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Clinical Nutrition 3 > Neonatal Nutrition > Flashcards

Neonatal Nutrition Flashcards

1
Q

Causes of prematurity?

A
  • Socio-economic
  • Complications during pregnancy
  • Multiple pregnancy
  • Fetal issues
  • Gynaecological
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2
Q

Socio-economic factors?

A

-Low income groups, close pregnancies, work related stress, age, alcohol and drug abuse, smoking

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3
Q

Gynaecological factors

A

-uterine anomalies, incompetent or short cervix

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4
Q

Fetal factors?

A

-Congenital malformations, intrauterine growth restriction

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5
Q

Multiple pregnancy factors?

A

Having twins, triplets

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6
Q

Complications during pregnancy factors?

A

-Placenta previa, pre-eclampsia, infection

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7
Q

Pre-term classification?

A

<37 weeks at birth

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8
Q

Extreme pre-term classification?

A

GA <29 weeks at birth

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9
Q

Late pre-term classification?

A

GA 34-37 weeks at birth

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10
Q

ELBW?

A

<1000g

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11
Q

VLBW?

A

1001-1500g

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12
Q

LBW

A

1501-2500g

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13
Q

Normal BW?

A

> 2500 g

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14
Q

What is used a a growth curve for pre-mature babies?

A

The Fenton growth curve

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15
Q

How was the fenton growth chart developed?

A
  • Large pre-term birth sample size of 4-million infants

- Data developed from countries including Germany, U.S, Australia, Scotland and Canada

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16
Q

What does the Fenton chart start at? What is it’s equivalent on the WHO growth chart?

A
  • Starts at 22 weeks of gestation until 50 weeks corrected GA
  • Equivalent to the WHO growth-charts at 50 weeks corrected GA
  • Chart is designed to enable plotting as infants are measured NOT as completed weeks
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17
Q

When is a baby small for gestational age/ (SGA)

A

When less than 10%ile birthweight for GA

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18
Q

When is a baby appropriate for gestational age? (AGA)?

A

Between 10th and 90th%ile for GA

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19
Q

When is a baby large for gestational age? (LGA)

A

When greater than 90th% for GA

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20
Q

What is intrauterine growth restriction (IUGR)?

A

-Failure of the fetus to achieve normal predicted growth in-utero

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21
Q

What is symmetric IUGR?

A

-Weight, length and head circumference less that 10%ile. Indicative of chronic malnutrition

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22
Q

What is asymmetric IUGR?

A

-Length and head circumference are appropriate, but weight is below the 10%ile. Better as head sparing, recall that any nutrition will protect the head first

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23
Q

How is corrected GA calculated?

A

GA + (CA/7)

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24
Q

If an infant was born at 24 weeks + 5 days of life gestation, and is at day of life 28, what is the CGA?

A

GA= 24 weeks+ 5 days+ 28/7

Is at 28 weeks and 5 days of life

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25
Q

What is the ohio neonatal screening criteria (ONSC) used for

A

Identifying Hospitalized infants at the Highest nutritional risk

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26
Q

ONSC <1 week of age?

A

> 15% weight-loss from birth-weight

<1 kg at birth

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27
Q

ONSC 1-2 weeks of age?

A

<70 kcal/kg/day or any continued weight-loss

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28
Q

ONSC >2 weeks of age intake and expected weight gain?

A
  • Intake <80% of expected energy requirements
  • <15 g/kg/day weight gain and <36 weeks GA
  • <1/2 expected weight gain and >36 weeks GA
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29
Q

ONSC >2 weeks lab values?

A
  • Pre-albumin <8 mg/dL or albumin <2.5 g/dl
  • BUN <7 mg/dL
  • Serum phosphorous <4 mg/dL
  • Alkaline phosphatase >600 mg/dL
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30
Q

ONSC >2 month of age?

A
  • Same as >2 weeks age plus

- No source of dietary iron and continuedPN

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31
Q

Nutritional Goals in the Neonate?

