neonatal nutrition Flashcards
what is the main cause of death in infants?
prematurity
causes of prematurity: socio-economic factors
Low-income groups, close pregnancies, work related stress, age ,alcohol and drug abuse, smoking.
causes of prematurity: gynecological factors
Uterine anomalies , Incompetent or short cervix.
causes of prematurity: fetal factors
Congenital malformations, Intrauterine growth restriction.
causes of prematurity: complications during pregnancy
placenta previa, Pre-eclampsia, Infection.
can multiple pregnancies be a cause of prematurity?
yes
what are the characteristics put Hospitalized Infants at Highest Nutritional Risk:
< 1 week of age
➢ >15% weight loss from birth weight
➢ < 1kg at birth
what are the characteristics put Hospitalized Infants at Highest Nutritional Risk:
1-2 weeks of age
➢ <70 kcal/kg/d or any continued weight loss
what are the characteristics put Hospitalized Infants at Highest Nutritional Risk:
>2 weeks of age
➢ Intake < 80% of expected energy requirements
➢ < 15g/kg/d weight gain (<36 weeks GA)
➢ <1/2 expected weight gain (>36 weeks GA)
➢ Prealbumin < 8mg/dl or albumin <2.5g/dl
➢ BUN < 7mg/dl
➢ Serum phosphorus< 4mg/dl / Alkaline phosphatase >600mg/dl
what are the characteristics put Hospitalized Infants at Highest Nutritional Risk:
2 months of age
Same as >2weeks of age, plus:
➢ No source of dietary iron -
➢ Continued TPN
Which factors would put any infant (no matter the age) at a high risk of malnutrition
➢ Any infant with newly diagnosed NEC (necrotizing enterocolitis), BPD, osteopenia, cardiac disorders, neurologic problems, GI surgical anomalies or metabolic
aberrations.
➢ Any infant with birth weight <1.5kg(and current weight <2kg) on full feedings but not receiving fortified human milk or preterm formula.
what are the age cut-offs for baby, infant and child
newborn: 0-2 months
infant: 2 mo-1 year
baby: 1-4 yrs
what are nutritional goals for pre-terms
➢ provide nutrition to ensure the same rate of growth as it would have been achieved in the womb by a term baby
➢ To maintain normal concentrations of blood and tissue nutrients.
➢ To ensure individualized nutrition support adapted to ongoing medical complications.
Factors Affecting Nutritional Status of term-babies
- Immature systems
- Medical Co- morbidities
- Decreased nutrient Absorption
- Decreased nutrient reserves
relationship between size of the baby and nutrient reserves
the smaller the baby, the smaller the reserves
List Factors Affecting Nutritional Status
➢ Gastrointestinal Immaturity ➢ Thermoregulation ➢ GI and Respiration ➢ Respiration ➢ Medical Co-morbidities ➢ Decreased Absorption of Nutrients
How does Gastrointestinal Immaturity affect nutritional status
➢ Reduced gastric capacity,
decreased GI motility,
reduced gastric emptying,
decreased concentration of digestive enzymes,
inadequate LES closure, (inadequate LES closure= increased risk of reflux and regurgitation)
inadequate capacity to suck and swallow.
How does Thermoregulation affect nutritional status
Decreased fat reserves, unable to maintain body temperature.
How does GI and Respiration affect nutritional status
Poor suck, swallow and breathe coordination
How does Respiration affect nutritional status
Immature lungs, increased work of breathing.
How do Medical Co-morbidities affect nutritional status
➢ Medical Co-morbidities put bb in catabolic state, increasing nutrient reqs
Respiratory distress syndrome, hypoglycemia, Hyperbilirubinemia, hemodynamic instability, risk of sepsis, etc.
How does Decreased Absorption of Nutrients affect nutritional status
decreased reserves + decreased absorption- >hard to meet nutrient needs
➢ decreased bile salts and pancreatic lipase
( < 32 weeks, only 65-75% of fat absorption)
➢ Lactose ( 26-34 weeks ,30% absorption)
➢ Protein ( 28-34 weeks, 70% absorption)
What are the units for nutrients in pre-term babies vs term
Pre-term: ml or kcal or g per kg/d
Term: ml or kcal or g per day
What are the recommendations for nutrients based on in pre-term babies vs term
Pre-term: Koletzko
Term: RDA/Ai
what physiological functions are supported manually in pre-term babies in the baby zone
temp, nutrition and respiration
why would maternal history be important in nutritional assessment of pre-term babies?
