The management of low-birth weight infants requiring intensive care continues to improve dramatically

New technology Use of surfactant -A mixture of lipoproteins secreted by alveolar cells into the alveoli and respiratory air passages that contributes to the elastic properties of pulmonary tissues

- have increased the survival of preterm infants

Most LBW OR LOW-BIRTH WEIGHT INFANTS have the potential for long and productive lives FACTORS THAT DICTATE THE NUTRITIONAL REQUIREMENTS OF INFANTS Infants size Age Clinical condition Neonatal Intensive Care System Registered Dietitian - trained in neonatal nutrition makes the decisions necessary to facilitate optimal nutrition Regionalized Perinatal Care System - The neonatal nutritionist may also consult the healthcare providers in community hospitals and public health settings

PHYSIOLOGIC DEVELOPMENT
Weight of infant at birth: Less than 2500 g Less than 1500 g Less than 1000 g Low birth weight Very low birth weight Extremely low birth weight

Low birth weight is attributable to:

shortened period of gestation or prematurity

Retarded intrauterine growth rate makes infant SGA or small for gestational age GESTATIONAL AGE the age of an infant at birth as determined by he length of pregnancy ( the number of weeks since the last menstrual period) or clinical assessment.

ESTIMATE OF INFANTS GESTATIONAL AGE IS BASED ON:

Date of mothers last menstrual period Clinical parameters of uterine fundal height Presence of quickening

Fetal heart tones or ultrasound evaluation

After birth gestational age is determined by clinical assessment

CLINICAL PARAMETERS:
A series of neurologic signs depends primarily on posture and tone A series of external characteristics that reflect the physical activity if the infant

SGA OR SMALL FOR GESTATIONAL AGE - has a birth weight that is lower than the 10th percentile of the standard weight for that gestational age IUGR OR INTRAUTERINE GROWTH RETARDATION - a SGA infant whose intrauterine weight gain is poor but whose linear and head growth are between the 10th and 90th percentile on the intrauterine growth grid SYMMETRICAL IUGR - infant whose length and occipital frontal circumference are also below the 10th percentile of the standards AGA OR AVERAGE FOR GESTATIONAL AGE - infant has a birth weight between the 10th and 90th percentile on the intrauterine growth chart LGA OR LARGE FOR GESTATIONAL AGE - birth weight is above the 90th percentile

INFANT MORTALITY AND STATISTICS High incidence of LBW infants - may result to high infant mortality rate INVERSE RELATIONSHIP BETWEEN BIRTH RATE AND INFANT MORTALITY RATE Risk for infant death - infants weighing 1500 to 2499 g is 6 times higher than infants weighing more than 2500 g. - risk of infants weighing less than 1500 g is 96 times higher FACTORS AFFECTING INANT MORTALITY 1. TEENAGE PREGNANCY - have a 2.3% to 6% higher incidence of giving birth to LBW infants 2. INCIDENCE OF MULTIPLE BIRTHS - are 9 times likely to result in LBW

CHARACTERISTICS OF IMMATURITY PREMATURE INFANTS - high risk for poor nutritional status - physiologic immaturity - Illness - Nutrient demands FETAL NUTRIENT STORES - are deposited at the last 3 months of pregnancy LIMITED METABOLIC STORES nutritional support in the form of parenteral or enteral nutrition should be initiated as soon as possible Preterm infants Weighing 1000g constitutes only of 1% total fat

TERM INFANTS

has fat percentage of 16%

1000 g AGA PREMATURE INFANT glycogen fat reserve = 110 kcal per kilogram of bodyweight basal metabolic needs = approximately 50kcal/kg/day MOST QUICKLY DEPLETED NUTRIENTS - Infants with IUGR due to increase in basal metabolic rate SMALL PREMATURE INFANT particularly vulnerable to under nutrition UNDERNUTRITION deficient bodily nutrition due to inadequate food intake or faulty assimilation MALNUTRITION (PREMATURE INFANTS) - may increase the risk of infants - prolong chronic illness - adversely affect brain growth and function

Type of milk used for neonatal diet directly linked to neurodevelopment at 18 mos. of age HUMAN MILK OR PREMATURE INFANT FORMULA - fed on 1st month of life resulted in improved development NUTRITIONAL REQUIREMENTS: PARENTERAL FEEDING Parenteral feeding intravenous administration of nutrients Difficulty progressing to full enteral feeding - 1st several weeks/days of life WHAT MAKES THE DIFFICULTY? - Infants small stomach capacity - Immature gastrointestinal tract - Illness

PARENTERAL NUTRITION - becomes essential for nutrition support either as a supplement to enteral feedings or as the total source of nutrition

