1. Infant Nutrition Jennifer Levy, MD Children’s Hospital of Oakland

2. Overview Fetal Energy Expenditure & Sources Fetal Energy Expenditure & Sources Neonatal Energy Expenditure & Requirements Neonatal Energy Expenditure & Requirements Proteins Proteins Fats Fats Carbohydrates Carbohydrates Vitamins Vitamins Human Milk Human Milk Formulas Formulas Parenteral Nutrition Parenteral Nutrition

3. Fetal Energy Estimated Fetal Energy Expediture = 35 to 55 kcal/kg/day Estimated Fetal Energy Expediture = 35 to 55 kcal/kg/day Energy Sources Energy Sources 1. Maternal glucose (2/3) 2. Placental lactate (1/4) 3. Maternal amino acids

4. Neonatal Energy Form of EnergyCaloric Expenditure Resting Metabolic Rate*50 kcal/kg/day Activity15 kcal/kg/day Cold Stress10 kcal/kg/day Nutrition Processing50 kcal/kg/day Total120 kcal/kg/day

5. Proteins Milk Source Whey-to-Casein Ratio Colostrum80:20 Mature Milk 55:45 Formula20:80 Preterm Formula 60:40

6. Fats Placental transfer of essential and non- essential fatty acids Placental transfer of essential and non- essential fatty acids Fat stores are formed by lipogenesis from glucose Fat stores are formed by lipogenesis from glucose Most poorly digested macronutrient Most poorly digested macronutrient

7. Fats Types of Fatty Acids Stearic, Oleic, and Palmitic are common Stearic, Oleic, and Palmitic are common Linoleic and Linolenic are the most common Linoleic and Linolenic are the most common Long-chain polyunsaturated (LCPUFA) Long-chain polyunsaturated (LCPUFA) Short and Medium Chain Triglycerides (MCT) Short and Medium Chain Triglycerides (MCT)

8. Carbohydrates Lactose Enhances absorption of calcium and magnesium Enhances absorption of calcium and magnesium Promotes intestinal growth of lactobacilli Promotes intestinal growth of lactobacilli

9. Vitamins Water Soluble Vitamins Vitamin B Complex and Vitamin C Vitamin B Complex and Vitamin C Generally not formed from precursors Generally not formed from precursors Daily intake required Daily intake required No accumulation (except Vitamin B 12 ) No accumulation (except Vitamin B 12 ) Cross placenta by active transport Cross placenta by active transport

10. Vitamins Fat-soluble vitamins Vitamins A, D, E, K Vitamins A, D, E, K Synthesized from precursors Synthesized from precursors Daily intake not usually required Daily intake not usually required Not easily excreted and can accumulate Not easily excreted and can accumulate Placental transfer by simple or facilitated diffusion Placental transfer by simple or facilitated diffusion

11. Vitamin Deficiencies Vitamin B 12 and Folate Vitamin B 12 is synthesized by GI microorganisms and is required for folate metabolism Vitamin B 12 is synthesized by GI microorganisms and is required for folate metabolism Risk of B 12 deficiency in breast-fed infants of vegetarian mothers who do not ingest dairy or eggs Risk of B 12 deficiency in breast-fed infants of vegetarian mothers who do not ingest dairy or eggs Risk of folic acid deficiency in infants fed evaporated or goat’s milk Risk of folic acid deficiency in infants fed evaporated or goat’s milk Megaloblastic anemia and hypersegmented neutrophils Megaloblastic anemia and hypersegmented neutrophils

12. Vitamin Deficiencies Vitamin D Deficiency Vitamin D regulates the concentration of calcium and phosphorus in the bloodstream and bone Vitamin D regulates the concentration of calcium and phosphorus in the bloodstream and bone Important for bone mineralization and growth Important for bone mineralization and growth Deficiency results in osteopenia -> rickets Deficiency results in osteopenia -> rickets Hypocalcemia -> tetany, seizures Hypocalcemia -> tetany, seizures

