1. Feeding the Preterm Infant
Jill-Marie Spence, RD
April 2013

2. Outline Introduction Human Milk Preterm Formulas Nutritional Needs:
Micropreterm
SGA
Late Preterm Infant
Post-discharge Nutrition
Growth
Conclusion

3. Estimated Nutritional Requirements
AAP recommends:
the postnatal nutrient intake in the preterm infant should “provide nutrients to approximate the rate of growth and composition of weight gain for a normal fetus of the same post-menstrual age, and to maintain normal concentrations of blood and tissue nutrients.”
Is this goal achievable or desirable?

4. Scientific versus Knowledge Global Neonatal Consensus Symposium, Feeding the Preterm Infant (2010)
Gap exists -> new recommendations are needed
Requirements for specific nutrients
Immaturity of host defenses
Nutrient metabolism
Tissue repair mechanisms
Nutritional requirements
micropreterm (< 27 weeks gestation, < 800 grams)
late preterm (34 to < 37 weeks)
SGA vs. AGA (SGA > 35 weeks gestation, < 10th ile)
Postdischarge

5. Nutritional management of preterm infants varies between neonatal units, physicians, dietitians, provinces and countries
Lack of specific data and recommendations
What do we do?
Need for standardization of feeding practices (best practice)
Enteral feeding tables (< 1500 grams)
International consensus for nutritional requirements

6. Identify the challenges that prevent us from translating our understanding of science to practical application. Global Neonatal Consensus Symposium, Feeding the Preterm Infant 2010

7. Human Milk and the Nutritional Needs of Preterm Infants

8. Colostrum and Transitional Milk
Improves immune function
Promotes gut maturation
Colostrum
Transitional Milk
Mature Milk
Pre-milk fluid
Rich in immunoglobulins and immune cells, growth factors
Higher levels of fat, protein , sodium , Cl, Ca++, Zn, Cu, folate, lactose, and vitamins compared to term milk
Less concentrated, lower nutrient density maintained throughout the first postpartum year
First 24 – 48 hours postpartum
Day – 10 mL/kg/d
Day – 25 mL/kg/d
3rd – 14th day postpartum
2 weeks postpartum

9. Benefits of Human Milk Nutritional 70% whey:30% casein
Protein fractions are defined by their solubility in acid
Whey protein (α – lactalbumin):
Soluble proteins are more easily digested
promotes gastric emptying
contains lactoferrin, lysozyme, and secretory IgA which influences host resistance
Whey protein human and bovine milk are vastly different from both a compositional and functional point

10. Carbohydrate > 90% of the lactose in human milk is absorbed
Nonabsorbed lactose softens stool, improves absorption of minerals, and supports growth of beneficial intestinal flora
10 – 15% are oligosaccharides
Act as a prebiotic facilitating growth of bacteria (Bifidus spp.)
Prevent bacterial attachment to the host mucosa
Prevents systemic infection and NEC

11. Gastrointestinal Improves gut motility May increase stool frequency
May decrease feed intolerance
Full enteral feeds are reached quicker
Decreases the incidence of NEC

12. Enhances maturation of the mucosal barrier Human milk contains lipase
improves intestinal lipolysis and fat absorption
Preterm infants have reduced pancreatic and lingual lipase activity, reduced bile pool which decreases fat absorption and increases steatorrhea

13. Immunological protection
Inhibits proinflammatory cytokines
Lower incidence of late onset sepsis, UTI, diarrhea, and URT
Developmental
Promotes better longer-term outcomes – neurodevelopment, cardiovascular risk, bone health
Psychological
Stronger feelings of attachment, maternal empowerment, self confidence and esteem
UTI urinary tract infection
URT upper respiratory tract infection

14. Decreases the rate of sudden infant death syndrome
Endocrine
Decreases the incidence of type 1 and type 2 diabetes

15. Nutritional content of human milk varies with
Time after delivery
Length of gestation
Length of each lactation episode
Foremilk (2-3 minutes)
Hindmilk (higher fat and energy content)
Method of expression and collection
Sodium concentrations may be higher with hand pumping than mechanical pumping (Edmond, 2012)

16. Unique barriers and challenges result in decreased rates of breastfeeding
Inpatient
Lactation consultant referral on admission
Outpatient
Ask questions – refer mom’s to Breastfeeding Clinic

17. Donor Human Milk
Advantages and disadvantages of feeding DHM versus PTF need to be considered
Birth weight < 1250 grams
GA < 32 weeks
Severely growth-restricted infants of any gestation (< 3rd % ile)
Multiples
Post NEC (Stage ll or lll)
Neonates of any gestation with a surgical bowel
Donor human milk is pasteurized to suppress viral and bacterial activity.