FLUID - fluid balance must be monitored for preterm infants

INADEQUATE INTAKE LEADS TO: - Dehydration - Electrolyte Imbalance - Hypotension EXCESSIVE INTAKE LEADS TO: - Edema - Congestive heart failure - Possible opening of the ductus arteriosus ADDITIONAL CLINICAL COMPLICATION - Necrotizing entercolitis - inflammation or death of the gastrointestinal tract - Bronchopulmonary dysplasia - Intraventricular Hemorrhage
- - - Premature infants have greater % of body water than the term infant

REDUCTION OF EXTRACELLULAR WATER - should be accomplished which is accompanied by a normal loss of 10% to 15& body weight and improved renal function ELBW INFANTS lose up to 20% of birth weight WATER REQUIREMENTS - estimated by the sum of the predicted losses from the lungs and skin, urine and stool and water needed for growth INSENSIBLE WATER LOSS - highest in the smallest and least mature infants because longer body surface area relative to body weight including permeability to skin epidermis to water and greater skin blood flow relative to metabolic rate. - is increased by radiant warmers and phototherapy by lights -decreased by heat shields, thermal blankets and humidified incubators - can vary from 50 to 100ml/kg/day on 1st day of life and increase up to 120 to 200ml/kg/day

DEPENDING ON: - Infants size - gestational age - day of life - environment

EXRETION OF URINE - a major route in water loss - varies from 40 to 85ml/kg/day - depends on the fluid volume and solute load presented to kidney
ABILITY TO PENETRATE URINE increases with maturity STOOL WATER LOSS - generally up to 5 to 10ml/kg/day suggested for optimal growth - 10ml/kg/day Fluid administered 80 to 105ml/kg/day (1st day of life)

FLUID NEEDS EVALUATION: - assessing fluid intake - comparing clinical parameters - urine volume output - creatinine - specific gravity or osmolality - urea nitrogen levels - serum electrolyte DAILY ASSESSMENT: - Weight - Blood Pressure - Peripheral perfusion - Skin turgor - mucous membrane DAILY FLUID ADMINISTRATION: - increases to 10 to 20ml/kg/day End of 2nd week of life - 140 to 160ml/kg/day FLUID RESTRICTION -maybe necessary in preterm infants with patent ductus arteriosus or congestive heart failure ---- more fluid is needed by preterm infants placed under phototherapy light

NUTRITIONAL SUPPORT OF PREMATURE INFANTS

CAUSE small metabolic Reserves of fat & glycogen ILLNESS Small stomach & Immature GI tract Nutrient Demands of growth

High
Nutritional Risk status

PATHOPHYSIOLOGY MEDICAL MANAGEMENT Parenteral feeding with monitoring by -Nutritionists - Nurses - Pharmacists - Physicians
TRANSITION TO:

NUTRITIONAL MANAGEMENT Enteral feeding by -Gastric gavage

- Transpyloric tube
- Nipple feeding - Breast feeding

ENERGY (PRETERM INFANTS) NITROGEN BALANCE (FIRST 3 WEEKS OF LIFE) - providing VLBW infants with 1 to 2 g protein and 30 to50 kcal/kg/day
COMPARISON OF PARENTERAL AND ENTERAL ENERGY NEEDS OF PREMATURE INFANTS PARENTERAL MAINTENANCE Gradually increase 40 50 cal/kg/day 50kcal/kg/day ENTERAL

Intake to meet energy needs

by the end of the week GROWTH Meet energy needs As soon as the infants condition is stable 80 90 cal/kg/day 105- 130kcal/kg/day

GLUCOSE (DEXTROSE) - is the principal energy source GLUCOSE TOLERANCE - limited in premature infants especially VLBW infants HYPERGLYEMIA - an excess of sugar in the blood - less likely to happen when glucose is administered with amino acids than when infused alone TO PREVENT HYPERGLYCEMIA: - Glucose should be administered in small amounts GLUCOSE LOAD - is a function of the concentration of the dextrose infusion and the rate at which it is administered INITIAL GLUCOSE LOAD (PRETERM INFANTS) - less than 6mg/kg/min. with a gradual increase to 11 to 12 mg/kg/min. ELBW INFANTS - tolerate a lower glucose load of 4 to 6 mg/kg/min.

HYPOGLYCEMIA - an abnormal decrease of sugar in the blood - may occur if the glucose infusion is abruptly decreased or interrupted AMINO ACIDS PROTEIN - guidelines range from 2.5 to 3.8g/kg/day Intrauterine Growth rate of protein accretion - can be achieved at 3 g/kg/day

ELBW INFANTS - 3 to 4 g/kg/day PRETERM INFANTS - given 1 to 2 g of protein (1st few days of life)
PEDIATRIC SOLUTIONS - result in plasma amino acid profiles similar to those of healthy infants fed breast milk