- diabetes in mom would explain LGA
- Meds: magnesium sulphate is given for preeclampsia for mom and for the neural system of the baby, but can affect GI motility
why would medication assessment be important in nutritional assessment of pre-term babies?
pressors in case of hemodynamic instability of the baby might cause hyperperfusion of the gut-> needs to be considered for feeding
which physical signs need to be assessed in pre-terms
length, head circumference, weight, plot on Fenton growth curve, SGA/AGA/LGA, IUGR
which GI signs need to be assessed in pre-terms
abdomen, meconium, bowel sounds
How to calculate Corrected Gestational Age (CGA)
Gestational age + (Chronological age÷ 7) = CGA
If an infant was born at gestation age of 24 weeks & 5 days and is at chronological age of 28 days , then the CGA is
24weeks 5days + (28 days ÷7) = 24 weeks 5days + (4 weeks) = 28 weeks 5days CGA
➢ Contraindication to Enteral Nutrition in pre-terms
➢Hemodynamic instability
➢GI anomalies (esophageal atresia) or improper anus development
➢ Bowel obstructions or ileus
➢ NEC
➢ Acute abdominal distension ➢Upper GI bleed
➢ Persistent vomiting
does NEC occur in first days of life
no
What is OIT?
When and how is it administered?
Oral immune therapy
Given if EN cannot be administered
➢ Oral care with colostrum to help stimulate the immune system via cytokines in milk that will be absorbed orally and stimulate oral immune system
➢ Safe to give even if contraindication to feed the gut
➢ 0.1ml q 4hrs between cheek and gums, not expected to reach the gut
putting colostrum between check and gums. As it is not gonna reach the gut-> safe for GI
Do we give TPN or CPN
TPN
Indications for TPN
➢ Functional immaturity of GI tract or gestational aka TPN is recommended for age (< 32 weeks or birth weight <1800g)
➢ Delayed initiation or advancement of enteral feeds.
➢ Syndromes or medications associated with impaired GI perfusion
➢ Congenital GI anomalies requiring surgical repair (gastroschisis, bowel obstruction, bowel atresia,etc)
➢ Impaired GI motility (ileus from sepsis or surgery, gastroschisis, Hirschsprung disease) in some conditions like sepsis, baby will be NPO at first and then PN
➢ Malabsorption syndromes (SBS, cystic fibrosis)
➢ Necrotising enterocolitis (NEC)
what are the characteristics of the babies that will immediately be prescribed TPN
< 32weeks or birth weight <1800g
What are the syndromes or medications associated with impaired GI perfusion
Congenital heart disease(CHD), Hypoxic ischemic encephalopathy, hypotension, use of medications like ibuprofen)
all conditions that prevent sufficient oxygen delivery to the gut
are we hesitant about giving PN to babies
No
PN is required for most premature babies to make sure that there is sufficient energy and protein as commonly due to functional immaturity of GI, it is hard to start feeding via gut or with enough volume
Start as soon as the infant is born with at least a starter PN solution to help provide adequate calories and protein.
what is the usual diet prescription for babies with NEC?
with NEC baby is NPO for the first 7-10 days and then PN
PN: fluid intake reccs
initial 60-90ml/kg/d to 120-150ml/kg/d.
when exclusively PN: keep baby at 120-150ml/kg/day
when EN+PN, part of the fluid will be supplied by both of this methods
PN: amino acid intake reccs
start at 1.5-2 g/kg/d and advance by 1g/kg/d up to a goal 3.5-4g/kg/d.
before the recommendation was 4.5, but studies show that there is no benefit of going above 4
PN: dextorse intake reccs
can begin at 6-8g/kg/d and advance by 1.5- 3g/kg/d to a maximum of 14-18g/kg/d.
PN: lipid intake reccs
0.5-1g/kg/d and advance by 0.5-1g/kg/d to a maximum of 3-3.5g/kg/d.
do we prefer to send bb home with or w/o PO
W/o
is feeding or NPO associated with NEC
feeding
but the sooner u start feeding the gut, the better will the feeding tolerance be (lower NEC risk)
benefit of starting EN early
- Decreased risk of NEC
- Early feeding resulted in shorter duration of PN.