18. No RCT’s have been conducted to compare preterm DHM with term DBM
DHM is pasteurized - potentially harmful bacteria, lipase, lymphocytes and other components are removed from HM
Bile salt-stimulated lipase – increases fat absorption
30% reduction in fat absorption -> affects growth Anderssson Acta Paediatr 2007
Lymphocytes – offers immunologic protection to GIT
Nutritional content
No RCT’s have been conducted to compare preterm DHM with term DBM

19. Units /L Donor Human Milk Preterm Human Milk 22 – 30 days
Wojcik 2009
Michaelsen 1990
Preterm Human Milk
22 – 30 days
Schanler & Atkinson in Tsang 2006
Term Mature Milk
30 days
Energy
650
Protein
1.05
15 + 1
Sodium

20. Human milk is a living tissue that cannot be duplicated
Many of the benefits of HM are still unknown
Human milk is a living tissue
that cannot be duplicated

21. Composition of Preterm Transitional, mature, and term mature milk Schanler, Atkinson in Tsang 2005
Nutrient (U/L)
Preterm transitional days
Preterm mature
days
150 mL/kg/d
Term
Mature
> 30 days
Term mature
ESPGHAN
2010
Energy, kcal
104 kcal/kg
96 kcal/kg
Total protein, g
15 + 1
2.3 g/kg
1.8 g/kg
< 1 kg – 4.5
1 – 1.8kg 3.5 – 4.0
Fat, g
34 + 6
36 + 4
47%
34 + 4
48%
CHO, g
63 + 5
67 + 4
39%
67 + 5
42%
Calcium, mmol
1.1 mmol/kg
1.0 mmol/kg
3.0 – 3.5
Phosphorous, mmol
0.5 mmol/kg
0.7 mmol/kg
1.9 – 2.9
Sodium, mmol
1.3
mmol/kg
1.4 mmol/kg
Reminder: estimated requirements if the preterm infant have been defined as those needed to support the rates of growth and nutrient accretion of the third trimester fetus.
Preterm HM contains higher concentrations of protein, sodium, zinc and calcium than mature HM
Preterm HM contains higher concentrations of protein, sodium, zinc and calcium compared to mature HM, it does not provide adequate quantities of nutrients required by preterm infants. The amount of protein, sodium, phosphate, and calcium in preterm HM does not meet a preterm infants requirements.

22. Unfortified Human Milk < 36 weeks
Preterm HM does not provide adequate quantities of nutrients required by preterm infants
Associated with slower growth
Decreased protein and energy intake
Protein and fat concentrations vary widely
Protein content decreases throughout lactation
Higher risk of metabolic bone disease
Deficiencies of micronutrients
HM is preferred over formula feeding
Supplementation or fortification is required to support the higher nutrient requirements

23. Human Milk Fortifier Groh-Wargo Enteral nutrition support Nutr Clin Prac 2009
Bwt < 1500 grams, < 34 weeks
Bwt grams – 1800 grams
Consider 2 HMF/100 mL EBM -> reevaluate growth and adjust HMF accordingly
High acuity
PN > 2 weeks
Suboptimal growth
Nutrient needs are higher for preterm infants b/c of decreased stores, altered absorption and rapid growth rates.
Protein content is lower in hindmilk (9 vs. 12%) and is less than the 10 to 12% recommended for premature infants. Adding HMF to HM will increase the protein content to approx. 12%.

