In the name of AllahIn the name of Allah

Enteral Nutrition of Preterm Enteral Nutrition of Preterm BabyBaby

Mohamed KhashabaMohamed Khashaba

Prof. of Pediatrics/NeonatologyProf. of Pediatrics/Neonatology

Head of NICU, MUCHHead of NICU, MUCH

ObjectivesObjectives

1.1. Stress the importance and challenges of Stress the importance and challenges of

preterm nutrition.preterm nutrition.

2.2. Focus or general guidelines to feeding in Focus or general guidelines to feeding in

preterm and high risk babies.preterm and high risk babies.

• Improved perinatal care has resulted Improved perinatal care has resulted

in survival of large number of LBWT in survival of large number of LBWT

infants requiring prolonged nutritional infants requiring prolonged nutritional

support.support.

• Nutrition of LBWT infants represents Nutrition of LBWT infants represents

a continuing challenge.a continuing challenge.

I.I. Why is nutrition of preterm baby Why is nutrition of preterm baby

important?important?

II.II. What are the general guidelines to What are the general guidelines to

enteral feedings?enteral feedings?

III.III. Feeding in selected situationsFeeding in selected situations

I.I. Why is nutrition of Why is nutrition of

preterm baby important?preterm baby important?

1.1. Unmatched rate of fetal growth.Unmatched rate of fetal growth.

2.2. Nutritive & energy stores are laid down in the Nutritive & energy stores are laid down in the

33rdrd trimester. trimester.

3.3. Immaturity of digestive, absorptive, metabolic Immaturity of digestive, absorptive, metabolic

and excretory functions.and excretory functions.

4.4. Adverse effects of malnutrition.Adverse effects of malnutrition.

5.5. Potential catastrophic diseases.Potential catastrophic diseases.

6.6. Unanswered questions.Unanswered questions.

1- Unmatched rate of fetal growth1- Unmatched rate of fetal growth

Fetal Growth RateFetal Growth Rate

• Weight of 22 weeks fetus:Weight of 22 weeks fetus: 500 gms500 gms

• Weight of 27 weeks fetus:Weight of 27 weeks fetus: 1000 gms1000 gms

• Weight of 31 weeks fetus:Weight of 31 weeks fetus: 1500 gms1500 gms

• TPN is not the sole logic continuation of TPN is not the sole logic continuation of

fetal nutrition through placenta in utero.fetal nutrition through placenta in utero.

• Swallowed amniotic fluid has a role in Swallowed amniotic fluid has a role in

nutrition of the fetus especially during 3nutrition of the fetus especially during 3rdrd

trimester.trimester.

2- 2- Nutritive & energy stores are laid Nutritive & energy stores are laid

down in the 3rd trimester.down in the 3rd trimester.

Between 29 and 40 weeks gestation:Between 29 and 40 weeks gestation:

• Protein content rises from 8.8% to 12% Protein content rises from 8.8% to 12%

• F at content rises from 1% to 13.1%F at content rises from 1% to 13.1%

• Glycogen stores rise from 10 mg/gm liver to 50 Glycogen stores rise from 10 mg/gm liver to 50

mg/gm.mg/gm.

3-Immature digestive, absorptive, 3-Immature digestive, absorptive,

metabolic and excretory functions.metabolic and excretory functions.

Functional Immaturity of GITFunctional Immaturity of GIT

• Immature suck pattern: short bursts followed Immature suck pattern: short bursts followed

by swallows.by swallows.

• Poor tone of inferior esophageal sphincter. Poor tone of inferior esophageal sphincter.

Functional Immaturity of GITFunctional Immaturity of GITGastric activity and emptyingGastric activity and emptying

1.1. Diminished smooth muscle mass.Diminished smooth muscle mass.

2.2. Reduced propulsive activity.Reduced propulsive activity.

3.3. Less mature autonomic innervations.Less mature autonomic innervations.

4.4. Blunted hormonal & enzymatic response.Blunted hormonal & enzymatic response.

4- Adverse effects of malnutrition4- Adverse effects of malnutrition

• Many LBWT infants & almost all ELBWT Many LBWT infants & almost all ELBWT

babies experience significant growth babies experience significant growth

retardation during NICU stay retardation during NICU stay (Lemons et al., (Lemons et al.,

2001)2001)

A.A. Nutritional inadequacies have long term neuro Nutritional inadequacies have long term neuro

developmental outcome developmental outcome Lucas et al., 1990.Lucas et al., 1990.

B.B. Under nutrition affects pulmonary maturity, Under nutrition affects pulmonary maturity,

growth and immunity.growth and immunity.

C.C. Impaired insulin secretion leading to Impaired insulin secretion leading to

hyperglycemia. hyperglycemia.

Vitamin AVitamin A

• Deficiency predispose to CLD & susceptibility Deficiency predispose to CLD & susceptibility

to sepsis. to sepsis.

Vitamin EVitamin E

• Antioxidant.Antioxidant.

• Facilitate phagocytosis & heme synthesis.Facilitate phagocytosis & heme synthesis.

• Important for ROP prevention.Important for ROP prevention.

• Protective role in IVH & BPD. Protective role in IVH & BPD.

