Feeding the Preterm Infant

Sharon Groh-Wargo PhD, RD, LDAssociate Professor Nutrition and Pediatrics

Senior NutritionistCase Western Reserve University School of Medicine

MetroHealth Medical Center, Cleveland, OhioJune 2, 2012

·

Cleveland, Ohio ~ on The Great North Coast

Surfing in Cleveland: October 15, 2011

Objectives: For the critically ill newborn

Describe elements of ideal nutritional supportDiscuss safety concerns related to nutritional supportReview the what, when, why and how of nutritional support

The impact of prematurity

NICHD Growth Observational Study

Ehrenkranz RA, et al. Pediatrics 1999;104:280-9.

24 28 32 36Postmenstrual Age (weeks)

Wei

ght (

gram

s)

500

1000

1500

2000

Extrauterine Growth

Restriction

Intrauterine growth (50th and 10th percentile)

24-25 weeks

26-27 weeks

28-29 weeks

= Return to birth weight

50th 10th

Poor Weight Gain Increases Odds for Poor Outcomes

Ehrenkranz RA, et al.

Pediatrics 2006;117:1253-61.

1.00.2 10.0 50.0Odds Ratio (95% Confidence Interval)

2.53 (1.27–5.03)

2.25 (1.03–4.93)

8.00 (2.07–30.78)

ELBW infants, in-hospital growth: 12.0 vs 21.2 g/kg/day

Cerebral palsy

Bayley MDI <70

MDI=Mental Development Index

Neurodevelopmental Impairment

Enteral Protein Intake Associated With Improved Head Circumference Gain

HC gain 0.08 cm/wk each additional g of protein

Average Protein Intake (g/kg/d)

HC

Gr o

wth

(cm

/we e

k)

Ernst KD, et al. J Perinatol 2003;23:477-82.

N=69 infants <1000 g.

R2=0.53

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

Initiate parenteral nutrition as soon as the infant is medically stabilized

Improves glucose toleranceMinimizes negative nitrogen balance and improves protein accretionLower incidence of retinopathy of prematurityPromotes better growthLowers loss of lean body massImproves developmental outcomesIbrahim HM, 2004; Hellstrom A, et al. 2003; Lofqvist C, et al 2006; Martin CR, et al 2009; Ehrenkranz RA et al, 2006; Pointdexter BB, 2006; Stephens BE et al, 2009; Isaacs EB, et al, 2009

Critical Elements of Enteral Nutritional Support

Human milk and breastfeedingHuman milk fortificationInitiating and advancing feedingsDischarge and follow-up

1. Human milk and breastfeeding

Decreased necrotizing enterocolitis and late onset sepsis [Lucas & Cole 1996; Meinzen-Derr et al 2009; Sisk et al 2007; McGuire & Anthony 2003; El-Mohandes et al 1997; Hylander et al 1998; Furman et al 2003; Schanler et al 1999 and 2005]Faster progression to full feeding [Sisk et al 2007 and 2008; Schanler et al 1999; Simmer et al 1997]Improved cognitive and visual outcomes [Lucas 1989; O’Connor 2007; Birch 1992; Vohr, B 2007]Meier P et al Clin Perinatol 2010 37:217-245

Clinical Outcomes by Feeding (Mean±SD) (Schanler et al, 1999)

FHM (n=62 ) PTF (n=46)Oxygen (days)¶ 19 ±

21 33 ±

41

NEC, n (%)‡ 1 (1.6) 6 (13)Late-Onset Sepsis, n (%)§ 19 (31) 22 (48)Positive Blood Cultures (no. per infant) ‡

0.5 ±

0.9 1.2 ±

1.7

NEC or Late-Onset Sepsis, n (%) ‡

19 (31) 25 (54)

¶P=0.2 ‡P≤.01 §P=.07

Copyright ©1999 American Academy of Pediatrics

Schanler, R. J. et al. Pediatrics 1999;103:1150-1157

Human Milk (HM) Reduces Time to Full Feeding

(Sisk et al Pediatrics 2008)

