Presentation on theme: "Nutrition Management of the Premature Infant"— Presentation transcript:
1 Nutrition Management of the Premature Infant Melissa Nash, MPH, RDWashington County Field Team
2 ObjectivesDescribe 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.
4 Typical Feeding Progression Gestational Age (Weeks)Pacifier Sucking (non-nutritive suck)Gag ReflexRooting Reflex Early Intermediate MatureCoordinate Suck,Nutritive Suck Swallow, BreatheTPN for 1-2 weeks as enteral Gradually start breast/ Infant nipplingfeeds advance via tube bottle per infant cues all feeds
5 Post-Discharge Premature Infant Nutritional Issues Switch from ‘super-milks’ to standard milkSlower growth in follow-upNeonatal period critical for ‘programming’ of development and healthLimited 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, MDNeonatalogist
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 lifeCombination of poor growth & rapid catch-up weight may increase riskAdditional research is needed to determine when catch-up growth is “excess growth”
8 What does the research say? Weight Gain & GrowthFeeding a post-discharge formula (PDF) for months following discharge results in improved wt, lt, & HCGreatest results in infants < gGreater results in males vs. femalesLong-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-dischargeHighest Ca formulas = greatest BMCChan, J Pediatr 1993;123:439-43Bishop, Arch Dis Child;1993:573-8Carver, 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 wksWHO growth charts from term to 24 monthsCDC growth charts from 24 months to 18 yrs old
11 Fenton Growth Grids http://ucalgary.ca/fenton/2013chart •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 chartSolid lines = 2013Dashed lines = 2003
13 Growth Assessment Start with correct growth parameters Term-3 mo CA3-6 mo CAWeight Gain~6-8 oz/wk~4 oz/wkLength Gain~1 cm/wk~0.5 cm/wkHC Gain~0.2 cm/wk
14 Corrected AgeUse corrected age for all premature infants <37 weeks until 24 months when assessing:GrowthNutritional needsFeeding (solids, cow’s milk)Developmental milestones
15 First Choice Formulas for Premies: Post-Discharge Formula Post-Discharge (transitional) formulasEnfamil Enfacare*Similac Neosure*Good Start Nourish**WIC provides with an RxProvide add’l vits & nutrients: Ca, Phos & ProWhey-dominate, less lactose, 20% MCT oilProvide add’l calories: 22 vs. 20 kcal/ozMay be mixed to 24 or 27 kcal/ozMay be used to fortify EMM to 22, 24, 27 kcal/ozReduce Lactose:Controls osmolalityEnhances tolerance (dec stool output & fussiness)Inc. absorption of Ca, Pro & minIntake & wt gain improvedMCT:readily absorbable fat, fat absorption 40-90% reflects immaturityInc. Ca absorptionWhey:Fewer , smaller curds, avoid lacto bezoars.Faster emptying from stomachSofter stools40% more proteinLactose:first seen at 26 weeksNot functional until 32 wksContinue to inc. until 1 mo CA
16 Second Choice Formulas for Premies: Term Formulas Standard Term FormulasEnfamil PremiumGood Start Gentle; Good Start ProtectSimilac Advance (WIC)Reduced/No Lactose and/or Partially HydrolyzedEnfamil GentleaseGood Start Sooth, GS Gentle, GS ProtectSimilac Sensitive, Similac Total Comfort (19 kcal/oz)Uses: GI upset, constipation, lactose sensitivityProvides 20 kcal/ozCan fortify EMM or be prepared to 22, 24, 27 kcal/ozWait 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 <1800gLower serum albumin levelsHigh amts of phytatesLower levels of markers for bone formationRisks for aluminum toxicityConcerns w/ disruption of thyroid fct, suppression of testosterone, & phytoestrogen-like effectExamples: Isomil & Prosobee (WIC)Bhatia, Pediatrics 2008;121:1062potential negative effects on sexual development and reproduction, neurobehavioral development, immune function, and thyroid functionPytates binds with Phos, Ca, iron & zinc120 kccal/kg = 330 kcal 120 kcal/kg = 8200 kcalBone markers = lower phos & higher alk phos = risk of osteopeniaEven after Ca & phos supply, x-ray showed signs of osteopeniaAluminum competes with Ca for absorptionInc’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/ RxRice cereal NOT indicated to thicken feeds:Displaces nutrientsReduces symptoms, not episodesChanges body composition w/ added cals by CHO