A
  • Provide nutrients to approximate the rate of growth and composition of weight gain for a normal fetus
  • Maintain normal concentrations of blood and tissue nutrients
  • Achieve a satisfactory functional outcome similar to that of an infant born at term
  • Ensure individualized nutrition support adapted to ongoing medical complications
  • Establish and adequate follow-up in the community
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32
Q

What is the placenta previa?

A

When the placenta is very close to the birth canal, will block the baby and there is a large risk of bleeding
–> A cause of prematurity

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33
Q

Factors Affecting nutritional status in the neonate?

A
  • Immature systems
  • Decreased reserves
  • Decreased Absorption
  • Medical issues
  • GI Immaturity
  • Thermoregulation
  • GI and Respiration
  • Respiration
  • Medical Issues
  • Decreased Absorption of Nutrients
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34
Q

Gastrointestinal immaturity?

A

-Reduced gastric capacity, decreased GI motility, reduced gastric emptying, decreased concentration of digestive enzymes, inadequate LES closure, inadequate capacity to suck and swallow

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35
Q

Thermoregulation?

A

-Decreased fat reserves, unable to maintain body temperature

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36
Q

GI and Respiration?

A

-Poor suck, swallow and breathe coordination

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37
Q

Respiration?

A

-Immature lungs, increased work of breatning

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38
Q

Medical Issues?

A

-Respiratory distress syndrome, hypoglycemia, hyperbilirubinemia, hemodynamic instability, risk of sepsis

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39
Q

Decreased absorption of nutrients specific to fats?

A

-Decreased bile salts and pancreatic lipase, at 32 weeks only 65–75% fat absorption

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40
Q

(T/F) A baby with IUGR is always SGA

A

False

IUGR is defined by a reduction in growth rate in utero, technically if the inhibition of the growth rate does not produce a child less than 10% percentile they may actually by AGA or LGA. Notably, children who are SGA may not necessarily be IUGR either - it could simply be that they were born to small parents
–> Good to see if it is symmestric or disproportional IUGR

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41
Q

Decreased absorption of nutrients specific to lactose?

A

-At 26-34 weeks, only 30% of absorption

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42
Q

Decreased absorption of nutrients specific to protein?

A

-At 28-34 weeks, only 70% absorption

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43
Q

When do we stop correcting the GA?

A

After 40 weeks

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44
Q

When can we start identifying the premature babies age in months?

A

Only when they have reached the term age

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45
Q

What is extremely notable about the premature baby?

A

They have extremely decreased cab, fat and protein reserves (Almost half the amount of the term baby)
–>Therefore, this is why the requirements of the term baby are much, much higher

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46
Q

What should be included in the initial nutritional assessment?

A
  • Maternal History
  • Infant
  • Medications
  • Physical
  • GI
  • Biochemical
  • Clinical signs
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47
Q

Maternal history in initial nutritional assessment?

A
  • VERY important
  • PMHX to interpret towards the baby
  • Previous premie baby or issues with other babies - may be used to interpret with this baby
  • Allergies (Keep an eye on feeding intolerances)
  • Medications
  • Social factors, skin-to-skin contact with the baby is important
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48
Q

When is Magnesium sulfate given?

A
  • If mothers experience pre-eclampsia during pregnancy
  • It will also help with neuroprotection of the baby
  • Unfortunately it decreases the GI motility and make sure to watch out for feeding intolerances
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49
Q

Infant information in initial nutritional assessment ?

A
  • Gender
  • Level of prematurity
  • Weight category
  • Days of life
  • CGA
  • APGAR score
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50
Q

What is the APGAR score?

A

Doctors routinely assess a baby’s general condition by measuring performance in five categories: heart rate, respiratory effort, colour, muscle tone, and reflex irritability (the baby’s response to suctioning)

  • -> If less than 5, may be hesitant to start feeds
  • ->If there is every oxygenated issues, there will be issues with feeds which is why we may hold them
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51
Q

Why may some babies be on antibiotics?

A

Due to risk of sepsis, or they do have sepsis

–> However, can interfere with the gut microbiome

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52
Q

Why is caffeine used in premies?

A

-To help with respiratory issues or apnea

53
Q

Physical information in the initial nutritional assessment?

