Neonatal Nutrition Flashcards
1
Q
Causes of prematurity?
A
- Socio-economic
- Complications during pregnancy
- Multiple pregnancy
- Fetal issues
- Gynaecological
2
Q
Socio-economic factors?
A
-Low income groups, close pregnancies, work related stress, age, alcohol and drug abuse, smoking
3
Q
Gynaecological factors
A
-uterine anomalies, incompetent or short cervix
4
Q
Fetal factors?
A
-Congenital malformations, intrauterine growth restriction
5
Q
Multiple pregnancy factors?
A
Having twins, triplets
6
Q
Complications during pregnancy factors?
A
-Placenta previa, pre-eclampsia, infection
7
Q
Pre-term classification?
A
<37 weeks at birth
8
Q
Extreme pre-term classification?
A
GA <29 weeks at birth
9
Q
Late pre-term classification?
A
GA 34-37 weeks at birth
10
Q
ELBW?
A
<1000g
11
Q
VLBW?
A
1001-1500g
12
Q
LBW
A
1501-2500g
13
Q
Normal BW?
A
> 2500 g
14
Q
What is used a a growth curve for pre-mature babies?
A
The Fenton growth curve
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
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
17
Q
When is a baby small for gestational age/ (SGA)
A
When less than 10%ile birthweight for GA
18
Q
When is a baby appropriate for gestational age? (AGA)?
A
Between 10th and 90th%ile for GA
19
Q
When is a baby large for gestational age? (LGA)
A
When greater than 90th% for GA
20
Q
What is intrauterine growth restriction (IUGR)?
A
-Failure of the fetus to achieve normal predicted growth in-utero
21
Q
What is symmetric IUGR?
A
-Weight, length and head circumference less that 10%ile. Indicative of chronic malnutrition
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
23
Q
How is corrected GA calculated?
A
GA + (CA/7)
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
25
What is the ohio neonatal screening criteria (ONSC) used for
Identifying Hospitalized infants at the Highest nutritional risk
26
ONSC <1 week of age?
>15% weight-loss from birth-weight
| <1 kg at birth
27
ONSC 1-2 weeks of age?
<70 kcal/kg/day or any continued weight-loss
28
ONSC >2 weeks of age intake and expected weight gain?
- 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
29
ONSC >2 weeks lab values?
- 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
30
ONSC >2 month of age?
- Same as >2 weeks age plus
| - No source of dietary iron and continuedPN
31
Nutritional Goals in the Neonate?
- 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
32
What is the placenta previa?
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
33
Factors Affecting nutritional status in the neonate?
- Immature systems
- Decreased reserves
- Decreased Absorption
- Medical issues
- GI Immaturity
- Thermoregulation
- GI and Respiration
- Respiration
- Medical Issues
- Decreased Absorption of Nutrients
34
Gastrointestinal immaturity?
-Reduced gastric capacity, decreased GI motility, reduced gastric emptying, decreased concentration of digestive enzymes, inadequate LES closure, inadequate capacity to suck and swallow
35
Thermoregulation?
-Decreased fat reserves, unable to maintain body temperature
36
GI and Respiration?
-Poor suck, swallow and breathe coordination
37
Respiration?
-Immature lungs, increased work of breatning
38
Medical Issues?
-Respiratory distress syndrome, hypoglycemia, hyperbilirubinemia, hemodynamic instability, risk of sepsis
39
Decreased absorption of nutrients specific to fats?
-Decreased bile salts and pancreatic lipase, at 32 weeks only 65--75% fat absorption
40
(T/F) A baby with IUGR is always SGA
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
41
Decreased absorption of nutrients specific to lactose?
-At 26-34 weeks, only 30% of absorption
42
Decreased absorption of nutrients specific to protein?
-At 28-34 weeks, only 70% absorption
43
When do we stop correcting the GA?
After 40 weeks
44
When can we start identifying the premature babies age in months?
Only when they have reached the term age
45
What is extremely notable about the premature baby?
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
46
What should be included in the initial nutritional assessment?
- Maternal History
- Infant
- Medications
- Physical
- GI
- Biochemical
- Clinical signs
47
Maternal history in initial nutritional assessment?
- 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
48
When is Magnesium sulfate given?
- 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
49
Infant information in initial nutritional assessment ?
