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Nutrition in the High-Risk Neonate Currently, nearly all hospitilised infants experience significant growth retardation during their stay in the NICU.

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Presentation on theme: "Nutrition in the High-Risk Neonate Currently, nearly all hospitilised infants experience significant growth retardation during their stay in the NICU."— Presentation transcript:

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3 Nutrition in the High-Risk Neonate

4 Currently, nearly all hospitilised infants experience significant growth retardation during their stay in the NICU. (less than 1000 g)

5 The fetus gains approximately The fetus gains approximately at 16 weeks : 5 g/d at 16 weeks : 5 g/d at 21 weeks : 10 g/d at 21 weeks : 10 g/d at 29 weeks : 20 g/d at 29 weeks : 20 g/d at 37 weeks : 35 g/d at 37 weeks : 35 g/d

6 ENERGY REQUIREMENTS Energy Balance Energy balance = energy intake – (energy loss + storage). Energy balance = energy intake – (energy loss + storage). Energy loss = energy expenditure + excretion of energy (containing substances in urine and feces). Energy loss = energy expenditure + excretion of energy (containing substances in urine and feces). If exogenous energy intake is less than expenditure, energy balance is negative, and body energy stores must be mobilized to meet ongoing needs. If exogenous energy intake is less than expenditure, energy balance is negative, and body energy stores must be mobilized to meet ongoing needs.

7 FACTORkcal/kg/d Energy expenditure Resting metabolic rate Resting metabolic rate 40–60 40–60 Activity Activity 0–5 0–5 Thermoregulation Thermoregulation 0–5 0–5 Synthesis/energy cost of growth Synthesis/energy cost of growth 15 15 Energy stored 20–30 20–30 Energy excreted 15 15 Estimated total energy requirement 90–120 90–120

8 Resting metabolic rate (RMR) Resting metabolic rate (RMR) Preterm > term infants Preterm > term infants Nutritional requirements Preterm > term infants In preterm infants receiving full enteral feeding, approximately 90% of energy intake is absorbed.

9 The energy required for thermoregulation and activity can be minimized by keeping the infant in a for thermoregulation and activity can be minimized by keeping the infant in a thermo neutral environment thermo neutral environment and limiting stimulation. and limiting stimulation. Incubator Incubator

10 The estimated RMR of infants with LBW is lower immediately after birth than The estimated RMR of infants with LBW is lower immediately after birth than later later approximately 50 to 60 kcal/kg / day is needed to maintain weight.

11 Because neonates sleep 80% to 90% of the time, the energy expended in physical activity is a smaller component of energy expenditure in neonates than in adults. Because neonates sleep 80% to 90% of the time, the energy expended in physical activity is a smaller component of energy expenditure in neonates than in adults.

12 If the preterm infant is growing at the same rate as the fetus during the third trimester gaining approximately 15 g/kg/d. If the preterm infant is growing at the same rate as the fetus during the third trimester gaining approximately 15 g/kg/d. … then about 15% of the total energy intake is used for synthesis of new tissue. … then about 15% of the total energy intake is used for synthesis of new tissue.

13 Most studies of enterally fed preterm infants receiving either human milk or formula report a higher rate of energy storage per gram of weight gain than that estimated for the fetus. Most studies of enterally fed preterm infants receiving either human milk or formula report a higher rate of energy storage per gram of weight gain than that estimated for the fetus. The total daily energy requirements for full- term infants increase sharply from fetal levels during the first 48 hours of life and continue to increase at a lower rate until the end of the second week of life, reaching to 100 - 120 kcal/kg per day. The total daily energy requirements for full- term infants increase sharply from fetal levels during the first 48 hours of life and continue to increase at a lower rate until the end of the second week of life, reaching to 100 - 120 kcal/kg per day.

14 Preterm infants have limited total body energy stores, so providing adequate early energy resources is more crucial for preterm neonates than for full-term infants. Preterm infants have limited total body energy stores, so providing adequate early energy resources is more crucial for preterm neonates than for full-term infants.

