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Nutrition Management of the Premature Infant

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Presentation on theme: "Nutrition Management of the Premature Infant"— Presentation transcript:

1 Nutrition Management of the Premature Infant
Melissa Nash, MPH, RD Washington County Field Team

2 Objectives Describe appropriate growth in premature infants, including growth charts. Describe current practices for feeding and supplementation for premature infants. Understand how to better support the breastfeeding premature infant. Recognize potential feeding problems and solutions in premature infants.

3 Newborn Classifications
LBW: Low Birth Weight <2500g (5 1/2 lbs) VLBW: Very Low Birth Weight <1500g (3 1/3 lbs) ELBW: Extremely Low Birth Weight <1000g (2 1/4 lbs) Preterm: <37 weeks GA Late Preterm: 34 0/7 – 36 6/7 weeks GA

4 Typical Feeding Progression
Gestational Age (Weeks) Pacifier Sucking (non-nutritive suck) Gag Reflex Rooting Reflex Early Intermediate Mature Coordinate Suck, Nutritive Suck Swallow, Breathe TPN for 1-2 weeks as enteral Gradually start breast/ Infant nippling feeds advance via tube bottle per infant cues all feeds

5 Post-Discharge Premature Infant Nutritional Issues
Switch from ‘super-milks’ to standard milk Slower growth in follow-up Neonatal period critical for ‘programming’ of development and health Limited information/research on post- discharge nutrition

6 The Underlying Question…
“Do you want a smart, tall, fat adult who will die prematurely of cardiovascular disease or a dumb, short, thin adult who will outlive the other?” Richard Schandler, MD Neonatalogist

7 Developmental Origins of Health & Disease
“Fetal Programming” Under-nutrition during pg & LBW are strongly associated with HTN, obesity, insulin resistance and dyslipidemia later in life Combination of poor growth & rapid catch-up weight may increase risk Additional research is needed to determine when catch-up growth is “excess growth”

8 What does the research say?
Weight Gain & Growth Feeding a post-discharge formula (PDF) for months following discharge results in improved wt, lt, & HC Greatest results in infants < g Greater results in males vs. females Long-term developmental advantages inconclusive

9 What does the research say?
Bone Mineral Content (BMC) BMC higher in premies receiving a PDF for 9 months post-discharge Highest Ca formulas = greatest BMC Chan, J Pediatr 1993;123:439-43 Bishop, Arch Dis Child;1993:573-8 Carver, Pediatr 2001;107: Cooke, Pediatr Res 2001;49: Morley, Am J Clin 2001;71:822-8

10 Growth Charts Recommended growth charts:
2013 Fenton growth charts from birth to ~50 wks WHO growth charts from term to 24 months CDC growth charts from 24 months to 18 yrs old

11 Fenton Growth Grids
•Based on the recommended growth goal for preterm infants: The fetus and the term infant •Girl and boy specific charts •Equivalent to the WHO growth charts at 50 weeks gestational age (10 weeks post term age). •Large preterm birth sample size of 4 million infants; •Recent population based surveys collected between 1991 to 2007 •Data from developed countries including Germany, Italy, United States, Australia, Scotland, and Canada •Curves are consistent with the data to 36 weeks, thus can be used to assign size for gestational age up to and including 36 weeks. •Chart is designed to enable plotting as infants are measured: actual age vs. completed weeks.

12 Why should we use the updated Fenton charts?
Boys chart Solid lines = 2013 Dashed lines = 2003

13 Growth Assessment Start with correct growth parameters
Term- 3 mo CA 3-6 mo CA Weight Gain ~6-8 oz/wk ~4 oz/wk Length Gain ~1 cm/wk ~0.5 cm/wk HC Gain ~0.2 cm/wk

14 Corrected Age Use corrected age for all premature infants <37 weeks until 24 months when assessing: Growth Nutritional needs Feeding (solids, cow’s milk) Developmental milestones

15 First Choice Formulas for Premies: Post-Discharge Formula
Post-Discharge (transitional) formulas Enfamil Enfacare* Similac Neosure* Good Start Nourish* *WIC provides with an Rx Provide add’l vits & nutrients: Ca, Phos & Pro Whey-dominate, less lactose, 20% MCT oil Provide add’l calories: 22 vs. 20 kcal/oz May be mixed to 24 or 27 kcal/oz May be used to fortify EMM to 22, 24, 27 kcal/oz Reduce Lactose: Controls osmolality Enhances tolerance (dec stool output & fussiness) Inc. absorption of Ca, Pro & min Intake & wt gain improved MCT: readily absorbable fat, fat absorption 40-90% reflects immaturity Inc. Ca absorption Whey: Fewer , smaller curds, avoid lacto bezoars. Faster emptying from stomach Softer stools 40% more protein Lactose: first seen at 26 weeks Not functional until 32 wks Continue to inc. until 1 mo CA

