nutrition and growth in primary care of the premature infant ma. teresa c. ambat, md...

Nutrition and Growth in Primary Care Nutrition and Growth in Primary Care of the Premature Infantof the Premature Infant

Ma. Teresa C. Ambat, MDMa. Teresa C. Ambat, MD

Neonatology-TTUHSCNeonatology-TTUHSC

10/21/200810/21/2008

Postnatal Growth of Premature InfantsPostnatal Growth of Premature Infants

Goal of nutrition support for VLBW from birth to term: match the in utero growth rates of the normally growing fetus

This goal is rarely achieved

Problem of chronic undernutrition and poor growth Problem of chronic undernutrition and poor growth – 99% of ELBW and 97% of VLBW had weights <1099% of ELBW and 97% of VLBW had weights <10thth percentile at percentile at

36 wks PMA36 wks PMA


For each gestational age category, the postnatal study growth curve was shifted to the right of the reference curve


Extra-uterine growth retardationExtra-uterine growth retardation– Caused by early growth delay, coupled with a lack of catch-up

growth

– Most frequent cause of morbidity seen in VLBWMost frequent cause of morbidity seen in VLBW

– Have long term consequences on neurodevelopmental Have long term consequences on neurodevelopmental outcomesoutcomes

Postdischarge Nutrition of Premature InfantsPostdischarge Nutrition of Premature Infants

Only recently that attention has been paid to nutritional support of these infants after hospital discharge

Best practice should continue to evolveBest practice should continue to evolve

Key questions– Whether VLBW infants have special nutritional requirements in

the postdischarge period and

– Whether this period of nutrition is also critical for later health and development

Infants at Highest Risk for Nutritional Infants at Highest Risk for Nutritional Deficiencies after NICU DischargeDeficiencies after NICU Discharge

1.1. ELBW, VLBWELBW, VLBW

2.2. SGA, IUGRSGA, IUGR

3.3. Exclusively breastfedExclusively breastfed

4.4. Requiring special formulasRequiring special formulas

5.5. Requiring tube feedings at Requiring tube feedings at homehome

6.6. Fail to gain at least 20g/day Fail to gain at least 20g/day before D/Cbefore D/C

7.7. G Tube / tracheostomiesG Tube / tracheostomies

8.8. TPN >4 wksTPN >4 wks

99.. Diagnosis of any of the ffg:Diagnosis of any of the ffg:

BPBP

Chronic renal insufficiencyChronic renal insufficiency

Congenital GI anomaliesCongenital GI anomalies

Cyanotic CHDCyanotic CHD

IEMIEM

MalabsorptionMalabsorption

OsteopeniaOsteopenia

Poverty/LSESPoverty/LSES

Severe neurologic impairmentSevere neurologic impairment

SBSSBS

Human Milk for Premature InfantsHuman Milk for Premature Infants

Preferred feeding for ELBW/VLBWPreferred feeding for ELBW/VLBW– Nutritional valueNutritional value– Immunologic and antimicrobial componentsImmunologic and antimicrobial components– Contains hormones and enzymesContains hormones and enzymes

Once growth is established, nutritional needs of the Once growth is established, nutritional needs of the preterm infant exceed the content of human milk for preterm infant exceed the content of human milk for protein, Ca, P, Mg, Na, Co, Zn and vitaminsprotein, Ca, P, Mg, Na, Co, Zn and vitamins


Unsupplemented HM Unsupplemented HM – Associated with slower growth rate Associated with slower growth rate – Nutritional deficiencies: hyponatremia, hypoproteinemia, Nutritional deficiencies: hyponatremia, hypoproteinemia,

osteopenia, Zn deficiencyosteopenia, Zn deficiency

Infants discharged with subnormal weight for CA should Infants discharged with subnormal weight for CA should be supplementedbe supplemented

??? continued use of HMF??? continued use of HMF


Transition from supplemented EBM to exclusive Transition from supplemented EBM to exclusive breastfeedingbreastfeeding– Favorable strategy???Favorable strategy???

– Optimal supplementary/complementary feeding?Optimal supplementary/complementary feeding?