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 optimalnutrient intake for infants weighing <1500 gat birth.”Policy Statement: Breastfeeding and the Use of Human Milk, Pediatrics 2012; 129:e827In 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 & NECFewer hospital readmissions↑ intelligence thru adolescentsELBW infants fed ↑ of human milk show significantly ↑ scores for mental, motor, & behavior ratings at ages 18 months and 30 monthsEven after adjusting for cofoundersOutcomes assoc. w/ predominant human milk, not exclusiveLower rates of metabolic syndromePolicy 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-upEnsure good nutritional statusMaintain & increase breast milk supplySustain or improve feedings at the breastLimit bottle & formula feedings
23 Guidelines for Initiating & Maintaining Milk Supply First 2-3 weeksUse hand expression & compression w/ pumpingPump w/ double electric pumpEmpty breasts at every pumpingPump q 2-3 hrs/day & 1x/night (not to exceed 4 hrs)Pump 7-10x/24 hours while establishing supplyAfter first 2-3 weeks (if adequate milk supply)Pump q 4hr/day & 1x/night (not to exceed 5 hrs)Pump 6-8x/24 hoursPreterm mothers are able to express twice as much breastmilk with hand expression and pumping combined to pumping alonePreterm milk x 2 wks = higher in Pro, Ca, PhosPump for min or for 2 min after the last drop of milk
24 Ideas for Increasing Milk Supply Increase skin-to-skin contactEnsure adequate fluid intakeEnsure optimal pump and/or flangeIncrease frequency of pumping, up to 10x/dUse breast massage/compression while pumpingDiscuss ways to decrease tensionTry power or cluster pumpingDiscuss use of galactagogues/meds w/ LCCluster pumping: pump, nurse, pump q 1/2 -1 hr for several hoursPower Pumping:1. Pump for 10 min, rest for 10 min, repeat for 60 min, 1-2x/d2. 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 pumpBirth weight & gestational ageComplexity of NICU courseInfant 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 feedingGive MVI w/ iron dailyMOB pumps q feedingRarely, 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 itSome 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 weekConsider nipple shieldCont. to offer fortified bottles q feeding & after BFGive 1 ml MVI w/ iron dailyMOB to continue to pump at q feeding & after BF until at least weeks GASupport, 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 growthAbility to sustain appropriate ad lib milk intakeLab values are WNL (ck’d one mo post-discharge)Methods to decrease fortification:Decrease by 2 bottles q 4-6 days orDrop 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 ironOR1ml daily infant MVI without iron + separate iron supplementContinue until 12 mo corrected ageIron-Fortified Formula0.5 ml daily infant MVI without ironStop 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 ALPRisk for bone fractures & growth stunting
31 Osteopenia of Prematurity Risk factors:VLBW infants (<1500 g)Any IUGR infant with a BW <1800gInfants with CLD or BPDInfants requiring long-term TPN (>4 weeks)Infants on certain meds that affect mineral absorptionInfants starting feeds of unfortified breastmilk or standard/soy formulaMeds: diuretics & corticosteroids
32 Osteopenia of Prematurity Indications for reassessment of bone labs:1 mo post discharge for infants w/ BW <1500g1 mo post discharge if any labs at discharge were abnormalAn infant <3 mo CA who is transitioning to breast or term formulaInfant 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 supplementStandard dose is 1/8 tsp BID, up to TIDBone labs should be monitored q 4-6 wks while on TribasicInfant 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 functionImmature neural functionLower staminaLower oral-motor tone
35 Late Preterm Infants Breastfeeding: Many discharged home before MOB’s milk supply establishedLate preterms may not be able to provide enough stimulation to bring in adequate supplyMOB will usually have to pump after BF for several weeks to ensure adequate supplyInfants can EBF, BF + bottle of EMM, BF + bottle of fortified EMM to kcal/ozOffer MVI until 12 mo CA
