bernadette daelmans, who: feeding low birth weight babies - update on who guidelines
TRANSCRIPT
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7/28/2019 Bernadette Daelmans, WHO: Feeding Low Birth Weight Babies - Update on WHO Guidelines
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Feeding low birth weight babies:
Update on WHO guidelines
Bernadette Daelmans,
Coordinator Policy, Planning and Programmes
Department of Maternal, Newborn, Child and Adolescent Health (MCA)
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Outline
Definition of LBW and effective interventions
Principles and process of guideline development
Illustration of process with one example: choice of mother's milk
versus formula
Summary of recommendations:
Choice of milk
Supplements
When and how to feed
Frequency and progression of feeds
Overview of other newborn guidelines
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Definitions
Low Birth Weight infant: infant with birth weight< 2500 gram regardless of gestational age.
Preterm infant: infant born before 37 weeks of gestational
age.
Small for Gestational Age (SGA) infant: birth weight
below the 10th percentile for gestational age, usually a
result of IUGR.
Preterm and SGA infant
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35% of globalunder-five deaths
are associated withundernutrition*
Major causes of death in children under 5 (2010)
LBW directly or
indirectly contribute
to 60 80 % of all
newborn deaths
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Burden and distribution (2006)
Global prevalence of LBW: 15.5%, e.g., about 20.6 million LBWbabies born each year
South-Central Asia: 27.1%
Asia (other): 5.9% 15.4%
Africa: 14.3%
LAC: 10%
Oceania: 10.5%
North America: 7.7%
Europe: 6.4%
Source: Optimal feeding of LBW infants: technical review (2006)
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Improved care of LBW infants
Improved childbirth care
Antenatal maternal steroids Attention of early warming, drying and resuscitation
Extra care at home
Appropriate feeding, including additional support for
breastfeeding, expressed breast-milk feeding Keeping the infant warm, including skin-to-skin care
Early recognition and care-seeking for infections
Facility based care for very small infants
Appropriate feeding, including I/G expressed BM feeding
Thermal care, including Kangaroo mother care
Oxygen and continuous positive airway pressure
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Developmental readiness
32 36 weeks:
Infants should be able to attach, suck and extend tongueappropriately and begin breastfeeding
35 37 weeks:
Full breastfeeding maturation between 35 37 weeks
Demand feeding may be possible for some infants between 32
36 weeks
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Guidelines development: principles
Systematically developed, based on all availableevidence
Clear, unambiguous recommendations, but stating the
quality of evidence on which they are based
Strength of recommendation based on the balance of
benefits and risks, values and preferences, and costs
Should take into account the range of circumstances inwhich they will be used
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Guidelines development: principles
Systematically developed, based on all availableevidence
Clear, unambiguous recommendations, but stating the
quality of evidence on which they are based
Strength of recommendation based on the balance of
benefits and risks, values and preferences, and costs
Should take into account the range of circumstances inwhich they will be used
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2. Scoping the guidelines:
key questions and critical
outcomes
1. Establishing WHOSteering Group and
independent Guidelines
Development Group3. Systematic reviews andsynthesis of evidence4. Grading quality of
evidence using GRADE
7. Field testing,
implementation and
6. Peer-review and
finalization
5. Formulation of
recommendations by GDG:Benefits, Harms,
values and preferences,
t
Process of guideline development
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Examples of PICO questions
What should Low Birth Weight Babies be fed?
In LBW infants (P), what is the effect of feeding mother's own milk
(I) compared with feeding infant formula (C) on critical outcomes -
mortality, severe morbidity, neurodevelopment and anthropometric
status (O)?
In LBW infants who cannot be fed mother's own milk (P), what is
the effect of feeding donor human milk (I) compared with feeding
infant formula (C) on critical outcomes (O)?