– No best practice protocolsNo best practice protocols


Other practical pointsOther practical points– Fresh milk may be fed immediately or refrigerated at ~4Fresh milk may be fed immediately or refrigerated at ~400 C C– Refrigerated milk should be fed within Refrigerated milk should be fed within – Freezing: ~ -20Freezing: ~ -2000 C C– Frozen milk retains most of its immunologic properties and Frozen milk retains most of its immunologic properties and

vitamin content withinvitamin content within– Frozen milk should be thawed in cool or lukewarm running tap Frozen milk should be thawed in cool or lukewarm running tap

water or in a basin of warm waterwater or in a basin of warm water– Use of microwave not recommendedUse of microwave not recommended

Reduces IgA levels and lyzozyme activity, produce hot spotsReduces IgA levels and lyzozyme activity, produce hot spots

48 hrs

3 months

Postdischarge Nutrition of Premature InfantsPostdischarge Nutrition of Premature Infants

Potential discharge strategiesPotential discharge strategies– Provide calorically enhanced, EBM at the energy density Provide calorically enhanced, EBM at the energy density

tolerated before D/C tolerated before D/C gradual increase in exclusive gradual increase in exclusive nursing sessions (-1 bottle feeding at a time) as the infant nursing sessions (-1 bottle feeding at a time) as the infant outgrows the need for extra caloriesoutgrows the need for extra calories

– Nurse on demand but specify a required daily intake of Nurse on demand but specify a required daily intake of nutrient enriched post discharge formula (e.g. 2-3 feedings nutrient enriched post discharge formula (e.g. 2-3 feedings of PDF per day)of PDF per day)

– Strategy should be individualizedStrategy should be individualized– Collaboration with dietitian/lactation consultantCollaboration with dietitian/lactation consultant

Postdischarge Formula for Premature InfantsPostdischarge Formula for Premature Infants

Nutrient-enriched formula for preterm infants after hospital discharge - postdischarge formula (PDF)– Enfacare 22 cal, Neosure 22 cal– Intermediate in composition between preterm and term formulae

Compared to term formula, PDF contains– Increased amount of protein with sufficient additional energy– Contains extra Ca, P, Zn - necessary to promote linear growth– Additional vitamins and trace elements

Postdischarge Formula for Premature InfantsPostdischarge Formula for Premature Infants

Use of PDF after discharge in preterm infants improved growth, with differences in weight and length

AAP recommendationsAAP recommendations1. Use of PDF vs term formulas to 9mos chronological age 1. Use of PDF vs term formulas to 9mos chronological age

greater linear growth, weight gain and bone mineral contentgreater linear growth, weight gain and bone mineral content

2. Iron and vitamin fortified 2. Iron and vitamin fortified no other supplements no other supplements

3. If average intake 150ml/k/day 3. If average intake 150ml/k/day +Iron 1mg/k/day until 12 mos +Iron 1mg/k/day until 12 mos

Other Infant FormulasOther Infant Formulas

AAP RecommendationsAAP Recommendations– No role for use of low iron formulasNo role for use of low iron formulas

– Hypoallergenic formulasHypoallergenic formulas HM, protein hydrolysates – may be useful in prophylaxis or HM, protein hydrolysates – may be useful in prophylaxis or

eradication of symptoms in sensitized infantseradication of symptoms in sensitized infants No evidence to support the routine use for tx of colic, No evidence to support the routine use for tx of colic,

sleeplessness or irritabilitysleeplessness or irritability

– Soy formulasSoy formulas Carbohydrate, protein and mineral absorption and utilization Carbohydrate, protein and mineral absorption and utilization

not well documented in pretermnot well documented in preterm Not recommended for: PT <1800g, prevention of colic or Not recommended for: PT <1800g, prevention of colic or

allergy, cow-milk protein induced enterocolitis or enteropathyallergy, cow-milk protein induced enterocolitis or enteropathy

Caloric SupplementationCaloric Supplementation

IndicationsIndications1.1. Flat or decelerating growth curve patternFlat or decelerating growth curve pattern