EN indications on premies
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 (until they develop good coordination, they will remain on EN)
Trophic feed recommendations and benefits
➢ To begin as soon as clinically appropriate (10- 24ml/kg/d, smaller than in adults)
➢ Helps to stimulate GI motility, development of microbial flora, growth of microvilli.
➢ ↑Milk tolerance, ↑postnatal growth, ↓systemic sepsis, ↓length of stay.
What is the daily frequency of feed administration
Trophic feeds are usually given q 4h,i.e, 6 feeds in
24hrs
Calculation for Trophic Feeds
➢ BB boy born at gestational age of 25 weeks and birth weight of 650g. Infant with no contraindication to initiate enteral feeds. As per discussion with team, to start trophic feeds at 10ml/kg/d.
Calculate the prescription
➢ 0.650kg X 10ml/kg/d = 6.5ml/d
Trophic feeds are usually given q 4h,i.e, 6 feeds in 24hrs->
➢ 6.5ml/d ÷ 6 feeds/d = 1.0 ml q 4hrs
NJ/OJ tube vs Gastroduodenal/ gastrojejunal tube: when would either one be given?
NJ/OJ tube: when bb has high incidence of reflux
Gastroduodenal/ gastrojejunal tube: when EN is required for long periods or when bb has severe oral aversion
Enteral Nutrition Methodology: Bolus feeds
Bolus feed (q 2-3hr x 24hrs)
What is the gold standard (prefered option) of EN formula?
What is less and the least preferred?
Breast milk is the best option, followed by PHM (pasteurized) and last choice is formula (NPO is the WORST)
Why is milk the golden standard?
➢ Optimal distribution of calories
➢ easy digestibility
➢ Immune factors (IgA, IgG), hormones, enzymes -> NOTE: pasteurization kills IgA and IgG
➢ Decreased gastric transit time
➢ Better absorption of nutrients( fat, Iron, Zn)
➢ Lower renal solute load
➢ Protection from NEC
➢ Long term effects ( better neurocognitive development, immunity, prevention of allergies)
what is the macronutrient distribution of breast milk
7% protein, 55% fat, 38% CHO
What is recommended as an alternative to formula for preterm infants in the NICU
Pasteurised Human Milk
Who is eligible for Pasteurised Human Milk
most infants that are born <34 weeks and <2kg should be eligible
In Quebec, mothers with infants less than 10months of age at time of registering are eligible
What is the health benefit of PHM?
➢ Proven to help decrease incidence of NEC
Why is mother’s milk the best for premies
has higher amounts of protein and antibodies
Formulas For Preterm vs term Infants
Formulas For Preterm Infants has higher amounts of nutrients than term infant formulas
Describe macro and micro nutrient composition of milk
➢ Protein: Cow’s milk protein (intact or partially hydrolysed)
➢ Carbohydrate: Corn syrup solids or maltodextrin and 50% lactose
➢ Fat: Variety of vegetable oils and MCT (40-50%)
➢ Vitamins: Adapted to premature infant needs
➢ Minerals: almost double the amount of calcium and phosphorus vs that of a term infant formula
What should be initiated at the same time with PN
OIT
should PN be discontinued as soon as EN is given?
no, PN being used to support normal growth until adequate enteral feedings are established.
Nutritional Assessment and Care Plans (during follow ups)
➢ Nutritional adequacy ➢ Biochemical parameters ➢ Clinical signs ➢ Feeding tolerance ➢ Growth
What is included in TFI
Includes all IV fluids, IV medications and enteral
nutrition volume.
TFI initial recommended volumes
➢ < 1kg : 90-120ml/kg/d (more if medically necessary)
➢ 1-1.5 kg: 70-90ml/kg/d
➢ > 1.5kg: 60-80ml/kg/d
TFI final recommended volumes
↑ by 20-30ml/kg/d from initial volume
➢ 135-200ml/kg/d (at least 150ml/kg/d for optimal nutrition)
Are fluid intakes high or low in premies?
Requirements are high secondary surface to skin
ratio, immature kidney, rapid growth rate and need for phototherapy
higher fluid reqs (higher losses) with yellow light vs blue light
when would lower fluid intake be required in premies?