A
  • Length
  • Head
  • Circumference
  • Weight
  • Plot on fenton curve, SGA/AGA/LGA
  • IUGR
54
Q

GI information in the initial nutritional assessment?

A
  • Abdomen
  • Meconium
  • Bowel sounds
55
Q

What are the variables to consider for mode of nutrition?

A
  • GA
  • SGA/AGA/IUGR
  • Clinical status
  • Medications
  • Coordination of the suck/swallow/breathe
56
Q

What are the feeding options to consider?

A
  • PN (total or partial)
  • EN (total or partial)
  • Breast feeding
  • Bottle feeds
57
Q

What are the indications for PN?

A
  • Congenital GI anomalies requiring surgical repair
  • Impaired GI motility
  • Malabsorption syndomes
  • Delayed or advancement of EN feeds
58
Q

Congenital GI anomalies which may be indications for PN?

A
  • Gastroschisis
  • Bowel obstruction
  • -> Will NOT be able to feed enough volume into this
59
Q

Impaired GI motility which may be indications for PN?

A
  • Ileus from sepsis
  • After surgical repair of gastroschisis
  • Hirsch Sprung disease
60
Q

Malabsorption syndromes which may be indications for PN?

A
  • SBS

- -Cystic Fibrosis

61
Q

When is the delayed initiation or advancement of feeds an issue?

A

Usually in larger infants

62
Q

When should the coordination of suck/swallow/breathe be developed?

A

Usually at term

63
Q

What are causes of impaired GI perfusion which may decrease GI motility

A
  • Patent ductus arteriosus (PDA)
  • Congenital heart disease (CHD)
  • Hypotension
  • Use of medications like ibuprofen
  • -> May be an indicator for PN
64
Q

What are other indications for PN? 93)/

A
  • Functional immaturity of the GI tract or GA at birth <30-32 weeks
  • NEC
  • Impaired GI perfusion that decreases GI motility
65
Q

When should PN be used as supplemental nutrition while advancing EN feeds?

A

When there is functional immaturity of the GI tract or gestational age at birth <30-32 weeks

66
Q

How show PN be initiated?

A

-Start as soon as the infant is born with at least a starter PN solution to help provide adequate kcals and protein

67
Q

What is gastric schisis?

A

When the baby is born with the intestine is outside of the abdomen

68
Q

Fluid minimum and maximum in TPN?

A

-initially 60-90 to 120-150 ml/kg/day

69
Q

Trophamine minimum and maximum in TPN?

A

-Start at 1.5-2 and advance up to a goal of 3.5-4g/kg/day

70
Q

Dextrose minimum and maximum in TPN?

A

-Can begin at 5-10 g/kg/day and to a maximum of 10-18 g/kg/day

71
Q

Lipids minimum and maximum in TPN?

A

0.5-1 g/kg/day to a maximum of 3 g /kg/day

72
Q

In adult nutrition, we do ml/day for fluids, how does this differentiate for neonates?

A

We will do ml/kg to be more precise

73
Q

In TPN, providing less than ____ may put the infant into a catabolic state

A

<50 kcal/kg/day

74
Q

PN should be continued until when? (2)

A
  • Until the infant tolerates at least 75-80% of energy goal or is within 2-3 days of achieving the goal enteral volume
  • being within 2-3 days of achieving the goal enteral volume
75
Q

Infants _____ need TPN to help optimize nutritional status

A

<1800 g

76
Q

How is TPN provided?

A
  • Given by peripheral (short-term/low-osmolality) or central line (long-term/higher osmolality)
  • Short term is about one week
77
Q

En indiactions?

A

All infants unable to meet nutritional requirements orally:

  • Premature infants <34 weeks of GA
  • Transition from PN towards oral intake
  • Poor suck/swallow/breathe coordination
78
Q

EN contraindications?

A
  • Severe respiratory distress syndrome
  • GI anomalies (esophageal atresia, bowel obstruction)
  • Necrotising enterocolitis
79
Q

EN routes available?

A
  • Orogastric tube

- Nasogastric tube

80
Q

What are the two types of EN methodologies?