15 ELBW : Higher weight-normalized nutrient intakes are necessary.ELBW : Higher weight-normalized nutrient intakes are necessary. Prenatal growth rate body composition Prenatal growth rate and body composition also may influence postnatal nutritional requirements. (SGA) require more nutrient intake …have been shown, infants who are small for gestational age (SGA) may require more nutrient intake per kilogram of body weight than larger infants.

16 Individual infants their activity their efficiency of nutrient absorption Individual infants vary in their activity, in their ease of achieving basal energy expenditure at thermoneutrality, and in their efficiency of nutrient absorption.

17 Enteral intakes 120 or 130 kcal/kg /day allows most infants LBW at 15 to 20 g/d growth rates similar toin uteroEnteral intakes of 120 or 130 kcal/kg /day have been recommended, as this allows most infants with LBW to grow at 15 to 20 g/d —growth rates similar to those achieved in utero. 130 to 140 kcal/kg per day (ELBW). a target enteral energy intake of 130 to 140 kcal/kg per day may be reasonable for infants with extremely low birthweights (ELBW).

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19 CARBOHYDRATE REQUIREMENT S Lactose is the p pp predominant carbohydrate in h hh human milk and supplies 4 44 40% to 50% of the caloric content. Despite low lactase activities in premature infants, l ll lactose is well tolerated by premature infants, and stable isotope data suggest efficient lactose digestion. Most P PP Premature infant formulas i nclude Glucose polymers a s a significant source of carbohydrate. Glucose polymers have the advantage of i ii increased caloric density without a rise in osmolality, and they may also enhance gastric emptying.

20 PROTEIN REQUIREMENTS protein content compositionhuman milk change throughout lactation : The protein content and composition of human milk change throughout lactation : at birth : 2 g/dl to mature milk : 1 g/dl at birth : 2 g/dl to mature milk : 1 g/dl Qualitative changesalsowhey-to- casein ratio 80:2055:45 Qualitative changes also occur during lactation, resulting in a whey-to- casein ratio of 80:20 at the beginning of lactation, changing to 55:45 in mature milk. casein, α-lactalbumin, albumin, and lysozyme constantsecretory immunoglobulin A lactoferrin decrease. Indeed, whereas the levels of casein, α-lactalbumin, albumin, and lysozyme remain constant, the levels of secretory immunoglobulin A and lactoferrin decrease.

21 birthweights between 1200 and 1800 grrequirement 2.7 and 3.5 g/kg/d For preterm infants with birthweights between 1200 and 1800 gr, the protein requirement is somewhere between 2.7 and 3.5 g/kg/d. Standard preterm formulas2.5 and 3 g of protein per 100 kcal Standard preterm formulas containing between 2.5 and 3 g of protein per 100 kcal can meet those requirements if fluid intake is not restricted. less than 1200 g require more Infants weighing less than 1200 g may require more protein.

22 LIPID REQUIREMENTS Fat provides the major source of energy for growing preterm infants. Fat provides the major source of energy for growing preterm infants. Fatty acid absorption increases with decreasing chain length the degree of unsaturation medium-chain triglycerides (MCTs) hydrolyzed more readily Fatty acid absorption increases with decreasing chain length and with the degree of unsaturation, meaning that medium-chain triglycerides (MCTs) with chain lengths of 6 to 12 carbons are hydrolyzed more readily than long-chain triglycerides (LCTs), and that fatty acids with more double bonds are absorbed more efficiently.

23 Standard commercial f ff formulas for healthy t tt term infants d dd do not contain MCTs, and h hh human milk typically contains 8 88 8% to 12% of fat as MCTs. Unlike LCTs, M MM MCTs are r rr readily hydrolyzed in the gut, and the r rr released fatty acids are transported across the gut barrier w ww without the need for bile acids. M MCTs are then t tt transported directly to the liver via t tt the portal vein as nonesterified fatty acids. In addition, MCTs c cc can enter mitochondria and be oxidized w ww without the need for carnitine-mediated transport through mitochondrial membranes.