2 PEDIATRIC SOLUTIONS IN USE (U.S) - Trophamine - Aminosyn PF FUNCTION: - promote adequate weight gain and nitrogen retention STANDARD AMINO ACID SOLUTION - are not designed to meet the particular needs pf premature infants LOW HIGH - Cysteine Methionine - Tyrosine Glycine - Taurine CYSTEINE - a sulfur-containing amino acid occurring in many proteins - cannot be effectively synthesized by premature infants Cysteine supplement - has been suggested - insoluble and unstable in solution = added as cysteine chloride when PN is prepared

METABOLIC PROBLEMS ASSOCIATED WITH AMINO ACID INFUSION - metabolic acidosis - hyperammonemia - azotemia

LIPIDS ( intravenous fat emulsions) FUNCTION: - To meet essential fatty acid requirements - To provide concentrated source of energy EFA NEEDS provide 0.5 to 1 g/kg/day of lipids EFA DEFICIENCY - 1ST week of life in VLBW fed parenterally without fat CLINICAL CONSEQUENCES: - coagulation abnormalities - abnormal pulmonary surfactant - adverse effects on lung metabolism LIPIDS (PRETERM INFANTS) - should be introduced slowly with periodic monitoring of plasma triglyceride levels PLASMA TRIGLYCERIDE LEVELS should remain 150 mg/dl

LIPID ADMINISTRATION - over 24 hours at a maximum rate of 0.15 g/kg/hr to prevent a rise in triglyceride and fatty acid TOTAL LIPID LOAD - less than 30 to 40% of non- protein calories but should not exceed 60% HEPARIN - commonly administered at 1 U/ml - prevents thrombosis formation - with the administration of lipids, prolongs the life of peripheral veins - continues administration may improve lipid clearance CARNITINE - frequently added to PN solution provided to premature infants - facilitates the mechanism by which fatty acids are transported across the mitochondrial membrane allowing their oxidation to provide energy

CARNITINE SUPPLEMENTATION - enhanced lipid utilization in LBW infants receiving PN for longer than 1 month - can also be helpful to preterm infants who are receiving only PN at 2 4 weeks of age ELECTROLYTE (AFTER A FEW DAYS OF LIFE) - sodium, potassium and chloride are added to parenteral solutions to compensate for the loss of extracellular fluid POTASSIUM - should be withheld until renal flow is demonstrated - to prevent hyperkalemia and arrhythmia
PRETERM INFANT TERM INFANT SAME ELECTROLYTE REQUIREMENTS

FACTORS THAT AFFECT THE REQUIREMENTS: - Renal function - State of hydration - Use of diuretics

VERY IMMATURE INFANTS - limited ability to conserve sodium - require increased amounts of sodium to maintain a normal serum sodium concentration SERUM ELECTROLYTE LEVELS - should be monitored periodically URINE ELECTROLYTES - should be quantified when serum levels are abnormal to detect inappropriate electrolyte excretion

GUIDELINES FOR ADMINISTRATION OF PARENTERAL ELECTROLYTES FOR PREMATURE INFANTS

ELECTROLYTE Sodium Chloride Potassium AMOUNT (mEq/kg/day) 2-3 2-3 2-3

MINERALS Calcium and Phosphorus -important components of the Parenteral Nutrition solution PREMATURE INFANTS: Low Calcium and Phosphorus VLBW INFANTS: Receive PN for prolonged periods

at risk of developing osteopenia of prematurity

likely to have poor bone mineralization

HOW TO MONITOR CALCIUM & PHOSPHORUS STATUS: - serum calcium, phosphorus and alkaline phosphatase levels - radiographic bone studies

CALCIUM AND PHOSPHORUS - Have higher amounts of needs in preterm infants than term infants - Should be provided simultaneously in PN solution - Not recommended on alternate day infusion --- because abnormal serum mineral intake and decreased mineral retention develop GUIDELINES FOR ADMINISTRATION OF PARENTERAL MINERAL FOR PREMATURE INFANTS MINERALS Calcium Phosphate Magnesium AMOUNT (mg/L) 500-600 400-500 50-70

TRACE ELEMENTS Zinc - should be given to all preterm infants receiving PN Enteral feedings (cannot be started in 2 weeks) - additional trace elements should be added Amounts of Copper & Magnesium - should be reduced for infants with obstructive jaundice Amounts of Selenium, Chromium & Molybdenum - should be reduced in infants with renal dysfunction PARENTERAL IRON - not routinely provided because treated infants often receive blood transfusion soon afterbirth - dosage is approximately 10% of the enteral dosage - guidelines range from 0.1 to 0.2mg/kg/day ENTERAL FEEDINGS - provides a source of iron and can often be initiated

GUIDELINES FOR ADMINISTRATION OF PARENTERAL TRACE ELEMENTS FOR PREMATURE INFANTS TRACE ELEMENTS AMOUNT (g/kg/day) Zinc 400 Copper 20* Manganese 1* Selenium 2+ Chromium 0.2+ Molybdenum 0.25+ Iodine 1 *Reduced or not provided for infants with obstructive jaundice +Reduced or not provided for infants with renal dysfunction