24. Breast milk fortification: effect on gastric emptying Yigit J Maternal-Fetal and Neonatal Medicine 2009:21(11)
20 infants, average 29.8 weeks, bwt 600 – 1470grams
Infants between 6 and 30 days of age
Feeding volumes 100 – 120 mL/kg/day
Balanced crossover design
Measured the mean percentage changes in the antral cross sectional area against time
Same infant on the same day with each of the test feedings
Unfortified HM
Half-fortified HM
Fully fortified HM
3 hr period of observation

25. Average ½ emptying time
BM minutes
Half-fortified HM minutes
Full strength fortified HM minutes
Differences of average half-emptying time
between feeding groups were not statistically
significant
No correlation between gastric emptying rate
and gestational age or postnatal age

26. 76 human milk-fed premature infants
To evaluate feeding intolerance in premature infants immediately after the addition of HMF to their EHM Moody JPGN 2000:30(4)
76 human milk-fed premature infants
Bwt: grams
GA: weeks
Assessed for 5 days before and after the addition of HMF
Results: Abdominal distension, GRV, emesis NS
Conclusion: Feeding intolerance and outcome of premature infants were not affected by the addition of HMF to expressed mother’s milk.
Age fortifier added: days

27. HM supplemented with nutrients is recommended for all infants born < 32 weeks and supplementation may be required for infants weeks of gestation
Global Neonatal Consensus Symposium, Feeding the Preterm Infant (2010)

28. Preterm Formulas
Enriched with energy, macronutrients, minerals, vitamins and trace elements
Indications:
< 34 weeks gestation age – 2000 grams birth weight
Inadequate supply of mother’s milk
Mom not able to or wishing to breast feed
Donor human milk not available

29. Cysteine and Taurine added
Whey dominant
Promotes gastric emptying and digestion
Cysteine and Taurine added
Methionine -> Cysteine
Cysteine -> Taurine
Conditionally essential

30. LCPUFA
Fetus does not synthesize LCPUFAs from their precursors at rates sufficient to support an adequate DHA accretion rate
DHA content in human milk is highly variable

31. DHA in breast milk varies with maternal diet Auestad et al
DHA in breast milk varies with maternal diet Auestad et al. Pediatrics 2001;108: Camielli et al. Am J Clin Nutr 2007;86:
This slide illustrates the influence of dietary DHA on DHA levels in breast milk and, specifically, the fish and seafood content of the diet in Japan and the Philippines, where there is high consumption of fish and seafood, and where some of the highest levels have been reported.
Within Europe, Spain and Sweden have higher fish consumption than Germany and Hungary, and consequently, women have higher levels of DHA in their breast milk.
Breast milk contains over 160 different fatty acids.
This is just one example of how the average level of DHA varies based on diet.
Many other fatty acids will vary as a result of diet.
Other factors that affect lipid content include: duration of lactation (rises slightly as lactation continues), time of day, phase of milk expression (increases from foremilk (42%) to hindmilk (55%)). These variations result in a difference in lipid content from 2.2 to 4.7 g/dL and contribute to variations in energy content. The quantity of lipid in milk is unrelated to the maternal diet.

32. Formulas are supplemented with DHA (docosahexaenoic acid) and ARA (arachidonic acid)
Better neurological outcomes
May improve visual acuity and cognitive development
Potentially significant modulatory effects on growth, body composition, immune and allergic responses

33. AI based on Linoleic Acid (2%) and Linolenic Acid (0.3%
160 mL/kg/d
DHA mg/kg/d
Fetal Accretion Rate 45
Human Milk
(0.2 – 0.4% fatty acids as DHA)
12 – 25
Special Care 24 kcal/oz 16
Enfamil Premature A+ 24 kcal/oz 22
Term
AI based on Linoleic Acid (2%) and Linolenic Acid (0.3%
Assuming a DHA intestinal absorption rate of 80%, DHA intake between 55 – 60 mg/kg/d provides DHA at the fetal accretion rate.