- Gender
- Level of prematurity
- Weight category
- Days of life
- CGA
- APGAR score
50
What is the APGAR score?
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
51
Why may some babies be on antibiotics?
Due to risk of sepsis, or they do have sepsis
| --> However, can interfere with the gut microbiome
52
Why is caffeine used in premies?
-To help with respiratory issues or apnea
53
Physical information in the initial nutritional assessment?
- Length
- Head
- Circumference
- Weight
- Plot on fenton curve, SGA/AGA/LGA
- IUGR
54
GI information in the initial nutritional assessment?
- Abdomen
- Meconium
- Bowel sounds
55
What are the variables to consider for mode of nutrition?
- GA
- SGA/AGA/IUGR
- Clinical status
- Medications
- Coordination of the suck/swallow/breathe
56
What are the feeding options to consider?
- PN (total or partial)
- EN (total or partial)
- Breast feeding
- Bottle feeds
57
What are the indications for PN?
- Congenital GI anomalies requiring surgical repair
- Impaired GI motility
- Malabsorption syndomes
- Delayed or advancement of EN feeds
58
Congenital GI anomalies which may be indications for PN?
- Gastroschisis
- Bowel obstruction
- -> Will NOT be able to feed enough volume into this
59
Impaired GI motility which may be indications for PN?
- Ileus from sepsis
- After surgical repair of gastroschisis
- Hirsch Sprung disease
60
Malabsorption syndromes which may be indications for PN?
- SBS
| - -Cystic Fibrosis
61
When is the delayed initiation or advancement of feeds an issue?
Usually in larger infants
62
When should the coordination of suck/swallow/breathe be developed?
Usually at term
63
What are causes of impaired GI perfusion which may decrease GI motility
- Patent ductus arteriosus (PDA)
- Congenital heart disease (CHD)
- Hypotension
- Use of medications like ibuprofen
- -> May be an indicator for PN
64
What are other indications for PN? 93)/
- Functional immaturity of the GI tract or GA at birth <30-32 weeks
- NEC
- Impaired GI perfusion that decreases GI motility
65
When should PN be used as supplemental nutrition while advancing EN feeds?
When there is functional immaturity of the GI tract or gestational age at birth <30-32 weeks
66
How show PN be initiated?
-Start as soon as the infant is born with at least a starter PN solution to help provide adequate kcals and protein
67
What is gastric schisis?
When the baby is born with the intestine is outside of the abdomen
68
Fluid minimum and maximum in TPN?
-initially 60-90 to 120-150 ml/kg/day
69
Trophamine minimum and maximum in TPN?
-Start at 1.5-2 and advance up to a goal of 3.5-4g/kg/day
70
Dextrose minimum and maximum in TPN?
-Can begin at 5-10 g/kg/day and to a maximum of 10-18 g/kg/day
71
Lipids minimum and maximum in TPN?
0.5-1 g/kg/day to a maximum of 3 g /kg/day
72
In adult nutrition, we do ml/day for fluids, how does this differentiate for neonates?
We will do ml/kg to be more precise
73
In TPN, providing less than ____ may put the infant into a catabolic state
<50 kcal/kg/day
74
PN should be continued until when? (2)
- 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
Infants _____ need TPN to help optimize nutritional status
<1800 g
76
How is TPN provided?
- Given by peripheral (short-term/low-osmolality) or central line (long-term/higher osmolality)
- Short term is about one week
77
En indiactions?
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
EN contraindications?
- Severe respiratory distress syndrome
- GI anomalies (esophageal atresia, bowel obstruction)
- Necrotising enterocolitis
79
EN routes available?
- Orogastric tube
| - Nasogastric tube
80
What are the two types of EN methodologies?
1) Bolus feeds (q 2-3 hours x 24 hours)
| 2) Continuous feeds (every hour x 24 hours)
81
When can oral feeds be given?
- 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
How may the transition between EN and oral be seen?
-Transition may be gradual necessitating supplementation with EN feeds until the infant is able to take all p.o feeds
83
How can we assess a baby's ability to suck, swallow or breathe?
- Start with breast or bottle
| - Breast is best due to the psychosocial effects
84
Why did we use to have late EN? Why are we now using early EN?
- 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
What is the BEST choice for EN feeds?
Breast milk
86
Advantages of breast milk?
- 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
What is one of the most notable advantages of breast milk within the context of the NICU?