2.2. Volume restricted (severe BPD, cardiac disease)Volume restricted (severe BPD, cardiac disease)

3.3. Unable to take enoughUnable to take enough

Monitor for dietary intolerance (GI symptoms, bloody Monitor for dietary intolerance (GI symptoms, bloody stools), hydration statusstools), hydration status

If increased caloric supplementation does not improve If increased caloric supplementation does not improve growth growth further evaluation by endo, GI, dietitian further evaluation by endo, GI, dietitian


Caloric amountCaloric amount Breast MilkBreast Milk

24 cal24 cal 1 tsp formula powder to 90 ml EBM1 tsp formula powder to 90 ml EBM

26 cal26 cal 1 ½ tsp formula powder to 90ml EBM1 ½ tsp formula powder to 90ml EBM

Potential formulas: Enfacare, Neosure, Enfamil Lipil, Similac AdvancePotential formulas: Enfacare, Neosure, Enfamil Lipil, Similac Advance

Other prep: 1 tsp Neosure advance + 75 ml water (24 cal )Other prep: 1 tsp Neosure advance + 75 ml water (24 cal )

Caloric amountCaloric amount Enfacare LipilEnfacare Lipil Neosure AdvanceNeosure Advance

24 cal24 cal 2 scoops + 3.5 oz water 2 scoops + 3.5 oz water 4 4 oz formulaoz formula

3 scoops + 5.5 oz water 3 scoops + 5.5 oz water 6.5 oz formula 6.5 oz formula

27 cal27 cal 2 scoops + 3 oz water 2 scoops + 3 oz water 3.5 3.5 oz formulaoz formula

5 scoops + 8 oz water 5 scoops + 8 oz water 9 oz formula9 oz formula


WeaningWeaning1.1. Gradual adjustments to caloric density followed by weight Gradual adjustments to caloric density followed by weight

checkschecks

2.2. Serial measurements of growth (adjusting for prematurity) Serial measurements of growth (adjusting for prematurity) including length and HCincluding length and HC

3.3. Breastfed: assessment of infant’s ability to transfer sufficient Breastfed: assessment of infant’s ability to transfer sufficient quantities of milk as well as adequacy of mother’s milk quantities of milk as well as adequacy of mother’s milk supplysupply

4.4. Formula-fed: assessment of infant’s volume intakeFormula-fed: assessment of infant’s volume intake

Micronutrient SupplementationMicronutrient Supplementation

No guidelines for supplementing premature infants with No guidelines for supplementing premature infants with water-soluble vitamins after dischargewater-soluble vitamins after discharge– Supplementation until 1 yr chronological age is not unreasonableSupplementation until 1 yr chronological age is not unreasonable– PDF supply more water-soluble vitamins > term formulasPDF supply more water-soluble vitamins > term formulas

Little info about supplementation of fat-soluble vitaminsLittle info about supplementation of fat-soluble vitamins– For HM fed, oral solutions of A,D,E availableFor HM fed, oral solutions of A,D,E available– PDF supply adequate amounts of fat-soluble vitaminsPDF supply adequate amounts of fat-soluble vitamins– For healthy PT, probably not necessary to supplement after For healthy PT, probably not necessary to supplement after

attaining weight of 3 kgattaining weight of 3 kg


NutrientNutrient BreastfedBreastfed Formula fedFormula fed

Elemental ironElemental iron11 2mg/k/d starting at 1 mo 2mg/k/d starting at 1 mo 12 mos12 mos

Only iron-fortified formulasOnly iron-fortified formulas

Intake of 150ml/k/d = 1.8mg/k/d Intake of 150ml/k/d = 1.8mg/k/d of iron. Infants may benefit from of iron. Infants may benefit from additional 1mg/k/d.additional 1mg/k/d.