Trace MineralsTrace Minerals

• Preterms have low stores at birth.Preterms have low stores at birth.

• 8 trace elements are essential.8 trace elements are essential.

• Deficiency affect cell growth, enzyme system & Deficiency affect cell growth, enzyme system &

heme synthesis.heme synthesis.

5- 5- Potential catastrophic diseases as NEC Potential catastrophic diseases as NEC

and acute conditions e.g respiratory and acute conditions e.g respiratory

distress, hypoxia.distress, hypoxia.

6- 6- Many questions remain partially or Many questions remain partially or

completely unanswered.completely unanswered.

A.A. How quickly should enteral feeding be How quickly should enteral feeding be

advanced, and in what manner?advanced, and in what manner?

B.B. How should feeding protocols be altered by How should feeding protocols be altered by

specific factors.specific factors.

II.II. General guidelines to enteral General guidelines to enteral

feedings.feedings.

1.1. Parenteral nutrition should begin early and Parenteral nutrition should begin early and

continue till full enteral feeds are reached.continue till full enteral feeds are reached.

2.2. Minimal enteral feeds should be started early.Minimal enteral feeds should be started early.

3.3. Breast milk is preferable “fortified”.Breast milk is preferable “fortified”.

4.4. Slow advancement of feeds.Slow advancement of feeds.

5.5. Observation of signs of intolerance.Observation of signs of intolerance.

6.6. Attention to sensory needs.Attention to sensory needs.

7.7. Keep accurate records of intake. Keep accurate records of intake.

Contraindications of Contraindications of enteral feedingenteral feeding

DownsDowns’’s score > 6s score > 6

HypotensionHypotension

Gastrointestinal obstruction or Gastrointestinal obstruction or NECNEC

A 5 minute Apgar score of 4A 5 minute Apgar score of 4

Method of feedingMethod of feeding

Cup feedingCup feeding..

Syringe feedingSyringe feeding..

Nasogastric versus orogastric Nasogastric versus orogastric feedingfeeding..

Direct breast feedingDirect breast feeding..

2. 2. Minimal Enteral FeedsMinimal Enteral Feeds (Gut priming-trophic feeds)(Gut priming-trophic feeds)

1.1. Reduces feeding intolerance.Reduces feeding intolerance.

2.2. Reduces incidence of jaundice.Reduces incidence of jaundice.

3.3. Reduces time to full enteral feeds attainment.Reduces time to full enteral feeds attainment.

2.Minimal Enteral Feeds2.Minimal Enteral Feeds (Gut priming- trophic feeds)(Gut priming- trophic feeds)

4. Induces release of intestinal hormones.4. Induces release of intestinal hormones.

5. Direct trophic effects on GIT. 5. Direct trophic effects on GIT.

Indications of gut primingIndications of gut priming

Extremely LBWExtremely LBW

Umbilical artery catheter in placeUmbilical artery catheter in place

Unstable baby with sepsisUnstable baby with sepsis

Unstable baby with asphyxiaUnstable baby with asphyxia

3- 3- Breast MilkBreast Milk

A.A. Incidence of NEC is 6 times higher in formula fed.Incidence of NEC is 6 times higher in formula fed.

B.B. Better cognitive & intellectual development.Better cognitive & intellectual development.

C.C. LC-PUFA may have important role in brain & LC-PUFA may have important role in brain &

retinal development.retinal development.

D.D. Better tolerance.Better tolerance.

4- 4- Advancement of FeedsAdvancement of Feeds

• Rapid advancement (>20 ml/kg/day) is Rapid advancement (>20 ml/kg/day) is

associated with increased risk of NEC.associated with increased risk of NEC.

4- 4- Advancement of FeedsAdvancement of Feeds

1.1. Assess the nurse’s report.Assess the nurse’s report.

2.2. Feeding order : precise & clear.Feeding order : precise & clear.

3.3. Avoid advancing both volume & number of Avoid advancing both volume & number of

feeds at the same time.feeds at the same time.

4.4. Nasogastric tube need not be removed for Nasogastric tube need not be removed for

early enteral feeding. early enteral feeding.

5- 5- Feeding ProblemsFeeding Problems

Indicate possible GI pathology:Indicate possible GI pathology:

1.1. Bile-stained residuals.Bile-stained residuals.

2.2. Distended abdomen.Distended abdomen.

3.3. Guiac positive stool.Guiac positive stool.

4.4. Significant residuals.Significant residuals.

5.5. Significant systemic symptoms. Significant systemic symptoms.

Abnormal gastric residual volumeAbnormal gastric residual volume

Abnormal gastric residual volume Abnormal gastric residual volume has been defined as follows: >2 has been defined as follows: >2 mL/kg per feeding mL/kg per feeding

OR >50 percent of the volume of OR >50 percent of the volume of feeds over the last three hourfeeds over the last three hour

quality of the gastric residualquality of the gastric residual

Gastric residuals that are green, or Gastric residuals that are green, or bilious, could indicate intestinal bilious, could indicate intestinal obstruction,obstruction,

but more often indicate but more often indicate overdistention and retrograde reflux overdistention and retrograde reflux of bile into the stomach. of bile into the stomach.

quality of the gastric residualquality of the gastric residual

A blood tinged residual could indicate A blood tinged residual could indicate an inflammatory process, an inflammatory process,

but may only be due to a slight but may only be due to a slight mucosal irritation from the indwelling mucosal irritation from the indwelling gastric tube.gastric tube.

