1. Nutritional support in nicu/picu
Lecturer: Hengame Shariati Rad Registered Dietitian September 2016

2. Goals of nutrition
To achieve a postnatal growth at a rate that approximates the same post-conceptional age
Provide balance in fluid homeostasis and electrolytes
Avoid imbalance in macro-nutrients
Provide micro-nutrients and vitamins

3. Fetal nutrition Parenteral (mostly) Stores are laid late in gestation
At 28 weeks, a fetus has:
20% of term calcium and phosphorus stores
20% of term fat stores
About a quarter of term glycogen stores

4. Adaptation to nutrition after birth
Gut adaptation is regulated by
Endocrine factors
Intraluminal factors
Breast milk hormones and growth factors
Bacteria

5. Normal output Daily stool and urine output guidance
1 wet nappy and meconium at least once a day
Day 0
2 wet nappies and meconium at least once a day
Day 1
3 or 4 wet nappies and changing stools at least once a day
Day 2 & 3
5 or 6 heavy wet nappies and yellow stools at least once a day
Day 4+
A baby who is passing meconium at 3 or 4 days old may not be getting enough milk
A baby who does not have yellow stools by day 5 may not be getting enough milk
A baby who is not doing as many wet nappies each day as expected may not be getting enough milk

6. Nutrition for the preterm or sick baby

7. Early vs late feeding Early feeders had:
Fewer days parenteral nutrition
fewer investigations for sepsis
No difference in:
NEC
Weight gain

8. Rapid vs slow increase Rapid: 20 to 35 ml/kg/day
Slow: 10 to 20 ml/kg/day
Rapid group:
Reached full enteral feeds and regained birthweight faster
No difference in NEC rate or length of stay

9. Minimal enteral nutrition
12 to 24 ml/kg/day for 5 to 10 days
MEN group:
Faster to full enteral feeds
Shorter length of stay
No difference in NEC

10. Probiotics for preventing nec
Reduced risk of:
NEC
Death
Achieved full feeds faster
No difference in rates of sepsis

11. Feeding small or preterm infants:choices
Human milk
Mother’s own
Banked donor milk
Fortified
Artificial
Term formula
Preterm formula
Parenteral Nutrition

12. Parenteral nutrition

13. Parenteral nutrition
If an infant can’t, won’t or shouldn’t be fed enterally
What’s in the bag?
Fluid
Carbohydrate
Protein
Fat
Minerals and Trace elements

14. energy Requirements: kcal/kg/day Basal metabolic rate 40
Physical activity
specific dynamic action of food 10%
Thermoregulation variable
Growth

15. protein
With glucose infusion alone, infants lose 1-2% of endogenous protein stores daily
1g/kg/day gives protein balance
2.5 to 3.5 g/kg/day allows accretion
nb energy requirement
Safe to start soon after birth

16. fat Energy source Essential fatty acids source( intralipid)
Cell uptake and utilization of free fatty acids is deficient in preterm infants
Start at max 1g/kg/day, increasing gradually to 3g/kg/day (less if septic)

17. risks of pn Benefits of pn
Earlier and faster weight gain
Avoidance of problems associated with enteral feeds
Line associated sepsis
Line associated complication( eg thrombosis)
Hyperammonaemia
Hyperchloraemic acidosis
Cholestatic jaundice
(Liver dysfunction and renal overload)

18. Milk feeds

19. Human milk advantages Protection from NEC Improved host defences
Protection from allergy and aczema
Faster tolerance of full enteral feeds
Better developmental and intellectual outcome

20. Human milk shortcomings if preterm
Human milk may not provide enough
Protein
Energy
Sodium
Calcium, Phosphorus and Magnesium
Trace elements( Fe, Cu, Zn)
Vitamins( B2, B6, Folic acid, C, D, E, K)

21. Breast milk fortifiers
Improved
Short term growth
Nutrition Retention
Bone mineralization
Concerns: Trend towards increased NEC