16 Second Choice Formulas for Premies: Term Formulas
Standard Term Formulas Enfamil Premium Good Start Gentle; Good Start Protect Similac Advance (WIC) Reduced/No Lactose and/or Partially Hydrolyzed Enfamil Gentlease Good Start Sooth, GS Gentle, GS Protect Similac Sensitive, Similac Total Comfort (19 kcal/oz) Uses: GI upset, constipation, lactose sensitivity Provides 20 kcal/oz Can fortify EMM or be prepared to 22, 24, 27 kcal/oz Wait 7-10 days before changing formula – takes 5 days to re-grow intestinal cells. “I am changing this formula because…”

17 Contraindicated Formulas for Premies: Soy Formula
AAP does not recommend soy formula for preterm infants born <1800g Lower serum albumin levels High amts of phytates Lower levels of markers for bone formation Risks for aluminum toxicity Concerns w/ disruption of thyroid fct, suppression of testosterone, & phytoestrogen-like effect Examples: Isomil & Prosobee (WIC) Bhatia, Pediatrics 2008;121:1062 potential negative effects on sexual development and reproduction, neurobehavioral development, immune function, and thyroid function Pytates binds with Phos, Ca, iron & zinc 120 kccal/kg = 330 kcal 120 kcal/kg = 8200 kcal Bone markers = lower phos & higher alk phos = risk of osteopenia Even after Ca & phos supply, x-ray showed signs of osteopenia Aluminum competes with Ca for absorption Inc’d aluminum deposition in bone & CNS, esp in infants w/ compromised renal fct like premies

18 Contraindicated Formulas for Premies: Thickened Formulas
These “reflux” formulas contain rice starch with thicken upon entering the stomach. Contraindicated for premature infants <38 weeks GA due to risk of the formation of lactobezoars (hard clumps of undigested milk curds) Examples: Enfamil AR* & Similac for Spit-Up* *Available thru WIC w/ Rx Rice cereal NOT indicated to thicken feeds: Displaces nutrients Reduces symptoms, not episodes Changes body composition w/ added cals by CHO

19 EMM & Formula Comparison
Values Per 100ml Term EMM 20 kcal EMM + Enfacare 24 kcal/oz Enfacare 24 kcal/oz Enfamil 20 kcal Calories 68 80 Pro, G 1 1.36 2.3 1.4 Ca, mg 28 44 97 53 Phos, mg 15 24 29 Iron, mg 0.04 0.3 1.2

20 Breastfeeding the Premature Infant
“The potent benefits of human milk are such that all preterm infants should receive human milk.” “Human milk should be fortified, with protein, minerals, and vitamins to ensure optimal nutrient intake for infants weighing <1500 g at birth.” Policy Statement: Breastfeeding and the Use of Human Milk, Pediatrics 2012; 129:e827 In general, the smaller infant, the higher the nutritional needs & the longer they may need fortification.

21 Breastfeeding the Preterm Infant
There are several significant short & long-term benefits to feeding a preterm infant human milk: ↓ rates of sepsis & NEC Fewer hospital readmissions ↑ intelligence thru adolescents ELBW infants fed ↑ of human milk show significantly ↑ scores for mental, motor, & behavior ratings at ages 18 months and 30 months Even after adjusting for cofounders Outcomes assoc. w/ predominant human milk, not exclusive Lower rates of metabolic syndrome Policy Statement: Breastfeeding and the Use of Human Milk, Pediatrics 2012;129:e827

22 Goals for Breastfeeding the Premature Infant
Promote adequate wt gain, including catch-up Ensure good nutritional status Maintain & increase breast milk supply Sustain or improve feedings at the breast Limit bottle & formula feedings

23 Guidelines for Initiating & Maintaining Milk Supply
First 2-3 weeks Use hand expression & compression w/ pumping Pump w/ double electric pump Empty breasts at every pumping Pump q 2-3 hrs/day & 1x/night (not to exceed 4 hrs) Pump 7-10x/24 hours while establishing supply After first 2-3 weeks (if adequate milk supply) Pump q 4hr/day & 1x/night (not to exceed 5 hrs) Pump 6-8x/24 hours Preterm mothers are able to express twice as much breastmilk with hand expression and pumping combined to pumping alone Preterm milk x 2 wks = higher in Pro, Ca, Phos Pump for min or for 2 min after the last drop of milk

