Nutrition Management of the Premature Infant

Melissa Nash, MPH, RD Washington County Field Team

melissa_nash@co.washington.or.us

Objectives1. Describe appropriate growth in premature

infants, including growth charts.2. Describe current practices for feeding and

supplementation for premature infants.3. Understand how to better support the

breastfeeding premature infant. 4. Recognize potential feeding problems and

solutions in premature infants.

Newborn Classifications

LBW: Low Birth Weight <2500g (5 1/2 lbs)

VLBW: Very Low Birth Weight <1500g (3 1/3 lbs)

ELBW: Extremely Low Birth Weight <1000g (2 1/4 lbs)

Preterm: <37 weeks GALate Preterm: 34 0/7 – 36 6/7 weeks GA

Typical Feeding ProgressionGestational Age (Weeks)

24 25 26 27 28 29 30 31 32 33 34 35 36 37 38Pacifier Sucking (non-nutritive suck)

Gag Reflex Rooting Reflex Early Intermediate Mature

Coordinate Suck,

Nutritive Suck Swallow, Breathe

TPN for 1-2 weeks as enteral Gradually start breast/ Infant nippling

feeds advance via tube bottle per infant cues all feeds

Post-Discharge Premature Infant Nutritional Issues

Switch from ‘super-milks’ to standard milk

Slower growth in follow-upNeonatal period critical for

‘programming’ of development and health

Limited information/research on post- discharge nutrition

The Underlying Question…

“Do you want a smart, tall, fat adult who will die prematurely of cardiovascular disease or a dumb, short, thin adult who will outlive the other?”

Richard Schandler, MD

Neonatalogist

Developmental Origins of Health & Disease

“Fetal Programming” Under-nutrition during pg & LBW are

strongly associated with HTN, obesity, insulin resistance and dyslipidemia later in life

Combination of poor growth & rapid catch-up weight may increase risk

Additional research is needed to determine when catch-up growth is “excess growth”

What does the research say?Weight Gain & Growth

Feeding a post-discharge formula (PDF) for 9-12 months following discharge results in improved wt, lt, & HC

Greatest results in infants <1250-1500g Greater results in males vs. females Long-term developmental advantages

inconclusive

What does the research say?

Bone Mineral Content (BMC) BMC higher in premies receiving a PDF for 9

months post-discharge Highest Ca formulas = greatest BMC

Chan, J Pediatr 1993;123:439-43

Bishop, Arch Dis Child;1993:573-8 Carver, Pediatr 2001;107:683-689

Cooke, Pediatr Res 2001;49:717-722

Morley, Am J Clin 2001;71:822-8

Growth ChartsRecommended growth charts: 2013 Fenton growth charts from birth to

~50 wks WHO growth charts from term to 24 months CDC growth charts from 24 months to 18 yrs

old

Fenton Growth Gridshttp://ucalgary.ca/fenton/2013chart

Why should we use the updated Fenton charts?

Boys chartSolid lines = 2013Dashed lines = 2003

Growth Assessment

Start with correct growth parameters

Growth parameter

Term-3 mo CA 3-6 mo CA

Weight Gain

~6-8 oz/wk ~4 oz/wk

Length Gain ~1 cm/wk ~0.5 cm/wk

HC Gain ~0.5 cm/wk ~0.2 cm/wk

Corrected Age

Use corrected age for all premature infants <37 weeks until 24 months when assessing: Growth Nutritional needs Feeding (solids, cow’s milk) Developmental milestones

First Choice Formulas for Premies: Post-Discharge Formula Post-Discharge (transitional) formulas

Enfamil Enfacare* Similac Neosure* Good Start Nourish**WIC provides with an Rx

Provide add’l vits & nutrients: Ca, Phos & Pro Whey-dominate, less lactose, 20% MCT oil Provide add’l calories: 22 vs. 20 kcal/oz May be mixed to 24 or 27 kcal/oz May be used to fortify EMM to 22, 24, 27

kcal/oz

Second Choice Formulas for Premies: Term Formulas Standard Term Formulas

Enfamil Premium Good Start Gentle; Good Start Protect Similac Advance (WIC)

