Neonatal Nutrition Part II Flashcards
(T/F) Unfortified breat milk may not meet the recommended nutrient needs of growing pre-term infants
T
Even though human milk is the recommended nutritional source for newborn infants for at least the first six months of post-natal life, we need to increase the nutrient concentration so that infant meets requirements at the customary feeding volume
(T/F) For the first 2-3 weeks the milk of the pre-term mother is notably sub-optimal
F
It is nutritionally optimal to compensate for the needs of the pre-term baby. However, after 3 weeks it becomes the composition of the term babies mothers milk, but the premie is still a premie, thus after 3 weeks the mothers milk is sub-optimal. If we provided them with this milk, we would need to provide a LOT of volume to meet their nutritional requirements, and often pre-term babies are on fluid restrictions.
Indications for breastmilk fortification?
- Infants = to 34 weeks gestation
- = 1500 g at brith
- On PN > 2 weeks
- > 1500 g at birth with suboptimal growth
- > 11500 g at birth with the limited ability to tolerate increased volumes
What is the safe volume to being fortifying breast milk?
- From 80 ml/kg/day to 120 ml/kg/day
- -> Some newer studies recommend fortification as early as 50 ml/kg/day
- ->Re-call that fortification is a process that increases the osmolarity of the formula, where we dont want to feed a hyperosmolar solution into the gut (which is immature) if unstable.
- ->Therefore we want to achieve an adequate rate of EN before we add the fortifier to know that the baby can tolerate it OK
(T/F) In fortification n of breast milk, we are able to achieve optimal composition of protein, energy, calcium, phosphorous, vitamin D and iron
F
We do not get enough iron even with fortification, and requires another source of supplementation
An infant weight 1250g (BW of 1150g) takes 12 ml every 2 hours of BM via EN. How many ml/kg/day?
12 ml q 2 hours = 12 feeds per day x 12ml = 144 ml/day
144 m/day /1.250 kg - 115 ml/kg/day
in EN calculations, which weight should we use?
The actual birthweight as lone as the birthweight has been re-gained. If the baby has not yet re-gained the birthweight, use the birthweight (an IBW)
An infant with a TFI of 150 ml/kg/day and is taking fortified breast milk at 81 kcal/100ml. How many kcal/kg/day of BM?
81kcal/100ml means 81% of the TFI is breastmilk. Therefore, 0.81 x150 ml/kg/day = 121.5 kcal/kg/day of breastmilk
An infant with a TFI of 150ml/kg/day where fortified BM provides 2.15g/100 ml of protein. How many g/kg/day of protein is the infant receiving?
2.15g/100ml means 2.15% of the TFI is protein. Therefore, 0.0215 x 150 ml/kg/day = 3.22 g/kg/day
What is the acceptable weight loss within this first 4-6 days of life?
10-15%
When should the regain of birth weight occur? What is ideal?
- Between 10-14 days of life
- Ideal is 10 days of life
What is the desirable growth velocity once the BW is regained?
15-20 g/kg/day
What is the goal for length growth?
0.9-1cm/week
What is the goal for HC growth?
0.5-0.9 cam/week
What is measured daily? Weekly?
- Weight
- Length and HC
Until the birthweight is regained, what should always be calculated?
The percentage of weight loss
An infant with a current body weight of 1500g at day of life 14, but weighed 1350 g at day of life 7. What is the growth velocity of the infant? Use the formula of [1000 x (Wn-W1)] / [(Dn-D1) x (Wn+W1/2)]
[1000 x (1500-1350)] / [(14-7) x (1500+1350/2)]
= 15 g/kg/day over last 7 days
–> within desirable growth velocity range
If there is inadequate growth velocity, what are our options? (3)
- Increase total fluid intake if not at maximum level
- If only on breastmilk, try fortifying
- If already on FBM< can further enrich with pre-term discharge formula to provide more kcals and protein
What is catch-up growth?
-The accelerated growth of an organism following a period of slowed development, particularly as a result of nutrient deprivation
Is there a clear quantification of catch up growth rate or velocity?
No
When a preterm infant has catch-up growth, is the order of catch-up?
Weight –> HC –> length
–> This is why premature babies are usually shorter
What nutrient requirements are higher during catch-up growth?
Energy and protein
What is the simpler, easier way to calculate growth adequacy?
1) Current DOL - Previous DOL ex: 14-7 = 7 (The change in days between weight gain)
2) Current weight-Previous weight ex: 1500-1350 = 150g (The change in weight between days)
3) Find the change in grams per day (150/7 = 21.4 g)
4) 21.4 g/kg/day –> 21.4 g/1.5 kg = 14 g/kg/day
Basically change in weight over time = x, then x/current weight = growth velocity
How should “catch-up” be monitored?
ideally, they should go back to their initial percentile, and should not exceed it
- -> beyond that, there may be fat deposits
- ->
When are energy and protein increased to sustain catch-up growth?
-Requirements are increased for the first 26-40 weeks
In terms of catch-up growth, what is the best result that we could achieve within the context of a premie?
-When the length catches up, this means that the baby is caught up completely
Biochemical parameters to monitor in PN?
- Glucose
- Electrolytes
- Ca, Mg and P
- TGs
- BUN/Creatinine
- Serum proteins
- Liver enzymes
- Alk phos
- CBC
Biochemical parameters to monitor in EN?
- Electrolytes
- BUN/Creatinine
- BUN alone
- Alk phos and C/P ratio
- Vitamin D
- Albumin, pre-albumin
- Liver enzymes
- CBC
Clinical signs to monitor?
- Skin colour
- Fluid status
- Vital signs
Bluish skin or lips?