24 Ideas for Increasing Milk Supply
Increase skin-to-skin contact Ensure adequate fluid intake Ensure optimal pump and/or flange Increase frequency of pumping, up to 10x/d Use breast massage/compression while pumping Discuss ways to decrease tension Try power or cluster pumping Discuss use of galactagogues/meds w/ LC Cluster pumping: pump, nurse, pump q 1/2 -1 hr for several hours Power Pumping: 1. Pump for 10 min, rest for 10 min, repeat for 60 min, 1-2x/d 2. Pump every 2 hours during waking hours for 1 full day

25 Breastfeeding the Premature Infant
The ability to BF is multi-factorial, depends on: MOB’s milk supply & willingness to pump Birth weight & gestational age Complexity of NICU course Infant maturity

26 Breastfeeding the Premature Infant
Typical plan of BF premature infant at discharge: BF 2x/d (with time limit) Offer bottle of fortified EMM q feeding Give MVI w/ iron daily MOB pumps q feeding Rarely, previously frozen milk that has been thawed may smell or taste soapy and/or smell rancid. This milk is sage and most babies will continue to drink it Some women have milk high in an enzyme called lipase which causes the breakdown of the milk fats (lipolysis). To prevent this, before freezing lots of milk, freeze a batch or two and then thaw it. If the milk smells or if a baby refuses it, future batches can be heated to scalding (180 degrees) after expression, then quickly cooled and frozen which deactivates the lipase enzyme.

27 Breastfeeding the Premature Infant
Progression of BF plan: Add one additional BF q week Consider nipple shield Cont. to offer fortified bottles q feeding & after BF Give 1 ml MVI w/ iron daily MOB to continue to pump at q feeding & after BF until at least weeks GA Support, support, support!!! If needed, use of nipple shields to increase milk transfer: 8.4 ml w/ shield vs. 3.9 ml w/o (Meier, J Hum Lact 2000;16:106-14)

28 Breastfeeding the Premature Infant
Evaluation of readiness to reduce fortification: Ability to sustain growth Ability to sustain appropriate ad lib milk intake Lab values are WNL (ck’d one mo post-discharge) Methods to decrease fortification: Decrease by 2 bottles q 4-6 days or Drop fort bottles at night * Check weight WEEKLY during transition

29 Vitamin/Mineral Supplementation
If infant is primarily on: What supplements are recommended? When can the supplements be stopped? Breastmilk (Unfortified or Fortified) 1 ml daily infant MVI with iron OR 1ml daily infant MVI without iron + separate iron supplement Continue until 12 mo corrected age Iron-Fortified Formula 0.5 ml daily infant MVI without iron Stop when intake reaches ~ 32 oz/d *Poly vitamin = A, C, D, E, B vitamins + iron? *Tri vitamin = A, C, D + iron?

30 Osteopenia of Prematurity
Condition of decreased bone density in premature, LBW infants. Characterized by low Ca, low P, and high ALP Risk for bone fractures & growth stunting

31 Osteopenia of Prematurity
Risk factors: VLBW infants (<1500 g) Any IUGR infant with a BW <1800g Infants with CLD or BPD Infants requiring long-term TPN (>4 weeks) Infants on certain meds that affect mineral absorption Infants starting feeds of unfortified breastmilk or standard/soy formula Meds: diuretics & corticosteroids

32 Osteopenia of Prematurity
Indications for reassessment of bone labs: 1 mo post discharge for infants w/ BW <1500g 1 mo post discharge if any labs at discharge were abnormal An infant <3 mo CA who is transitioning to breast or term formula Infant with marginal intake & slow growth

33 Osteopenia of Prematurity
Some very small premature infants gain weight well while taking only breastmilk, despite having abnormal bone labs. Tribasic: Ca/P supplement Standard dose is 1/8 tsp BID, up to TID Bone labs should be monitored q 4-6 wks while on Tribasic Infant continues w/ Tribasic for 2-3 mo while EBF

34 Late Preterm Infant Infants born between 34 0/7 – 36 6/7 weeks GA
Birth weights ~ g (4 ½ -6 ½ lbs) No current recommendations for additional nutrient requirements, besides a multivitamin. At risk of inadequate nutrient intake due to: Immature gastrointestinal function Immature neural function Lower stamina Lower oral-motor tone

35 Late Preterm Infants Breastfeeding:
Many discharged home before MOB’s milk supply established Late preterms may not be able to provide enough stimulation to bring in adequate supply MOB will usually have to pump after BF for several weeks to ensure adequate supply Infants can EBF, BF + bottle of EMM, BF + bottle of fortified EMM to kcal/oz Offer MVI until 12 mo CA

36 Late Preterm Infants Formula Feeding: Offer TERM infant formula
Offer MVI until volume reaches 32 oz/d May start/increase to kcal/oz if infant unable to consume enough volume to provide adequate growth. Usually need inc. calories for first month.

