Neonatal Nutrition Flashcards
Causes of prematurity?
- Socio-economic
- Complications during pregnancy
- Multiple pregnancy
- Fetal issues
- Gynaecological
Socio-economic factors?
-Low income groups, close pregnancies, work related stress, age, alcohol and drug abuse, smoking
Gynaecological factors
-uterine anomalies, incompetent or short cervix
Fetal factors?
-Congenital malformations, intrauterine growth restriction
Multiple pregnancy factors?
Having twins, triplets
Complications during pregnancy factors?
-Placenta previa, pre-eclampsia, infection
Pre-term classification?
<37 weeks at birth
Extreme pre-term classification?
GA <29 weeks at birth
Late pre-term classification?
GA 34-37 weeks at birth
ELBW?
<1000g
VLBW?
1001-1500g
LBW
1501-2500g
Normal BW?
> 2500 g
What is used a a growth curve for pre-mature babies?
The Fenton growth curve
How was the fenton growth chart developed?
- Large pre-term birth sample size of 4-million infants
- Data developed from countries including Germany, U.S, Australia, Scotland and Canada
What does the Fenton chart start at? What is it’s equivalent on the WHO growth chart?
- 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
When is a baby small for gestational age/ (SGA)
When less than 10%ile birthweight for GA
When is a baby appropriate for gestational age? (AGA)?
Between 10th and 90th%ile for GA
When is a baby large for gestational age? (LGA)
When greater than 90th% for GA
What is intrauterine growth restriction (IUGR)?
-Failure of the fetus to achieve normal predicted growth in-utero
What is symmetric IUGR?
-Weight, length and head circumference less that 10%ile. Indicative of chronic malnutrition
What is asymmetric IUGR?
-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
How is corrected GA calculated?
GA + (CA/7)
If an infant was born at 24 weeks + 5 days of life gestation, and is at day of life 28, what is the CGA?
GA= 24 weeks+ 5 days+ 28/7
Is at 28 weeks and 5 days of life
What is the ohio neonatal screening criteria (ONSC) used for
Identifying Hospitalized infants at the Highest nutritional risk
ONSC <1 week of age?
> 15% weight-loss from birth-weight
<1 kg at birth
ONSC 1-2 weeks of age?
<70 kcal/kg/day or any continued weight-loss
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
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
ONSC >2 month of age?
- Same as >2 weeks age plus
- No source of dietary iron and continuedPN
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
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
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
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
Thermoregulation?
-Decreased fat reserves, unable to maintain body temperature
GI and Respiration?
-Poor suck, swallow and breathe coordination
Respiration?
-Immature lungs, increased work of breatning
Medical Issues?
-Respiratory distress syndrome, hypoglycemia, hyperbilirubinemia, hemodynamic instability, risk of sepsis
Decreased absorption of nutrients specific to fats?
-Decreased bile salts and pancreatic lipase, at 32 weeks only 65–75% fat absorption
(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
Decreased absorption of nutrients specific to lactose?
-At 26-34 weeks, only 30% of absorption
Decreased absorption of nutrients specific to protein?
-At 28-34 weeks, only 70% absorption
When do we stop correcting the GA?
After 40 weeks
When can we start identifying the premature babies age in months?
Only when they have reached the term age
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
What should be included in the initial nutritional assessment?
- Maternal History
- Infant
- Medications
- Physical
- GI
- Biochemical
- Clinical signs
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
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
Infant information in initial nutritional assessment ?
- Gender
- Level of prematurity
- Weight category
- Days of life
- CGA
- APGAR score
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
Why may some babies be on antibiotics?
Due to risk of sepsis, or they do have sepsis
–> However, can interfere with the gut microbiome
Why is caffeine used in premies?
-To help with respiratory issues or apnea
Physical information in the initial nutritional assessment?
- Length
- Head
- Circumference
- Weight
- Plot on fenton curve, SGA/AGA/LGA
- IUGR
GI information in the initial nutritional assessment?
- Abdomen
- Meconium
- Bowel sounds
What are the variables to consider for mode of nutrition?
- GA
- SGA/AGA/IUGR
- Clinical status
- Medications
- Coordination of the suck/swallow/breathe
What are the feeding options to consider?
- PN (total or partial)
- EN (total or partial)
- Breast feeding
- Bottle feeds
What are the indications for PN?
- Congenital GI anomalies requiring surgical repair
- Impaired GI motility
- Malabsorption syndomes
- Delayed or advancement of EN feeds
Congenital GI anomalies which may be indications for PN?
- Gastroschisis
- Bowel obstruction
- -> Will NOT be able to feed enough volume into this
Impaired GI motility which may be indications for PN?
