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Enteral Feeding in LBW Neonates

CHAIRPERSON Dr. A.G. Shingwekar, MD,DCH Professor & Head

Presented by Dr. KISHORE CHANDKI

Guided by : Dr. Ajay Gaur MD, PhD Dr. G. Das MD Dr. Y.S. Verma MD Dr.(Mrs) Neetu MD Dr. (Mrs) Sunita MD

Department of Paediatrics, G.R.M.C. & J.A. Group of Hospitals, Gwalior

Enteral Feeding in LBW Neonates


 Introduction Indications & Contraindications  Goals of Feeding  Routes of Enteral Feeding  Choice of Milk for Feeding  Amount & Schedule of Feeding  Minimal Enteral Nutrition  Converting Gavage to Oral Feeds  Feeding Term LBW neonate

Enteral Feeding in LBW Neonates


 Judging the adequacy of nutrition  Kangaroo Mother Care  Micronutrient Supplementation  Immunonutrition  MCT Oil  Post discharge feeding & advice  Summary

Enteral Feeding
Defined as the administration of nutrients directly into the gastrointestinal tract.  If the patient is unable to meet his/her nutritional requirements with oral diet/ nutritional supplements, then enteral feeding is indicated.  Once the gastrointestinal tract is functional, enteral feeding is the optimal method of nutritional support.

Advantages w.r.t. Parenteral


 More Physiologic  More safe  More nutritionally complete  Less expensive
But decision for mode of nutrition is based on : Weight Gestational Age Clinical Condition
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Indications
 Absent / impaired swallow  Inadequate oral intake  Neonates <1800 gm or < 34 weeks gestation, unable to breast feed
Necessity :

 Functioning & accessible gastrointestinal tract

Contraindications
Complete bowel obstruction, Ileus Intestinal ischemia Necrotizing Enterocolitis

Complications of Enteral Nutrition


 GI : Perforation, stricture, esophagitis, gastritis, nausea, vomiting, bleeding, GER  Mechanical : Dislodgement, tube migration, blockade, inflammation, granulation of skin site, aspiration, nasopharyngeal trauma, sinusitis, otitis media, laryngeal ulceration  Metabolic : Fluid overload, dehydration, hyper- & hypo-glycemia, electrolyte imbalance, azotemia, hypercapnea, hyperphosphatemia, vit. & mineral deficiency  Misc. : Aspiration pneumonia, Feed contamination & resulting infection, Abnormal LFT Development, 3 Ed., 2004 Elizabeth K E, Nutrition & Child
rd

Goals Of Feeding


Achieve well-defined short-term growth & nutrient retention Mimic intrauterine growth rates Mimic reference fetal composition Prevent Neonatal morbidities Improve feeding tolerance Reduce NEC Minimize nosocomial infection Optimize long-term outcome Optimize neurodevelopmental outcome Reduce rates of allergy & atopic diseases

Ghai O.P., Essential Paediatrics, 2004

What is the Optimal Diet for LBW neonate ?


Optimal diet should support a rate of growth approximating that of the third trimester intrauterine life without imposing stress on the developing & excretory functions!

the statement encourages mimicking the intrauterine environment by stimulating fetal accretion rates of nutrients & intrauterine growth rates!

Is it possible to extrapolate the extrauterine growth?


Thermal Protection Preferential nutrient delivery Excretion handled by placenta Oxygen via placenta  Thermal instability  Exogenous nutrients  Immature kidney  Birth asphyxia

Is it possible to extrapolate the extrauterine growth?


 Poor Feeding reflexes  Low gastric acidity, low enzyme levels, low bile secretion  NEC  qsurfactant HMD  Immature respi. Center apnea, aspiration, pulmonary hemorrhage  q UDPG prolonged jaundice  IVH, cerebral anoxia  Low glycogen stores/brown fat  Poor lactate metabolism acidosis  Poor immunity sepsis  Congenital anomalies

Contd

Contd

Is it possible to extrapolate the extrauterine growth?