34. Protein intake -> Lean mass accretion
Current formulas support growth and protein accretion at or slightly greater then intrauterine rates.
may increase fat deposition
Current 150 mL/kg/d provide 3.5 – 3.6 g/kg/d and 120 kcal/kg/d (PE: 2.9 grams protein:100 kcal)
Protein intake -> Lean mass accretion
Energy intake -> Fat accretion

35. Cochrane Database Systematic Review (2010)
The more immature an infant, the greater the need for enteral feeding with a higher protein:energy ratio to meet the goal of greater protein gain relative to fat
Cochrane Database Systematic Review (2010)
Meta-analysis of five RCT’s of LBW infants
Higher protein group (3-4 g/kg/day) had a better weight gain and rate of nitrogen accretion compared to the lower protein group (< 3 g/kg/day)
Promoted lean body mass gain

36. Based on 160 mL/kg/day Preterm Mature Milk 22 – 30 days
4 HMF/100 mL EBM
Special Care 24 kcal/oz
ESPGHAN
2010
Energy, kcal/kg
110
133
130
Total protein
g/kg
2.4
PE 2.2
4.0
PE 3.0
3.8
PE 2.9
< kg – 4.5
1 – 1.8 kg – 4.0
Calcium, mmol/kg
1.2
5.8
4.9
3.0 – 3.5
Phosphorous, mmol/kg
0.5
3.7
1.9 – 2.9
Sodium, mmol/kg
1.4
2.5
2.9
3.0 – 5.0

37. Amino-Acid Based Infant Formulas
Cow’s milk protein allergy
Multiple food protein intolerance
Infants unable to tolerate hydrolysate based formulas
Short Bowel Syndrome
Other GI disorders

38. 150 mL/kg/day Kcal/kg g protein/kg mg Ca/kg mg/PO4-/kg Neocate
0.67 kcal/mL
.450 g Linoleic acid/100 mL
.0547 g Linolenic acid/100 mL
33% MCT
101
3.2
124
(120 – 140) 93
Nutramigen AA
0.68 kcal/mL
.58 g Linoleic acid/100 mL
.054 g Linolenic acid/100 mL
2.8% MCT
102
2.9 96
(60 – 90) 53

39. Current Recommendations
CPS 1995
Life Science Research Office of American Society 2002
Nutrient requirements for stable, growing preterm infants > 1000 grams birth weight and nutrient composition of PTF’s
Tsang et al 2005
Reasonable Nutrient Intakes (RNI’s) for ELBW and VLBW infants and for different stages of post-natal life

40. World Health Organization 2006
Recommended nutrients for infants < 32 wks gestation, weeks and >37 weeks but birth weight < 2500 grams
European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition 2010
1000 to 1800 grams birth weight
< 1000 grams protein recommendation only

41. Enteral Requirements ESPGHAN 2010 TSANG 2005 WHO 2006 4 HMF/100 mL
Per kg/day
1.0 – 1.8 kg
< 1 kg
1.0 – 1.5 kg
> 1000 kg
Fluid (mL)
135 – 200
160
Energy (kcal)
133
Protein (g)
3.5 – 4.0 (1–1.8 kg)
4.0 – 4.5 (< 1kg)
4.0
Vitamin D
800 – 1000 IU/d
IU/kg/d
IU/kg/d
400 – 800 IU/kg/d
192 IU/d
(based on 1 kg)
Iron (mg)
2.0 – 3.0
2.0 – 4.0
0.6
Calcium (mg)
232
Phosphorous (mg)
60-90
60-140
78-118
124

42. Nutritional Needs of the Micropreterm Infant
< 30 weeks gestation
(subset are SGA; weight < 10th percentile at birth)
Tudehope J Ped 2013;162:s72-80

43. Body water as a percentage of body weight decreases rapidly during the last trimester
24 – 28 weeks
80% weight gained as water
8% weight gained as fat
36 to 40 weeks
60% weight gained as water
Term
20% weight gained as fat
SGA < 10th percentile

44. By 25 weeks gestation 25 – 30 weeks
Fetal intestine capable of digesting and absorbing milk
25 – 30 weeks
Disorganized motility

45. Lack of published data to guide nutritional management
At risk for postnatal growth failure
Complications of extreme prematurity
Longer period of time to meet recommended dietary intake
Failure to provide adequate nutrients for recovery or catch-up growth
Accumulate greater nutritional deficits
Associated with adverse neurodevelopment outcomes