Prospective study VLBW infantsTwo groups formed based on HM intake: –

High (≥50%; n=93) and

–

Low (<50%; n=34)Days to reach 100 ml/kg per day (15 vs.19) and 150 ml/kg per day (22 vs. 27) enteral feeding was significantly lower for High vs. Low groups (p<.01)

Copyright ©2007 American Academy of Pediatrics

Vohr, B. R. et al. Pediatrics 2007;120:e953-e959

Human Milk: Long term benefits

Breast is Best Initiative: MetroHealth

Strategies–

Within 24 hours of admission, mothers receive electric pump kit, storage containers & labels, and printed materials

–

All nurses are in-serviced–

Electric pumps on mobile carts are added to electric pumps available in breastfeeding rooms

–

Bedside cards “I get my mom’s milk”–

Scripting developed for physicians

Results after 9 months–

Increase from 20% to 70% of babies receiving their own mothers’

milk

2. Human Milk Fortification

Increasing Lean Body MassBuilding strong bonesMixing safely and accurately

Discuss challenges of providing human milk

Macro and micronutrients: contentVariability (Weber A et al. Acta Pediatr 2001)–

By gestation (preterm vs. term)

–

By stage of lactation (colostrum, transitional, mature)–

By time of day

–

Between mothers

Breast milk analysis –

Creamatocrit

–

Near-

and mid-Infrared–

Ultrasound

Variability of Human Milk

Protein g/dl

Preterm DOL #7 2.4 1.9 Full term DOL #7

Preterm 1st

week 2.4 1.8 Preterm 4th

week

Foremilk @ 1 mo 1.3 1.4 Hindmilk @1 mo

1st

month 1.6 0.9 6-12 months

Mother’s own 1.6 1.2 Donor

Mother #1 2.3 0.6 Mother #2Picciano MF, Peds Clin N Am 2001; Wojcik KY JADA 2009; Gross SJ J Peds 1980; Saarela T Acta Pediatr 2005; Groh-Wargo S et al SPR 2011

AnalyzersCalais Milk Analyzer; Metron Instruments

Creamatocrit Plus; Medela

Ultrasonic Milk Analyzer;Milkotronic Inc

Breast Milk Analysis: A Paradigm Shift in Fortification for Preterm Newborns

Pediatric Academic Societies’ Meeting, Denver 2011

Sharon Groh-Wargo, PhD, RD Jennifer Valentic, BS

Sharmeel Khaira, MDDennis Super, MD, MPH

Marc Collin, MD

Objectives

Determine the energy and macronutrient content of breast milk found in 24-hour samples collected longitudinally from mothers of preterm infantsDescribe variability in breast milk composition within and between mothers–

Determine how variability could potentially affect nutritional intake of individual infants

Methods

MetroHealth Medical Center (Cleveland, OH)IRB approvedRecruited mothers of infants admitted to NICU weighing < 2 kgCollected 24 hour supplyHomogenized and removed a 15 ml sampleCalais Milk Analyzer (Metron Instruments, Solon, OH)

Preparing a sample

Calais Milk Analyzer

Results: Variability

Variability is greater between mothers than within a mother for all macronutrients

p=0.043

Study Conclusions

High variability between mothers supports use of milk analysis technology in clinical setting Low variability within a mother suggests occasional analysis would be adequate to establish an individualized fortification planIndividualized breast milk analysis is a paradigm shift in fortification for preterm newborns

Discuss options and strategies for human milk fortification (HMF)

WHOWHAT WHENWHEREWHY

WHY do we give HMF?

Inadequate concentration of–

Protein

–

Minerals, for example•

Calcium

•

Phosphorus•

Zinc

•

Sodium

Intake for 1 kg infant @ ~120 kcal/kg/d

NutrientHuman

Milk (PT) HMF 1:25 HM:PT HP 1:1

HM:PT 30 1:1

Prolact+ 4 ®

Volume, mL/kg 180 150 165 145 150

Protein, g/kg 2.5 3.6 3.3 3.2 33

Calcium, mg/kg 45 190 125 150 192192

Phos, mg/kg 23 118 71 71 9494

Zinc, mcg/kg 612 1776 1286 1351 1110

Vitamin D, IU/d 4 178 102 112 41

Estimated needs: Protein (3-4 g/kg); Ca (100-220 mg/kg); P (60- 140 mg/kg); Zn (1000-3000 mcg/kg); Vitamin D (>400 IU/d)

30

% Fat mass: preterm (PT) infants at or near term vs. term newborns

0

2

4

6

8

10

12

14

16

18

20

Butte '00Term

Ramel '11PT

Bolt '02 PT

G-W '05PT

Walyat'12 PT

Roggero'10 PT

% Fat at Term

WHAT are the options for human milk fortification?