Fetal Energy & Protein Accretion Weight gain 18 gm/kg/d (24-28 (24wks) 16 gm/kg/d (32-36 (32wks) ~ 2 gm/kg/d 1.4-1.9 gm/kg/d 1.4~30 kCal/kg/d (>28 wks) Postnatal Energy & Protein Accretion 15 gm/kg/d (During acute phase : Avoid catabolism) 3 gm/kg/d ~1.5 gm/kg/d ~50 kCal/kg/d

Protein Accretion Fat Accretion Calorie Accretion

So, the answer is probably NO


Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Fluid Requirements For Neonates


Fluid (mL/kg/d)
Day 1 2 3 4 5 6 7+
Birth weight <1000 gm 100 115 130 145 160 175 190 BirthWeight 10011001-1500 gm 80 95 110 125 140 155 170 Birth Weight >1500 gm 60 75 90 105 120 135 150

Additional Allowances : Phototherapy : 20-40 ml/kg/d, Radiant Warmer : 40-80 ml/kg/d 2040IAP Textbook of Pediatrics, 2nd Ed. 2002

Guidelines for Fluids & Feeding to LBW Babies


Age

Category of Neonates
< 1200 gm <30 weeks IVF. Try gavage if not sick 12001200-1800 gm 3030-34 weeks Gavage >1800 gm >34 weeks Breast feeding. If unsatisfactory, give katori-spoon katorifeeds. Breast feeding Breast feeding Breast feeding

Initial

Gavage After 1-3 1days KatoriKatori-spoon Later (2- 4 weeks) (2Breast feeding After sometime (4- 6 weeks) (4-

Katori-spoon KatoriBreast feeding Breast feeding

Ref. Teaching Aids : NNF

Routes of Administration of Enteral Nutrition


Least preferred TPN TPN + MEN PPN Alternative Feeding Exclusive Breast Feeding Most preferred

Routes of Administration of Enteral Nutrition

Oral- Spoon & katori, etc. Nasogastric/Orogastric Nasoduodenal / Nasojujenal Surgical or Percutaneous Endoscopic gastrostomy Surgical or Percutaneous Endoscopic jejunostomy

Indian J Pediatr 2002; 69 (5) : 411-415

Inserting a Nasogastric (NG) Tube

Normal anatomical Path

Inserting a Gastric Tube

Insert through nostril

Principles of Newborn Baby Care, WHO/UNICEF, 2003

Confirming Proper Placement of Tube




Air insufflation & auscultation method : with 1 to 2 ml of air - If a whistling sound is heard through the stethoscope as the air is injected, the end of the tube is correctly positioned in the stomach. You should also be able to withdraw the air you pushed in. Acidity of the aspirate: [Only suitable for babies more than 24 hours old or preterm LBW babies who are more than 48 hours old] If the blue litmus paper turns pink, the fluid is acidic and the tip of the tube is correctly positioned in the stomach.

Inserting a Gastric Tube


Signs that the tube may not be placed correctly are: X Coughing X Apnea X Cyanosis

Nasogastric Tube
Advantages
Easy to place Easy to secure Lasts longer, Cheaper No need to pass every time

Disadvantages
Risk of nasopharyngeal trauma Space occupying effect GER, aspiration (Gag reflex should be intact)

Agrawal K.N., Pediatrics & Neonatology, 1st Ed., 2000

Nasoenteric Tubes
Properties :
Has a small diameter available for patient comfort Is long enough for nasoenteric feeding Is flexible for easy insertion and removal Is radioopaque for X-Ray confirmation of Placement XHas several feed outlets at the distal end to prevent clogging Has a smooth rounded tip to prevent insertion trauma If a guide wire is used, the guide wire will not dislodge during insertion; it is easy to remove. Is preferably made of premium material, resistant to gut secretions
http://www.nutriciame-clinicalnutrition.com

Nasoenteric Tubes
react to gastric juices. Can stay for 6-8 weeks. Some juices. weeks. contain a guide wire for easy insertion. insertion.  Polyvinylchloride (PVC): Contain a plasticizer to (PVC): keep the tube flexible, because the compound is sensitive to the low pH, becomes rigid after 7-10 days which can lead to irritation of the pharynx and to the esophagus. esophagus. If not replaced after 7 days of usage a digestion happen to the tube it self which make the content of toxic products to be leached and may cause nectorizing entercolitis in premature infants. After 7 infants. days as the tube become rigid and stiff it may cause perforation and intussusception. intussusception.
 Polyurethane tubes (PUR): Soft, flexible and do not (PUR):

http://www.nutriciame-clinicalnutrition.com

Inserting an Orogastric (OG) Tube

Orogastric Tube
Advantages
No space occupying effect Larger bore tube can be passed easily

Disadvantages
Difficult to secure, dislodgement Lasts shorter Need to pass with every feed

