sap - pn nutrition in vlbw infants: improvement of postnatal … neonatologia... · 2016. 7....

33°° CongresoCongreso ArgentArgentBuenos Buenos AeresAeres

PN nutrition in VLBW iPN nutrition in VLBW ipostnatal growtpostnatal growtpostnatal growtpostnatal growt

J Rigo University of Liège, Cy g ,

tinotino de de NeonatologiaNeonatologiass 1_3 July 20161_3 July 2016

nfants: improvement of nfants: improvement of th using optimalth using optimalth using optimalth using optimal

MD PhDCHU de Liège, Belgiumg , g

PN Compounded PN Compounded vsvs industrial sol.industrial sol.CVC Central

Venous Catheter

tcPO2tcPCO2

CCore Temperature

Periperal Infusion

Urine Collection

Peripheral Temperature

Mechanical Ventilation

FeedingTube

Cardio Respiratory Monitoring

Arterial Line blood sampl.

g

Non Invasive

pBP monit.

Oxygen

Invasive BP

Oxygen Saturation

Carnielli VP 2003

Growth similar to intrauterine growth; Myth or Reality?

Growth rate ac

70 16

18

20

60

70

ars) 10

12

14

16

t gai

n (g

/kg/

d)40

50

gain

(cm

/yea

2

4

6

8

Wei

ght

20

30

gth/

heig

ht g

Boys

26 28 300

0

10

leng

Girls

0-1 0 1 2 3 4 5 6 7 8 9

Age (y

ccording to age

6

7

ss (k

g)d)

Weight gain Body weight Fat free massProtein

3

4

5

and

fat f

ree

mas

ccre

tion

(g/k

g/d Protein

Fat mass

1

2

3

Bod

y w

eigh

t aP

rote

in a

c

32 34 36 38 40 42 44 46 48 50 52 54 56 58 60

Postmenstrual age (wks)

0

10 11 12 13 14 15 16 17 18 19 20

years)

Postnatal growth restric

100 Length

80

90Weight

Head circumfere

50

60

70

scha

rge

(%)

30

40

50

SGA

at d

is

10

20

023 24 25 26 27 2

Gestati

ction in preterm infants

ence SGA VLBW infants at discharge• 91% in USA (Fanaroff 2007)

• 57% in Shanghai (Shan 2008)

• 57% in Japan (Sakurai 2008)

• 58% in Norway (Henriksen 2009)

28 29 30 31 32 33 34ional age (weeks)

Clarck 2003

Failure to Achieve Nutritional GoalNutritional Deficits

Energy Intake andCumulative Energy Deficit

Postnatal Age (weeks)

*

N=105 preterm infants ≤34 weeks GA and a birth weight ≤17Energy goal = 120 kcal/kg/d


Embleton NE, et al. Pediatrics. 2001;107:270-273.

Actual recommendations: EnerProt

s Produces

Protein Intake andCumulative Protein Deficit


*

750 g


Protein goal = 3 g/kg/d

6

rgy goal = 120 kcal/kg/dein goal = ± 4.0 g/kg/d

Early Growth and Lo

GrowthGrowth similarsimilar to to intrauterineintrauterine gg

Early Growth and Lo

80

50

60

70

30

40

50

0

10

20

0Quartile1 (12,0±2,1)

Quartile 2 (15,6±0,8)

RA. Ehrenkr

Ex Neur Normal (%) Déficit neurod

ng Term Development

growthgrowth; ; MythMyth or Realityor Reality?

ng Term Development

Quartile 3 (17,8±0,8)

Quartile 4 (21,2±2,0)

ranz & al Pediatrics 2006

dev (%) Rehosp (%) taille<p10 (%)

IntraIntra‐‐uterinuterin growthgrowth; ; MM

First week protein and energy intd l t l tdevelopmental outco

Day 1 : 0.4 g AA /kg*day and 31 kCal/kg*

Day 7 : 2.9 g AA /kg*day and 81 kCal/kg*

+8.2

+1

MythMyth or Realityor Reality?

takes associated with 18-months i ELBW i f tome in ELBW infants

*day

*day Stephens BE, 2009

+4 6+4.6+10

Nutritional approach foNutritional approach fo

Growth similar to intra‐uter

Did we need mineral’s and efirst dayy

Potential side effect of earlyof protein overload?

or the VLBW infantsor the VLBW infants

in growth: Myth or Reality?

electrolyte’s supplies from the

y high AA intake. Is there a risk

9

Growth similar to intrauterine

Is it possible to reduce post natalIs it possible to reduce post natalgrowth restriction in ELBW and VLBW infants?

