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Nutrition and Feeding

Judy Philbrook, NNP-BC

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n  32 day old growing preemie now at 33 weeks adjusted age. 1700 grams

n  Feedings: Breast milk 33 ml every 3 hours

n  Nippling 3 times/day and doing well n  Baby has a 6 ml residual

n  What things would you want to consider when evaluating this?

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n  630 gram 24 week female n  Day 1 of life:

n  On the ventilator n  UAC and UVC: GIR 6 mg/kg/min n  Sodium 150, potassium 4.5 n  On GI Priming feeds of breast milk

n  What total fluid volume should be given?

n  What should be monitored to assess nutritional and electrolyte status?

n  Should feedings be increased?

n  6 day old 28 week infant on the ventilator

n  Oxygen requirement 50% n  Feedings 2ml 3 hours on and 1 hour off n  Echocardiogram with moderate PDA

and indocin started n  Should feedings be continued?

n  27 week infant; now 18 days old n  Post-op: exploratory lap due to NEC n  On TPN and lipids n  Replogle to LIWS

n  58 ml output in the past 8 hours n  Sodium 134, Potassium 3.1

n  Options?

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n  36 day old 31 week adjusted age female

n  On SC 24cal/oz at 155ml/kg/day n  Growth is at the 8.6th percentile

n  Options?

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Anatomy & Physiology of the GI tract

n  GI tract resembles that of a term newborn by 20 weeks gestation

n  Functional development is limited before 26 weeks

n  Biochemical and physiologic capacities for digestion and absorption are present at 28 weeks

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n  Sucking occurs in utero at 13-15 weeks, but is not developed before 31-34 weeks

n  Digestive enzymes for carbohydrates are functionally active >28 weeks

n  Protein enzyme activity increases after birth in premature and term infants

n  Preterm – limited production of gut digestive enzymes and growth factors

n  Premature infants have: n  Lack of sucking coordination n  Decreased esophageal sphincter tone n  Delayed gastric emptying n  Slow intestinal transit

n  Peristalsis begins to mature after 30-32 weeks – remains less organized until near term

n  Major factor in growth and function – DIET – influences the enzyme activities and gut flora

Nutrient Store Deficiencies of Preterm Infants n  Energy

n  Fat n  Carbohydrate

n  Vitamins and minerals n  Essential nutrients

n  Inadequate nutrition affects all organ systems.

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Fat n  At 24 weeks – 2% stored fat, 5% at 32

weeks, 15% at 40 weeks n  Increased accretion between 24 and 40 wks n  Essential fatty acids are needed for brain and

retinal growth and function n  Sources:

n  Adipose tissue stores n  From human milk or formula (50% of calories) n  IV lipids

Carbohydrate n  Second major energy source n  Brain is dependent on glucose –

accounts for 75% of glucose consumption

n  Stored as glycogen in the liver in the 3rd trimester n  Preterm infants have limited fat and

glycogen stores

Standards for Growth n  Growth curves – weight, length and

head circumference n  Postnatal growth curves for preterm

infants should be used

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Nutrition Requirements n  Water n  Calories n  Protein n  Fat n  Carbohydrates n  Electrolytes n  Vitamins and Minerals

Nutrition Requirements n  Healthy newborns

n  98-108 cal/kg/day for growth and development n  150-180 ml/kg/day of 20 cal/oz formula or breast

milk

n  Protein, fat and carbohydrate intake: n  Protein: 7-12% n  Fat: 35-55% n  Carbohydrate: 35-55%

Preterm Requirements n  Recommendations are guidelines n  Individual needs must be considered

n  Gestational age n  Birth weight n  Clinical status

n  Minimal intake is 120-150 ml/kg/day for a growing preterm infant on feeds

n  OR 120-150 ml/kg/day on parenteral fluids

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Factors that Increase Fluid Requirements n  Abnormal fluid losses (ileostomy, chest tube) n  Labile body temp, fever, stress n  Phototherapy n  Prematurity n  Radiant warmers n  Renal dysfunction n  Third spacing

Factors that Decrease Fluid Requirements

n  HIE n  BPD n  PDA n  Post-operative n  CHF n  Meningitis n  Renal failure

Factors that Increase Caloric Requirements n  Acute or chronic lung disease n  Temperature fluctuations n  Hypothermia/hyperthermia n  Increased cardiac output n  Increased muscle activity (agitation, pain) n  Infection n  Malabsorption or short gut n  SGA n  Periods of rapid growth

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Preterm Guidelines n  Protein: 7-12% of caloric intake

n  Adequate protein can not be achieved with unfortified breast milk!

n  Fat: 35-55% of caloric intake n  Human milk – 50% of energy from fat; formula

40-50%

n  Carbohydrates: 35-55% of total calories n  Usual amount of glucose is 4-6 mg/kg/min n  Can be achieved with D10W at 60-90 ml/kg/day