Reduced/No Lactose and/or Partially Hydrolyzed Enfamil Gentlease Good Start Sooth, GS Gentle, GS Protect Similac Sensitive, Similac Total Comfort (19 kcal/oz)

Uses: GI upset, constipation, lactose sensitivityProvides 20 kcal/ozCan fortify EMM or be prepared to 22, 24, 27

kcal/oz

Contraindicated Formulas for Premies: Soy Formula

AAP does not recommend soy formula for preterm infants born <1800g Lower serum albumin levels High amts of phytates Lower levels of markers for bone formation Risks for aluminum toxicity Concerns w/ disruption of thyroid fct, suppression

of testosterone, & phytoestrogen-like effect

Examples: Isomil & Prosobee (WIC) Bhatia, Pediatrics

2008;121:1062

Contraindicated Formulas for Premies: Thickened FormulasThese “reflux” formulas contain rice starch

with thicken upon entering the stomach.

Contraindicated for premature infants <38 weeks GA due to risk of the formation of lactobezoars (hard clumps of undigested milk curds)

Examples: Enfamil AR* & Similac for Spit-Up* *Available thru WIC w/ Rx

EMM & Formula ComparisonValuesPer 100ml

Term EMM 20

kcal

EMM + Enfacare

24 kcal/oz

Enfacare 24

kcal/oz

Enfamil20 kcal

Calories 68 80 80 68

Pro, G 1 1.36 2.3 1.4

Ca, mg 28 44 97 53

Phos, mg 15 24 53 29

Iron, mg 0.04 0.3 1.4 1.2

Breastfeeding the Premature Infant

“The potent benefits of human milk are such that all preterm infants should receive human milk.”

“Human milk should be fortified, with protein, minerals, and vitamins to ensure optimal nutrient intake for infants weighing <1500 g at birth.” Policy Statement: Breastfeeding and the Use of Human Milk, Pediatrics 2012;

129:e827

In general, the smaller infant, the higher the nutritional needs & the longer they may need fortification.

Breastfeeding the Preterm Infant

There are several significant short & long-term benefits to feeding a preterm infant human milk: ↓ rates of sepsis & NEC Fewer hospital readmissions ↑ intelligence thru adolescents ELBW infants fed ↑ of human milk show significantly ↑

scores for mental, motor, & behavior ratings at ages 18 months and 30 months

• Even after adjusting for cofounders• Outcomes assoc. w/ predominant human milk, not exclusive

Lower rates of metabolic syndromePolicy Statement: Breastfeeding and the Use of Human Milk, Pediatrics

2012;129:e827

Goals for Breastfeeding the Premature Infant Promote adequate wt gain, including catch-

up Ensure good nutritional status Maintain & increase breast milk supply Sustain or improve feedings at the breast Limit bottle & formula feedings

Guidelines for Initiating & Maintaining Milk Supply

First 2-3 weeks Use hand expression & compression w/ pumping

http://newborns.stanford.edu/Breastfeeding/MaxProduction.html

http://newborns.stanford.edu/Breastfeeding/HandExpression.html

Pump w/ double electric pump Empty breasts at every pumping Pump q 2-3 hrs/day & 1x/night (not to exceed 4 hrs) Pump 7-10x/24 hours while establishing supply

After first 2-3 weeks (if adequate milk supply) Pump q 4hr/day & 1x/night (not to exceed 5 hrs) Pump 6-8x/24 hours

Ideas for Increasing Milk Supply Increase skin-to-skin contact Ensure adequate fluid intake Ensure optimal pump and/or flange Increase frequency of pumping, up to

10x/d Use breast massage/compression while

pumping Discuss ways to decrease tension Try power or cluster pumping Discuss use of galactagogues/meds w/ LC

Breastfeeding the Premature InfantThe ability to BF is multi-factorial, depends on:

MOB’s milk supply & willingness to pump Birth weight & gestational age Complexity of NICU course Infant maturity

Breastfeeding the Premature Infant

Typical plan of BF premature infant at discharge: BF 2x/d (with time limit) Offer bottle of fortified EMM q feeding Give MVI w/ iron daily MOB pumps q feeding

Breastfeeding the Premature InfantProgression of BF plan:

Add one additional BF q week Consider nipple shield Cont. to offer fortified bottles q feeding

& after BF Give 1 ml MVI w/ iron daily MOB to continue to pump at q feeding &

after BF until at least 40-44 weeks GA Support, support, support!!!