- Protection from NEC
| - Therefore push for EN feeds (early) with breast-milk
88
What are the long-term effects of breast-milk?
- Better neurocognitive development
- Immunity
- Prevention of allergies
89
(T/F) If we can't get mothers best milk, providing the baby with formula is the second best choice
F
Using donor breast milk is the second best choice, an then we can go to formula
90
(T/F) Formulas for pre-term infants contain a higher amount of nutrients than term infant formulas
T
91
Protein source in formula for pre-terms?
- Cows milk protein
- 3.0-3.3g/100 kcal in pre-term
- 2.7-3.0 g/100 kcal interms formulas
92
CHO source in pre-term formula?
- Corn syrup solids or maltodextrin
| - 50% lactose
93
Fat source in preterm formula
-Variety of vegetable oils and MCT 40-50%
94
Vitamins in pre-term formulas?
-Adapted to pre-mature infant needs
95
Minerals in pre-term formulas?
-Almost double the amount of calcium and phosphorus vs that of a term infant formula
96
What type of EN is given?
- Oral immune therapy
| - Trophic feeds
97
Oral immune therapy?
- 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
Trophic feeds?
- 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
How are feed progressions based? What is the rate?
- Can be based on birthweight and/or gestational age
| - Feed progression rate can be between 20-40 ml/kg/day
100
What is important about the baby weight and feeds?
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
What are the different feeds that infants may be on? (5)
- PN
- PN and EN
- EN
- EN and P.O feeds
- Bottle feeds and or breastfeeding
102
PN and EN?
- 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
Nutrient recommendations fluids for pre-term vs RDA/AI 0-6 months?
- 135-200 ml/kg/day
| - 0.7 L/day
104
Nutrient recommendations energy for pre-term vs RDA/AI 0-6 months?
- 110-135 kcal/kg/day
| - 555 kcal/day
105
Nutrient recommendations proteins for pre-term vs RDA/AI 0-6 months?
- 3.5-4.5 g/kg/day
| - 9.1 g/day
106
Nutrient recommendations lipids for pre-term vs RDA/AI 0-6 months?
- 4.8-6.6 g/kg/day
| - 31 g/day
107
Nutrient recommendations calcium for pre-term vs RDA/AI 0-6 months?
- 120-200 mg/kg/day
| - 210 mg/day
108
Nutrient recommendations phosphate for pre-term vs RDA/AI 0-6 months?
- 60-140 mg/kg/day
| - 100 mg/day
109
Nutrient recommendations iron for pre-term vs RDA/AI 0-6 months?
- 2-3 mg/kg/day
| - 0.27 mg/day
110
What is the total fluid intake (TFI) in infants?
-All IV fluids,IV medications and EN volume
111
Initial TFI for <1 kg?
90-120 ml/kg/day
112
Initial TFI for <1-1.5 kg?
70-90 ml/kg/day
113
Initial TFI for >1/5 kg/dat
60-80 ml/kg/day
114
Final recommended volumes for fluid?
135-200ml/kg/day
| --> At least 150 ml/kf/day for optimal nutrition
115
When are the fluid intake requirements higher?
-Secondary surface to skin ratio, immature kidney, rapid growth rate, need for phototherapy
116
When are the fluid intake requirements lower?
-If oliguric or PDA (giving larger pressure on the heart)
117
What is the goal in fluid intake? What should be monitored?
- Prevent over-hydration or dehydration
| - Weight monitored on a DAILY basis
118
Minimum energy for infants per day?
120 kcal/kg/day
119
What results in the final number of 120 kcal/kg/day?
- Intermittent activity
- Resting caloric expenditure
- Occasional cold stress
- Specific dynamic action
- Fecal loss of calories
- Growth allowance
120
Intermittent activity?
15 kcal/kg/day
121
Resting caloric expenditure?
50 kcal/kg/day
122
Occasional cold stress?
10 kcal/kg/day
123
Specific dynamic action?
8 kcal/kg/dat
124
Fecal loss of kcals?
12 kcal/kg/day
125
Growth allowance?
25 kcal/kg/day
126
How does the milk content of the pre-term milk change?
- 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
Iron in breast milk?
- 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
How should we progress a babu with iron supplementation?
- 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
Calcium, phosphorous and vitamin D supplementation?
- 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**