If oliguric or PDA /CLD
Patent Ductus Arteriosus/ Chronic Lung Disease
Calculation of Enteral Intake
➢ An Infant weighing 1250g( *BW:1150g) takes 12mlq 2hrs of breast milk via enteral feeds. TFI at 150ml/kg/d
q 2hrs feeds = 12 feeds per day
12 ml q 2hrs = 12ml x 12feeds = 144ml/day
As all our calculations are usually ml/kg/day or g/kg/d
144ml/day ÷ 1.250kg = 115ml/kg/day
35ml come from IV fluids (TPN and IV meds)
* If infant has not regained birth weight always use the birth weight for your calculations
Why is timing important in terms of milk and nutritional adequacy
Composition of mother’s milk changes after 14-21 days of life, thus after this period milk has to be fortified to meet the reqs of premies
What has to be be monitored to assess protein intake adequacy?
growth, BUN and plasma proteins
Iron: issues with adequacy
➢ Decreased reserves,supplement by 2-4 weeks of life
➢ Fortification of breastmilk not adequate-> iron sulphate supplement has to be given
➢ Preterm formulas are enriched with iron
What has to be monitored to assess iron adequacy
Monitor blood Hgb levels closely, can affect growth
should we be bothered with bone health in preterms?
Yes, Osteopenia is a common problem among premature infants
Calcium/ Phosphorus/ Vitamin D adequacy recommendations and monitoring
➢ Need to fortify breast milk or give premature infant formulas
➢ Supplement with calcium and vitamin D
- vit d is usually always supplemented, even with fortified BM as there is not enough
➢ To monitor Calcium phosphorus ratio and alkaline phosphatase levels
why fortify breast milk fortifications
unfortified human breast milk may not meet the recommended nutritional needs of the growing preterm infants
giving bigger volume to meet the needs usually doesn’t work as bb guts are too small to handle it-> concentration is the way to go
To increase nutrient concentration so that infant meets requirements at customary feeding volumes
Indications for use of fortified milk
➢ Infants ≤ 35 weeks gestation
➢ ≤ 1800g at birth
➢ On total parenteral nutrition > 2 weeks
➢ > 1800g at birth with suboptimal growth
➢ > 1800g at birth with limited ability to tolerate increased volume
What is the safe volume to start fortifying breast milk?
Safe volume to start fortifying breast milk is from 80ml/kg/d to 120ml/kg/d
when ACTUAL enteral intake out of total TFI ia at 80-120ml/kg/d
what are the 2 types of protein milk fortifiers
there are 2 types of fortifiers available: liquid and powder
liquid is the newer format, made from hydrolyzed protein; has higher protein content compared to the powder
it was hard to meet prot reqs with powder due to lower protein content
what is the minimum, and adequate protein intake in preterms? why?
Preterm infants require at least 1g/kg/day initially to avoid negative nitrogen balance
At least 3 g/kg/day promotes positive nitrogen balance and protein accretion
~ 4 g/kg/day is needed to match fetal protein accretion rate
every 1g of protein towards meeting protein requirement has a significant benefit for mental development
insufficient protein in VLBW and associated complications
Providing <4 g/kg/d in VLBW infants results in protein deficiency that contributes to extrauterine growth restriction (EUGR)
when can liquid protein be added to breast milk?
Added to breast milk only after the process of fortification and if the fortification is well tolerated
Apart from protein enhancers, what are some other enriching agents?
Polycal: to increase calories
➢ Polysaccharides
➢ Per 5g of powder→4.8g CHO,19Kcal
Microlipid: to increase calories and fat
➢ Coconut oil,1005 safflower oil,veg/corn oil. It is emulsified
➢ Provides 0.5-1g fat(4.5-8kcal) per ml
Duocal: to increase, CHO and fat, to
increase kcal
➢ provides 4.9kcal per gram of powder
➢ hydrolysed corn starch,coconut/MCT oil
Calculation of Enteral Nutrient Intakes: Energy
➢ Infant at a total fluid intake of 150ml/kg/d taking fortified breast milk at 81kcal/ 100ml
calculate energy provided
Calculation of Enteral Nutrient Intakes
➢ Energy
➢ Infant at a total fluid intake of 150ml/kg/d taking
fortified breast milk at 81kcal/ 100ml
➢ 150ml/kg/d x 0.81 Kcal/ml = 121.5kcal/kg/day
Calculation of Enteral Nutrient Intakes: protein
➢ Fortified breast milk provides 2.15g/100ml of protein ➢
calculate protein provided
➢ 150ml/kg/d x .0215 g/ml = 3.22g/kg/d of protein
name biochemical parameters that should be monitored in premies according to their indication
Electrolytes: Diuretics; renal disease
BUN and creatinine: Renal disease
BUN alone: Protein intake adjustment
Aklaline phosphatase, P, Ca, Vit D: Osteopenia screen
Albumin, prealbumin: Poor nutrition history , slow growth , edema
Liver enzymes: cholestasis
CBC: Anemia
Vitamins, trace minerals r other specific tests: As indicated
assessment of skin color as a clinical sign
➢ Bluish skin , lips → low O2 sat, decreased gut perfusion (be careful about the feed!)