Vitamin DVitamin D22 200 IU/d starting at 2 mos 200 IU/d starting at 2 mos 12mos 12mos33

Ingesting <500ml/day, Ingesting <500ml/day, supplement with 200 IU/dsupplement with 200 IU/d

1. If on EPO: give 6mg/k/day2. Most standard MVI prep contains 400 IU per mL3. If weaned to at least 500mL per day of Vit-D fortified formula, this may be

d/cd


Calcium and PhosphorusCalcium and Phosphorus– Continued use of nutrient enriched formulas in PT until 9 mos Continued use of nutrient enriched formulas in PT until 9 mos

improved bone mineral content improved bone mineral content – Greater challenge in breastfed former PT (2-3 feedings of PDF Greater challenge in breastfed former PT (2-3 feedings of PDF

per day may enhance mineral intake)per day may enhance mineral intake)– Infant with hx of osteopenia (separate discussion)Infant with hx of osteopenia (separate discussion)

FluorideFluoride– Supplementation should be based on total amount of fluoride Supplementation should be based on total amount of fluoride

from all sources availablefrom all sources available


Trace mineralsTrace minerals1.1. Zinc: PTF, TF and HMF provide sufficient ZnZinc: PTF, TF and HMF provide sufficient Zn

2.2. Copper: RDI can be met by HM or PTFCopper: RDI can be met by HM or PTF

3.3. Iodine: all formula for PT will supply RDIIodine: all formula for PT will supply RDI

HM will not supply enough iodine by itself, though HM will not supply enough iodine by itself, though supplementation has not been establishedsupplementation has not been established

4. Selenium, chromium, molybdenum or manganese: deficiency 4. Selenium, chromium, molybdenum or manganese: deficiency in PT has not been reportedin PT has not been reported

Most optimal strategies for the postdischarge nutritional Most optimal strategies for the postdischarge nutritional management of ELBW/VLBW are unknownmanagement of ELBW/VLBW are unknown

Further research needed to determine best practice Further research needed to determine best practice guidelinesguidelines

Serial measurements of growth and maintaining Serial measurements of growth and maintaining postdischarge feedings may offer favorable strategy until postdischarge feedings may offer favorable strategy until more specific, universally accepted protocols are more specific, universally accepted protocols are establishedestablished

Complimentary FeedingComplimentary Feeding

1. Introduce solid foods when the infant is 1. Introduce solid foods when the infant is developmentally ready, generally between 4-6 monthsdevelopmentally ready, generally between 4-6 months

No nutritional indication to add complimentary foods to No nutritional indication to add complimentary foods to diet of the healthy term infant <4 months of agediet of the healthy term infant <4 months of age

2. 2. Introduce new foods slowly enough so that any allergic Introduce new foods slowly enough so that any allergic reaction or intolerance to food can be identifiedreaction or intolerance to food can be identified

AAP: no more than 3 foods be introduced/ weekAAP: no more than 3 foods be introduced/ week No particular orderNo particular order Meat has an advantage of providing iron and zincMeat has an advantage of providing iron and zinc


3. Juice should not be introduced into the diet of infants < 6 3. Juice should not be introduced into the diet of infants < 6 months (risk that juice will displace BM or formula months (risk that juice will displace BM or formula reduced intake of protein, fat, vitamins and minerals)reduced intake of protein, fat, vitamins and minerals)

Fruit juices should be limited to 4-6oz/day after 6 monthsFruit juices should be limited to 4-6oz/day after 6 months Neither breastfed nor formula-fed require extra waterNeither breastfed nor formula-fed require extra water

4. Do not give cow’s milk before 12 months, because it may 4. Do not give cow’s milk before 12 months, because it may adversely affect the infant’s iron statusadversely affect the infant’s iron status

5. Do not give reduced-fat cow’s milk to children < 2years 5. Do not give reduced-fat cow’s milk to children < 2years (children at this age should not have fat-restricted diet)(children at this age should not have fat-restricted diet)


6. Offer fruits and vegetables to infants daily beginning at 6. Offer fruits and vegetables to infants daily beginning at 6-8 months6-8 months

7. Limit the amount of salt added to foods fed to infants7. Limit the amount of salt added to foods fed to infants When salt is used, use iodized saltWhen salt is used, use iodized salt

8. Limit consumption of low-nutrient foods8. Limit consumption of low-nutrient foods

ReferencesReferences

1.1. Pediatric Nutrition HandbookPediatric Nutrition Handbook

2.2. Primary Care of the Premature InfantPrimary Care of the Premature Infant

nutrition and growth in primary care of the premature infant ma. teresa c. ambat, md...

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