46. Current recommendations New Recommendations
Nutrient
Theoretical concerns
Current recommendations
New Recommendations
Fluid
↑requirements – immature skin
Risk of fluid overload – PDA
135 – 200 mL/kg/d
Energy
Low energy stores
135 – 150 kcal/kg/d
120 – 140 kcal/kg
Protein (g/kg)
↑ requirement for growth
Some aa conditionally essential (cysteine and taurine)
Factorial – 4.0
Tsang – 4.4 (26 – 30 wks)
ESPGHAN 4.0 – 4.5 ELBW
3.8 – 4.4 VLBW
3.6 – 4.5 g/kg/d
P:E 3.0 – 3.6 g/100 kcal
Sodium
High fractional excretion during 1st 10 – 14 days
4 – 5 mmol/kg/d (1st 10 – 14 days)
2.5 – 3.0 mmol/kg/d (> 14 days)
Calcium
PO4
Majority of mineral accretion occurs during the last trimester , > risk of metabolic bone disease (Inadequate intake of Ca, PO4, Vitamin D; immobility, TPN, unfortified HM, Medications (steroids, diuretics)
Tsang
Calcium 100 – 220 mg/kg/d
Phosphorous 60 – 140 mg/kg/d
Calcium 120 – 180 mg/kg/d
PO – 90 mg/kg/d
(> 1.8 mmol/L)
Vitamin D
Lower body stores, reduced absorptive capacity
Tsang 150 – 400 IU/kg/d
800 – 1000 IU/d
Iron
Deficient stores at birth
2 – 3 mg/kg/d from 2 – 4 wk of age adjusted for transfusions and EPO
2 – 4 mg/kg/d from 2 – 4 wk of age adjusted for transfusions and EPO

47. New Recommendations 4 HMF/100 mL EBM 4 HMF/100 mL DHM
Special Care 24 kcal/oz
1.5 grams Neosure/100 mL EBM
3.0 grams Neosure/100 mL EBM
Fluid
135 – 200 mL/kg/d
160
Energy
120 – 140 kcal/kg
133
126
130
146
157
Protein
3.6 – 4.5 g/kg/d
P:E 3.0 – 3.6 g/100 kcal
4.0
3.0
3.3
2.6
3.8
2.9
4.3
4.6
Sodium
4 – 5 mmol/kg/d (1st 10 – 14 days)
2.5 – 3.0 mmol/kg/d (> 14 days)
2.7
2.8
Calcium
(50 – 65%)
PO4 (90%)
Calcium 120 – 180 mg/kg/d
PO – 90 mg/kg/d
(> 1.8 mmol/L)
232
124
228
195
115
245
134
258
139
Vitamin D
800 – 1000 IU/d
192
253 (1 kg)
379 (1.5 kg)
201 (1 kg)
301 (1.5 kg)
210 (1 kg)
314 (1.5 kg)
Iron
2 – 4 mg/kg/d from 2 – 4 wk of age adjusted for transfusions and EPO
0.6
2.4
0.8
1.0
Higher energy intakes may result in increased fat deposition
The more immature an infant the greater the need for higher protein:energy to meet the goal of greater protein gain relative to fat
Majority of fetal mineral accretion occurs during the third trimester

48. Minimal enteral feeds – 1st to 2nd day of life
TPN
Maintain a continuous nutrient supply until feeds can be established
Minimal enteral feeds – 1st to 2nd day of life
Incremental advancement to full feeds

49. Start fortifying human milk at 100 mL/kg/day
Supply sufficient protein, energy, sodium, calcium, phosphorous, trace elements and vitamins to compensate for accumulated deficits
Ideal postnatal growth rate for micropreterm infants is not known
Goal is to replicate the fetal growth rate of at least 15 – 20 g/kg/d

50. Evidence-based guidelines are not available
Nutrient requirements at discharge
Individual assessment
GA, BW
Presence or absence of growth restriction
Requirement for catch-up growth
Clinical factors

51. Nutritional Requirements for Small for Gestational Age Infants
> 35 weeks gestation and < 10th percentile on the Fenton Growth Chart
Tudehope J Ped 2013;162:s81-9

52. Constitutionally small
Parental stature, racial or ethnic factors
Symmetrical growth restriction at birth
IUGR
SGA (weight < 10th % ile)
Reduced linear growth in infancy
Excessive abdominal fat gain in childhood
Term or preterm