37 Feeding Progression/Solids
Feeding recommendations for premature infants should be based on corrected age: Breastmilk/formula until at least 12 mo CA Solids may be introduced between 4-6 mo CA (based on developmental stage & feeding skill) Withhold cow’s milk until 12 mo CA

38 Common Concerns in the Premature Infant
Constipation Spit-up &/or GERD Inadequate weight gain Rapid weight gain

39 Constipation in the Premature Infant
Stools that are dry, hard & difficult to pass, independent of frequency Causes/Assessment: Immature GI tract Medications Inadequate fluid intake Calorie-dense formulas Improper formula preparation Transitioning from breastmilk to formula Early intro to cereals in bottle Neurological delays

40 Constipation – Feeding Plan
Maximize breastmilk Warm bath, infant massage, bicycle movements Iron: Iron supplements may cause constipation Check hematocrit -if formula is meeting iron needs & hct is WNL: Switch to MVI w/o iron Juice (if infant is >40 weeks): Mix ½ oz prune, pear or apple juice with ½ oz water Start 1 oz diluted jc qod, inc to 1 oz diluted jc qd prn Max 1 oz full-strength jc qd Juices have higher sorbitol content & inc water in stools

41 Constipation – Feeding Plan
If taking PDF mixed >24 kcal/oz: Decrease from 27 kcal/oz to 24 kcal/oz to 22 kcal/oz If infant BW > g & if gaining weight well, consuming good vol, and nutritional needs met: D/C fortifier & offer 100% breastmilk Change to routine term formula Always check wt gain/intake wkly after making change If infant BW <1500g & <3 mo CA: Talk w/ RD who has experience with premature infants Always check bone labs before making a formula change If constipation continues, talk to MD re: stool softeners

42 Spit-up and/or GERD in the Premature Infant
Assessment: Assess weight gain Assess nipple flow Assess feeding behaviors and positioning Back arching? Volume in bottle slowly increasing or decreasing? Volume of spit-up Parental concerns Lower esophogeal sphyncter tone in premies – tone r/t GA Delayed gastric emptying- can be altered by numerous things: Fat Acid Osmalality Caloric density

43 Spit-up and/or GERD in the Premature Infant
Feeding Plan: Parental reassurance if growth ok Smaller, more frequent feeds Keep upright for 20 min after a feeding Educate on proper positioning No solids in bottle Limited use of added starch formula & only if > 40 wks CA Reflux meds needed? Poets, Pediatr 2004;112: Carroll, Arch Pediatr Adolesc Med 2002;156:109-11 Lightdale, Pediatr 2013; 131: Thickened feeds may reduce symptoms, not episodes

44 Inadequate Weight Gain in the Premature Infant
Assessment: Infrequent bottle feeding (> Q 3-4 hr) Improper mixing formula/fortifying EMM Lower kcal/oz formula Easily exhausted or not interested in breast, bottle Slow nipple flow on bottle, tight suction on cap Minimal BF skills Constipation affecting volume consumed GERD affecting volume consumed Neurological delays & limited coordination Recent illness

45 Inadequate Weight Gain in the Premature Infant
Feeding Plan: Observe feeding, trial of nipples If trying to transition to breast, make sure baby is offered bottle after BF, put time-limit on BF Switch to kcal/oz Calculate catch-up needs Give parents a goal intake volume Parents to keep diary for 2 weeks Weekly weight checks Discuss plan w/ MD

46 Rapid Weight Gain in the Premature Infant
Assessment: Improperly mixing formula Improperly fortifying EMM Large volumes consumed Feeding schedule vs. hunger cues Cereals in bottle After successful BF reached, cont. to offer bottle after BF

47 Rapid Weight Gain in the Premature Infant
Feeding Plan: Discuss feeding cues & volumes w/ family Switch kcal level down kcal/oz If >1500g-2000g BW & if growth ok: Switch to term formula If <1500 BW & if growth ok, ck bone labs: If WNLs, switch to term formula; re-ck labs in 1 mo If abnormal, continue w/ PDF & re-ck labs in 1 mo

48 Coordination of Care Family Pediatrician Nurses: PMD office & PHN
Dietitians: NICU, out-patient, WIC Lactation consultants Neurodevelopmental/ Feeding clinic Get involved!

49 Nutrition Practice Care Guidelines for Preterm Infants in the Community
Click on “For Medical Providers” Double click on “Nutrition Practice Care Guidelines…” OR Click on “For Oregon WIC Staff” on left-side column Click on “WIC Staff Resources” Scroll down to “Nutrition Information” header Double-click on “Nutrition Guidelines: Preterm Infants” & “Oregon Appendix”

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