTRITIONAL CARE OF VLBW BABIES•As soon as metabolically stable - if poss. in 1st week–Introduction of minimal enteral feeds - bowel maturation–Studies needed as to volume (0.1 - 4mg/Kg/day in use)–Gradual increase of enteral feeds–Research needed on continuous v bolus feeds–EBM should not be continuously fed - loss of LCPs•Transpyloric feeding is not now generally recommended•Tube feeds can be continued at home

Question 10

What are the indications for parental nutrition?

Answer 10

• Babies of very low birth weight/extreme prematurity - intolerance of enteral feeds
• Sick babies being ventilated - poor gut motility
• Babies with NEC - to rest gut
• Babies with intestinal defects
• Babies requiring surgery
• Babies who have large pieces of bowel removed

Question 11

Central lines

Answer 11

• Peripheral lines are inadequate
• Central venous lines needed but these have complications
• Metabolic – no digestive enzymes
• Mechanical – they can move
• Infection – damaged vessel walls and on plastic
• Blockage – food or blood clots

Question 12

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Answer 12

OROGASTRIC/NASOGASTRIC TUBE FEEDING•Babies < 34 weeks with poor ability to suck•Babies with conditions making sucking difficult•Babies who become exhausted/desaturated by sucking•Nasogastric tubes may alter breathing•Orogastric tubes displace easier unless dental plates used

Question 13

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Answer 13

NASOGASTRIC TUBES•Nasogastric tubes are measured from the tip of the sternum to the bridge of the nose on to the top of the ear. –This length should ensure the tip is in the stomach.–Checked by aspiration of acid contents •Syringe pump feeding - –Risk of infection–Fats adhere to plastic–Recommended for VLBW by some–Bolus feeding asap–Hourly feeds slowly increase to 3 hourly

Question 14

Transition to breast or bottle

Answer 14

•Non-nutritive suckling - a dummy
–Greater weight gain
–Associates sucking with food
–Accelerates maturation of sucking
•Gradual introduction of breast or bottle
•Direct expression is possible from 30 weeks
•Cup feeding can reduce the need for tubes and can replace bottles

Question 15

What other feeding methods are there?

Answer 15

• Finger feeding
• Syringe feeding
• Cup feeding – http://www.unicef.org.uk/BabyFriendly/News-and-Research/Research/Miscellaneous-illnesses/Cup-feeding-versus-other-forms-of-supplemental-enteral-feeding-for-newborn-infants-unable-to-fully-breastfeed/
• See also link to cochrane review at the end of this and a more recent study Yilmaz et al in the reference list below
• If possible learn how to cup feed on your SCBU placement it is easier with preterm babies than with term infants

Question 16

Why is breast milk best for the pre- term baby?

Answer 16

• Better absorption
• Less bowel irritation
• Anti-infective properties
• Reduced risk of allergies developing
• Contains substances absent in formulae
• Nerve growth factor
• Insulin like growth factor
• DHA & AA (LCPUFAS)
• Contains correct proportions of saturated: unsaturated fat and of linoleic: a linoleic acid
• Rapidly raises Vitamin E and betacarotene levels
• Reduces risk of NEC (see next slide)
• Reduces time on NNU

Question 17

Why is a mother’s own fresh breast milk best for a pre-term baby?

Answer 17

•Milk of mothers delivered preterm contains more
–Growth factors
–Protein
–Sodium chloride than term breast milk.
•Some evidence now that donor milk can be ‘seeded’ by mothers milk, and becomes more similar to that mothers own milk

Question 18

What are the effects of heating, freezing and thawing?

Answer 18

•Effects of heat treatment
–Destroys about 50% of protective substances
–Loss of some B6, C and folic acid
–Inactivates milk lipases
•Freezing and thawing effects
–Some vitamins are lost
–Milk lipases act on fat -> free fatty acids -> triglycerides (associated with breast milk jaundice)
–Fat globules are lost on containers
–Fat is disrupted -> loss of polyunsaturated fatty acids
•BUT – donor milk still better than formula

Question 19

What are the features of pre-term or LBW formulae?

Answer 19

• High energy 80 Kcal/100mls
• High protein - Cystine and taurine added
• Increased Ca, Ph and vitamin D
• Medium chain triglycerides – aid fat absorption, however Corn oil and Soya oil are low in docosahexanoic acid (DHA) and arachidonic acid (AA)
• Increased renal solute load – DANGEROUS FOR TERM BABIES

Question 20

Pre-term or LBW formulae

Answer 20

•Some formulae are being modified to alter LA: aLA ratios•Some add long chain polyunsaturated fatty acids•Most are low lactose, high in glucose polymers or corn syrup

Question 21

Why may breast milk supplements be used?

Answer 21

•Supplements may be required if:-
–Mother’s supply is inadequate
–Baby was malnourished as well as preterm
–Baby weighs < 1,800g (Baby requires more NaCl, Ca, Ph and vitamins)
–Baby cannot tolerate sufficient volume to meet energy needs (Energy supplements – Duocal or Maxijul)

• Some units use breast milk fortifiers – eg. Eoprotein
• Most units supplement with LBW formulae for babies < 1,800g
• Even small quantities of breast milk provide bile-salt stimulating lipase which may aid fat absorption
• Importance of colostrum

Question 22

What are some of the issues involved with feeding LBW babies?

Answer 22

•How to feed
–Gut maturity, Health, Treatment
–IV feeding, Naso/orogastric feeds
–Cup, Bottle, Breast, Other
•What to feed
–Breast milk alone
–Breast milk + minerals
–Breast milk + fortifiers
–Breast milk + LBW formula
–LBW formula

Question 23

Research issues

Answer 23

• Should we mimic intrauterine development?
• Should we mimic breast milk – which?
• Should we improve on breast milk?
• Preserving breast milk
• Controlled trials and maternal preference
• Ethics of withholding nutrients
• Confounding variables in studies involving breast feeding
• Problems in investigating one nutrient
• Measurement problems
• Is size important?
• Length of follow up

Question 24

Why might a special care baby need infant formula?

Answer 24

–Cows milk intolerance
–Lactose intolerance
–Fat malabsorption - cystic fibrosis
–Phenylketonuria
–Galactosaemia
–Errors of amino acid metabolism

Question 25

What are protein hydrolysate feeds?

Answer 25

•Generally used for:
–Babies with G.I. problems
–Babies with malabsorption problems
–Babies with suspected intolerance

Generally free from:- 
–soya
–lactose
–sucrose
–galactose
–Fructose

Hospital dieticians and the pharmacy can arrange for special formulae for specific disorder

Question 26

What are soya based feeds?

Answer 26

SOYA BASED FEEDS
•Infrasoy (C&G) and Wysoy (SMA)
•These are cows milk protein and lactose free
•Concerns –Allergies–Dental decay–High aluminium–Phytoestrogens
•They are not suitable for VLBW infants
•In many Trusts these formulae may only be given to newborns if they are prescribed by a paediatrician, however soy milk is available to mothers and the formulae are safer for babies than adult preparation

Question 27

How are babies with cleft palates fed?

Answer 27

• See Owens 2008 on reading list
• Do a google search but information is not very good
• Ask in SCBU what is done in your unit
• Importance of support for mother whatever she chooses to do
• Pierre Robins syndrome