Commercial human milk fortifier (1:25) (powder and concentrated liquid) (Kuschel CA, Harding JE. Cochrane Database Syst Rev. 2004;(1):CD000343)

Commercial nutrient dense preterm formula (1:1 etc) (liquid) (Moyer-Mileur L et al JPGN 1992; Lewis J et al J Invest Med 2010)

Concentrated donor human milk enriched with minerals (frozen liquid) [Prolacta Bioscience http://prolacta.com accessed 8/23/11] (~$40/oz) (Sullivan S et al. J Pediatr 2010)

HMF Meta-Analysis: Weight Gain

HMF Meta-Analysis: Length Gain

HMF Meta-Analysis: HC Gain

HMF Meta-Analysis: BMC

HMF Meta-Analysis: N Retention

HMF Meta-Analysis: NEC

HMF Meta-Analysis: Development

WHAT are the options for human milk fortification? (continued)

Individualized: –

Based on milk analysis (Polberger S et al. JPGN 1999; deHalleux V et al. Arch Pediatr 2007)

–

Based on nutrient content (Pohlandt F Pediatr Res 1993)

Adjustable: based on BUN (Arslanoglu S et al. J Perinatol 2006)

Weight gain (g/kg/d): Standard Fortification (Classique) vs. Preterm Formula vs. Individualized Fortification (A la carte)

de Halleux V et al 2007

Average protein intakes: STD vs. ADJ compared with OPTIMAL intrauterine protein intakes

(Arslanoglu S et al. J Perinatol 2006)

Weight, Length and HC Gains (Arslanoglu S et al. J Perinatol 2006)

STD ADJ P-value

Weight gain (g/day)

24.8 ±

4.8 30.1 ±

5.8 <0.01

g/kg per day

14.4 ±

2.7 17.5 ±

3.2 <0.01

Length gain (mm/day)

1.1±

0.4 1.3±

0.5 >0.05

HC gainmm/day

1.0±

0.3 1.4±

0.3 <0.05

WHO should receive human milk fortification? Indications include

≤ 34 weeks’ gestation≤ 1500 g birth weightParenteral nutrition > 2 weeks> 1500 g birth weight with suboptimal growth and/or feeding volume restriction and/or significant medical/surgical complications

[Schanler RJ and Abrams SA, 1995; Schanler RJ et al, 1999; Atkinson SA, 2000]

WHEN should human milk fortification start and stop?Start–

As early as 25 ml/day of human milk

–

As late as attainment of full enteral feedings (150 ml/kg per day)

–

Most usual start time is attainment of 80-100 ml/kg per day enteral feedings

Stop–

As early as a few days prior to NICU discharge (most usual)

–

As late as 52 weeks post-conceptional age or weight of 3.5 kg, whichever comes first

WHERE should human milk fortifier be added to human milk?

The addition of human milk fortifier to expressed human milk at the bedside is not advised (Ohio Department of Health, The American Dietetic Association, ASPEN)A NICU “Milk lab” as a separate location is ideal to insure–

Safety of expressed human milk

–

Accuracy and adequacy of mixing

Human Milk, Thickeners and Reflux

Effectiveness controversial for healthy infants; little evidence for preterm infants–

Horvath A et al Pediatrics 2008 (meta-analysis)–

BMJ 2010;341:c4420 (Drug and Therapeutics Bulletin)–

Birch JL, Newell SJ (Arch Dis Child Fetal Neonatal Ed 2009)

Xanthan gum (Simply Thick and HydraAid); polysaccharide produce by plant pathogen Xanthomonas campestris–

Withdrawn from the market for suspected cause of NEC; FDA safety

alert & related resources: www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHuma

nMedicalProducts/ucm256257.htm

[accessed 2/14/12]

