Feeding the Preterm Infant

Jill-Marie Spence, RDApril 2013

Outline

• Introduction• Human Milk• Preterm Formulas• Nutritional Needs:– Micropreterm– SGA– Late Preterm Infant

• Post-discharge Nutrition• Growth• Conclusion

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?

Scientific versus KnowledgeGlobal 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

• 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

Identify the challenges that prevent us from translating our understanding of science to

practical application.

Global Neonatal Consensus Symposium, Feeding the Preterm Infant 2010

Human Milk and the Nutritional Needs of

Preterm Infants

Colostrum and Transitional MilkImproves immune functionPromotes 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 postpartumDay 1 6 – 10 mL/kg/dDay 2 13 – 25 mL/kg/d

3rd – 14th day postpartum 2 weeks postpartum

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

• 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

• Gastrointestinal

– Improves gut motility – May increase stool frequency– May decrease feed intolerance• Full enteral feeds are reached quicker

– Decreases the incidence of NEC

• 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

• 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

• Decreases the rate of sudden infant death syndrome

• Endocrine– Decreases the incidence of type 1 and type 2

diabetes

• 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)

• 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

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

• 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

Units /L Donor Human Milk

Wojcik 2009Michaelsen 1990

Preterm Human Milk

22 – 30 daysSchanler & Atkinson in Tsang 2006

Term Mature Milk

30 daysSchanler & Atkinson in Tsang 2006

Energy 650 690 + 50 640 + 80

Protein 1.05 15 + 1 12 + 1.5

Sodium 8.8 + 2.0 9.0 + 4.1

• Many of the benefits of HM are still unknown

Human milk is a living tissue that cannot be duplicated

Composition of Preterm Transitional, mature, and term mature milk Schanler, Atkinson in Tsang 2005

Nutrient (U/L)

Preterm transitional 6 - 10 days

Preterm mature 22 - 30 days

Preterm mature150 mL/kg/d

Term Mature> 30 days

Term mature150 mL/kg/d

ESPGHAN2010

Energy, kcal 660 + 60 690 + 50 104 kcal/kg 640 + 80 96 kcal/kg 110 - 135

Total protein, g

19 + 0.5 15 + 1 2.3 g/kg 12 + 1.5 1.8 g/kg < 1 kg 4 – 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

8.0 + 1.8 7.2 + 1.3 1.1 mmol/kg

6.5 + 1.5 1.0 mmol/kg 3.0 – 3.5

Phosphorous, mmol

4.9 + 1.4 3.0 + 0.8 0.5 mmol/kg

4.8 + 0.8 0.7 mmol/kg 1.9 – 2.9

Sodium, mmol

11.6 + 6.0 8.8 + 2.0 1.3mmol/kg

9.0 + 4.1 1.4 mmol/kg 3.0 - 5.0

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

Human Milk Fortifier Groh-Wargo Enteral nutrition support Nutr Clin Prac 2009

• Bwt < 1500 grams, < 34 weeks• Bwt 1500 grams – 1800 grams– Consider 2 HMF/100 mL EBM ->

reevaluate growth and adjust HMF accordingly• High acuity• PN > 2 weeks• Suboptimal growth

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

• Average ½ emptying time– BM 49 + 23 minutes– Half-fortified HM 54 + 29 minutes– Full strength fortified HM 65 + 36 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

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: 1065 + 18 grams• GA: 27 + 0.1 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.

• HM supplemented with nutrients is recommended for all infants born < 32 weeks and supplementation may be required for infants 32 -36 weeks of gestation

Global Neonatal Consensus Symposium, Feeding the Preterm Infant (2010)

Preterm Formulas

• Enriched with energy, macronutrients, minerals, vitamins and trace elements

• Indications:– < 34 weeks gestation age + 1800 – 2000 grams birth

weight– Inadequate supply of mother’s milk– Mom not able to or wishing to breast feed– Donor human milk not available

• Whey dominant • Promotes gastric emptying and digestion

• Cysteine and Taurine added– Methionine -> Cysteine– Cysteine -> Taurine– Conditionally essential

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

DHA in breast milk varies with maternal dietAuestad et al. Pediatrics 2001;108:372-381 Camielli et al. Am J Clin Nutr 2007;86:1323-1330

• 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

Assuming a DHA intestinal absorption rate of 80%, DHA intake between 55 – 60

mg/kg/d provides DHA at the fetal accretion rate.

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

TermAI based on Linoleic Acid (2%) and

Linolenic Acid (0.3%

• Current formulas support growth and protein accretion at or slightly greater then intrauterine rates. – may increase fat deposition– Current formulas @ 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

• 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

Based on 160 mL/kg/day

Preterm Mature Milk 22 – 30 days

4 HMF/100 mL EBM

Special Care 24 kcal/oz

ESPGHAN2010

Energy, kcal/kg 110 133 130 110 - 135

Total proteing/kg

2.4

PE 2.2

4.0

PE 3.0

3.8

PE 2.9

< kg 4.0 – 4.5

1 – 1.8 kg 3.5 – 4.0

Calcium, mmol/kg

1.2 5.8 4.9 3.0 – 3.5

Phosphorous, mmol/kg

0.5 4.0 3.7 1.9 – 2.9

Sodium, mmol/kg

1.4 2.5 2.9 3.0 – 5.0

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

150 mL/kg/day Kcal/kg g protein/kg mg Ca/kg mg/PO4-/kg

Neocate0.67 kcal/mL

.450 g Linoleic acid/100 mL

.0547 g Linolenic acid/100 mL

33% MCT

101 3.2 124

(120 – 140)

93

Nutramigen AA0.68 kcal/mL

.58 g Linoleic acid/100 mL

.054 g Linolenic acid/100 mL

2.8% MCT

102 2.9 96

(60 – 90)