Breastfeeding the Premature Infant

Evaluation of readiness to reduce fortification: Ability to sustain growth Ability to sustain appropriate ad lib milk

intake Lab values are WNL (ck’d one mo post-

discharge)

Methods to decrease fortification:1. Decrease by 2 bottles q 4-6 days or2. Drop fort bottles at night* Check weight WEEKLY during transition

Vitamin/Mineral SupplementationIf infant is primarily on:

What supplements are recommended?

When can the supplements be stopped?

Breastmilk (Unfortified or Fortified)

1 ml daily infant MVI with iron OR1ml daily infant MVI without iron + separate iron supplement

Continue until 12 mo corrected age

Iron-Fortified Formula

0.5 ml daily infant MVI without iron

Stop when intake reaches ~ 32 oz/d

*Poly vitamin = A, C, D, E, B vitamins + iron?*Tri vitamin = A, C, D + iron?

Osteopenia of Prematurity

Condition of decreased bone density in premature, LBW infants.

Characterized by low Ca, low P, and high ALP

Risk for bone fractures & growth stunting

Osteopenia of PrematurityRisk factors:

VLBW infants (<1500 g) Any IUGR infant with a BW <1800g Infants with CLD or BPD Infants requiring long-term TPN (>4

weeks) Infants on certain meds that affect mineral

absorption Infants starting feeds of unfortified

breastmilk or standard/soy formula

Osteopenia of Prematurity

Indications for reassessment of bone labs: 1 mo post discharge for infants w/ BW

<1500g 1 mo post discharge if any labs at

discharge were abnormal An infant <3 mo CA who is transitioning

to breast or term formula Infant with marginal intake & slow

growth

Osteopenia of PrematuritySome very small premature infants gain

weight well while taking only breastmilk, despite having abnormal bone labs.

Tribasic: Ca/P supplement Standard dose is 1/8 tsp BID, up to TID Bone labs should be monitored q 4-6 wks

while on Tribasic Infant continues w/ Tribasic for 2-3 mo while

EBF

Late Preterm InfantInfants born between 34 0/7 – 36 6/7 weeks GABirth weights ~ 2000-3000g (4 ½ -6 ½ lbs)

No current recommendations for additional nutrient requirements, besides a multivitamin.

At risk of inadequate nutrient intake due to: Immature gastrointestinal function Immature neural function Lower stamina Lower oral-motor tone

Late Preterm InfantsBreastfeeding: Many discharged home before MOB’s milk

supply established Late preterms may not be able to provide

enough stimulation to bring in adequate supply

MOB will usually have to pump after BF for several weeks to ensure adequate supply

Infants can EBF, BF + bottle of EMM, BF + bottle of fortified EMM to 22-24 kcal/oz

Offer MVI until 12 mo CA

Late Preterm InfantsFormula Feeding:

Offer TERM infant formula Offer MVI until volume reaches 32 oz/d May start/increase to 22-24 kcal/oz if

infant unable to consume enough volume to provide adequate growth. Usually need inc. calories for first month.