Simply Thick and NEC

(Woods CW et al 2012)

Three Case StudiesPresentation: Late-onset (2nd postnatal month) presentation with colon involvementProbable physiological basis: increased intraluminal water, sugars, H2, SCFA and bile acids in distal small intestine and colon triggering an inflammatory cascade and bowel injuryRecommendations: Xanthan gum thickeners should not be used in premature infants

3. Initiating and advancing feedings

Breastfeeding–

Colostrum oral wash

–

Kangaroo care–

Scoring systems

Priming and progressive feedingsCue-based feedings

Colostrum as an oral wash for the high- risk newborn

(Meier P 2010)

Colostrum is secreted in the early days postpartum & is rich in protective components especially from mothers of PF infantsEspecially important for PT infants who have a shortened exposure to amniotic fluid and its trophic effects on the GI tractOropharyngeally administered colostrum is–

Safe and feasible (Rodriguez NA, 2009 and 2010)

–

May have additive effects to trophic feedings–

May protect against ventilator-associated pneumonia

Kangaroo Care –

Skin-to-Skin

Shown to–

Empower mothers

–

Increase success of breastfeeding –

Reduce neonatal morbidity and mortality

–

Reduce length of hospital stayConde-Agudelo A, et al Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews 2011,Issue 3.Art.No.:CD002771.DOI: 10.1002/14651858.CD002771.pub2.

Assessing breastfeeding adequacy

Latch–

Latch, Audible swallowing,

Type of nipple, Comfort, Hold/positioning

–

Jensen D et al. LATCH: a breastfeeding charging system and documentation tool. JOGNN 23:27-32:1994.

PIBBS –

The Preterm Infant Breastfeeding Behavior Scale–

Nyqvist KH et al. Early Human Development 55:247-264, 1999. MBA –

Mother/Baby Assessment: for the mother and baby learning to breastfeed

–

J Human Lactation 8(2),1992.

0 1 2L (Latch) Too sleepy or

reluctant; No latch achieved

Repeated attempts; holds nipple in mouth; stimulate to suck

Grasps breast; tongue down; lips flanged; rhythmic sucking

A (Audible swallowing)

None A few with stimulation

Spontaneous and intermittent <24°(frequent >24°)

T (Type of nipple) Inverted Flat Everted (after stimulation)

C (Comfort) Engorged; cracked/bleeding, large blisters,buises. Severe discomfort

Filling; reddened/ small blisters, bruises; mild/ moderate discomfort

SoftTender

H (Hold/ Positioning)

Full assist (staff holds infant at breast)

Minimal assist (elevate head of bed; place pillows); teach one side, mother does other; staff holds and then mother takes over

No assist from staff; mother able to position/hold infant

Breastfeeding Scoring Systems

MBA: Two steps in each of five stages: 1. Signaling, Readiness2. Positioning3. Fixing, latches4. Milk transfer5. Ending: breast softens, satiety

PIBBS: Several maturational steps in each of six stages:1. Rooting2. Areolar grasp3. Latching and fixed4. Sucking5. Longest suckingburst6. Swallowing

Initiation and progression of enteral feedings in preterm infants

Initiation: Priming Feeds @ low volumes of ~ 10-15 ml/kg/d by DOL # 3-7 and continued for 3-5 daysProgression: Increase by ~ 10-20 ml/kg/d but no more than 35 ml/kg per dayCommon methods of feeding include –

NG and OG gavage feeding

–

continuous and intermittent schedules

Monitoring tolerance to enteral feedings

Acceptable residuals–

Less than 50% of previous intermittent feeding

–

Less than 2 times the hourly feeding rate for continuous feedings

Stable abdominal girthMinimal episodes of emesisRegular stooling

Cue-based feeding

Feeding readinessFocus on infant cues vs. bottle or clockEffective eating:–

Organization–

Physiology–

Motor–

Caregiver attributes

Changing Feeding Documentation to Reflect Infant-Driven Feeding Practice (Ludwig SM and Waitzman KA, Newborn & Infant Nursing Reviews 2007:7(3), 155-159)