Agrawal K.N., Pediatrics & Neonatology, 1st Ed., 2000

Routes of Enteral Feeding

Nasoduodenal feeding

Nasojejunal feeding

Nasoduodenal or Nasojejunal Tubes


Length : From tip of nose to knee joint Advantages
Less aspiration Less expensive & safer than TPN Less chances of reflex bradycardia Less risk of dislodgement

Disadvantages
Requires fluoroscopic or endoscopic control for insertion Expensive tubes wrt NG/NJ Risk of gut perforation Frequent supervision
Agrawal K.N., Pediatrics & Neonatology, 1st Ed., 2000

Transpyloric Feeding
Candidates :
Intolerance to naso/orogastric feeding owing to gastric retention or regurgitation Neonates at increased risk for aspiration Anatomic abnormalities of GI tract e.g. microgastria

Problems :
Must be delivered continuously Fluoroscopic control required for placemnent Increased risk for fat malabsorption because of by passing of lipases
Cloherty, Eichenwald, Stark, Manual of Neonatal Care; 5th Ed, 2004

Transpyloric Feeding
 No difference in short/long term growth, rather increase in GI disturbance & increased mortality  Hence, avoided as far as possible

Indian J Pediatr 2002; 69 (5) : 401-404

Routes of Enteral Feeding

Gastrostomy (GT) feeding

Jejunostomy (JT) feeding

Enterostomy Tubes
Advantages
Less aspiration (qq with jejunostomy) Less chances of reflex bradycardia, trauma to air passages Less risk of dislodgement No interference with breathing

Disadvantages
Requires endoscopic control/anesthesia for insertion Expensive tubes wrt NG/NJ Peristomal infection, peritonitis, tube blockage, inadvertent removal, tube fracture and leakage
Postgraduate Medical Journal 2002;78:198-204

Enterostomy Tubes
Indications :
 Congenital anomalies of the mouth, jaw, pharynx, gastrointestinal tract, and/or airway (ie, esophageal fistula, tracheoesophageal fistula, cleft lip and palate, intestinal atresia, and abdominal wall defects)  Prolonged enteral nutrition (>6 weeks)

Contraindications :
 Abdominal wall infection  Coagulopathy  Massive ascites
http://www.naspghan.org/sub/ENTERAL_AND_PARENTERAL_NUTRITION.htm

Choice of Milk for Feeding


Human milk alone (Term/Preterm) Human Milk + Calcium Phosphate & Vit. Supplements Human Milk (EBM) + Preterm formula Human milk + Fortifier (HMF) Top milk with or without Fortifier

Contd
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Contd

Choice of Milk for Feeding

Human milk alone (Term/Preterm) : Expressed breast milk Besides usual advantages, has  Immunological advantages  Better neurodevelopmental and visual outcomes (possibly because of LC-PUFA)  Reduced incideence of NEC
But it does have short comings : Does not have enough protein and calorie to ensure optimal EARLY growth at 20 kCal/Oz Does not have enough sodium to compensate for high sodium losses. Does not have enough calcium or phosphate
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Contd

Choice of Milk for Feeding

Human milk alone (Term/Preterm) : Expressed breast milk


-

Is deficient in vitamins and iron relative to the needs of a preterm infant who will have mixed out on the last trimester placental transfer. Composition varies Losses A/W collection, storage, feeding procedures, esp. fats & vitamins.

Because of this, many units routinely supplement EBM with HMF upto 24 kCal/Oz in babies <32 weeks or <1500 gm (when the baby is tolerating 150ml/kg/day)

Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Contd

Choice of Milk for Feeding

Human Milk + Calcium Phosphate & Vit. Supplements Has :  All the biological advantages of Breast Milk! But :  Still will have LESS protein than the required

Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Contd

Choice of Milk for Feeding

Preterm formula Has :  Adequate calories, calcium, phosphate & vitamins fed at the rate of 150-180 mL/kg/d But :  Does not have any of biologically active immune substances, or enzymes of growth factors  May still require supplements of sodium, chloride, vitamin A & D and iodine  More chances of contamination while preparation Hence:  Not preferred in general  If required, given until neonate reaches a weight of 2-2.5 kg or on full breast feeds!
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Breast Milk Substitute : Formula Milk


Use when the mother cannot breastfeed or express breast milk. Use a breast-milk substitute designed for premature or small babies. Once the container is open, use within the recommended time according to the manufacturers instructions. Check the expiry date of the breast-milk substitute. Use aseptic technique to prepare the breast-milk substitute from liquid concentrates or powders, using high-level disinfected or sterile utensils and containers, and sterilized or boiled and cooled water.