24 The total fat content of human milk increases postnatally. The total fat content of human milk increases postnatally. cholesterol & phospholipids decreases as lactation progresses the percentage of cholesterol & phospholipids, both of which reside primarily in the milk fat globule membrane, decreases; in addition, the total phospholipid content decreases as lactation progresses.

25 milk fat contenthuman milk vary with time The milk fat content and nutritional value of human milk vary with time. composition and energy content vary in a pumping session throughout lactation Its composition and energy content may vary in a pumping session and throughout lactation.

26 Formula docosahexaenoic acid (DHA) arachidonic acid (AA) positive changes in neurodevelopment Formula supplemented with docosahexaenoic acid (DHA) and arachidonic acid (AA) has produced positive changes in neurodevelopment measured in infancy in some studies. minimum fat content 4.4 g/ 100 kcal 6.4 g/ 100 kcal A minimum fat content of 4.4 g/ 100 kcal (40% of total energy) and a maximum of 6.4 g/ 100 kcal (57% of total energy) were recommended.Formula

27 Breast milk pooled breast milk cannot provide sufficient sodium, calcium, phosphorus, iron, vitamins B 2, B 6, C, D, and E, and folic acid VLBW. Breast milk and even pooled breast milk cannot provide sufficient sodium, calcium, phosphorus, iron, vitamins B 2, B 6, C, D, and E, and folic acid to meet the needs of infants with VLBW. have higher rates weight, length, and head circumference when fed fortified preterm human milk Studies have shown that infants have higher rates of weight, length, and head circumference increases when fed fortified preterm human milk than those fed only mature human milk.

28 ORAL VITAMIN REQUIREMENTS Vitamins are organic compounds that are essential for metabolic reactions but are n nn not synthesized by the body. They are t tt therefore needed in trace amounts from e ee enteral or p pp parenteral sources. Higher amounts of select vitamins are required by p pp preterm infants, because they may have greater needs.

29 Water-soluble vitamins (C, B ):Water-soluble vitamins (C, B ): Cannot be formed by precursors do not accumulate in the body daily intake is required to prevent deficiency Cannot be formed by precursors and do not accumulate in the body (with the exception of vitamin B 12 ). Therefore, daily intake is required to prevent deficiency. Fat-soluble vitamins (K,E,D,A) : Fat-soluble vitamins (K,E,D,A) : They are important for the development and function of highly specialized tissues. They are important for the development and function of highly specialized tissues. built from precursors accumulate in the body therefore they can produce toxicity They can be built from precursors, are excreted with difficulty, and accumulate in the body, and therefore they can produce toxicity. They are not required daily, and deficiency states develop slowly.

30 Vit. A : Vit. A : Higher intakes(1400 U/Kg) safe healing from lung injury reducingincidence severity CLD Higher intakes(1400 U/Kg) are considered safe and may promote regenerative healing from lung injury, possibly reducing the incidence and severity of CLD. Vit. D : Vit. D : 400 IU/d adequatepreterm 400 IU/d appears to be adequate for preterm infants. Vit. E : Vit. E : 3 to 4 IU/d term higherpreterm The recommended total intake of v.E is 3 to 4 IU/d for term infants. Recommendations are somewhat higher for preterm infants. Vit. K : Vit. K : To prevent bleeding first week when enteral intakes are low 1-mg (IM) at birth term and preterm neonates > 1000 g birthweight To prevent bleeding in the first week of life when enteral intakes are low is recommended in the form of a 1-mg (IM) injection at birth in both term and preterm neonates > 1000 g birthweight. weighing < 1000 gr : 0.3 mg Premature infants weighing < 1000 gr : 0.3 mg

31 Maintenance Na: commencing at 48 to 72 hours : 2-4 meq/kg/d ( ELBW: روز 3 ) Maintenance K: commencing at 48 to 72 hours : 1-2 meq/kg/d وقتي ادرار خوب برقرار شد commencing at 48 to 72 hours : 1-2 meq/kg/d وقتي ادرار خوب برقرار شد تر : هر چه پره مچورتر Immature, Na-k AT pase پمپ شیفت K داخل سلولي به خارج سلول K بالاتر تر : هر چه پره مچورتر Immature, Na-k AT pase پمپ  شیفت K داخل سلولي به خارج سلول  K بالاتر MineralsMinerals