A

1) Bolus feeds (q 2-3 hours x 24 hours)

2) Continuous feeds (every hour x 24 hours)

81
Q

When can oral feeds be given?

A
  • When an infant bon at >/= 34 weeks GA or when it reaches >/= 34 weeks of CGA
  • Ultimately when their suck, swallow and breathing coordination is better
82
Q

How may the transition between EN and oral be seen?

A

-Transition may be gradual necessitating supplementation with EN feeds until the infant is able to take all p.o feeds

83
Q

How can we assess a baby’s ability to suck, swallow or breathe?

A
  • Start with breast or bottle

- Breast is best due to the psychosocial effects

84
Q

Why did we use to have late EN? Why are we now using early EN?

A
  • We used to be concerned with NEC and early EN, therefore we used to delay feeds
  • However, studies show that when full EN feeds are reached earlier, there is no evidence of a difference in NEC
  • Furthermore, early feeding resulted in a shorter duration of PN
85
Q

What is the BEST choice for EN feeds?

A

Breast milk

86
Q

Advantages of breast milk?

A
  • Optimal distribution of calories
  • Immune factors, hormones, enzymes
  • Decreased gastric transit times
  • Better absorption of nutrients (Fat, iron, zn)
  • Lower renal solute load
  • *Protection from NEC
  • Long-term effects
87
Q

What is one of the most notable advantages of breast milk within the context of the NICU?

A
  • Protection from NEC

- Therefore push for EN feeds (early) with breast-milk

88
Q

What are the long-term effects of breast-milk?

A
  • Better neurocognitive development
  • Immunity
  • Prevention of allergies
89
Q

(T/F) If we can’t get mothers best milk, providing the baby with formula is the second best choice

A

F

Using donor breast milk is the second best choice, an then we can go to formula

90
Q

(T/F) Formulas for pre-term infants contain a higher amount of nutrients than term infant formulas

A

T

91
Q

Protein source in formula for pre-terms?

A
  • Cows milk protein
  • 3.0-3.3g/100 kcal in pre-term
  • 2.7-3.0 g/100 kcal interms formulas
92
Q

CHO source in pre-term formula?

A
  • Corn syrup solids or maltodextrin

- 50% lactose

93
Q

Fat source in preterm formula

A

-Variety of vegetable oils and MCT 40-50%

94
Q

Vitamins in pre-term formulas?

A

-Adapted to pre-mature infant needs

95
Q

Minerals in pre-term formulas?

A

-Almost double the amount of calcium and phosphorus vs that of a term infant formula

96
Q

What type of EN is given?

A
  • Oral immune therapy

- Trophic feeds

97
Q

Oral immune therapy?

A
  • Oral care with colostrum, to help stimulate the immune system
  • To start if contraindications to feed to gut
  • NOT expected to reach the gut, 1.0 ml every 4 hours between cheek and gums
98
Q

Trophic feeds?

A
  • To begin as soon as clinically appropriate at 10-24 ml/kg/day
  • Helps stimulate GI motility, development of microbial flora, growth of microvilli
  • Increased milk tolerance, increased postnatal growth, decreased systemic sepsis, decreased length of stay
99
Q

How are feed progressions based? What is the rate?

A
  • Can be based on birthweight and/or gestational age

- Feed progression rate can be between 20-40 ml/kg/day

100
Q

What is important about the baby weight and feeds?

A

The weight needs to be adjusted nearly every day, as changes in weight is so rapid
–> Therefore they need to be followed up almost everyday

101
Q

What are the different feeds that infants may be on? (5)

A
  • PN
  • PN and EN
  • EN
  • EN and P.O feeds
  • Bottle feeds and or breastfeeding
102
Q

PN and EN?

A
  • When on PN and EN, PN is reduced as EN feeds are increased to maintain total fluid intake
  • once PN is running at keep vein open status (around 2ml/hr_ it is usually stopped and EN feeds are progressed to match total fluid intake
103
Q

Nutrient recommendations fluids for pre-term vs RDA/AI 0-6 months?