53. Strong association between low birth weight and insulin resistance
Epidemiologic evidence indicates obesity, insulin resistance, diabetes, and cardiovascular disease are more common in adults born smaller than normal

54. Human milk (> 30 days) Energy
160 – 200 mL/kg/d
Energy
Reduced energy stores (esp. fat & glycogen -> ↑ risk of hypoglycemia)
↑ O2 consumption and total energy expenditure
110 – 135 kcal/kg/d
Protein
Reduced muscle mass and ↑ catabolism from catecholamines, ↑ losses in stool (11-14%), ↑ aa turnover, more efficient protein synthesis, ↑requirements to support catch-up growth
3.0 – 3.6 g/kg/d
P:E 2.2 – 3.3 g/100 kcal
9 – 13% total calories
1.9 – 2.4
1.9
Fat
↓ absorption (11-14%), less body fat
40 – 54% total calories
Calcium
PO4
Low PO4 levels at birth, ↓ whole-body density and content compared to AGA infants
Calcium 120 – 160 mg/kg/d
PO – 90 mg/kg/d
42 – 52
Vitamin D
800 – 1000 IU /d
Iron
Normal serum iron but low stores at birth
2 mg/kg/d

55. Post-discharge Nutrition for SGA
Breastfeeding is preferred
Ideal postnatal growth rate for SGA infants is not known
Postnatal growth rate similar to normal intrauterine growth
Poorer neurodevelopmental outcomes compared to AGA infants

56. Goal: to increase linear growth and lean body mass
Catch-up growth should be gradual to decrease the risk of metabolic syndrome
Prone to persistent deficits in muscle mass
Normal or excessive gains in fat
Goal: to increase linear growth and lean body mass
Healthier SGA infants are more likely to respond to nutritional intervention and exhibit catch-up growth by 6 months of age

57. 34 to < 37 weeks Lapillonne J Ped 2013;162:s90-100
Late Preterm Infant
34 to < 37 weeks
Lapillonne J Ped 2013;162:s90-100

58. Greater rates of readmission after hospital discharge (> 2-3x )
Difficulty feeding
Less muscle strength -> more difficulty with latch, suck, swallow
Nutritional compromise - poor or inadequate feeding during hospitalization
Poor weight gain
May increase risk for abnormal neurodevelopmental outcome
Greater rates of readmission after hospital discharge (> 2-3x )
Jaundice, suspected sepsis, feeding difficulties, poor weight gain

59. Unique Nutritional Needs
Hypothermia
Hypoglycemia
Respiratory distress
Delayed fluid clearance
Infection
Feeding intolerance
Donor or human milk may not meet the theoretical nutritional needs
Fortification may be required
Feeding difficulties: poor oral-motor tone, function, and neural maturation

60. Discharged home before lactation is established
problems with latch and milk transfer need to be identified and addressed prior to discharge
Parental education and follow-up required

61. Feeding guidelines designed specifically to meet the nutritional requirements of late-preterm infants have not been established
Individualized feeding plans
Assess feeding skills
Breastfeeding support

62. Post-discharge Preterm Formula
Designed to meet the nutritional needs of preterm infants
Increased caloric density (22 kcal/oz)
33% more protein compared to term infant formulas
Improved body composition (greater LBM and < fat mass at 12 months) Cooke Ped Res 2010
Provides nutrients to address deficits (Ca++, P04-)
Accumulated deficits in calcium and phosphorous increase the risk of poor bone mineralization, metabolic bone disease, and reduced skeletal growth compared to term infants

63. Birth weight < 1500 grams
Transition infants after 35 weeks corrected gestational age OR
16 packets HMF/100 mL EBM per day
4 HMF/100 mL 160 ml/kg/day = 16 packets HMF

64. Discontinue PDPF
Continue fortification of HM with PDPF or PDPF until 3 to 12 months corrected age
Transition infant to a term infant formula with iron and long chain polyunsaturated fatty acids
Monitor growth – weight, length, HC
Plot anthropometrics on an appropriate growth curve based on corrected age until 24 to 36 months
Promote appropriate individual growth and development without overfeeding