32 MineralsMinerals peak of fetal accretion of minerals after 34 weeks’ preterm infants fed low mineral intakes poorly mineralized bones The peak of fetal accretion of minerals occurs primarily after 34 weeks’ and preterm infants fed low mineral intakes develop poorly mineralized bones. 70 to 200 mg calcium per 100 kcal50 to 117 mg phosphorus per 100 kcal The advisable intakes range from 70 to 200 mg calcium per 100 kcal, 50 to 117 mg phosphorus per 100 kcal, and 6 to 12 mg magnesium per 100 kcal. improvement of mineral retention or bone mineralization who receive higher calcium and phosphorus intakes Several studies have shown improvement of mineral retention or bone mineralization in preterm infants who receive higher calcium and phosphorus intakes....Minerals

33 unfortified human milk bone mineral deficits through 52 weeks postnatally Consumption of unfortified human milk by infants with VLBW after hospital discharge resulted in bone mineral deficits that persisted through 52 weeks postnatally, indicating the need for additional minerals after discharge. calcium and phosphorus salts required by breast-fed until weight reaches term weight Supplemental bioavailable calcium and phosphorus salts may be required by breast-fed, preterm infants until their weight reaches term weight (3 to 3.5 kg)....Minerals

34 Preterm at increased risk iron deficiency anemiaPreterm infants are at increased risk for the development of iron deficiency anemia because: deplete their stores from birth in half the time it takes a term at about 2 months they deplete their stores from birth in half the time it takes a term infant to do so (at about 2 months of age). VLBW sick neonates frequent blood sampling lose much of the iron which is then unavailable for erythropoiesis Infants with VLBW or sick neonates who are medically managed with frequent blood sampling lose much of the iron present in the circulating hemoglobin, which is then unavailable for erythropoiesis.IronIron

35 2 to 3 mg/kg /d no later than 2 months continued throughout the first year of life American Academy of Pediatrics (AAP), agree on a recommendation of 2 to 3 mg/kg /d of dietary elemental iron, begun no later than 2 months of age in preterm infants and continued throughout the first year of life. 2 mg/kg /dat 2 weeks safely augment ferritin stores Iron intakes of 2 mg/kg /d begun at 2 weeks of age were shown to safely augment ferritin stores in infants with LBW. Higher intakes : begun by 1 month continued through age 12 months. Higher intakes : begun by 1 month of age and continued through age 12 months. W < 1000 g :4 mg/kg/day W = 1000 - 1500 g : 3 mg/kg/ day weight at birth W < 1000 g : 4 mg/kg/day W = 1000 - 1500 g : 3 mg/kg/ day weight at birth W > 1500 g : 2 mg/kg/day IronIron

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37 Human milk i s the o oo optimal food for t tt term infants because it provides i ii immunologic and a aa antibacterial factors, h hh hormones, enzymes, and opioid peptides not present in alternative infant food sources. human milk is a aa also the o oo optimal primary nutritional source for p pp premature infants. The s ss strongest evidence of the benefit of h hh human milk for premature infants is the r rr reduced incidence of NEC. Other benefits include i mproved gastric emptying, reduced infections, and possibly better neurocognitive development. Human Milk

38 milkmothers of preterm infants more protein electrolytes The milk from mothers of preterm infants contains more protein and electrolytes than does milk from mothers of term infants. concentrations decline term human milkin several weeks These concentrations decline and approach the composition of term human milk in several weeks. Human milk does not completely meet the nutritional needs of premature infants insufficient premature Human milk does not completely meet the nutritional needs of premature infants ; insufficient protein, calcium, phosphorus, sodium, zinc, vitamins, and possibly energy are provided by human milk to optimally support most premature infants. Human Milk

39 Human milk fortifiers (HMF) h ave been developed and tested and a aa address many of these inadequacies. Premature infants fed fortified human milk may have growth rates slightly lower than those of infants fed formula, but they may also a aa achieve earlier discharge. H HMF : W < 1500 gr : should be used W = 1500 – 2000 gr : should be considered Human Milk