13. Vitamin Deficiencies Vitamin E Deficiency Vitamin E has antioxidant properties and is recommended to be taken concurrently with iron administration to protect from iron-induced hemolysis Vitamin E has antioxidant properties and is recommended to be taken concurrently with iron administration to protect from iron-induced hemolysis Manifests with anemia and reticulocytosis Manifests with anemia and reticulocytosis

14. Vitamin Deficiencies Vitamin K Required for carboxylation of prothrombin into the active form Required for carboxylation of prothrombin into the active form Newborns are predisposed: Newborns are predisposed: - Initial lack of microorganisms that synthesize Vitamin K - Immature newborn liver Maternal medications Maternal medications Breast fed infants Breast fed infants Associated with hemorrhagic disease of the newborn Associated with hemorrhagic disease of the newborn

15. Iron Deficiency Microcytic anemia Microcytic anemia Associated with short term and long term neurodevelopmental deficits Associated with short term and long term neurodevelopmental deficits Preterm infants more susceptible due to small iron stores at birth, high growth velocity, and phlebotomy loss Preterm infants more susceptible due to small iron stores at birth, high growth velocity, and phlebotomy loss

16. Human Milk Physiology Prolactin is secreted by maternal anterior pituitary throughout pregnancy Prolactin is secreted by maternal anterior pituitary throughout pregnancy At delivery, the decrease in estrogen and progesterone leads to increased milk production and delivery At delivery, the decrease in estrogen and progesterone leads to increased milk production and delivery Milk ejection is mediated by oxytocin from the posterior pituitary Milk ejection is mediated by oxytocin from the posterior pituitary

17. Human Milk Immunologic and Antibacterial Factors Secretory IgA Secretory IgA Protective and bactericidal enzymes Protective and bactericidal enzymes Lactobacilli growth is increased Lactobacilli growth is increased Colostrum has increased lymphocytes, macrophages, and immunoglobulins Colostrum has increased lymphocytes, macrophages, and immunoglobulins

18. Human Milk Electrolytes Decreased Na, K, Ca, Ph, Cl, and Mg Decreased Na, K, Ca, Ph, Cl, and MgProtein As breast milk matures, protein decreases As breast milk matures, protein decreases Amino acids are lower Amino acids are lowerFats 50% calories 50% calories Triglycerides are variable Triglycerides are variable

19. Human Milk Premature Milk Increased protein Increased protein Increased electrolytes Increased electrolytes Inadequate protein, calcium, phosphorus, and vitamin D for premies Inadequate protein, calcium, phosphorus, and vitamin D for premies Need to supplement with human milk fortifier (2 packets/ 50ml = 24kcal/30mL) Need to supplement with human milk fortifier (2 packets/ 50ml = 24kcal/30mL)

20. Human Milk Benefits Decreased IDDM, IBD, NEC, obesity Decreased IDDM, IBD, NEC, obesity Decreased infections Decreased infections Improved neurodevelopmental outcome Improved neurodevelopmental outcome Contraindications (in US) Infection Infection Galactosemia Galactosemia Drugs Drugs

21. Nutritional Supplements PretermFull term BMP. FormBM Formula IRON 2w-2mosFe Fortified6mos Fe Fortified (2-4 mg/kg/day) Vitamins HMF (ICN)NoneVit D None (200IU/day) Fluoride  ----------after 6 months---------------  (0.25-0.5 mg/day)

22. Formulas Classification by Carbohydrate Source Type of Carbohydrate Formula Lactose Enfamil, Neosure, Similac Sucrose and glucose polymers Alimentum, Isomil, Portagen Glucose polymers Enfamil Lactofree, Neocate, Nutramigen, Pregestimil

23. Premature Formulas Similac Special Care and Enfamil Premature Lipil 24kcal/30 mL or 20kcal/30mL 24kcal/30 mL or 20kcal/30mL Reduced lactose (50%) and glucose polymers Reduced lactose (50%) and glucose polymers 50% MCT, ARA and DHA added 50% MCT, ARA and DHA added Higher protein content Higher protein content Higher calcium and phosphorus content Higher calcium and phosphorus content Increased caloric density Increased caloric density Use in infants less than 1800g or 32 weeks GA Use in infants less than 1800g or 32 weeks GA