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GRADE tables: mother's milk vs. formula
Pooled effect size
(95% CI)Overall quality
DirectnessConsistencyPrecisionLimitations in
methods
DesignOUTCOME
(No. of studies)
OR 0.82
(0.72 to 0.93)
LOW
Most evidence from
developed countries
(-0.5)
No serious
inconsistency
(0)
Some
imprecision
(-0.5)
No serious
limitations
(0)
Obs. studies
(-1.0)
Mortality
(4 studies)
OR 0.40
(0.31 to 0.52)
MODERATE
Most evidence from
developed countries
(-0.5)
No
inconsistency
(0)
No
imprecision
(0)
No serious
limitations
(0)
Most of the
studies obs.
(-1.0)
Severe infection
or NEC
(8 studies)
Mean difference 5.2
points (3.6, 6.8)
LOW
Most evidence from
developed countries
(-0.5)
No serious
inconsistency
(0)
No
imprecision
(0)
Limitations in
outcome
measurement
(-0.5)
All
observational
studies
(-1.0)
Neuro-
development
(6 studies)
MD in SD score:
Weight: -0.27
(-0.59, 0.05)
Length: -0.47
(-0.79, -0.15)
VERY LOW
Study from developed
country setting
(-0.5)
Single study
(-1.0)
Some
imprecision
(-0.5)
Limitations in
analysis
(-0.5)
All
observational
studies
(-1.0)
Anthropometri
c status
(1 study)
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Evidence to recommendations:
mother's milk vs. formula
Importantbenefits: mortality (18% reduction) LOW QUALITY
severe infections or necrotizing enterocolitis (60% reduction) MODERATE
mental development scores (5.2 points higher) LOW QUALITY
Harms lower length at 9 months (0.47 cm lower) VERY LOW QUALITY
Policy makers, health care providers and parents in developing
country settings are likely to give a high value to the benefits
Observed benefits are clearly worth the costs.
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Recommendation
Low birth weight infants, including those with very
low birth weight, should be fed mothers own milk
Strong recommendation
Based on moderate quality evidence of reduced
severe morbidity and low quality evidence of
reduced mortality and improved neurodevelopment
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Summary of recommendations
LBW and VLBW infants should be fed mother's own breastmilk. If
the mother is not able to breastfeed, donor milk should be given
LBW should be put to the breast as soon as clinically stable after
birth
LBW should be exclusively breastfed on demand for 6 months
Daily oral Vitamin A or routine zinc supplementation is not
recommended for LBW infants who are breast-milk fed
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Summary of recommendations
LBW and VLBW who cannot be given breast milk should be fedstandard infant formula
LBW infants who can not be breastfed, but can swallow should be
fed by cup and spoon (or cup with beak), based on hunger cues,but at least every 3 hours
If breastmilk feeding is not possible after discharge, the infantshould continue to receive infant formula until 6 months of age
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Special considerations for VLBW
A VLBW infant who is breast-milk fed should be given the followingsupplements:
a) Vitamin D (400 i.u. 1000 i.u. per day) until 6 months of age
b) Calcium (120 140 mg/kg/day) for the first months of life
c) Phosphorus (60 90 mg/kg/day) for the first months of life
d) Iron (2 -4 mg/kg/day) from 2 weeks to 6 months of age
A VLBW infant who fails to gain weight despite adequate breast
milk feeding should be given human-milk fortifiers, preferably
human-based milk
If a VLBW infant fed standard formula fails to gain weight, preterm
formula should be given.
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Special considerations for VLBW
VLBW infants should be fed 10ml/kg/d of enteral feeds, ofpreferably expressed breast milk, from the first day of life, with
remaining fluid needs met by intravenous fluids
If a VLBW infants needs to be given intragastric tube feeding, this
should be given as intermittent bolus feeds, by either oral or nasal
feeding
If a VLBW infant is fed by intragastric tube, feed volumes can be
increased by up to 30ml/kg/d with careful monitoring for feed
intolerance
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List of recommendations: Choice of milk
StrongLow birth weight (LBW) infants, including those with very low birth weight, should be
fed mothers own milk
1.
Strong
situational
LBW infants, including those with very low birth weight, who cannot be fed mother's
own milk should be fed donor human milk (recommendation relevant for settings
where safe and affordable milk banking facilities are available or can be set-up)
2.