Low O2 saturation, decreased gut perfusion
Whitish/pale skin?
Anemia
Yellow skin?
- Jaundice
- Poo wound healing (usually due to zinc or protein deficiency)
Generalized edema and fluid status indication?
-Over hydration, protein deficiency
Hypo/hyperthermia indication?
- Increased BMR, and decreased weight gain
- Will need more kcals
Tachypnea or apnea?
- No nipple feeding in tachypnea (breathing too fast - high risk of choking where we may do EN feed)
- Feed cautiously in apnea, provide caffeine
Tachycardia?
Will increase energy consumption
Urine and stool output to monitor?
- Urine normal range is 1-3ml/kg/day (more important in PN)
- Timing of first stool, frequency, colour and blood
- ->First meconium varies, but usually within first 48-72 hours is a good sign as it show that there is proper GI motility
Feeding tolerances to monitory?
- Abdomen (soft, distended, girth –> more than 2cm could cause problems)
- Regurgitation (frequency, verify if it affects growth)
- Vomiting (frequency,bilious)
- GRVs are not monitored due to delays in feeds
What are common medical conditions in the the neonate?
- Respiratory Distress Syndrome (RDS)
- Necrotizing enterocolitis (NEC)
- Gastroesophageal Reflux Disease (GERD)
What is RDS characterized by?
-Cyanosis in room air, nasal flaring, grunting, retractions and tachypnea
When does RDS develop?
In preterm infants due to immaturity of the lung tissue structure and function
-Other causes include meconium aspiration, pneumonia, lung hypoplasia etc.
What may RDS progress to?
Bronchopulmonary dysplasia
Which infants are more likely to develop both RDS and BPD?
-IUGR infants
PN Energy in RDS?
- Higher
- Initial intake of 85-115 kcal/kg/day to eventually 100-120kcal/kg/day
EN energy in RDS?
- Higher
- Initial intake of 90-130 kcal/kg/day to eventual 120-150kcal/kg/day
Protein intake in RDS?
- Higher
- Adequate intake is required to support lean tissue accretion and organ growth
- Goal intake of t least 3.5-4 g/kg/day
- -> if on BM after 3 weeks of life, it will NOT be sufficient
Fluid restriction in RDS?
- MUST be fluid restricted in RDS
- Allow for initial diuresis with adequate weight loss of 10-15% to prevent pulmonary edema
- Limit fluids to 70-80 ml/kg/day and adjust daily
- Eventual fluid restriction of about 120-150 ml/kg/day necessitating increased nutrient density (recall that optimal nutrition is reached at 150 ml/kg/day)
Feeding problems with RDS?
- May require prolonged EN
- Consult a feeding therapist to help enhance oro-motor development
Drug nutrient interactions with RDS?
- Corticosteroids
- Chlorothiazide diuretics
Corticosteroids and RDS?
- Increase protein intake
- May cause hyperglycemia, monitor serum glucose levels and modify glucose infusion rates if on PN
Chlorothiazide diuretics and RDS?
-May cause delayed growth due to decreased serum levels of sodium, potassium and chloride
Which diuretic is K+ sparing and may increase sodium and chloride excretion?
Spironolactone
Why do all diuretics put infants at a higher risk of osteopenia?
As they all increase renal phosphorous excretion
How is NEC classified?
-Using Bell et al’s stages
Bell Stage I?
NEC suspected
Bell Stage II?
NEC definite
Bell Stage III?
Advanced disease (portal venous gas on abdo xray)
Systemic symptoms of NEC?
- Temperature instability
- Lethargy
- Apnea
- Tachycardia
- Hypotension
GI symptoms of NEC?
- Poor feeding
- Emesis
- Abdo distension
- Abdo wall discolouration
- Ileus with decreased bowel sounds
- Fresh blood in stool
Prevention of NEC?
- The use of human milk/breast milk is the most effective way to reduce NEC
- Development and use of a standardized approach to feeding
- Use of EN probiotic supplementation for infants (>1000 g has been shown to reduce NEC)
Treatment of NEC?
- No known optimal nutritional management
- Antibiotic therapy
Nutritional management suggestion for NEC? (1/2)
- Balanced and complete Pn with cessation of EN for bowel rest for days-weeks
- Gradual re-introduction of EN feed as tolerated (10-35 ml/kg/day)
Nutritional management suggestions for NEC (2/2)?
- Use of human milk, donor breast milk, preterm formula if human milk available or hydrolyzed formula
- If bowel resection - review nutrient that may be maldigested or malabsorbed and supplement
- Monitor fo late complications, including cholestatic jaundice, bowel strictures and osteopenia
What is GERD classifies as? When does it resolve?
- A common physiologic condition in infancy which is typically benign.
- The passage of gastric contents into the esophagus with or without the regurgitation and vomiting
Symptoms of GERD?
-Vomiting, esophagitis, abdominal pain and dysphagia
What can extra esophageal conditions, such as GERD manifest into?
-Respiratory disorders or poor weight gain
What is the primary intervention in GERD?
-Parental education and reassurance
Nutritional intervention options in GERD?
- SMFQM or continuous feeds
- Prone an left lateral positioning have been associated with less reflux
If symptoms of GERD are suspected to be due to CMPI, how could we intervene?
Change to hydrolyzed formulas or AA based formula. Infant on human milk may be re-introduced if the mother has followed a cow’s milk protein free diet for a specific number of days
Should we used thickened feeds for GERD?
The use of carob and xanthun gum based thickeners are not recommended for pre-term infants, however dry infant rice cereal is a better option
Which medications are used in GERD? how may they impact NEC?
- Acid suppressants and pro-kinetic medications
- PPIs may increase the risk of NEC