➢ Whitish, pale → Anemia;
➢ Yellow →Jaundice will need for phototherapy
if using yellow light-> increase TFI as
insensible losses increase
➢ Poor wound healing→ Zn or protein deficiency)
assessment of vital signs a clinical sign
➢ Temperature (hypo/hyperthermia→↑BMR, ↓weight gain)
➢ Respiratory rate (tachypnea → no nipple feeding; apnea→ feed cautiously)
➢ Heart rate ( tachycardia→↑energy consumption) -> ensure sufficient calories
assessment of urine and stool output as a clinical sign
➢ Urine normal range :1-3ml/kg/d,
➢ Stool→ Timing of first stool, frequency, color, blood
passing of stool, esp meconium is a sign of GI motility
usually a good sign is having meconium during 48h
assessment of fluid status a clinical sign
➢ generalized edema → overhydration increase feed concentration to limit fluid
➢ protein deficiency; dry mucus membrane
➢ poor skin turgor→ dehydration
➢ dry mucous membrane-> dehydration
Signs of feeding intolerance
➢ Abdominal changes - significant increase in girth - noticeable bowel loops - Skin discoloration - Hypoactive bowel sounds - Guarding on palpation ➢ Increased number of apneic and/or bradycardia during feed time ➢ Bilious emesis ➢ Bloody stools and/or emesis
What is the approach in the case of bilious emesis?
bloody emesis may be due to GI bleed-> NPO
What is the approach in the case of bloody stools?
Bloody stools may be due to NEC, if tis the case-> NPO
Acceptable weight loss in newborn premies
➢ Initial weight loss of 10-15% is acceptable - nadir (lowest point) by 4-6 days of life
Acceptable time to regain birthweight in newborn premies
Regain birthweight between 10-14 days of life (ideal is 10 days of life)
Desirable growth velocity in newborn premies
Desirable growth velocity is 15-20g/kg/d (once birthweight is regained)
Desirable length and height in newborn premies
frequency of assessment
Length:0.9- 1cm/week
HC:0.5-0.9cm/week
➢ (wt measured daily & L /HC measured weekly)
Calculation of growth velocity (GV)
➢ At DOL#7 → weight at 1350g
➢ At DOL#14 → weight at 1500g
➢ What is the growth velocity of the infant?
GV(g/kg/d) = [1000 x (Wn-W1)] ÷ {(Dn-D1)x [(Wn + W1) ÷2]}
Wn= 1500g W1= 1350g Dn= 14 D1= 7
GV = [1000 x (1500-1350)] / {(14-7) x [(1500+1350÷2)]}
GV = 15 g/kg/d over last 7 days
If inappropriate GV, options are
➢ To increase total fluid intake (TFI) if not at
maximum level
➢ Optimize nutrient intake via TPN
➢ If only on expressed breast milk, can fortify breast milk (FBM)
➢ If already on FBM, can further enrich to provide more calories and protein (especially if u are at max TFI)
- apart from kcal and protein, also increase micro and macro nutrients
➢ e.g, Add discharge formula to FBM
what is the maximum TFI
135-200ml/kg/d (at least 150ml/kg/d for optimal nutrition)
what is the first and last measurement to catch up during the catch up period?
When a preterm infant has catch up growth, it is the weight that catches up first, followed by the head circumference and then finally the length
Which requirements are higher in catch-up period?