Managing Newborn Problems, WHO/UNICEF, 2003

Breast Milk Substitute : Formula Milk


Wash hands with soap and water. Determine the required volume of milk for the feed. Measure the breast-milk substitute and water, mix them, and feed the baby using a cup, cup and spoon, or other device. Have the mother do this whenever possible. Store remaining milk in a labelled container in a refrigerator for a maximum of 24 hours. Breast-milk substitute is not available, have the mother use a breast-milk substitute that is based on animal milk and prepared at home.

Managing Newborn Problems, WHO/UNICEF, 2003

Choice of Milk for Feeding


Top Milk :
Term Breast Milk Cows Milk 67 3.2 4.1 4.4 120 90 0.2 70-220 700.76 5 Buffalos Milk 117 4.3 6.5 5.1 169 117 0.12 178 0.52 6 Goats Milk 72 3.3 4.5 4.4 134 111 0.05 185 0.50 1

Calories (Kcal/dl) Protein (gm/dl) Fat (gm/dl) Carbohydrate (gm/dl) Calcium (mg/dl) Phosphorus (mg/dl) Iron (mg/dl) Vitamin A (IU/dl) Sodium (mEq/dl) Folic Acid (mcg/dl)

67 1.1 4.5 7.1 33 15 0.03 250 0.8 5

Ref. : Deptt. of Agriculture, United States

Choice of Milk for Feeding


Top Milk : Animal milk and term formula milk are unsuitable for feeding preterm as composition does not meet recommended nutrient intake and it predisposes to late hypocalcemia as phosphate contains high. Animal milk with human milk fortifier is not yet studied.

Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Human Milk Fortifier (HMF)


Is the nutritional supplement product that may be added to breast milk to supplement its nutrient content
Cochrane review
Short term benefits Greater weight gain Greater length gain Greater HC gain Increased N2 balance Increased bone  mineral content Long term benefit (at 18 mo) No benefit in terms of :xWeight xLength xHC xNeurodevelopmental x outcome Adverse effects No increase in NEC Feed intolerance

Currently available HMF have low protein, low sodium, high soluble calcium & phosphate, high osmolality and difficulty in mixing leading to separation of fat and disruption of fat globules with addition of calcium Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Composition of various feeds


Mineral & Vitamin per 100 Kcal Calories (Kcal/kg/d) Protein (gm/kg/d) Carbohydrate (gm/kg/day) Calcium (mg) Phosphorus (mg) Iron (mg) PretermPretermRNI (AAPCON 1998) 105105-130 3.53.5-4 11-15.5 11175 91 1.7-2.5 1.7Preterm PretermPretermEBM (per 100 EBM + HMF (Per 100 ml) ml) 67 1.6 7.3 25 14 0.09 81 2 9.7 125 64 0.09 Preterm Formula (Per 100 ml) 80 2 9.1 128 64 0.8

Contd

Contd

Composition of various feeds


PretermPretermRNI (AAPCON 1998) 75-225 75270 2.12.1-2.9 >1.1 PretermPretermPreterm EBM (per 100 EBM + HMF ml) (Per 100 ml)* 48 8 1.26 1 1508 508 1.56 3 Preterm Formula (Per 100 ml) 241 72 2.2 4

Mineral & Vitamin per 100 Kcal Vitamin A (IU) Vitamin D (IU) Sodium (mEq) Vitamin E (IU)

* 1 Sachet (2 gm) of HMF is added to 50 ml of expressed breast milk.


Human Milk provides the Gold Standard for feeding LBW neonates!
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Gut Starvation : Need for early feeding ?