Feeding Progression/Solids

Feeding recommendations for premature infants should be based on corrected age: Breastmilk/formula until at least 12 mo

CA Solids may be introduced between 4-6

mo CA (based on developmental stage & feeding skill)

Withhold cow’s milk until 12 mo CA

Common Concerns in the Premature Infant Constipation Spit-up &/or GERD Inadequate weight gain Rapid weight gain

Constipationin the Premature InfantStools that are dry, hard & difficult to pass,

independent of frequency

Causes/Assessment: Immature GI tract Medications Inadequate fluid intake Calorie-dense formulas Improper formula preparation Transitioning from breastmilk to formula Early intro to cereals in bottle Neurological delays

Constipation – Feeding Plan Maximize breastmilk Warm bath, infant massage, bicycle movements Iron:

Iron supplements may cause constipation Check hematocrit -if formula is meeting iron

needs & hct is WNL: Switch to MVI w/o iron Juice (if infant is >40 weeks):

Mix ½ oz prune, pear or apple juice with ½ oz water

Start 1 oz diluted jc qod, inc to 1 oz diluted jc qd prn

Max 1 oz full-strength jc qd

Constipation – Feeding Plan If taking PDF mixed >24 kcal/oz:

Decrease from 27 kcal/oz to 24 kcal/oz to 22 kcal/oz If infant BW >1500-1800g & if gaining weight well,

consuming good vol, and nutritional needs met: D/C fortifier & offer 100% breastmilk Change to routine term formula Always check wt gain/intake wkly after making

change If infant BW <1500g & <3 mo CA:

Talk w/ RD who has experience with premature infants

Always check bone labs before making a formula change

If constipation continues, talk to MD re: stool softeners

Spit-up and/or GERD in the Premature InfantAssessment:

Assess weight gain Assess nipple flow Assess feeding behaviors and positioning Back arching? Volume in bottle slowly increasing or

decreasing? Volume of spit-up Parental concerns

Spit-up and/or GERDin the Premature InfantFeeding Plan:

Parental reassurance if growth ok Smaller, more frequent feeds Keep upright for 20 min after a feeding Educate on proper positioning No solids in bottle Limited use of added starch formula &

only if > 40 wks CA Reflux meds needed?

Poets, Pediatr 2004;112:212-217 Carroll, Arch Pediatr Adolesc Med

2002;156:109-11 Lightdale, Pediatr 2013; 131:1684-95

Inadequate Weight Gain in the Premature InfantAssessment:

Infrequent bottle feeding (> Q 3-4 hr) Improper mixing formula/fortifying EMM Lower kcal/oz formula Easily exhausted or not interested in breast,

bottle Slow nipple flow on bottle, tight suction on cap Minimal BF skills Constipation affecting volume consumed GERD affecting volume consumed Neurological delays & limited coordination Recent illness

Inadequate Weight Gainin the Premature Infant

Feeding Plan: Observe feeding, trial of nipples If trying to transition to breast, make sure baby

is offered bottle after BF, put time-limit on BF Switch to 24-27 kcal/oz Calculate catch-up needs Give parents a goal intake volume

• Parents to keep diary for 2 weeks Weekly weight checks Discuss plan w/ MD

Rapid Weight Gain in the Premature InfantAssessment:

Improperly mixing formula Improperly fortifying EMM Large volumes consumed Feeding schedule vs. hunger cues Cereals in bottle After successful BF reached, cont. to offer bottle

after BF

Rapid Weight Gain in the Premature InfantFeeding Plan:

Discuss feeding cues & volumes w/ family Switch kcal level down

• 27-24-22 kcal/oz If >1500g-2000g BW & if growth ok:

• Switch to term formula If <1500 BW & if growth ok, ck bone labs:

• If WNLs, switch to term formula; re-ck labs in 1 mo

• If abnormal, continue w/ PDF & re-ck labs in 1 mo

Coordination of Care Family Pediatrician Nurses: PMD office &

PHN Dietitians: NICU,

out-patient, WIC Lactation consultants Neurodevelopmental/

Feeding clinic

Get involved!

Nutrition Practice Care Guidelines for Preterm Infants in the Community

http://public.health.oregon.gov/HealthyPeopleFamilies/WIC/Pages/index.aspx

Click on “For Medical Providers” Double click on “Nutrition Practice Care

Guidelines…”

OR

Click on “For Oregon WIC Staff” on left-side column Click on “WIC Staff Resources” Scroll down to “Nutrition Information” header Double-click on “Nutrition Guidelines: Preterm

Infants” & “Oregon Appendix”