Preterm Guidelines n  Electrolytes

n  Sodium, potassium and chloride n  Increased urinary sodium excretion and

insensible losses during transition n  Stable growing preterm needs 2-4 mEq/kg/

day of sodium n  Vitamins and Minerals

n  Exact requirements needed have not been established

Where to Start! n  Suggested initial admission fluid intake

for newly born infants: < 1 kg 100 ml/kg/day 1-2.5 kg 80 ml/kg/day >2.5 kg 60 ml/kg/day Calcium is added (1.5 mEq/kg/day) on

admission for babies with BW > 1.5 kg

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What fluid? n  TPN is ordered on admission if <1500

grams n  D5 or D10 W n  1.5 mEq/kg of calcium n  1.5 grams/kg of amino acids n  1.5 grams/kg lipids

n  Minimal enteral nutrition (GI priming) is also ordered

Parenteral Nutrition n  Indications

n  Birth weight < 1500 grams; gestational age < 32 weeks

n  GI disorders (gastroschisis, TEF, malrotation, NEC) n  Short gut n  Severe respiratory or cardiac disease n  Renal failure

n  Administration n  Peripheral n  Central

Guidelines for TPN Administration n  Calories: 20% less than enteral n  Water: 100-150 ml/kg/day (next slide!) n  Protein: 2-4 g/kg/day n  Fat: 10 or 20% - 3g/kg/day n  Carbohydrates: 5 or 10% glucose n  Glucose infusion rate: 4-6 grams/kg/min; max

12-14 mg/kg/min n  Calcium and phosphorus n  Vitamins and minerals

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Complications of TPN Administration

n  Metabolic disturbances n  Cholestasis and jaundice n  Hyperglycemia/hypoglycemia n  Rickets n  IV infiltrates n  Infection

Enteral feedings n  Human milk is ideal!

n  20 cal/oz initially n  24 cal/oz when feeds are half volume –

increase calories and nutrients

n  Formula – 24 cal/oz – is used if breast milk is not available

n  OG/NG/PO

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Advantages of breast milk n  Improved gastric emptying n  Enhanced absorption and digestion n  Optimal distribution of calories n  Anti-infective properties n  Low renal solute load n  Long chain fatty acids n  Maternal involvement

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Supplementation with Breast Feeding

n  Iron supplementation n  2mg/kg/day for all preterm infants at 2

months or when birth weight is doubled n  Required if baby is being treated for

physiologic anemia with erythropoietin

n  Poly-vi-sol with iron 0.5 ml bid when on full feedings

Formula n  Milk based n  Soy based

n  Lactose intolerance, galactosemia n  Not for babies <1800 grams

n  Elemental n  Protein intolerance n  Fat malabsorption

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Advantages to Early Feeding (GI Priming; Minimal Enteral Feedings)

n  Promotes gut mucosal development n  Stimulates GI activity n  Increased secretion of GI hormones n  Colonization with normal flora n  Improved metabolic status n  Reduced cholestasis and lower bili levels n  May decrease NEC n  Improved lactase activity

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How to Feed n  Minimal enteral feedings (GI priming) n  Breast milk or 24cal/oz formula within

the first 24 hours of life n  1001-1500 grams - 2ml every 8 hours n  751-1000 grams - 1 ml every 8 hours n  <750 grams – 0.5 ml every 8 hours

n  Do not check residuals!

How to Feed (cont) n  Trophic feedings – started at 48-72

hours of age; continue 24-48 hours n  Continuous – <1200 grams n  Bolus - every 3 hours > 1200 grams

n  Feedings are increased 20 ml/kg/day n  TPN is decreased to accommodate enteral

increase, or increased to give more volume if baby is only a few days old

n  Lipids are stopped when enteral calories are > 80 cal/kg/day

n  TPN is stopped when enteral fluid volume is > 120 ml/kg/day

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Total # IV Days: 401-1500g BW

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5

10

15

20

25

30

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1996 1997 1998 1999 2000 2001 2002 2003 2004*

Reasons to Withhold feeds n  Severe apnea and bradycardia n  Decreased peristalsis (not stooling,

decreased bowel sounds) n  Meconium obstruction of prematurity n  PDA – decreased GI perfusion n  Acute sepsis

Oral feedings n  Facilitate digestive capacity n  Allows infant to self regulate feeding n  Promotes social behavior states n  May have increased risk of aspiration if

suck/swallow are not coordinated n  Should be able to nipple at 34 weeks n  Can try breast feeding at 32 weeks

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Gavage Feeding n  < 32 weeks n  OG vs. NG n  Residuals of 2-4 ml/kg or one hour of

volume are considered normal and should be refed

n  Administer by gravity or pump in 15-30 min.

Transpyloric feeds n  Recommended if there is a high risk of

aspiration n  Bypass stomach – fat malabsorption n  Verify location by x-ray

Gastrostomy tube feedings n  Inability to suck and swallow n  Congenital anomalies of the GI tract n  Need for long term gavage

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Nutritional Assessment n  Weight n  Head and length n  Monitor intake n  Monitor lab values

Feeding Tolerance n  Bowel sounds n  Abdominal assessment n  Girth n  Stools

Post Discharge Formula n  NeoSure 22 cal/oz for babies receiving

formula n  Breast milk – may supplement with a

couple feedings of 22 cal/oz NeoSure n  NeoSure is continued until 6 months

adjusted age

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40

45

50

55

60

65

70

2003 2004 2005 2006 2007 2008 2009 2010

Days

Length of Stay: 501-1500 grams (mean)

Vermont Oxford Database

0102030405060708090

100

2005 2006 2007 2008 2009 2010 2011

Breast milk andfortifierFormula only

Feedings at Discharge; all VLBW Infants

Vermont Oxford Database

References n  Verklan, et. al.; Core Curriculum for

Neonatal Intensive Care Nursing, Elsevier, Philadelphia, 2004.