36 Late Preterm Infants Formula Feeding: Offer TERM infant formula Offer MVI until volume reaches 32 oz/dMay 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 CASolids 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 ConstipationSpit-up &/or GERDInadequate weight gainRapid weight gain
39 Constipation in the Premature Infant Stools that are dry, hard & difficult to pass, independent of frequencyCauses/Assessment:Immature GI tractMedicationsInadequate fluid intakeCalorie-dense formulasImproper formula preparationTransitioning from breastmilk to formulaEarly intro to cereals in bottleNeurological delays
40 Constipation – Feeding Plan Maximize breastmilkWarm bath, infant massage, bicycle movementsIron:Iron supplements may cause constipationCheck hematocrit -if formula is meeting iron needs & hct is WNL: Switch to MVI w/o ironJuice (if infant is >40 weeks):Mix ½ oz prune, pear or apple juice with ½ oz waterStart 1 oz diluted jc qod, inc to 1 oz diluted jc qd prnMax 1 oz full-strength jc qdJuices 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/ozIf infant BW > g & if gaining weight well, consuming good vol, and nutritional needs met:D/C fortifier & offer 100% breastmilkChange to routine term formulaAlways check wt gain/intake wkly after making changeIf infant BW <1500g & <3 mo CA:Talk w/ RD who has experience with premature infantsAlways check bone labs before making a formula changeIf constipation continues, talk to MD re: stool softeners
42 Spit-up and/or GERD in the Premature Infant Assessment:Assess weight gainAssess nipple flowAssess feeding behaviors and positioningBack arching?Volume in bottle slowly increasing or decreasing?Volume of spit-upParental concernsLower esophogeal sphyncter tone in premies – tone r/t GADelayed gastric emptying- can be altered by numerous things:FatAcidOsmalalityCaloric density
43 Spit-up and/or GERD in the Premature Infant Feeding Plan:Parental reassurance if growth okSmaller, more frequent feedsKeep upright for 20 min after a feedingEducate on proper positioningNo solids in bottleLimited use of added starch formula & only if > 40 wks CAReflux meds needed?Poets, Pediatr 2004;112: Carroll, Arch Pediatr Adolesc Med 2002;156:109-11Lightdale, 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 EMMLower kcal/oz formulaEasily exhausted or not interested in breast, bottleSlow nipple flow on bottle, tight suction on capMinimal BF skillsConstipation affecting volume consumedGERD affecting volume consumedNeurological delays & limited coordinationRecent illness
45 Inadequate Weight Gain in the Premature Infant Feeding Plan:Observe feeding, trial of nipplesIf trying to transition to breast, make sure baby is offered bottle after BF, put time-limit on BFSwitch to kcal/ozCalculate catch-up needsGive parents a goal intake volumeParents to keep diary for 2 weeksWeekly weight checksDiscuss plan w/ MD
46 Rapid Weight Gain in the Premature Infant Assessment:Improperly mixing formulaImproperly fortifying EMMLarge volumes consumedFeeding schedule vs. hunger cuesCereals in bottleAfter successful BF reached, cont. to offer bottle after BF
47 Rapid Weight Gain in the Premature Infant Feeding Plan:Discuss feeding cues & volumes w/ familySwitch kcal level downkcal/ozIf >1500g-2000g BW & if growth ok:Switch to term formulaIf <1500 BW & if growth ok, ck bone labs:If WNLs, switch to term formula; re-ck labs in 1 moIf abnormal, continue w/ PDF & re-ck labs in 1 mo
48 Coordination of Care Family Pediatrician Nurses: PMD office & PHN Dietitians: NICU, out-patient, WICLactation consultantsNeurodevelopmental/ Feeding clinicGet involved!
49 Nutrition Practice Care Guidelines for Preterm Infants in the Community Click on “For Medical Providers”Double click on “Nutrition Practice Care Guidelines…”ORClick on “For Oregon WIC Staff” on left-side columnClick on “WIC Staff Resources”Scroll down to “Nutrition Information” headerDouble-click on “Nutrition Guidelines: Preterm Infants” & “Oregon Appendix”