- Ileus from sepsis
- After surgical repair of gastroschisis
- Hirsch Sprung disease
Malabsorption syndromes which may be indications for PN?
- SBS
- -Cystic Fibrosis
When is the delayed initiation or advancement of feeds an issue?
Usually in larger infants
When should the coordination of suck/swallow/breathe be developed?
Usually at term
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
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
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
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
What is gastric schisis?
When the baby is born with the intestine is outside of the abdomen
Fluid minimum and maximum in TPN?
-initially 60-90 to 120-150 ml/kg/day
Trophamine minimum and maximum in TPN?
-Start at 1.5-2 and advance up to a goal of 3.5-4g/kg/day
Dextrose minimum and maximum in TPN?
-Can begin at 5-10 g/kg/day and to a maximum of 10-18 g/kg/day
Lipids minimum and maximum in TPN?
0.5-1 g/kg/day to a maximum of 3 g /kg/day
In adult nutrition, we do ml/day for fluids, how does this differentiate for neonates?
We will do ml/kg to be more precise
In TPN, providing less than ____ may put the infant into a catabolic state
<50 kcal/kg/day
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
Infants _____ need TPN to help optimize nutritional status
<1800 g
How is TPN provided?
- Given by peripheral (short-term/low-osmolality) or central line (long-term/higher osmolality)
- Short term is about one week
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
EN contraindications?
- Severe respiratory distress syndrome
- GI anomalies (esophageal atresia, bowel obstruction)
- Necrotising enterocolitis
EN routes available?
- Orogastric tube
- Nasogastric tube
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)
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
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
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
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
What is the BEST choice for EN feeds?
Breast milk
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
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
What are the long-term effects of breast-milk?
- Better neurocognitive development
- Immunity
- Prevention of allergies
(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
(T/F) Formulas for pre-term infants contain a higher amount of nutrients than term infant formulas
T
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
CHO source in pre-term formula?
- Corn syrup solids or maltodextrin
- 50% lactose
Fat source in preterm formula
-Variety of vegetable oils and MCT 40-50%
Vitamins in pre-term formulas?
-Adapted to pre-mature infant needs
Minerals in pre-term formulas?
-Almost double the amount of calcium and phosphorus vs that of a term infant formula
What type of EN is given?
- Oral immune therapy
- Trophic feeds
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
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
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
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
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
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
Nutrient recommendations fluids for pre-term vs RDA/AI 0-6 months?
- 135-200 ml/kg/day
- 0.7 L/day
Nutrient recommendations energy for pre-term vs RDA/AI 0-6 months?
- 110-135 kcal/kg/day
- 555 kcal/day
Nutrient recommendations proteins for pre-term vs RDA/AI 0-6 months?
- 3.5-4.5 g/kg/day
- 9.1 g/day
Nutrient recommendations lipids for pre-term vs RDA/AI 0-6 months?
- 4.8-6.6 g/kg/day
- 31 g/day
Nutrient recommendations calcium for pre-term vs RDA/AI 0-6 months?
- 120-200 mg/kg/day
- 210 mg/day
Nutrient recommendations phosphate for pre-term vs RDA/AI 0-6 months?
- 60-140 mg/kg/day
- 100 mg/day
Nutrient recommendations iron for pre-term vs RDA/AI 0-6 months?
- 2-3 mg/kg/day
- 0.27 mg/day
What is the total fluid intake (TFI) in infants?
-All IV fluids,IV medications and EN volume
Initial TFI for <1 kg?
90-120 ml/kg/day
Initial TFI for <1-1.5 kg?
70-90 ml/kg/day
Initial TFI for >1/5 kg/dat
60-80 ml/kg/day
Final recommended volumes for fluid?
135-200ml/kg/day
–> At least 150 ml/kf/day for optimal nutrition
When are the fluid intake requirements higher?
-Secondary surface to skin ratio, immature kidney, rapid growth rate, need for phototherapy
When are the fluid intake requirements lower?
-If oliguric or PDA (giving larger pressure on the heart)
What is the goal in fluid intake? What should be monitored?
- Prevent over-hydration or dehydration
- Weight monitored on a DAILY basis
Minimum energy for infants per day?
120 kcal/kg/day
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
Intermittent activity?
15 kcal/kg/day
Resting caloric expenditure?
50 kcal/kg/day
Occasional cold stress?
10 kcal/kg/day
Specific dynamic action?
8 kcal/kg/dat
Fecal loss of kcals?
12 kcal/kg/day
Growth allowance?
25 kcal/kg/day
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
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
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
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**