Senterre T and Rigo J. Acta Paediatrica. 2012;101(2):e64‐70

Role of an early aggressivenutritional programme using anutritional programme using a premixed ready‐to‐use parenterasolutionSenterre T and Rigo J. J Pediatr Gastroenterol Nutr. 2011;53(5):536‐42.

growth; Myth or Reality?

ll

al

Need for a Balanced Parenteral S


in VLBWa) AA & energy intakes:

1. Early “aggressive” nutrition reduimproves early postnatal growth

1 12. AA intake >2.5g kg‐1 d‐1 and eneday induces positive nitrogen ba

3 Appropriate fluid intake 50 to 803. Appropriate fluid intake 50 to 80loss (evaporation, perspiration) and 10% improves electrolyte holife

4. Early AA (prot) and energy intak

Solution from the First Day of Life

growth; Myth or Reality

W Infants

uces cumulative nutritional deficit and h in VLBW infants

1 1rgy intake >40 kcal kg‐1 d‐1 on the first alance and promotes LBM deposition

0 ml kg‐1 d‐1 and the limitation of water0 ml kg 1 d 1 and the limitation of water to limit the weight loss to between 5 omeostasis during the first few days of

kes to reach 4.0 g AA and 120 kcal/kg*d


H id d i k d i

Enteral feeding was initiated on t

How to provide adequate intakes during t

Enteral feeding was initiated on tHM, OMM or banked HM

First 20 ml/kg was not considered/ g

HM Fortification was initiated at 5

Individual fortification were perfo Individual fortification were perfocompensate the low fat contentprotein/kg*d

When HM was not available , VLBP/E ratio 3.3 to 3.6 g/100 kcal


h i i l i d l i i

he first or the second day of age with

the transitional period to enteral nutrition

he first or the second day of age with

d in protein and energy count.p gy

50 ml/kg*d

ormed in some preterm infants toormed in some preterm infants to t of OMM and to provide 4.3 g of

BW infants received a PTF with a high

Significant improvement d

IntraIntra‐‐uterinuterin growthgrowth; ; g f p

Recommendations are meet4,5

Recommendation for Stable Gro ing on Oral N trition1

3

3,5

4

g*d)

Embleton 2001Stephen 2009Martin 2009

Recommendation for Stable Growing on Oral Nutrition1

1 5

2

2,5

3

n in

take

(g/k

g Martin 2009Senterre 2011

0,5

1

1,5

Pro

tein

0day 1 week 1 week 2 week 3 week 4

Senterre T and Rigo J. J Pediatr Gastroenterol Nutr.. 2011;53(5):536‐42. .Senterre T and Rigo J. Acta Paediatrica. 2012;101(2):e64‐70 .

during the first week of life

MythMyth or Realityor Reality?g f f f

t at the end of the first week140

Recommendation for Stable Gro ing on Oral N trition1

100

120

l/kg*

d)

Embleton 2001Stephen 2009

Recommendation for Stable Growing on Oral Nutrition1

60

80

y in

take

s (k

cal Stephen 2009

Martin 2009Senterre 2011

20

40

Ene

rgy

0day 1 week 1 week 2 week 3 week 4

IntraIntra‐‐uterinuterin growthgrowth; ;

Cumulative Intakes

Cumulative nutritional deficit

ulative de

ficit

Cumu

● <28 weeks○ 28‐30 weeks∆ <31 weeks (Embleton 2001)

t Intakes

At 6 weeksmulative de

ficitAt 6 weeks

Cum

Th Senterre & J Rigo 2011

Energy (kcal/kg)

MythMyth or Realityor Reality?gy ( g)

400

600

800

1000

1200

-600

-400

-200

0

200

1 2 3 4 5 6-1200

-1000

-800objective = 5040 kcal/kg

Protein (kg/kg)40

-10

0

10

20

30

-60

-50

-40

-30

-20

<28 weeks 28-30 weeks <31 weeks (Embleton 2001)

objective = 160 g/kg

1 2 3 4 5 6

Postnatal age (weeks)

-70

-60

Standardized PN in the NICU C


Standardized PN in the NICU C

Weight Z-score change from birth0 6

0,0

0,3

0,6

-0,9

-0,6

-0,3

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Postnatal age (days)

-1,5

-1,2N=102

• Growth restriction limited to the first earlier studies

• Growth similar to intrauterine growth


• Growth similar to intrauterine growth

Senterre T and Rigo J. Acta Paediatrica. 2011—in press.