Weak
situational
LBW infants, including those with very low birth weight, who cannot be fed mother's
own milk or donor human milk should be fed standard infant formula
(recommendation relevant for resource-limited settings).VLBW infants who cannot be fed mother's own milk or donor human milk should
be given preterm infant formula if they fail to gain weight despite adequate feeding
with standard infant formula.
3.
Weak
situational
LBW infants, including those with very low birth weight, who cannot be fed mother's
own milk should be fed standard infant formula from the time of discharge until 6
months of age (recommendation relevant for resource-limited settings).
4.
Weak
situational
Very Low Birth Weight (VLBW) infants who are fed mothers own milk or donor
human milk should not be routinely given bovine-milk based human milk fortifier.
VLBW infants who fail to gain weight despite adequate breast milk feeding should
be given human milk fortifiers, preferably those that are human-milk based.
5.*
*
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WeakVLBW infants should be given vitamin D supplements at a dose ranging from
400 i.u to 1000 i.u. per day until 6 months of age
6.**
WeakVLBW infants who are fed mothers own milk or donor human milk should be
given daily calcium (120-140 mg/kg/day) and phosphorus (60-90 mg/kg/day)
supplementation during the first months of life
7.**
WeakVLBW infants fed mothers own milk or donor human milk should be given 2-
4 mg/kg/day iron supplementation starting at 2 weeks until 6 months of age
8.**
WeakDaily oral vitamin A supplementation for LBW infants who are fed mother's
own milk is not recommended at the present time because there is not enough
evidence of benefits to support such a recommendation.
9.
WeakRoutine zinc supplementation for LBW infants who are fed mother's own milkis not recommended at the present time because there is not enough evidence of
benefits to support such a recommendation.
10.
List of recommendations: Supplements
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List of recommendations: when and how to feed
StrongLBW infants who are able to breastfeed should be put to the breastas soon as possible after birth when they are clinically stable.11.
Weak
situational
VLBW infants should be given 10ml/kg/day of enteral feeds,
preferably expressed breast milk, starting from the first day of life,
with the remaining fluid requirement met by intravenous fluids
(recommendation relevant for resource-limited settings).
12.*
*
StrongLBW infants should be exclusively breastfed until 6 months of age13.
Strong
situational
LBW infants who need to be fed by an alternative oral feeding
method should be fed by cup (orpalladai which is a cup with a beak)
or spoon.
14.
WeakVLBW infants requiring intragastric tube feeding should be given
bolus intermittent feeds
15.*
*
WeakIn VLBW infants who need to be given intragastric tube feeding, the
intragastric tube may be placed either by oral or nasal route,
depending upon the preferences of health care providers
16.*
*
f
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List of recommendations:
frequency and progression of feeds
Weak
situational
LBW infants who are fully or mostly fed by an alternative oral
feeding method should be fed based on infants hunger cues, except
when the infant remains asleep beyond 3 hours of the last feed
(recommendation relevant to settings with adequate number of health
care providers)
17.
WeakIn VLBW infants who need to be fed by an alternative oral feedingmethod or given intragastric tube feeds, feed volumes can be
increased by up to 30 ml/kg/day with careful monitoring for feed
intolerance
18.**
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Implications for programmes
Policies: update national policies, clinical care standards. Make linkageswith other policies such as on KMC
Health workerskills and competencies: update training materials anddesign ways for on-going education
Commodities: weighing scales, equipment to support milk expression,cups and spoons, supplies for intragastric and intravenous feeding, standard
and preterm formula, micronutrient supplements, milk banking facilities
Community awareness
Service delivery: agree on indicators and monitor quality
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Guidelines updated 2010 - 2013
Care of the newbornimmediately after birth
Newborn resuscitation
Newborn immunization
Postnatal care
Care of the preterm and low
birth weight baby
Management of neonatalsepsis
Management of neonatal
seizures
Management of neonataljaundice
Management of necrotizing
enterocolitis
Care of the HIV-exposed
newborn
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Thank you
WHO: Optimal feeding of