65. 160 ml/kg/day EBM EBM 24 kcal/oz (Neosure) Neosure 24kcal/oz
Based on 2.5 kg
EBM
EBM 24 kcal/oz (Neosure)
Neosure 24kcal/oz
Term Formula 24 kcal/oz
Energy kcal/kg
102
126
131
128
Protein g/kg
1.9
2.6
3.7
2.7
Calcium mmol/kg
1.0
1.7
3.5
2.5
Phosphorous mmol/kg
0.8
1.2
Vitamin D IU
43 IU
231
168
Iron mg/kg
2.4
2.3

66. Formula Cost Comparison
Term Formulas (powder)
$5.64/L
Term Formulas (RTF)
$12.1/L
Term Formulas (Concentrate)
$8.09/L
Post-discharge Preterm Formulas
$6.38/L
Hydrolyzed Formulas
$7.37/L
Amino Acid Formula (Neocate/Nutramigen AA)
$19-20/L

67. How do we measure up?

68. Postnatal Growth Failure
US Study (124 NICUs, , preterm infants)2003
Prevalence of growth restriction (< 10th centile) at d/c
28% weight, 34% length, 16% HC
NICHD (birth weight < 1000 grams)2001
89% weighed < 10th centile for gestation age at 36 wks PMA
40% weight, length, HC < 10th centile at months corrected age
Embleton and Colleagues 2001
Daily nutritional deficits by the end of the first week
kcal/kg, g protein/kg
National Institute of Child Health and Human Development

69. Associated with adverse neuro-developmental outcome
Strong evidence exists to support nutritional programming or late effects of early nutritional experiences
Improved neurocognitive outcomes Ehrenkranz 2006

70. Growth Sensitive indicator of postnatal health
Most common measure of nutritional adequacy
Clinical measures of growth:
Weight
Length
Head circumference
Weight is an insensitive marker of growth
Needs to be completed with body composition assessment
Currently, body composition cannot be measured in hospital

71. Most common variable used to monitor growth is gestational age
Reliable measures of growth for premature infants is vital

72. Post-natal catch-up growth depends on:
Birth weight
Gestational age
Intrauterine growth restriction
Parental size
Intrauterine and extrauterine environment
Temperature stress, sepsis …
Neurological impairment
Clinical course i.e. steroids, long term TPN, respiratory
Nutritional management

73. Late gestation fetus: accretes fat at a higher rate than early in gestation
Postnatal growth and observed accretion of fat and LBM differ from fetal growth
The optimal composition of growth for preterm infants after birth is unknown.
Growth is characterized by changes in body size and tissue composition

74. Growth Weight growth velocity (g/kg/day)
Weight gain over a specific time interval
Identifies changes in growth, growth failure and monitors the response to nutritional interventions
Preterm Fetus/Infants: 15 – 20 g/kg/d
Term 15 – 30 g/d

75. Growth Curve Fenton growth chart (2003) Based on completed weeks
22 weeks to 50 weeks gestation

76. Length Weekly measurements Tracks linear growth
Most accurate measurement of lean body mass

77. Head Circumference Weekly measurements
Increases at a rate of 0.89 – 1.00 cm/week in VLBW infants
Rate of HC growth increases with postnatal age
Infants with the lowest birth weights have the steepest rates of HC growth
HC catch-up growth is an index of brain growth
Associated with early, aggressive protein administration and better neurological outcomes

78. Table 1: Expected Approximate Growth Velocity
Adapted from: WHO Growth Velocity Standards
[i] Faulhaber D. Nutrition assessment of infants and children. In Nevin-Folino N, ed. Pediatric Manual of Clinical Dietetics. 2nd ed. Chicago, IL:Pediatric Nutrition Practice Group 2003;
[ii] Catrine, K. Anthropometric assessment. In: Groh-Wargo S, Thompson M, Hovasi Cox J, Hartline JV eds. Nutritional Care for High Risk Newborns 3rd ed. Chicago IL: Precept Press; 2000:11-22.
[iii] World Health Organization. Child growth standards: Weight velocity [data tables on the Internet] [cited 2013 Feb 22]. Available from:
Approximate Weekly (Daily*) Gain in grams
Age in Months
Girls
Boys
1 – 2
130 – 360 g
( g/d)
165 – 420 g
(23.6 – 60 g/d)
2 – 4
90 – 235 g
(12.9 – 33.6 g/d)
100 – 250 g
(14.3 – 35.7 g/d)
4 – 6
50 – 170 g
(7.1 – 24.3 g/d)
50 – 180 g
(7.1 – 25.7 g/d)
6 – 12
30 – 110 g
(4.3 – 15.7 g/d)
35 – 110 g
( g/d)
Approximate Weekly Length Gain (cm) cm cm cm cm cm cm cm
Approximate Weekly Head Circumference (cm) cm cm cm cm