53

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

• World Health Organization 2006• Recommended nutrients for infants < 32 wks gestation,

32-36 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

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 – 200 160-220 135-190 160

Energy (kcal) 110-135 130-150 110-130 105-135 133

Protein (g) 3.5 – 4.0 (1–1.8 kg)

4.0 – 4.5 (< 1kg)

3.8-4.4 3.4-4.2 3.0-3.6 4.0

Vitamin D 800 – 1000 IU/d 150 -400 IU/kg/d

150-400 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 2.0 – 4.0 2.0 – 3.0 0.6

Calcium (mg) 120-140 100-220 100-220 160-240 232

Phosphorous (mg)

60-90 60-140 60-140 78-118 124

Enteral Requirements

Nutritional Needs of the Micropreterm Infant

< 30 weeks gestation (subset are SGA; weight < 10th percentile at

birth)Tudehope J Ped 2013;162:s72-80

• 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

• By 25 weeks gestation– Fetal intestine capable of digesting and absorbing

milk

• 25 – 30 weeks – Disorganized motility

• 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

Nutrient Theoretical concerns Current recommendations

New Recommendations

Fluid ↑requirements – immature skinRisk 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 growthSome aa conditionally essential (cysteine and taurine)

Factorial 3.5 – 4.0Tsang 3.8 – 4.4 (26 – 30 wks)ESPGHAN 4.0 – 4.5 ELBW 3.8 – 4.4 VLBW

3.6 – 4.5 g/kg/dP: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)

CalciumPO4

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)

TsangCalcium 100 – 220 mg/kg/dPhosphorous 60 – 140 mg/kg/d

Calcium 120 – 180 mg/kg/dPO4 60 – 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

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 160 160 160 160 160

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

3.0

4.6

3.0Sodium 4 – 5 mmol/kg/d (1st 10 – 14 days)

2.5 – 3.0 mmol/kg/d (> 14 days)3.82.9 2.9 2.7 2.8

Calcium(50 – 65%)

PO4 (90%)

Calcium 120 – 180 mg/kg/d

PO4 60 – 90 mg/kg/d (> 1.8 mmol/L)

232

124

228

133

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

• 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

• 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

• 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

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

• 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

• 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

Human milk (> 30 days)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 102 - 128

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 kcal9 – 13% total calories

1.9 – 2.4

1.9

Fat ↓ absorption (11-14%), less body fat 40 – 54% total calories

CalciumPO4

Low PO4 levels at birth, ↓ whole-body density and content compared to AGA infants

Calcium 120 – 160 mg/kg/d

PO4 60 – 90 mg/kg/d

42 – 52

24 - 30

Vitamin D 800 – 1000 IU /d

Iron Normal serum iron but low stores at birth

2 mg/kg/d

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

• 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

Late Preterm Infant

34 to < 37 weeks

Lapillonne J Ped 2013;162:s90-100

• 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

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

• 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

• 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

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

• 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 EBM @ 160 ml/kg/day = 16

packets HMF

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

160 ml/kg/day

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 2.6 1.7

Vitamin D IU 43 IU 231 168

Iron mg/kg 2.4 2.3

Formula Cost ComparisonTerm 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

How do we measure up?

Postnatal Growth Failure

• US Study (124 NICUs, 1997-2000, 24000 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 18-22 months corrected age

• Embleton and Colleagues 2001

– Daily nutritional deficits by the end of the first week– 406 + 92 kcal/kg, 14 + 3 g protein/kg

• 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

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

• Most common variable used to monitor growth is gestational age

• Reliable measures of growth for premature infants is vital

• 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

– 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

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

Growth Curve

• Fenton growth chart (2003)

– Based on completed weeks

– 22 weeks to 50 weeks gestation

www.biomedcentral.com

Length

• Weekly measurements

• Tracks linear growth

• Most accurate measurement of lean body mass

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

Approximate Weekly (Daily*) Gain in grams

Age in Months Girls Boys

1 – 2 130 – 360 g (18.6 - 51.4 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(5 - 15.7 g/d)

Approximate Weekly Length Gain (cm)Age in Months Girls Boys

1 – 2 0.7-1.2 cm 0.8-1.2 cm

2 – 4 0.4-0.8 cm 0.5-0.8 cm

4 – 6 0.2-0.6 cm 0.3-0.6 cm

6 – 12 0.2-0.4 cm 0.2-0.4 cm

Approximate Weekly Head Circumference (cm)

Age in Months Girls Boys

1 – 2 0.4-0.6 cm 0.4-0.7cm

2 – 4 0.2-0.4 cm 0.2-0.4 cm

4 – 6 0.15-0.3 cm 0.15-0.3 cm

6 – 12 0.1-0.15 cm 0.1-0.15 cm

Table 1: Expected Approximate Growth VelocityAdapted 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;145-62.[ii] Catrine, K. Anthropometric assessment. In: Groh-Wargo S, Thompson M, Hovasi Cox J, Hartline JV eds. Nutritional Care for High Risk Newborns 3 rd ed. Chicago IL: Precept Press; 2000:11-22.[iii] World Health Organization. Child growth standards: Weight velocity [data tables on the Internet]. 2011 [cited 2013 Feb 22]. Available from: http:// http://www.who.int/childgrowth/standards/en/

“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

• 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

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

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

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

• 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….

ReferencesAgostoni 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):85-91.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:S37-47.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; 2005. p. 333-356.Tudehope D. Human milk and the nutritional needs of preterm infants. J Pediatr 2013;162:S17-25. Tudehope D. Nutritional needs of the micropreterm infant. J Pediatr 2013;162:S72-80.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:S90-100.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.