Nutrient requirements for catch up growth, especially that for energy and protein, are hence higher
Protein needs for preterms
26-30 weeks:
30-36 weeks:
36-40 weeks:
26-30 weeks: 3.4-4.2 g/kg/d
30-36 weeks: 3.4-3.6 g/kg/d
36-40 weeks: 2.8-3.2 g/kg/d
Energy needs for preterms
26-30 weeks:
30-36 weeks:
36-40 weeks:
26-30 weeks: 126-140 kcal/kg/ d
30-36 weeks: 121-128 kcal/kg/ d
36-40 weeks: 116-123 kcal/kg/ d
Age as a defining factor for initiation of oral feeding route
32-34 weeks GA, coordination of suck, swallow and breath.
Physiological state as a defining factor for initiation of oral feeding route
➢ Tolerates feeds into stomach
➢ On <2L of oxygen
➢ Respiratory rate between 20-50bpm and no more than 70bmp
➢ Stable work of breathing
State (emotional) as a defining factor for initiation of oral feeding route
Ability to reach and maintain a quiet alert state
Maturation as a defining factor for initiation of oral feeding route
➢ Tolerates handling and transitions without
excessive signs of stress.
➢ Root and nutritive sucking emerging or established
Nutrition at discharge home for infants with birth weight of ≤ 1500g
➢ Will benefit from enrichment with PTDF (Preterm discharge formula) until normal growth is achieved
➢ If suboptimal growth persists, may continue up to 6-12 months CGA
Nutrition at discharge home for infants with birth weight of 1500g-1800g
➢ May benefit from enrichment with PTDF if suboptimal growth until normal growth is achieved.
Nutrition at discharge home for infants with birth weight of >1800g
May benefit from enrichment with term formula (with Fe,DHA) if suboptimal growth until normal growth is achieved.
why do we enrich BM with PTDF instead of fortifiers?
fortifiers are not available outside the hospital, so we enrich the feeds with preterm discharge formula by adding it to breast milk
__ should be encouraged for all preterm infants if possible
Breast milk should be encouraged for all preterm infants if possible
Risk and no risk options for infants at discharge when mom has no stored EBM, no longer pumping
➢ Risk: enriched PTDF, transition to regular PTDF at 3.5kg
➢No risk: PTDF.
Risk and no risk options for infants at discharge when mom has stored EBM, no longer pumping
➢ Risk: enriched breast milk with transition to PTDF when EBM stores exhausted.
➢ No risk: breast milk alternated with PTDF with transition to PTDF when EBM stores exhausted
Do we need to administer PTDF when bb is going home and is stable on fenton curve?
infant that grows well and not dropping at fenton curve, he would still require some enriched feeds to ensure adequacy of growth after discharge, but he would also benefit from breastfeeding-> do a mix of breastfeeding + enriched formula
when should we discontinue PTDF at home when growth is not optimal?
if baby is going home on PTDF, we might want to enrich it if the growth is not optimal and then switch to regular concentration of regular PTDF when bb is at good weight (~3.5kg) and then make sure that breastfeeding and bottle feeding occurs
Risk and no risk options for infants at discharge when mom has little or no stored EBM, interested in BF, pumping
➢ Risk: enriched PTDF alternated with BF, transition to regular PTDF at 3.5kg, lactation support, continue pumping.