Possible Causes of Feeding IntolerancePossible Causes of Feeding Intolerance

1.1. NEC.NEC.

2.2. Sepsis.Sepsis.

3.3. Hemodynamic problems.Hemodynamic problems.

4.4. Hypoxemia.Hypoxemia.

5.5. Electrolyte disturbances.Electrolyte disturbances.

6.6. High theophylline serum levels.High theophylline serum levels.

Feeding IntoleranceFeeding Intolerance Possible OptionsPossible Options

1.1. Decrease amount of each feed.Decrease amount of each feed.

2.2. Switch to more dilute formula.Switch to more dilute formula.

3.3. Change the interval between feeds.Change the interval between feeds.

4.4. Switch to predigested formula.Switch to predigested formula.

5.5. Change to continuous gastric drip.Change to continuous gastric drip.

6.6. Start parenteral nutrition & NPO.Start parenteral nutrition & NPO.

6- 6- Attention to Sensory NeedsAttention to Sensory Needs

• Feeding should represent a pleasurable Feeding should represent a pleasurable

experience.experience.

• Use of non nutritive sucking.Use of non nutritive sucking.

• Rocking the baby between feeds. Rocking the baby between feeds.

7- 7- Non Nutritive SuckingNon Nutritive Sucking

1.1. May have an effect on weight gain & gastric May have an effect on weight gain & gastric

motility & metabolic rate.motility & metabolic rate.

2.2. Facilitate transition to oral feeding.Facilitate transition to oral feeding.

(Pinelli, (Pinelli,

2000) 2000)

When the infant tolerates at least When the infant tolerates at least 100 mL/kg per day or has fed 100 mL/kg per day or has fed unfortified human milk for at least unfortified human milk for at least one week, the caloric density of milk one week, the caloric density of milk is increased by either switching to is increased by either switching to preterm formula. or adding human preterm formula. or adding human milk fortifier.milk fortifier.

Average daily energy requirements Average daily energy requirements for enteral fed premature infants are for enteral fed premature infants are 120 kcal/kg per day120 kcal/kg per day

Total energy needs in infants with Total energy needs in infants with chronic illness, such as chronic illness, such as bronchopulmonary dysplasia, bronchopulmonary dysplasia, increase up to 150 kcal/kg per dayincrease up to 150 kcal/kg per day

Growth ParametersGrowth Parameters

Weight minimum increment of 15/kg Weight minimum increment of 15/kg per day.per day.

Once the infant reaches 2.0 kg, the Once the infant reaches 2.0 kg, the daily weight gain of 20 to 30 g/d daily weight gain of 20 to 30 g/d should be the goalshould be the goal

Length minimum increment of 1 cm Length minimum increment of 1 cm per week.per week.

Head circumference minimum Head circumference minimum increment of 1 cm per weekincrement of 1 cm per week

Biochemical assessmentBiochemical assessment

Bone mineral status: serum calcium, Bone mineral status: serum calcium, phosphorus, and alkaline phosphorus, and alkaline phosphatase activity. phosphatase activity.

Protein status: serum albumin and Protein status: serum albumin and urea nitrogen. urea nitrogen.

The hemoglobin and reticulocyte The hemoglobin and reticulocyte countcount

III.III. Feeding in Selected SituationsFeeding in Selected Situations

Feeding of Ventilated BabiesFeeding of Ventilated Babies

1.1. Babies kept NPO until need for ventilatory Babies kept NPO until need for ventilatory

assistance is minimized & baby stable.assistance is minimized & baby stable.

2.2. Post-extubation NPO (4-12 hrs.).Post-extubation NPO (4-12 hrs.).

3.3. Low UAC is a relative contraindication.Low UAC is a relative contraindication.

Feeding of Perinatal Asphyxia BabiesFeeding of Perinatal Asphyxia Babies

NPO until stability:NPO until stability:

1.1. Bowel sounds are present.Bowel sounds are present.

2.2. Abdominal examination is benign.Abdominal examination is benign.

3.3. Passed meconium.Passed meconium.

4.4. Stable hemodynamically.Stable hemodynamically.

Feeding After Exchange TransfusionFeeding After Exchange Transfusion

• NPO for 24 hrs. after line is removed.NPO for 24 hrs. after line is removed.

Necrotizing EnterocolitisNecrotizing Enterocolitis

• Feeding should be withheld for 2 weeks Feeding should be withheld for 2 weeks

minimum.minimum.

• Total parenteral nutrition should be Total parenteral nutrition should be

immediately started.immediately started.

ObjectivesObjectives

1.1. Stress the importance and challenges of Stress the importance and challenges of

preterm nutrition.preterm nutrition.

2.2. Focus or general guidelines to feeding in Focus or general guidelines to feeding in

preterm and high risk babies.preterm and high risk babies.