40 Formulas for premature have been developed nutritional needs of growing preterm infants Formulas for premature infants have been developed to meet the nutritional needs of growing preterm infants. Premature formulas reduced amount of lactose intestinal lactase activity may be low in premature infants. Premature formulas contain a reduced amount of lactose,because intestinal lactase activity may be low in premature infants. remainder glucose polymers maintain low osmolality The remainder of the carbohydrate content is in the form of glucose polymers, which maintain low osmolality of the formula. The fat 20% to 50% MCTs The fat blends of preterm formulas are 20% to 50% MCTs, a level that is designed to compensate for low intestinal lipase and bile salts. The protein content is higher The protein content of preterm formulas is higher than that of term formulas (2.7 to 3 g/100 kcal). Preterm Formulas

41 Specialized Formulas Preterm Discharge Formulas

42 TERM INFANTS :TERM INFANTS : Supplementation for healthy, term, breast- fed infants is usually not necessary.Supplementation for healthy, term, breast- fed infants is usually not necessary. (except for vitamin D,Iron) (except for vitamin D,Iron) To prevent rickets, 200 IU/d of vitamin Dduring the first 2 months To prevent rickets, the AAP recommends that breast-fed infants receive 200 IU/d of vitamin D beginning during the first 2 months of life. iron after 4 to 6 months Breast-fed infants usually require an additional iron source after 4 to 6 months of age. Supplementation of Infant Feedings

43 PRETERM INFANTS : PRETERM INFANTS : Daily m mm multivitamin or m mm mineral preparations may be necessary for preterm infants o oo once enteral feedings have been established. Multivitamin supplements that contain the e ee equivalent of the recommended daily allowances f ff for term infants can be given. Liquid multivitamin drops do not contain folic acid because of its lack of stability, but it can be added or g gg given separately. Supplementation of Infant Feedings

44 Breast-fed infants who weigh less than 3.5 kg do not consume enough human milk to acquire the recommended intakes of some vitamins and minerals. Breast-fed infants who weigh less than 3.5 kg do not consume enough human milk to acquire the recommended intakes of some vitamins and minerals. Supplementation with a multivitamin, folic acid, calcium, phosphorus, zinc, and iron may be necessary, Unless one of the commercially available milk fortifiers is used. Unless one of the commercially available milk fortifiers is used. Breast-fed infants who weigh less than 3.5 kg do not consume enough human milk to acquire the recommended intakes of some vitamins and minerals. Breast-fed infants who weigh less than 3.5 kg do not consume enough human milk to acquire the recommended intakes of some vitamins and minerals. Supplementation with a multivitamin, folic acid, calcium, phosphorus, zinc, and iron may be necessary, Unless one of the commercially available milk fortifiers is used. Unless one of the commercially available milk fortifiers is used.

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46 Minimal enteral feeding Early feedingsbegun at about 3 days human milk or formulaEarly feedings were begun at about 3 days of age and consisted of human milk or formula 12 to 24 mL/kg/day. at 12 to 24 mL/kg/day.. Minimal enteral feedings hypocaloric does not contain sufficient calories to sustain somatic growthMinimal enteral feedings involve hypocaloric, low-volume enteral nutrition that does not contain sufficient calories to sustain somatic growth. benefitsmaturation of the preterm intestine reduced liver dysfunction improved feeding tolerance Proposed benefits include maturation of the preterm intestine (both structurally and functionally), reduced liver dysfunction, and improved feeding tolerance. Without an increase inNEC.Without an increase in the incidence of NEC.

47 Breast milk should be the first choice undiluted.Breast milk should be the first choice and can be used undiluted.. Diluting premature formulas but the data supporting this approach are limited Diluting premature formulas for initial feedings is common clinical practice, but the data supporting this approach are limited. full enteral feedings full nipple feedings earlier Infants achieved full enteral feedings and full nipple feedings earlier than did their counterparts who were fed sterile water. evidence strongly supports initiating early enteral feeding.The available evidence strongly supports initiating early enteral feeding.