➢ No risk: alternate PTDF with direct BF, lactation support, continue feeding
PTDF:
Risk and no risk options for infants at discharge when mom has no EBM stores, not interested in BF, pumping
➢Risk: enriched PTDF alternated with EBM from bottle, transition to PTDF at 3.5kg,continue pumping to improve supply
➢No risk: alternate PTDF with EBM from bottle, continue pumping to improve supply
Risk and no risk options for infants at discharge when mom has Stored EBM, interested in BF, pumping
➢Risk: enriched EBM for ≥1⁄2 feeds until 3.5kg then BF, lacatation support to move from pumping to BF
➢No risk: 60-90ml “booster” fed along with EBM until 3.5kg, then EBM, lactation support to move from pumping to BF
Risk and no risk options for infants at discharge when mom has or EBM stores, not interested in BF, pumping
➢Risk: enriched EBM for ≥1⁄2 feeds until 3.5kg,then alternate EBM with PTDF, continue pumping
➢No risk: 60-90ml “booster” fed along with EBM until 3.5kg,then EBM, continue pumping
RDS
characteristics
causes
dangers
➢ Characterized by cyanosis in room air, nasal flaring,
grunting ,retractions and tachypnea
➢ Develops in preterm infants due to immaturity of the lung tissue structure and function
➢ Other causes are meconium aspiration, pneumonia, lung hypoplasia, etc
➢ RDS may progress to bronchopulmonary dysplasia(BPD)
➢ IUGR infants are more likely to develop both RDS and BPD
RDS: energy and protein reqs
Energy
➢ PN: Initial intake of 85-115 kcal/kg/d to eventual 100- 120kcal/kg/d
➢ EN: Initial intake of 90-130kcal/kg/d to eventual 120- 150kcal/kg/d
Protein
➢ Adequate intake is required to support lean tissue accretion and organ growth
➢ Goal intake of at least 3.5-4 g/kg/d
RDS: fluid restriction
➢ Allow for initial diuresis with adequate weight loss (10- 15%) to prevent pulmonary edema
➢ Limit fluids to 70-80ml/kg/d and adjust daily
➢ Eventual fluid restriction of about 120-150ml/kg/d necessitating increased nutrient density
RDS: feeding problems
➢ May require prolonged EN
➢ Consult a feeding therapist (to help enhance oro-motor development)
Respiratory Distress Syndrome ➢ Drug Nutrient Interactions
➢ Corticosteroids (dexamethasone):
↑protein intake for better growth.
May cause hyperglycemia → monitor serum glucose levels and modify glucose infusion rates if on PN
➢ Chlorothiazide Diuretics (HCTZ)
may cause delayed growth due to ↓ serum levels of sodium, potassium and chloride. Spironolactone may ↑ serum potassium levels but ↑urinary sodium and chloride excretion.
All diuretics cause ↑renal phosphorus excretion, putting infants at high risk of osteopenia
Symptoms of NEC
➢ Systemic: temperature instability, lethargy, apnea, tachycardia, hypotension
➢ Gastrointestinal: poor feeding, emesis, abdominal distension, blue abdominal wall discoloration, ileus with decreased bowel sounds, fresh blood in stool
NEC prevention
➢ Use of human milk/donor breastmilk as the most effective way to reduce NEC
➢ Development and use of a standardized approach to feeding
➢ Use of enteral probiotic supplementation for infants > 1000g has been shown to reduce NEC (optimal probiotic strain, dose, duration, and safety remain to be determined)
NEC treatment
1st step NPO for7-10 days
on day 10 do an X-ray to check if u can feed again -> gradual reintroduction of EN
➢ Antibiotic therapy
➢ No known optimal nutritional management
➢ Balanced and complete PN with cessation of EN for bowel rest ranging in clinical practice from days to weeks
➢ Gradual reintroduction of enteral feedings as tolerated (10-35ml/kg/d)
➢ Use human milk, donor breast milk, preterm not formula if human milk is not available or hydrolyzed formulas
➢ If bowel resection, review nutrients that may be maldigested or malabsorbed and supplement
➢ Monitor for late complications such as cholestatic jaundice, bowel strictures and osteopenia
GERD
what is it
symptoms
➢ It is the passage of gastric contents into the
esophagus with or without regurgitation and vomiting
➢ A common physiologic condition in infancy that is usually benign, typically resolving by 1 year of age
➢ Symptoms include vomiting, esophagitis, abdominal pain, dysphagia, and abdominal pain.
➢ Extraesophageal conditions manifest as respiratory disorders (cough, laryngitis and wheezing) or poor weight gain
GERD interventions
➢ Parental education and reassurance are the primary
intervention
Nutrition Intervention Options
➢ Small frequent feeds or continuous feeds
➢ Prone (not advised post discharge home) and left lateral positioning have been associated with less reflux
➢ If symptoms due to cow’s milk protein intolerance, a change to hydrolysed formulas or amino acid based formula may be useful. Infant on human milk can be re-introduced to human milk if mother has followed a cow’s milk protein free diet for a specific number of days
➢ Thickened feeds: Use of Carob and Xanthun gum based thickeners are not recommended for preterm infants. Dry infant rice cereal is a better option
GERD medications
Acid suppressants and prokinetic medications may be beneficial . However, need to be cautious w.r.t possible side effects. These medications with PPI’s have been shown to increase the risk of NEC