VITAMINS After birth - All newborn infants receive: - an injection of 0.5 to 1 mg of Vitamin K Vitamin K - helps prevent hemmorhagic disease of the newborn from Vit. K deficiency - limited in newborns - little intestinal bacteria production of Vit. K occurs until bacterial colonization takers place INTRAVENOUS MULTIVITAMIN PREPARATIONS - recently approved and designed for use in infants should be given to provide the appropriate vitamin intake and prevent toxicity from additives used in adult multivitamin injections

VITAMIN A - large supplemental doses had been suggested for the prevention of BPD (Bronchopulmonary dysplasia)
BPD (Bronchopulmonary Dysplasia) - involves abnormal development of lung tissue characterized by inflammation and scarring in the lungs - facilitating tissue repair intramuscular injection of Vitamin A at 5000 IU per day 3 times a week 1st month of life --- decreases the incidence of BPD

Inositol

- present in human milk and infant formula - present in low concentration in PN solutions - additon of this to PN solutions increased survival and a decreased incidence of BPD and retinopathy of prematuriy in preterm infants with respiratory disease syndrome
Respiratory Disease Syndrome - a lung disease that is caused buy a surfactant deficiency, develops shortly after birth and common in preterm infants --- However Inositol is not used clinically because its effectiveness has not yet been established

TRANSITION FROM PARENTERAL TO ENTERAL FEEDING Enteral feeding delivery of a nutritionally complete feed directly into the stomach, duodenum or jejunum - beneficial for preterm infants as early as possible REASONS: - stimulates gastrointestinal enzymatic development and activity - promotes bile flow - increase villous growth in the small intestine - promotes mature gastrointestinal motility - decrease the incidence of cholestatic jaundice - improve subsequent feeding tolerance in preterm infants Cholestatic jaundice occurs when essentially normal liver cells are unable to transport bilirubin through capillary membrane of the liver because of damage in that area

- It is important to maintain parenteral feeding until enteral feeding is well established VLBW INFANTS - it may take 7 -14 days to provide a full enteral feeding - May take longer with infants having feeding intolerance or illness Small sickest infants receive increments of onlyb10ml/kg/day Larger more stable preterm infants may tolerate increments of 20 to 30 ml/kg/day ENTERAL ALIMENTATION - preferred for preterm infants - more physiologic and nutritionally superior

CONSIDERATIONS IN PROVIDING ENTERAL FEEDINGS: - degree of prematurity - history of perinatal insults - current medical condition - function of gastointestinal tract - respiratory status - In general, enteral nutrient requirements are different from parenteral requirements ENERGY - the energy requirements of premature infants vary with individual biologic and environmental factors Energy needs may be increased by: - stress - illness - rapid growth Intake of 50kcal/kg/day 105 to 130 kcal/kg/day required to meet maintenance energy needs needed for growth

Some premature infants may need 130 to 150 kca/kg/day - to achieve appropriate growth PROTEIN Amount and quality of protein intake - must be balance to avoid inducing amino acid or protein toxicity AMOUNT advisable protein intake is 3.5 to 4g.kg.day

well tolerated by stable infants growing rapidly - may increase stress in sick infants who are not growing

TYPE - breastmilk or formulas containing predominantly whey protein should be chosen whenever possible Whey Protein - the essential amino acid Cysteine is more concentrated

TAURINE - is a sulfuric amino acid that may be important for preterm infants Sources: - human milk - added to infant formula

Inadequate protein intake: Excessive intake: - growth limiting - elevated plasma amino acid levels - azotemia - acidosis
LIPIDS Growing preterm infant

needs an adequate intake of well absorbed dietary fiber To meet essentially fatty acid needs: LINOLEIC ACID should comprise 3.1% of the total calories Arachidonic acid & Docosahexonic acid present in human milk and are added to standard infant formula for term infants

TYPE LIPASES are enzymes needed for trygliceride breakdown BILE SALTS solubize fat for ease in digestion and absorption EFA linoleic acid found in human milk and vegetable oil Infants absorb vegetable oil more efficiently than saturated animal fat PREMATURE INFANT FORMULA MUST CONTAIN: - vegetable oil - MCT oil (medium-chain trygliceride) to provide long chain fatty acid CARBOHYDRATES (important source of energy) AMOUNT Human milk & standard infant formula approx. 40% of total calories is derived from carbohydrates Too little carbohydrates may lead to hypoglycemia Too much carbohydrates may lead to osmotic diuresis/loose stool