48 Gavage feeding : is appropriate for infants who demonstrate a aa an immature suck and swallowing reflex or a c cc clinical condition that is precludes nipple feeding, such as t tt tachypnea or o oo oral-facial anomalies. Therefore, most infants f ff fed by gavage are G GG GA < 34 Weaks. METHODS OF FEEDING HIGH- RISK INFANTS

49 weighing > 2 kg (OGT) or (NGT)Infants weighing > 2 kg have tolerated both orogastric (OGT) or nasogastric tube (NGT) placement without difficulty. weighing < 2 kg (OGT)Infants weighing < 2 kg Placement of an anchored orogastric tube (OGT) is therefore recommended. transition to NGT when the infant’s weight exceeds 2 kg. with transition to NGT when the infant’s weight exceeds 2 kg.

50 Infants appear to tolerate feedings better if rapid gastric distention is avoided. Infants appear to tolerate feedings better if rapid gastric distention is avoided. bolus feedings over 20 to 25 minutesbolus feedings over 20 to 25 minutes are generally recommended. every 3 to 4 hours termevery 3 hours less than 2500 gevery 2 to 3 hoursless than 1500 g.Bolus feedings are usually delivered in equal volumes every 3 to 4 hours for term infants, every 3 hours for infants less than 2500 g, and every 2 to 3 hours for infants less than 1500 g. Gastric emptying human milk feedings prone right- sided position. Gastric emptying may be a clinical problem but is enhanced with human milk feedings and when infants are in the prone or right- sided position.

51 A number of retrospective studies suggest that rapid advancement of feedings (greater than 25 cc/kg per day) increase the risk of NEC. (greater than 25 cc/kg per day) may increase the risk of NEC.

52 Continuous drip feedings : Continuous drip feedings : colonization of expressed milk is universal logarithmic growth of bacteria occurs in milk left at room temperature for more than 6 hours.colonization of expressed milk is universal, and logarithmic growth of bacteria occurs in milk left at room temperature for more than 6 hours. potential loss of nutrient (up to 34% of the expressed milk fat). Another disadvantage of continuous drip breast milk feedings is the potential loss of nutrient delivery (up to 34% of the expressed milk fat). METHODS OF FEEDING HIGH- RISK INFANTS

53 The mother’s milk supply directly related to prolactin and oxytocin breast stimulationThe mother’s milk supply is directly related to the response of prolactin and oxytocin to breast stimulation. preterm infant often cannot be placed at the breast mechanical pumping is frequently elected.Because a preterm infant often cannot be placed at the breast, mechanical pumping is frequently elected. Emptying the breasts pumpEmptying the breasts with the pump should 8 to 10 times daily. be attempted 8 to 10 times daily. a double collection kit If a double collection kit is used, pumping approximately 10 minutes. takes approximately 10 minutes. Establishing Lactation

54 Freshly expressed milk immediately, the preferred methodFreshly expressed milk can be fed to infants immediately, which is the preferred method of delivery. If milk is refrigerated24 to 48 hours If milk is refrigerated, it should be discarded 24 to 48 hours after collection. Milk that is frozen thawed by running it under tepid water until it is room temperature microwave should not be used Milk that is frozen should be thawed by running it under tepid water until it is room temperature. A microwave should not be used for thawing, to ensure maximum preservation of the host defenses. All thawed milk left over from a feeding should be discarded.All thawed milk left over from a feeding should be discarded.