Morphological Changes mass q Cell production q Villus height o Permeability q Amino acid absorption q Sucrase q Lactase q Number of lymphocytes q IgA secretion o Bacterial translocation
Zeigler,Lucas,Moro Nutrition of the VLBW Infant, 1999

qMucosal

Functional Changes Enzymes Immunity

Minimal Enteral Nutrition (MEN)


Syn. Trophic feeding, Gut priming feeding, minimal feeds, gut stimulation, early feeding, or hypocaloric feedings

Def. : Feedings that are delivered in very small amounts (e 10 mL/kg/d) for the purpose of induction of gut maturation rather than nutrient delivery! Advantages :
 Improved levels of gut hormones Trophic effects on mucosa  Improved peristalsis Improved calcium & phosphorus retention
Cloherty, Eichenwald, Stark, Manual of Neonatal Care, 5th Ed, 2004

Contd

Minimal Enteral Nutrition (MEN)


 Less feeding intolerance  Earlier progression to full enteral feedings, Fewer days on parenteral nutrition  Improved weight gain  Reducation in episodes of culture positive sepsis  Low serum bilirubin levels  No increased risk of NEC

Cochrane review, Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Contd

Minimal Enteral Nutrition (MEN)


No consensus guideline as when to start, how to progress, how long to continue MEN & when to advance to full nutritive feeding
 Recommended for all babies  Sick babies with significant respiratory distress & hemodynamic instability remain NPO till they are stable, ideally by 1st 2nd day of life  Donot use in suspected or confirmed NEC or evidence of ileus. ileus.  Can be started with EBM at a volume of e10 mL/kg/d @ 3-8 hourly intervals

Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Rapid (Vs Slow) Advancements


Better gain in weight, length & HC Shorter hospital stay  Risk of GER, aspiration  Risk of NEC with very fast advancements

Recommendation You can make rapid enhancements upto 30 ml/kg/d in stable LBW infants without increased risk of NEC, esp. after day 4/5 of life!
Indian J Pediatr 2002; 69 (5) : 401-404

Guidelines for Tube Feeding


Birth weight (gm) < 800 800800-1000 10011001-1250 12511251-1500 15001500-1800 18011801-2500 >2500 Initial rate (mL/kg/day) 10 10-20 1020 30 30-40 3040 50 Volume Increase (mL/kg/day) 10-20 1010-20 1020-30 2030 30-40 3040-50 4050

Feeding MUST always be individualized depending on neonates condition!


Cloherty, Eichenwald, Stark, Manual of Neonatal Care; 5th Ed, 2004

Intermittent Bolus Vs Continuous


Advantages
More physiological

Disadvantages
Risk of GER Risk of aspiration

Preferred in general!

May be used for : GER Bolus feeding Intolerance


Indian J Pediatr 2002; 69 (5) : 401-404

Expressing Breast Milk


Teach the mother how to express breast milk herself. The mother should: - obtain a clean (washed, boiled or rinsed with boiling water, and air-dried) cup or container to collect and store the milk; - wash her hands thoroughly; - sit or stand comfortably and hold the container underneath her breast; - express the milk - support the breast with four fingers and place the thumb above the areola; - squeeze the areola between the thumb and fingers while pressing backwards against the chest;
Principles of Newborn Baby Care, WHO/UNICEF, 2003

Expressing Breast Milk


- express each breast for at least four minutes, alternating breasts until the flow of milk stops (both breasts are completely expressed). If the milk does not flow well: - ensure that the mother is using the correct technique; - have the mother apply warm compresses to her breasts

Expressing Breast Milk

While feeding, babys lips should cover areola in addition to nipple!


www.breastfeeding.org

Recommendations for storage of Breast Milk


Duration of Storage with respect to temperature Room Temperature Refrigerator (<4C; 39F) (<4 Freezer Compartment, or Deep Freezer ( <-20 C; <-4 F) <<6-8 hours 24 hours 6 months

 Store in hard plastic or glass containers with well-fitting tops.  Warm frozen or refrigerated milk in a warm water bath (~40 C). C).  Use the rewarmed milk promptly. Discard the remaining once promptly. warmed. warmed.

Feeding by Alternative Methods


Ensure that the mother can properly express breast milk Feed the baby using a cup, a cup and spoon, or other suitable device (e.g. paladai) Use clean (washed, boiled or rinsed with boiled water, and air-dried) utensils and feeding devices for each feed. Feed the baby immediately after the milk is expressed, if possible. If the baby does not consume all of the milk, store the remaining milk

Feeding by Alternative Methods


Have the mother feed the baby unless she is not available. The mother should: - measure the volume of breast milk in the cup - hold the baby sitting semi-upright on her lap; - rest the cup (or paladai or spoon) lightly on the babys lower lip and touch the outer part of the upper lip with the edge of the cup; - tip the cup (or paladai or spoon) so the milk just reaches the babys lips; - allow the baby to take the milk; do not pour - end the feeding when the baby closes her/his mouth and is no longer interested in feeding.