TYPE Lactose - a disaccharide composed of glucose and galactose - predominant carbohydrate in all mammalian milk - important to neonates for glucose homeostasis Sucrose - a disaccharide commonly found in commercial infant formula products Glucose Polymers - common carbohydrates in the preterm infants diet - consist mainly of 5 to 9 glucose units linked together VITAMINS AND MINERALS Calcium & Phosphorus - required for optimal bone mineralization Recommended intake: -175mg/100kcal/day of calcium - 91.5mg/100kcal/day of phosphorus

Osteopenia of prematurity in preterm infants develop when: - poor mineral stores - low dietary intake

OSTEOPENIA: - is a disease characterized by demineralization of growing bones and documented by radiologic evidence of washed out or thin bones
OSTEOPENIA IS MOST LIKELY TO DEVELOP IN PRETERM INFANTS WHO ARE: 1. Fed infant formula that is not specifically formulated for preterm infants 2. Fed human milk that is not supplemented with calcium and phosphorus 3. Receiving long term PN without enteral feedings

VITAMIN D (recommended intake) - range from 150 to 400 IU/day for preterm infants VITAMIN E - protects biologic membranes against oxidative lipid breakdown Recommended intake: - 0.7 IU/100kcal of Vit. E per kilogram of linoleic acid --- A premature infant with Vit. E deficiency may experience hemolytic anemia Hemolytic anemia anemia caused by oxidative destruction of mature red blood cells HIGH DOSES OF VITAMIN E MAY LEAD TO: - intraventricular hemmorhage - sepsis - necrotizing entercolitis - liver & renal failure - death

RECOMMENDATIONS FOR ENTERALADMINISTRATION OF VITAMINS IN THE PREMATURE INFANT VITAMIN VITAMIN A VITAMIN D VITAMIN E VITAMIN K ASCORBIC ACID THIAMIN RIBOFLAVIN PYRIDOXINE NIACIN PANTOTHENATE BIOTIN FOLATE VITAMIN B12 AMOUNT (kg/day) 700-1500IU 150-400IU 6-12IU 8-10g 18-24g 180-240g 250-360g 150-210g 3.6-4.8mg 1.2-1.7G 3.6-6g 25-50 g 0.3g

IRON (RECOMMENDED INTAKE) - 2 to 4mg/kg/day --- Infants fed with human milk should be given ferrous sulfate drops FOLIC ACID - premature infants have higher folic acid needs than term infants DAILY FOLIC ACID INTAKE - 25 to 50g (effectively maintains normal serum folate concentration) SODIUM DAILY SODIUM INTAKE: - 4 to 8 mEg/kg or more --- may be required by some infants to prevent hyponatremia

Hyponatremia lower than normal concentration of sodium in the blood --- Milk can be supplemented with sodium if repletion is necessary

Goal in Feeding: - To feed the infant via the most physiologic method possible and supply nutrients for growth without creating clinical complications. FEEDING METHODS:
A. GASTRIC GAVAGE (by the oral route) - often chosen for infants who are unable to suck because of immaturity or problems with the CNS - a soft feeding tube is inserted through the infants mouth and into the stomach Infant less than 32 to 34 weeks of GA : - expected to have poorly coordinated sucking and swallowing abilities because of developmental immaturity . MAJOR RISKS: - aspiration - gastric distention

TO MINIMIZE THE RISK: - electronic monitoring of vital functions - proper positioning of the infant during feeding POTENTIAL PROBLEMS (delivering on intermittent bolus schedule) - gastric distention - vagal nerve stimulation w/ resultant bradycardia

Continuous Drip Feedings - are sometimes preferred for tiny immature infants whose small gastric capacity and slow intestinal motility may impede the tolerance of large bolus feeds BOLUS- a mass of chewed food moving through the digestive tract Randomized control trial - was conducted in premature infants of 26 to 30 weeks gestation to compare continuous and bolus feedings Bolus Feedings - resulted in better weight gain and feeding tolerance than continuous infusion of feedings

NASAL GASTRIC GAVAGE - sometimes better tolerated than oral tube feedings - helpful for infants who are learning to nipple-feed - however , may compromise the nasal airway B. TRANSPYLORIC FEEDING - indicated for infants who are at risk for aspirating formula into the lungs or who have slow gastric emptying - also used for infants whose respiratory function is compromised & who are at risk for formula aspiration - requires considerable expertise & radiographic confirmation of the catheter tip location Goal: - to circumvent the often slow gastric emptying of the immature infant by passing the feeding tube through the stomach and pylorus - and placing its tip within the duodenum or jejunum

POSSIBLE DISADVANTAGES: - decreased fat absorption - diarrhea - dumping syndrome (rapid gastric emptying) - alterations of the intestinal microflora - intestinal perforation - bilious fluid in the stomach C. NIPPLE FEEDING - maybe attempted with infants where gestational age is greater than 32 weeks - should be initiated only when the infant is under minimal stress & is sufficiently mature and strong to sustain the sucking effort Ability to feed on a nipple: - indicated by evidence of an established sucking reflex and sucking motion