Feeding Readiness ScaleQuality of nippling scaleCaregiver technique scale

Feeding Readiness Scale

1 Drowsy, alert or fussy prior to care. Rooting and/or hands to mouth/takes pacifier. Good tone

2 Drowsy or alert once handled. Some rooting or takes pacifier. Adequate tone

3 Briefly alert with care. No hunger behaviors. No change in tone.

4 Sleeping throughout care. No hunger cues. No change in tone.

5 Needs increased O2 with care. Apnea and/or bradycardia and/or tachypnea over baseline with care.

Quality of nippling scale

1 Nipples with strong coordinated suck throughout feed.

2 Nipples with a strong coordinated suck initially, but fatigues with progression.

3 Nipples with consistent suck, but difficulty coordinating swallow; some loss of liquid or difficulty pacing. Benefits from external

pacing.4 Nipples with a weak/inconsistent suck. Little to no rthythm. May

require some rest breaks.5 Unable to coordinate suck/swallow/breathe pattern despite

pacing. May result in frequent or significant A/Bs or large amounts of liquid loss and/or tachypnea significantly above baseline with feeding.

Caregiver technique scale

A External pacing

B Modified Side-lying

C Chin Support

D Cheek Support

E Oral Stimulation

Support for feeding advancement

Pacifier dips initiallyNon-nutritive sucking at breastKangaroo care continuesNipples:–

Slow flow best–

Progress to standard–

Orthodontic and cross cut nipples not usually recommended

4. Discharge and follow-up

Human milk and breastfeedingFormula choiceVitamin and mineral supplementsFeeding Progressions of the first year

Nutrition Goals for Breastfeeding

Promote adequate weight gain, including necessary catch-up growthEnsure good nutritional status of protein, calcium, phosphorus, and other micronutrientsMaintain or build breast milk supplySustain or improve feedings at the breastLimit bottle and formula feeding to that required for the first and second goals

Intake for 2 kg infant @ 120 kcal/kg/d

Nutrient

Human Milk (HM)

HM enriched with PDF*

HM alternated with PDF*

HM with HMF 1:50

HM with HMF 1:25

Volume, mL/kg 175 150 165 155 150

Protein, g/kg 1.6 1.9 2.5 2.2 2.92.9Ca, mg/kg 49 64 92 124 197197P, mg/kg 26 35 52 69 110110Zn, mcg/kg 210 412 848 852 1470Vit D, IU/d 4 36 95 216 411*PDF: post-discharge formulaEstimated needs at D/C: Protein (2.8-3.4 g/kg); Ca (100-220 mg/kg); P (60-140 mg/kg); Zn (1000-3000 mcg/kg); Vitamin D (>400 IU/d)

Human Milk (HM) After Discharge: Evidence

Feeding HM is associated with improved neurocognitive outcomes but decreased growth (O’Connor DL 2003, Lucas A 2001)Feeding fortified HM improves nutrient intake, bone mineralization, and length and head growth compared to feeding HM without fortification (O’Connor DL 2008, Aimone A 2009)Feeding fortified HM may not improve overall growth compared to feeding preterm formula (Zachariassen G 2011)Fortification of HM following discharge does not interfere with breastfeeding success (O’Connor DL 2008; Zachariassen G 2011)

Anthropometric measurements of human milk-fed infants sent home (study day 1) fed human milk alone (-

-) or with approximately half of the human milk–fed mixed with a multi-nutrient fortifier (–) for 12 weeks. Asterisks denote a significant difference between feeding groups

at a specific time point.

(Aimone A et al 2009)

Human Milk After Discharge: Evidence

Preterm Formula (PF) and/or Post-Discharge Formula (PDF) for Feeding PT Infants after Discharge: Advantages

Improved nutritional intake of key nutrientsIncreased weight, length and head circumference growthImproved bone mineral content (BMC)Enhanced lean body mass accretionNormalization of biochemical indices of nutritional status

Selected Nutrient Levels (per 100 kcal) for Three Formulas

Preterm Formula

Post- Discharge (Enriched) Formula

Standard Term

FormulaKcal/oz 24 22 20

Pro (gm) 3 2.8 2.1

A (IU) 1250 460 350

B6

(µg) 250 100 60

Ca (mg) 180 105 78

Zn (mg) 1.5 1.2 0.75

Brunton JA et al 1998

Enriched Formula & Lean Body Mass

Brunton JA et al 1998

Enriched Formula & Bone Mineral Content

According to the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists

(AAP/ACOG, 2007)