22. Term vs preterm formulas
Term formulas do not provide for preterm protein, calcium, sodium and phosphate requirements, even at high volumes
Term formula( vs preterm formula) fed infants
. grow more slowly
. have lower developmental score and
IQ at follow up

23. Feeding preterm infants: aim
To provide nutrient intakes that permit the rate of postnatal growth and the composition of weight gain to approximate that of a normal fetus of the same gestational age, without producing metabolic stress

24. Catch-up growth
Enhanced nutritional intake sufficient to allow “catch-up” growth improves long term neurodevelopmental outcome
Compared to term infants, ex-preterm infants fed at 120 kcal/kg/day
Have more body fat
Have a different fat distribution

25. Nutritional assessment

26. How best to assess growth & nutrition ?
Weight
Reflects mass of lean body tissue, fat, intra-
and extra- cellular fluid compartments
Length
More accurately reflects lean tissue mass
Head circumference
Correlates well with overall growth and developmental achievement

27. Laboratory assessment
TPN requires regular monitoring of acid base status, liver function, bone profile and electrolytes
In enterally fed infants, monitoring albumin, transferrin, total protein, urea, alkaline phosphatase and phosohate may be useful

28. Methods of feeding Oral feeding >32 weeks respiration<60-80
try 20 minutes
Naso-gastric (NG) feeding bolus
NG feeding continuous
Trans-pyloric
Gastrostomy feeding

29. Trophic feeding Keeping infant fasting (NPO)
.decrease in intestinal mass
.decrease in mucosal enzyme
.increase in gut permeability
Trophic feeding:
.small amount of feeding to prepare the intestine
.release enteric hormones, better tolerance to feed

30. Growth goals
Weight: g/day
Length: ~1 cm/week
HC: cm/week

31. Caloric requirements for growth
Preterm goal: ~120 kcal/kg/day
Term goal: ~110 kcal/kg/day
Total fluid of enteral feeds required to deliver adequate calories for growth is ~150 cc/kg/day

32. tpn Determine fluid requirement for first day:
full term: ml/kg/day
late preterm & preterm infants(30-37 weeks): 80 ml/kg/day
very-preterm infants: ml/kg/day
Determine gluose infusion rate(GIR);
GIR: (%dextrose. IV rate) / (6. wt in kg) calculated GIR from known dextrose concentration(%)

33. tpn Protein and amino acids goal for premature infants: 4g/kg/day
goal for term infants: 3 g/kg/day
source: trophamine
Other added nutrients:
lipids cystein phosphorous magnesium
trace minerals heparin MVI

34. ENTERAL NUTRITION Breast milk is best
The American Academy of Pediatrics recommends breastfeeding for the first year of life
Started when an infant is clinically stable
Breast milk and standard infant formula have 20kcal/30cc
Trophic tube feeds may be continuous or bolus and advanced gradually (10-20 ml/kg/day)
Transition to bolus from continuous typically begins after achieving full feeds
PO feeds typically attempted around weeks, when develop suck and swallow coordination
Premies are often supplements with TPN as they work up on feeds

35. Biochemestric in picu 20% decreasing in Mg 25% increasing in TG
30% increasing in urea
52% decreasing in Albumin
↑ uremia→↓ SD scores for weight & arm circumferance between admission and discharge
↑ TG→>ventilator dependence days & length of stay

36. Unique nutritional aspects of the vlbw infants
Higher rate of protein synthesis & turnover
Greater oxygen consumption during growth
Higher energy cost due to transepidermal water loss
Higher rate of fat deposition
Prone to hyperglycemia
Higher total body water content

37. Early attachment
Skin to skin contact may strengthen the mother-infant dyad and lead to longer breastfeeding periods over the first two years of life
Non-nutritive breastfeeding can stimulate milk volume and imprive breastfeeding success rates

38. Best practice
Infants should be transitioned from gavage to oral feedings when physiologically capable, not based on arbitrary weight or gestational age criteria.