STANDARDIZED ORAL STIMULATION PROGRAM - help infants successfully nipple feed more quickly before oral feedings begin INITIAL ORAL FEEDINGS -may be limited to 1 to 3 times a day to prevent undue fatigue Healthy premature infants (younger than 32 weeks) - may tolerate the introduction of 1 nipple feeding per day

D. BREASTFEEDING - nursing at the breast should begin as soon as the infants is ready Premature breast-fed infants - have better sucking, swallowing and breathing coordination and less breathing disruption than bottlefed infants

KANGAROO BABY CARE - allows the mother to maintain skin to skin contact while holding her infant - facilitates her lactation - promotes continuation of breast feeding - enhances the mothers confidence in carrying for her high- risk infant Feeding infants with cups to supplement breast feeding - prevents nipple confusion POSSIBLE PROBLEMS: - Milk aspiration - Refusal to breast feed - Low- volume intakes

TOLERANCE OF FEEDINGS Vomiting of Feedings - usually signals the infants inability to retain the provided amount of milk - may also indicate that feeding volumes were increased too quickly or are exclusively for the infants size and maturity Bile stained emesis - may indicate the infant has an intestinal blockage and needs additional evaluation or that the feeding tube has slipped into the intestine Abdominal distention - maybe caused by excessive feeding, organic obstruction, excessive swallowing of air, resuscitation or sepsis - often indicates the need to interrupt feeding until its cause is determined and the abdomen becomes soft and is not distended

Gastric residuals - measured by aspiration of the stomach contents - should be determined routinely before each bolus gavage feeding and intermittently in all continuous drip feedings SIGNIFICANCE OF VOLUME IN RELATION TO TOTAL VOLUME OF FEEDING Ex. A residual volume of more than 50% of a bolus feeding or equal to the continuous infusion rate might be a sign of feeding intolerance The frequency and consistency of bowel movements - should be constantly monitored when feeding preterm infants

SELECTION OF ENTERAL FEEDING Initial feeding period -premature infants may often require additional time to adjust to enteral nutrition feedings Primary Goal: - to establish tolerance to the milk being provided ( Infants need a period of adjustment to be able to assimilate a large volume and concentration of nutrients) THUS - enteral feedings often require supplementation with parenteral fluids until infants can tolerate adequate amounts of feeding by mouths After initial period of adjustment GOAL: - to provide complete nutritional support for growth and rapid organ development (All essential nutrients should be provided in quantities that support sustained growth)

FOLLOWING FEEDING CHOICES: 1. Human milk supplemented with human milk fortifiers and iron Human milk fortifiers - supplements of protein, carbohydrates, fat, minerals & vitamins added to human milk to meet the increased nutrient needs of premature infants 2. Iron fortified premature infant formula for infants who weigh less than 2 kg 3. Iron fortified standard infant formula for infants who weigh more than 2 kg Discharged premature infants - can be given a transitional formula unless they have osteopenia

Infants with osteopenia - need calcium & phosphorus enriched premature infants formula until the condition improves

Breastfed infants w/ osteopenia - should also receive supplement with bottles of fortified human milk or premature infant formula

Breastfed infants w/out osteopenia - should receive a multivitamin & mineral supplement that contains Vitamin D & Iron

HUMAN MILK - is the ideal food for healthy term and premature infants - although it requires nutrient supplementation to meet the needs of premature infants - its benefits for the infants are numerous because of its unique mix of amino acids and long chain fatty acids

1st month of lactation ( composition of milk of mothers) birth to premature infant differ from those who gave birth to term infant PREMATURE INFANTS - have higher concentration of protein and sodium in breastmilk when fed with their own mothers milk - they grow more rapidly than infants fed banked or mature breastmilk ZINC & IRON ( HUMAN MILK) - are more readily absorbed FAT - is more easily digested because of presence of lipases

Lipase is an enzyme that catalyzes the breakdown of fats and lipoproteins usually into fatty acids and glycene

FACTORS IN HUMAN MILK (NOT PRESENT IN FORMULAS) Components include: 1. Live cells, macrophages, T & B lymphocytes Macrophages a phagocytic tissue cell of the immune system that maybe fixed or freely motile, function in the destruction of foreign antigens such as bacteria or viruses. T cell lymph several lymphocytes that differentiate in the thymus, possess highly specific cell- surface antigen receptor associated with the initiation of a cell-mediated humoral immunity B Cell have antigen binding antibody molecules on the surface that comprise the antibody secreting plasma cells when mature

2. Antimicrobial factors, secretory immunoglobulin A, lactoferin

3. Hormones - a product of living cells that circulates in body fluids and produces a specific often stimulatory effect on the activity of cells usually remote from its point of origin