A
  • 135-200 ml/kg/day

- 0.7 L/day

104
Q

Nutrient recommendations energy for pre-term vs RDA/AI 0-6 months?

A
  • 110-135 kcal/kg/day

- 555 kcal/day

105
Q

Nutrient recommendations proteins for pre-term vs RDA/AI 0-6 months?

A
  • 3.5-4.5 g/kg/day

- 9.1 g/day

106
Q

Nutrient recommendations lipids for pre-term vs RDA/AI 0-6 months?

A
  • 4.8-6.6 g/kg/day

- 31 g/day

107
Q

Nutrient recommendations calcium for pre-term vs RDA/AI 0-6 months?

A
  • 120-200 mg/kg/day

- 210 mg/day

108
Q

Nutrient recommendations phosphate for pre-term vs RDA/AI 0-6 months?

A
  • 60-140 mg/kg/day

- 100 mg/day

109
Q

Nutrient recommendations iron for pre-term vs RDA/AI 0-6 months?

A
  • 2-3 mg/kg/day

- 0.27 mg/day

110
Q

What is the total fluid intake (TFI) in infants?

A

-All IV fluids,IV medications and EN volume

111
Q

Initial TFI for <1 kg?

A

90-120 ml/kg/day

112
Q

Initial TFI for <1-1.5 kg?

A

70-90 ml/kg/day

113
Q

Initial TFI for >1/5 kg/dat

A

60-80 ml/kg/day

114
Q

Final recommended volumes for fluid?

A

135-200ml/kg/day

–> At least 150 ml/kf/day for optimal nutrition

115
Q

When are the fluid intake requirements higher?

A

-Secondary surface to skin ratio, immature kidney, rapid growth rate, need for phototherapy

116
Q

When are the fluid intake requirements lower?

A

-If oliguric or PDA (giving larger pressure on the heart)

117
Q

What is the goal in fluid intake? What should be monitored?

A
  • Prevent over-hydration or dehydration

- Weight monitored on a DAILY basis

118
Q

Minimum energy for infants per day?

A

120 kcal/kg/day

119
Q

What results in the final number of 120 kcal/kg/day?

A
  • Intermittent activity
  • Resting caloric expenditure
  • Occasional cold stress
  • Specific dynamic action
  • Fecal loss of calories
  • Growth allowance
120
Q

Intermittent activity?

A

15 kcal/kg/day

121
Q

Resting caloric expenditure?

A

50 kcal/kg/day

122
Q

Occasional cold stress?

A

10 kcal/kg/day

123
Q

Specific dynamic action?

A

8 kcal/kg/dat

124
Q

Fecal loss of kcals?

A

12 kcal/kg/day

125
Q

Growth allowance?

A

25 kcal/kg/day

126
Q

How does the milk content of the pre-term milk change?

A
  • The milk production can “sense” that there is a pre-term baby
  • Is significantly higher in protein (2.1 kcal/ml vs 1.0 kcal/ml)
  • BUT breastmilk still needs to be fortified to meet requirement
  • Monitor growth, BUN and plasma proteins
127
Q

Iron in breast milk?

A
  • Decreased iron reserves in the baby, and not much in the breastmilk (adaptation to increase iron by the mother)
  • Must receive supplementation to baby 2-4 week of life**
  • Fortification of breast milk is not adequate
  • Pre-term formulas are enriched with iron
  • Monitoring of blood Hgb levels closely, may affect growth
128
Q

How should we progress a babu with iron supplementation?

A
  • We should optimize nutrition first, and make sure the baby is tolerating feeds as the iron may be irritating to they baby’s stomach
  • We have a 2-4 week window for this adaptation
129
Q

Calcium, phosphorous and vitamin D supplementation?

A
  • Osteopenia is a common problem among pre-mature infants
  • Need to fortify breastmilk given premature infant formulas
  • Supplement with calcium and vitamin D
  • To monitor calcium phosphorous ratio and alkaline phosphatase levels **
  • *Formulas usually have enough vitamin D, but depends on requirements**

Clinical Nutrition 3 (30 decks)

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