55 Early Breast-Feeding Experiences

56 (KMC) early skin-to-skin contact motherstheir preterm infants(KMC) It is suggested that early skin-to-skin contact between mothers and their preterm infants is advantageous for a variety of reasons. 32 - 34 weeks ability to coordinate sucking with swallowing and breathing when offered a breast feedingInfants born as young as 32 - 34 weeks ’ gestation have demonstrated the ability to coordinate sucking with swallowing and breathing when offered a breast feeding. when bottle fed (PO) difficulty with respiratory control frequently “cyanotic attacks.”These same infants, when bottle fed (PO), showed difficulty with respiratory control and frequently demonstrated “cyanotic attacks.” Oral feedings infant reaches the equivalent of 34 weeksOral feedings are usually offered once daily, with supplementation by orogastric tube, until the infant reaches the equivalent of 34 weeks ’ gestation. Early Breast-Feeding Experiences

57 should listen for sounds of swallowing during feeding point them out to the mother because infant feeding noises are highly reinforcing. The clinician should listen for sounds of swallowing during feeding and point them out to the mother, because infant feeding noises are highly reinforcing. First feeding experiences often only one breast may be brief.First feeding experiences often involve only one breast and may be brief. A successful feeding both the infant and the mother enjoy it should not be measured by the volume consumed. A successful feeding is one that both the infant and the mother enjoy, and it should not be measured by the volume consumed. volume will rise The volume will rise as the mother’s and infant’s performances improve over time. It is difficult to clinically assess the volume suckled at a feedingIt is difficult to clinically assess the volume suckled at a feeding. weight difference in gramsThe weight difference in grams estimates the milliliters consumed. Early Breast-Feeding Experiences

58 Routine mechanical expression can be reducedRoutine mechanical expression can be reduced when the infant feeds vigorouslywhen the infant feeds vigorously both breasts Nurses from both breasts at each feeding gaining weight steadily (15 to 40 g/d). And is gaining weight steadily (15 to 40 g/d). Early Breast-Feeding Experiences

59 Parenteral nutrition (TPN) should begin early continue until full enteral feedings are reached.Parenteral nutrition (TPN) should begin early and continue until full enteral feedings are reached. should also reinitiated without delay when enteral feedings are interrupted parenteral nutrition should also be reinitiated without delay when enteral feedings are interrupted. As parenteral nutrition is being provided and advancedminimal early enteral intakeshould be strongly considered, at day 2 or 3As parenteral nutrition is being provided and advanced, minimal early enteral intake for the infant with extremely low birthweight should be strongly considered, beginning at day 2 or 3 of life. PRACTICAL APPROACH

60 mechanical ventilation umbilical arterial line (UAC) should not prevent initiating minimal enteral feeding. The requirement for mechanical ventilation or the presence of an umbilical arterial line (UAC) should not prevent initiating minimal enteral feeding. Breast milk from the infant’s mother is the preferred undiluted fortified Human milk fortifier (HMF) when the infant has achieved full-volume feeds. Breast milk from the infant’s mother is the preferred enteral substrate; it is usually provided undiluted and ultimately fortified with a standard Human milk fortifier (HMF) when the infant has achieved full-volume feeds. PRACTICAL APPROACH

61 Small aliquots human milk premature formula OGTa regular intermittent schedule Small aliquots of human milk or premature formula may be provided by the OGT on a regular intermittent schedule (1 to 2 cc/kg every 2 to 3 hours) (1 to 2 cc/kg every 2 to 3 hours) PRACTICAL APPROACH

62 One common approach advance feedings by 20 cc/kg /day if the infant tolerated the previous 24 hours of feedingOne common approach is to advance feedings by 20 cc/kg /day if the infant tolerated the previous 24 hours of feeding full enteral feeding (150 cc/kg/day) in 7 to 10 days. this typically results in full enteral feeding (150 cc/kg/day) in 7 to 10 days. prolonging small feeding volumes for a period of time may reduce NEC. Some period (5 to 10 days) of small enteral feedings (20 cc/g/day) before advancingespecially ELBW.More recent data suggest that prolonging small feeding volumes for a period of time may reduce NEC. Some period (5 to 10 days) of small enteral feedings (20 cc/g/day) should be considered before advancing, especially in the high-risk population of infants with ELBW. PRACTICAL APPROACH

63 signs and symptoms of feeding intolerance are observed residuals, abdominal distention, blood in stools, increased respiratory distress).Throughout the process of advancing feeds, adjustments are made if signs and symptoms of feeding intolerance are observed (e.g., residuals, abdominal distention, blood in stools, increased respiratory distress). Best Rigards…

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