79. “Fetal origins of adult health and disease” and “Catch-up growth” Ho
Identifies critical windows that may reflect genetic, nutrient, and/or environmental interactions
Nutritional deficit followed by accelerated growth
Compensates for initial deficits
Changes in adiposity occur during catch-up growth
May be associated with adverse consequences not evident until later in adult life

80. Strongly associated with increased risks of developing HTN, insulin resistance, and type 2 diabetes
All components of the metabolic syndrome
“Optimal Growth”
Implies growth follows specific sex and age patterns using reference curves
A pattern of early growth that may prevent adverse outcomes later in life
Cardio-metabolic diseases

81. Neurodevelopmental Outcome
Suboptimal nutrition and poor growth
Reduced brain growth
Adverse neurocognitive function later in life
Improve nutritional strategies during hospitalization and during the catch-up growth period
Includes all preterm infants (ELBW, late preterm infants)
New evidence strongly supports the use of human milk on neurodevelopment
Nutritional goals should be considered throughout childhood and adult life

82. Now what do I do? Perinatal Follow up Clinic Admission Criteria
Born < 29 weeks gestation, regardless of birth weight and/or
Born < 1000 grams, regardless of gestation
Respiratory Home Care Clinic
Neonatal Transition Team Follow-up (Nurse and RD)
< 1250 grams, < 29 weeks
Follow all Perinatal Follow up infants (4 months corrected age)
Pediatrician Referral
Direct departmental referral to Clinical Nutrition Services for outpatient RD follow-up

83. Conclusion
Nutritional status is critically important in determining outcome and plays a roles in early brain development. Appropriate nutrition in hospital may prevent nutrient deficits at discharge.
Inadequate nutrition will result in poor growth and cognitive compromise
Rapid growth may adversely affect long term outcomes

84. Incomplete data for infants of birth weight < 1000 grams or gestation < 28 weeks
An infant’s nutrient requirements should be determined ideally on an individual basis taking into consideration gestational age, birth weight (growth restriction), and clinical factors
medications, TPN, surgical patients, growth….

85. References
Agostoni C et al. Enteral Nutrient supply for preterm infants: commentary from the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition Committee on Nutrition. JPGN 2010;50(1): Bhatia J. Growth curves: how to best measure growth of the preterm infant. J Pediatr 2013;162:S2-6. Bhatia J. Evaluation of adequacy of protein and energy. J Pediatr 2013;162:S31-6. Fenton TR. A new growth chart for preterm babies: Babson and Benda’s chart updated with recent data and a new format. BMC Pediatr 2003;3:13. Klein CJ. Nutrient requirements for preterm infant formulas. J Nutr 2002;132:1395S-577S. Lapillonne A et al. Lipid needs of preterm infants: updated recommendations. J Pediatr 2013;162:S Schanler RJ, Atkinson SA. Human milk. In: Tsang RC, Uauy R, Koletzko B, Zlotkin S, eds. Nutrition of the preterm infant. Cincinnati, OH: Digital Educational Publishing Inc; p Tudehope D. Human milk and the nutritional needs of preterm infants. J Pediatr 2013;162:S Tudehope D. Nutritional needs of the micropreterm infant. J Pediatr 2013;162:S Tudehope D et al. Nutritional requirements and feeding recommendations for small for gestational age infants. J Pediatr 2013;162:S81-9. Lapillonne A et al. Nutritional recommendations for the late-preterm infant and the preterm infant after hospital discharge. J Pediatr 2013;162:S Tsang RC, Uauy R, Koletzko B, Zlotkin S. Nutrition of the preterm infant, Scientific basis and practical guidelines. Cincinnati, OH: Digital Educational Publishing Inc; 2005.