24. Premature Discharge Formulas Neosure or Enfacare Lipil 22 kcal/30mL 22 kcal/30mL Increased protein Increased protein Increased calcium and phosphorus content Increased calcium and phosphorus content Increased caloric content Increased caloric content Give until 9 months PCA Give until 9 months PCA

25. TPN Recommend 80-90 kcal/kg/day Recommend 80-90 kcal/kg/day Most calories are provided by lipids and glucose Most calories are provided by lipids and glucose Glucose infusion rate: 6-8mg/kg/min Glucose infusion rate: 6-8mg/kg/min GIR: 0.167 x concentration x rate weight

26. TPN Carbohydrates Mostly glucose Mostly glucose 1g CHO provides 3.4 kcal 1g CHO provides 3.4 kcal With increasing glucose concentration, increasing osmolarity With increasing glucose concentration, increasing osmolarity Should provide 55-65% of total kilocalories Should provide 55-65% of total kilocalories Maximum concentration is 12.5% peripherally Maximum concentration is 12.5% peripherally

27. TPN Fats 1 g fat provides 9 kcal (20% solution provides 2 kcal/1 ml) 1 g fat provides 9 kcal (20% solution provides 2 kcal/1 ml) Should provide 30-50% of total calories Should provide 30-50% of total calories Limit to 3g/kg/day Limit to 3g/kg/day Monitor serum TG levels Monitor serum TG levels

28. TPN Proteins Goal is to prevent negative energy and nitrogen balance Goal is to prevent negative energy and nitrogen balance Required early in life to achieve goals Required early in life to achieve goals 1g of protein provides 4 kcal 1g of protein provides 4 kcal Should provide 7-10% of total calories Should provide 7-10% of total calories Calcium and Phosphorus Ratio should be 1.3:1 to 1.7:1 Ratio should be 1.3:1 to 1.7:1 Risk of bone demineralization Risk of bone demineralization Cysteine prevents precipitation Cysteine prevents precipitation

30. Sample TPN for Just Born LBW Infants Adapted from Nutrition and Gastroenterology Clinical Review Committee, 2002 ComponentQuantity Amino Acids 2.4g/100mL Glucose5-10g/100mL Calcium gluconate 500-650mg/100mL MVI-Pediatric2mL/kg/day Heparin 1 U/mL Lipid5mL/kg/day

31. Monitoring Parenteral Nutrition Daily Weight Weight Urine for glycosuria Urine for glycosuria Intake and Output Intake and Output Serum electrolytes (initially) Serum electrolytes (initially) Serum glucose (advanced dextrose) Serum glucose (advanced dextrose) Serum triglycerides (advancing lipids) Serum triglycerides (advancing lipids)

32. Monitoring Parenteral Nutrition Weekly Serum glucose, electrolytes, Ca, Phos, and Mg Serum glucose, electrolytes, Ca, Phos, and Mg Serum albumin and total proteins Serum albumin and total proteins Liver function tests, bilirubin (T & D) Liver function tests, bilirubin (T & D) Serum triglycerides Serum triglycerides Complete blood count Complete blood count

33. TPN Supplements for Premature Infants TPN Supplements for Premature Infants Insulin infusions Insulin infusions Vitamin A Vitamin A Cysteine hydrochloride Cysteine hydrochloride Carnitine Carnitine Glutamine Glutamine

34. TPN Complications Cholestasis Cholestasis Metabolic Acidosis Metabolic Acidosis Hyperglycemia Hyperglycemia Metabolic Bone Disease Metabolic Bone Disease Nosocomial Infections Nosocomial Infections Complications of fat Complications of fat

35. Early Feeding for Preterm and Sick Infants Begin at day 2-3 if stable Begin at day 2-3 if stable Human milk 12-24 mL/kg/day Human milk 12-24 mL/kg/day Reduced hospital stay Reduced hospital stay Reduced sepsis and sepsis evaluations Reduced sepsis and sepsis evaluations Reduced days to full feedings Reduced days to full feedings Increased calcium and phosphorus absorption Increased calcium and phosphorus absorption No increased incidence of NEC No increased incidence of NEC Fewer infants with central venous catheters Fewer infants with central venous catheters