4. Enzymes - any of numerous complex proteins that we produced by living cells and catalyze specific biochemical reactions at body temp. 5. Growth factors Human milk fed to preterm infants - reduce the incidence of necrotizing entercolitis & sepsis and improves neurodevelopment Necrotizing entercolitis - inflammation or death of the gastrointestinal tract DISADVANTAGE: - human milk does not meet the calcium & phosphorus needs for normal bone mineralization in premature infants Calcium & phosphorus supplements - are recommended for rapidly growing infants

3 HUMAN MILK FORTIFIERS: Similac Natural (liquid form) Similac & Enfamil human milk fortifiers (powdered form) - contain calcium, phosphorus, protein, carbohydrates, fat, vitamins and minerals Providing human milk to a premature infant - can be a very positive experience for the mother - promotes involvement and interaction PREMATURE INFANT FORMULA - these preparations have been developed to meet the unique nutritional & physiologic needs of growing preterm infants Quantity & Quality - promote growth at intrauterine rates - have caloric densities of 20 & 24kcal/oz - are available only in a ready to feed form

- the types of carbohydrates, protein,& fat differ to facilitate digestion & absorption of nutrients - have higher concentrations of protein, minerals & vitamins TRANSITIONAL INFANT FORMULA - contain 22kcal/oz & are designed or premature infants - nutrient content is less than that of the nutrient dens premature infant formulas & more than that of the standard infant formula - can be introduced when the infant reaches a weight of 1800 g or more & can be used throughout the 1st year of life - available in powder form for home use - ready to feed form for hospital use POTENTIAL BENEFICIARIES: - infants who weigh less than 1250 g and do not consume enough nutrients when hospitalized - those who cannot consume adequate amount of standard formula to grow when discharged

COMPARISON OF THE NUTRITIONAL CONTENT OF HUMAN MILK & FORMULAS

HUMAN Caloric density (kcal/oz) Protein whey, 70:30 Casein ratio Protein (g/L) 9-14 Carbohydrate Lactose Carbohydrate (g/L) Fat Fat(g/L) Calcium(mg/L) Phosphorus (mg/L) Vitamin D (IU/L) Vitamin E (IU/L) Folic acid (g/L) Sodium(mEq/L) 66-73 Human fat 39-42 248-280 128-147 20-21 2.8-10.7 33-85 7.9-10.8 MILK 20 FORTIFIED MILK 24 STANDARD FORMULA 20 TRANSITIONAL FORMULA 22 PREMATURE FORMULA 20,24

whey 60:40, 48:52, 100:0 60:40, 50:50 60:40 predominant 19-20 14-16 19-21 18-24 Lactose, glucose Lactose or lactose Lactose/glucose Lactose/glucose polymers & glucose polymers polymers polymers 77-88 73-74 77-79 72-90 human fat, MCTs 44-52 1180 1141 650-790 1190-1520 34-49 30.6-33.5 14-15 vegetable 34.1 36.5 429-530 241-360 402-410 10.1- 13.5 60-108 7-8 veg., MCT oil 39-41 784-890 463-490 522-590 26.9-30 187-192 10.7-11.3 veg., MCT oil 34.5- 43.8 1115- 1452 561-806 1014-2200 27-51 237-298 11.5-15.1

FORMULA ADJUSTMENTS (occasionally increasing the energy content of formulas fed to small infants) - maybe appropriate when infant is not growing quick enough & is already consuming as much as possible during feedings CONCENTRATION Providing hypercaloric formula - prepare the formula w/ less water Concentrated infant formula w/ energy contents of 24kcal/oz - are available to hospitals as ready to feed nutrients - consider the infants fluid intake & fluid losses in relation to the renal solute load of the concentrated feeding, to ensure a positive water balance is maintained Transitional formula can be concentrated from 24 to 30 kcal/oz - should be provided in amounts that can be tolerated by the infant & caloric supplements can be added as needed

Infants consume less due to illness - infant formula powder is often added to provide more calories & nutrients - provide enough calcium, phosphorus, magnesium,& Vit. D to treat osteopenia Caloric supplements - an approach to increasing the energy content of a formula - Corn oil - MCT oil - glucose polymers ex. Polycose - increase the formulas caloric density w/out markedly altering solute load or osmolality - alter the relative distribution of total calories derived from protein, carbohydrate & fat --- Adding these supplements to human milk of standard infant formula is not advised - should be used only when a formula already meets all nutrient requirements other than energy or when the renal solute load is a concern

WHEN A HIGH ENERGY FORMULA IS NEEDED: - MCT oil & Polycose can be added to a base that has a concentration of 24kcal/oz or greater - could either be a full strength premature formula or a concentrated standard formula w/ a maximum of 50% total calories from fat - a minimum of 9% total calories from protein For infant who can tolerate long chain fatty acid - an emulsified fatty acid product (Microlipid) may be appropriate because it stays in solution better than MCT oil