“their use has been shown to result in greater linear growth, weight gain, and bone mineralization when compared with the use of term formula. Small, preterm neonates (born at or before 34 weeks of gestation, with a birth weight less than or equal to 1,800 g) and neonates with other morbidities (eg, BPD) may benefit from the use of such formulas for up to 9 months after hospital discharge.”AAP/ACOG, Guidelines for Perinatal Care, 6th Edition 2007

Suggested Schedule: Use of Post-discharge Formula

Birthweight:< 750 g750-1000 g1000-1500 g1500-2000 g2000-2500 g> 2500 g

Length of use (CA*):12 months9 -

12 months

6 -

9 months3 -

6 months

1 -

3 monthsterm -

1 month

*CA=corrected ageMetroHealth Medical Center, Cleveland, OH

Supplements: Preterm (PT) Infants at Discharge

Multivitamin – consider for PT infants discharged on–

PDF and continue until full term size

–

HM or non-preterm formulaZinc – consider for PT infants discharged on HMVitamin D – all newborns; 400 IU/dayIron – by 1 month; 2 mg/kg per day (Baker RD, Greer FR and The Committee on Nutrition. Pediatrics 2010;126:1040–1050)

Fluoride – at 6 months for selected infants (AAP, Committee on Nutrition. Fluoride supplementation for children: interim policy recommendations. Pediatrics 1995;95:777)

Vitamin D Recommendations

WHO: All Breastfed infants and any formula fed infant taking < 1 quart or liter per dayWHEN: Within the first few days of lifeWHAT: 400 IU vitamin D per day supplementHOW: Infant ADC drop 1 ml per dayWHY: Increasing incidence of vitamin D deficiency in the maternal population has resulted in deficiency in newbornsReference: Wagner C, Greer FR, Section Breastfeeding and CON. Pediatrics 2008 122:1142-1152; Taylor SN et al, Vitamin D Needs of Preterm Infants. NeoReviews 2009;10;e590-e599

NICU Screening MetroHealth 2009 (n=186)

Mean ± SD (range)–

Birth weight (g): 2061 ±

936 (462-4499)

–

Gestational Age (wk): 32.8 ±

4.3 (23-41)–

Day of life: 33 ±

42 (2-343)

Serum 25 (OH) vitamin D at discharge –

Normal >30 ng/ml

–

Mean ±

SD (range) 27.7 ±

18.2 (6.4-118.8)

Feeding recommendations for former preterm infants at term and term Infants

Breastfeeding on demandCommercial infant formula until one year if breastfeeding not chosen or stopped earlyVitamin D (400 IU/day) supplementIron by 4-6 months as iron supplement 1 mg/kg/d to maximum of 15 mg/d or as iron fortified formula

Feeding Recommendations for Term Infants (continued)

Fluoride supplement AFTER 6 months if water is not fluoridated (0.25 mg/d)Solid foods by 4-6 months by spoonWhole cows milk after one yearFenton growth chart to 50 weeks post-conceptional age and/or WHO growth chart from term to 2 years

Feeding Progression and Growth Assessment

Based on Corrected Age (also called adjusted age)Chronological age minus prematurityExample: 4 months old - 2 months premature = 2 months corrected ageDuration: use corrected age for ~1 year

Common Feeding Problems in NICU Graduates

Poor suck-swallow coordinationExcessive tongue thrustProblems with gag reflex; oral aversiongastroesophageal reflux; vomitingIncreased work of breathing from respiratory/cardiac disease may compromise ability to eat by decreasing feeding endurance or interest

To build a better baby, nutrition can….

Promote weight gainCreate lean body massBuild strong bonesDecrease infectionImprove neurocognitive outcomesSupport visual development

And YOU can do this by….

Encouraging breastfeeding and adequate supplies of expressed breastmilkProviding a nutrient (not just calorie) dense diet Ensuring adequate micronutrientsStaying informed about advancementsBeing a nutrition champion

Thank you…