Feeding by Gastric Tube


Ensure that the mother properly express breast milk can

Insert a gastric tube, if one is not already in place. Confirm that the tube is properly positioned before EACH feeding. Encourage the mother to hold the baby and participate in feedings. Determine the required volume of milk for the feed according to the babys age

Feeding by Gastric Tube


Remove the plunger of a high-level disinfected or sterile syringe or a clean (washed, boiled or rinsed with boiled water, and air-dried) syringe and connect the barrel of the syringe to the end of the gastric tube: Pour the required volume of milk into the syringe with tip of the syringe pointed downward. Have the mother hold the syringe 5 to 10 cm above the baby or suspend the tube above the baby and allow the milk to run down the tube by gravity. Do not force by plunger.

Feeding by Gastric Tube


o You may apply slight pressure with the plunger initially (just to start the feeding) o When the feeding is completed, clear the tube with some of water. Try not to put extra air into the stomach. o There is no need to burn the baby after feeding o Place the baby on his or her right side or hold upright after feeding

Feeding by Gastric Tube

Right-side lying position after feeding


Whaley & Wongs Essentials of Pediatric Nursing, 5th Ed, Mosby, 1997

Feeding by Gastric Tube


Using this method, each feeding should take 10 to 15 minutes. When the feeding is finished, remove, wash, and high-level disinfect or sterilize the syringe, and cap the tube until the next feeding. Progress to feeding by cup/spoon when the baby can swallow without coughing or spitting milk. Replace the gastric tube with another clean gastric tube after 2-3 days, or earlier if it is pulled out or becomes blocked.

Feeding by Gastric Tube


Continuous Feeding :
Set up feeding pump and give the feeding Flush the feeding tube with water every 4 hours. Change the feeding bag every 24 hours

Feeding the Term LBW neonates


Constitute 2/3rd of LBW neonates in India Growth retarded Have inadequate transplacental transfer of nutrients like Calcium, phosphate & multivitamins

No guidelines available yet about how to provide them optimum nutrition.


But, if inadequate weight gain on full breast feeds, may be supplemented with extra calories or proteins with fortifiers or preterm formulas!

Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Feeding the baby : Standards of Care


 

Encourage & teach the mother to express breast milk at least eight times in 24 hours Assess the feeding ability TWICE DAILY, and encourage & support the mother to begin breast feeding as soon as the baby shows signs of readiness to suckle Record the following EACH TIME the baby is fed :  Time of feeding  Amount & kind of milk given  Any feeding difficulty Assess the babys growth frequently.

Monitoring
Monitor : Abdominal girth >2 cm is significant Pre feed gastric aspirate Compare with amount of previous feed

<30% of pre feed volume

30-50% of pre feed volume/vomiting / abd. distension.

>50% of pre feed volume, or u3 mL/kg (whichever greater)

Stop feeding, IVF for 12 hrs.


Improving Not improving

Continue with same

Restart at same rate as last feed & observe

Continue IVF for another 12 hrs & reassess


Indian Pediatrics, Vol. 41, May, 2004: 436

Contd...

Monitoring
>50% of pre feed volume, or u3 mL/kg (whichever greater)  Discontinue feeding for next 24 hours, then reassess  Investigate for Sepsis & NEC

Negative

Positive

Restart feeding at half the volume at the time of discontinuation

Continue with management of the condition

Indian Pediatrics, Vol. 41, May, 2004: 436 2003

Monitoring
Assess hydration daily: - If there are signs of dehydration (e.g. sunken eyes or fontanelle, loss of skin elasticity, or dry tongue and mucous membranes), increase the volume of fluid by 10% of the babys body weight on the first day; - If there are signs of over hydration (e.g. excessive weight gain, puffy eyes, or increasing oedema over lower parts of the body), reduce the volume of fluid by half for 24 hours. Weigh the baby daily. If the daily weight loss is more than 5%, increase the total volume of fluid by 10 ml/kg body weight for one day to compensate for inadequate fluid administration. Monitor Hb/PCV, Serum sodium weekly till 4-6 weeks Monitor serum calcium, phosphate and alkaline phosphatase fortnightly till discharge, and at term corrected age before stopping calcium supplements.
Managing Newborn Problems, WHO/UNICEF, 2003

Judging the adequacy of Nutrition


Weight Pattern :
  