GROWTH & NUTRITIONAL ASSESSMENT - All neonates typically lose some weight after birth

PRETERM INFANTS - are born with more extracellular water than term infants & thus tend to lose more weight than term infants --- The post natal loss should not be excessive Those who lose more than 15% to 20% - may become dehydrated - birth weight should be regained by the 2nd or 3rd weeks of life FIRST 98 DAYS OF LIFE - Ehrenkranz growth chart is commonly used to assess weight progress Birth weight assessment charts: 1.Ehrenkranz growth chart - longitudinally depicts daily weight changes & actual growth curves of 1660 infants who were born with a weight of 501 to 1500g

2. INTRAUTERINE GROWTH CURVES - have also been developed using birth weight data of infants born at several successive weeks of gestation - however, these do not depict the initial period of postnatal weight loss & probably set unrealistic goals for preterm infants in the neonatal period After infants condition stabilizes: - infant may be able to grow at a rate that parallels these c curves Intrauterine weight gain of 15g/kg/day - can be achieved before 38 weeks of gestation 3. Growth curve - can be used to evaluate the adequacy of growth in areas such as: weight, length, head circumference - has a built in correction factor for prematurity 7 the infants growth can be followed on one chart through the 1st year of corrected age

(CDC) Center for Disease Control Growth Charts - from birth to 3 years of age - can also be used for preterm infants after 40 weeks of gestation, as long as the age is adjusted LABORATORY INDICES (usually involve measuring the ff) - Fluid & electrolyte balance - PN tolerance - Bone mineralization - Hematologic status DISCHARGE CARE Establishment of successful feeding - pivotal factor in determining whether an infant could be discharged

PRETERM INFANTS MUST BE ABLE TO: 1. Tolerate their feedings & usually obtain all of their feedings from the breast or bottle 2. Grow adequately on a modified demand feeding schedule - usually 3-4 hours during the day for bottle fed infants - every 2 to 3 hours for breast fed infants 3. Maintain their body temperature without the help of an incubator Neonatal intensive care unit - parents are permitted to room in Room in - to stay with the infant all day & night in the nusery before discharge - helps build confidence in their duty to care for a high risk ifant Preterm infants - weigh less than 5 lb during discharge Small preterm infants - should be followed very closely during 1st month after discharge

1ST WEEK OF DISCHARGE (home visit by nurse or nutritionist or both & office visit to the pediatrician) - can be extremely helpful educationally - can provide eary intervention for developing problems FACTORS AFFECTINTG FEEDING SKILLS PHYSICAL FACTORS - variable heart rate physiologic events - rapid respiratory rate that interfere - tremulousness with feeding Tremulousness - shaking or shivering of the muscles Infants weighing less than 51/2 lb have poor muscle tone

FEEDING - is often difficult for infants who have limited muscle flexion & strength & poor head and neck control w/c are needed to maintain a good feeding posture --- Position infants in a manner that supports normal body flexion & ensures proper alignment of the head & neck during feedings --- Premature infants may also need their chin & cheeks supported while bottle feeding

SMALL INFANTS - tend to sleep more than larger & term infants --- It is much easier for preterm infants to feed effectively if they are fully awake
TO AWAKEN A PRETERM INFANT: 1. The caregiver should provide one type of gentle stimulation for a few minutes and then change to a different type, repeating this pattern until infant is fully awake

2. Lightly swadling infants and then placing them in a semiupright position may also help

Feeding environment - should be as quiet as possible

---Infants may tire quickly & show subtle signs of distress parents should recognize these cues to provide rest or comfort AFTER DISCHARGE (most preterm infants may need:) - approximately 180ml/kg/day of breast milk or standard infant formula containing 20kcal/oz - this amount of milk provides 120 kcal/day Alternatively: - transitional formula w/ a concentration of 22kcal/oz can be provided at a rate of 160ml/kg/day

Determining the adequacy of amounts for individual infants - compare their intakes with their growth progress over time --- Some infants may need a formula that provides 24kcal/oz Evaluate needs based on the 3 growth parameters: - weight - height - head circumference

Patterns of growth should be assessed to determine whether: 1. Individual curves at least parallel reference curves 2. Growth curves are shifting inappropriately across growth percentiles 3. Weight is appropriate for length 4. Growth is proportional in all three areas
NEURODEVELOPMENTAL OUTCOME ---More tiny premature infants are surviving than ever before because of adequate nutritional support & recent advances in neonatal intensive care technology

Increased survival rate of VLBW infants - has increased concerns about their short & long term neurodevelopmental outcomes As a rule: - VLBW infants should be referred to a follow- up clinic to evaluate their development & growth & begin early intervention Surviving ELBW infants (particularly w/ birth weight less than 750g) - have an increased risk of developing handicapped central nervous system conditions, which vary in severity & type of functional impairment = Many of these premature infants reach childhood w/ no evidence of any disability