Not >10-15% cumulative weight loss during first week of life 10-15% Birth weight regained between 10-14th day of life 10Starts gaining weight by second week of life at 15-20 gm/day. 15- gm/day. (SFD neonates may start without any appreciable weight loss at all) unless sick. sick. For this weigh the baby : o Daily when in the hospital o At 2 weeks, 4 weeks & then monthly after discharge! Baby should gain 0.75 cm of HC per week till 40 weeks of gestation Baby should gain 1.1 cm of length per week between 28-40 28weeks of gestation
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Managing Newborn Problems, WHO/UNICEF, 2003

Weight Gain & Feeding


If the baby still requires feeding using an alternative feeding method but is on full milk feeds: - Increase the volume of milk in increments of 20 ml/kg body weight per day until the baby reaches 180 ml/kg body weight of breast milk per day; - Continue to increase the volume of milk as the babys weight increases to maintain a volume of 180 ml/kg body weight of breast milk per day.

Managing Newborn Problems, WHO/UNICEF, 2003

Weight Gain & Feeding


If weight gain is inadequate (less than 15 g/kg body weight per day over three days): - Increase the volume of milk to 200 ml/kg body weight per day; - You can have the mother express breast milk into two different cups. Have her give the contents of the second cup, which contains more of the fat-rich hind milk, to the baby first, and then supplement with whatever is required from the first cup. - If weight gain is inadequate for more than one week and the baby has been taking 200 ml/kg body weight breast milk per day, treat for inadequate weight gain
Managing Newborn Problems, WHO/UNICEF, 2003

Inadequate weight gain / Excessive Weight Loss


      

Inadequate calorie provided/consumed Cold stress Anemia Underlying systemic illness, e.g. sepsis. Urinary tract infection Late hyponatremia Late metabolic acidosis

Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Recording & Monitoring Weight

Converting Gavage to Oral Feeds


Neonate of ~34 wk gestation with coordinated suck-swallow-breathe pattern & respiratory rate e60/min  Transition should be slow  At first, give a supervised spoon feed & if the baby accepts well I.e. can finish the measured amount within 20-30 min without any sign of fatigue (apnea, vomiting, color changes, poor weight gain & slow to finish the full volume), then, number of spoon feeds can be increased over next few days like : o One spoon feed every 6 feeds o One spoon feed per 2 gavage feeds o Alternate spoon & gavage feed o 2 spoon feeds per gavage feed o And finally to full spoon feeds  Always try NNS while on gavage from 30-32 weeks gestation
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

 Candidates

Non Nutritive Sucking (NNS)




Used  In transition from gavage to breast feeding  During gavage feeding Rationale  Facilitates the development of sucking behaviour  Improves digestion of enteral feeding Benefits  Early transition from gavage to breast feeding  Decrease length of hospital stay Method  Done with empty breast or with a pacifier  Burping is a MUST because aerophagia is likely

Combining IV Fluid & Feeding


If the baby tolerates the feed and there are no problems, continue to increase the volume of feeds while decreasing the volume of IV fluid to maintain the total daily fluid volume according to the babys daily requirement Feed the baby every three hours, or more frequently if necessary, adjusting the volume at each feeding accordingly. Add the total volume of feeds and fluid given each day. Compare this volume with the required daily volume, and adjust the volume that the baby receives accordingly. Discontinue the infusion of IV fluid when the baby is receiving more than two-thirds of the daily fluid volume by mouth and has no abdominal distension or vomiting. Encourage the mother to breastfeed exclusively as soon as the baby is receiving 100% of the daily fluid volume by mouth.
Managing Newborn Problems, WHO/UNICEF, 2003

Kangaroo Mother Care (KMC)


Kangaroo mother care (KMC) is care of a baby who is continuously carried in skinto-skin contact by the mother and exclusively breastfed (ideally). It is the best way to keep a small baby warm and it also helps establish breastfeeding.

Kangaroo In-Hospital Adaptation


KMC can be started in the hospital as soon as the babys condition permits (i.e. the baby does not require special treatment, such as oxygen or IV fluid). KMC, however, requires that the mother stay with the baby or spend most of the day at the hospital.

Kangaroo Mother Care (KMC)


Ensure that the mother is fully recovered from any childbirth complications before she begins KMC. Ensure that the mother has support from her family to stay at the hospital or return when the baby is ready for KMC and to deal with responsibilities at home. Explain to the mother that KMC may be the best way for her to care for her baby once the babys condition permits: - the baby will be warm; - the baby will feed more easily; - episodes of apnea will be less frequent.

Kangaroo Mother Care (KMC)


Take the baby away from the mother only to change napkins (diapers), bathe, and assess for clinical findings. Babies can be cared for using KMC until they are about 2.5 kg or 40 weeks post-menstrual age.

Sodium Supplementation


Preterms especially <34 weeks are often hyponatremic due to excessive sodium loss in urine. Hence monitor serum sodium weekly till post conceptional age of 34 weeks. If serum sodium <130 mEq/L, extra sodium supplementation given.
o o

3% NaCl (1ml = 0.5 mEq), or 0.9% NaCl (1ml = 0.15 mEq).

Supplement should be orally diluted with feeds to maintain serum sodium between 135-140 mEq/L.

Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Iron Supplementation


Although iron stores are low in preterms & term-SFDs, requirements are minimum in first few weeks of life!

Birth weight e1000 gm

Birth weight >1000 gm

Iron @ 3-4 mg/kg/d

Iron @ 2-3 mg/kg/d

 Start at 4-6 weeks of life when active erythropoiesis starts  Start earlier at 4 weeks of life if baby had frequent phlebotomies
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

How long to continue supplements ?




Stop the HMF or Preterm formula when the baby reaches 2 kg or starts accepting full breast feeds, and start calcium-phosphate and vitamin supplements. If the baby was only on breast milk continue calcium-phosphate till baby reaches corrected age of term (wt. ~3-3.5 kg) check serum calcium, phosphate and alkaline phosphatase before stopping especially in ELBW babies to rule out any osteopenia or prematurity. Stop multivitamins when the baby reaches 6 months or 4.5 kg. Continue iron for atleast 1 year, and if weaning is not adequate continue till 2-3 year of age.

 

Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Immunonutrition
 Diets that are specifically designed to enhance immune function.

Glutamine L-arginine N-acetyl Cysteine Glutathione MCT & LCT n3 fatty acid Vitamin A, E, C, Zinc, Selenium
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Immunonutrition
 Use of specific nutrients supplements singly or in combination, stimulate the immune response and should result in fewer infections, particularly in LBW infants.  Maximum benefit of immune enhancement has been shown to occur in postoperative adult patients. Whether overall mortality is actually improved still remains to the established.

Present Status : More studies are needed for their use in low birth babies.
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

MCT Oil
 Primarily has caprylic & capric fatty acids and is a yellow, odorless, and translucent liquid.  Human milk contains 3-7% of fat as MCT. Cows milk has 1% and formula milk has ~10%  Rapidly absorbed into blood stream from lacteals without biliary binding  Exhibit rapid mitochondrial uptake  Rapidly cleared from blood stream

Indian J Pediatr 2001; 68 (4) : 333-337

MCT Oil
 When added to enteral feeds, significantly increases the caloric density without increasing much osmolar load  Does not contain any EFA. Excessive use of MCT i.e. >60% of total fat intake decreases the uptake of EFA.  Growth is not improve.  Expensive, however coconut oil can be used in place  Can be added as 2 kCal/Oz to the milk (has 7.8 kCal/ml)
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Present status : Routine use is not recommended.

Advice on Discharge


Explain the mother that


Her milk is best for the baby Breast feeding is especially important for a small baby It may take longer for a small baby to establish breast feeding It is usually normal if the baby :  Tires easily & suckles weakly at first  Suckles for shorter periods of time before resting  Falls asleep during feeding  Pauses for long periods between suckling
Contd

Contd

Advice on Discharge
Breast feeding will become easier once the baby becomes bigger

 Assure the mother that




 Ensure that the baby is fed frequently




If the baby weighs 1250 to 2500 gm, feed the baby at least eight times in twenty four hours (I.e. every 3 hours). If the baby weighs less than 1250 gm, feed the baby at least twelve times in twenty four hours (i.e. every 2 hours).

Contd

Advice on Discharge
Lethargy, refusal to feed. Hypothermia Tachypnoea, Grunting, Gasping Seizures, Vacant Stare. Abdominal distension Bleeding, icterus over palms / soles.

Danger signals (Early detection & referral) :


     

Ref. : Teaching Aids, NNF-India.

Summary
Appropriate & adequate nutrition to LBW Babies. Babies. Early nutrition for long term growth and neurodevelopment. neurodevelopment. Breast milk provides standard for feeding. feeding. the gold

Role of non nutritive sucking, KMC and micronutrient supplementation. supplementation.

Thanks