Can Meet Guidelines


Can Meet Guidelines

Weight z-score change from birth0 0

-0,4

-0,2

0,0 <28 weeks 28-30 weeks <31 weeks (Embleton 2001)

-1,0

-0,8

-0,6

0 1 2 3 4 5 6Postnatal age (weeks)

-1,4

-1,2

three days of life by contrast with

h after first 3 days of life

Postnatal age (weeks)

h after first 3 days of life

15

bl b l h


2600

Is it possible to abolish Post N

2000

2200

2400Mean

1600

1800

2000

eigh

t (g)

1000

1200

1400We

26 27 28 29 30 31 32 33 34600

800

Gestational age (weeks)

l h ?


Natal Growth Restriction?

n -2SD

1800

2000 Intrauterine growth 24-25 weeks 26-27 weeks 28-29 weeks

50th 10th

1000

1200

1400

1600

Wei

ght (

g)

35 36 37 38

22 24 26 28 30 32 34 36

Gestational age (weeks)

600

800

1000


Birth

80%

6%

AGA

6%

20%

SGASGA20%

Usher & McLean


Discharge

94% 79%

%

80% 21%LiLitterature

40‐90%

1 Optimal nutrition from birth in t

Conclusions1. Optimal nutrition from birth in t

allows to reduce initial weight lonitrogen balance and to promotg pthe intra‐uterine growth rate.

2. Early HM fortification <50ml/kg,provide at least 4.3g/kg*d of prouse of preterm formula with higuse of preterm formula with higmaintain an adequate growth rarelative catch up growth before p g f

3. Cumulative nutritional deficit carestriction is not an inevitable ph

the range of the recent guidelinesthe range of the recent guidelines oss, to induce early positive te early weight gain in the range of y g g g f

, adequate HM fortification to otein and 130 kcal/kg*g and the h Prot/energy ratio allow toh Prot/energy ratio allow to ate >17g/kg*d and to obtain a discharge or theoretical term.g

an be abolish and postnatal growth henomena in the ELBW infants.









19

l

More aggressive nutrition may inducin VLBW in

Ca & P intakes:Parenteral

• Ca and P supplies are nelife in VLBW infants on P

• In parenteral solution, oclose to 1/1 or slightly<1

• Phosphorus need can bethe Ca intakes provided by

ce a new metabolic syndrome fants

nutrition

ecessary from the first day of PN

optimal molar Ca/P ratio is

e estimated from the AA and y the parenteral solution

Electrolyte’s Homeost

Need for a balanced p

Electrolyte s Homeost

• Extra‐Uterin Adaptation = transitioExtra‐Uterin Adaptation = transitio– Physiological Water loss : extracellular vo– Oliguria during the first 24‐48 hours of li– Weight loss: 5‐10% du BW Term infants, 1

• Fréquents Electrolytic Disorders in – Hypernatriemia >150 mmol/L : 30‐50%

H k li i 7 l/l 20 25%– Hyperkaliemia >7 mmol/l : 20‐25% = Challenge for the Neonatologists

Recommendations :Recommendations :• No Na and K intakes during the first days o

tasis in VLBW infants

arenteral solution

tasis in VLBW infants

nal Phasenal Phaseolume reductionfe10‐20% preterm <1500g (Fusch 2005)

VLBW infants <1500g (Huston 2007, Gawlowski 2006, Kermorvant‐Duchemin 2012)( ) (Mildenberger 2002, Thayyil 2008, Yaseen 2009, Iacobelli 2010)

of life.(Fusch 2005, ESPGHAN 2005, Bhatia 2006)

More aggressive nutrition masyndrome in VL

1 By turning the nitrogen balance f

a) Current guidelines

1. By turning the nitrogen balance fadministration could also minimidisturbances after birth especial

2. In addition P supply cannot be pr

y induce a new metabolic LBW infants

from negative to positive AAfrom negative to positive, AA ize the occurrence of water and ions ly in ELBW infants.

rovide without Na or K.

Need for a balanced p

Electrolyte’s Homeost

c) Na, K & Cl intakes:

Electrolyte s Homeost

1. Phosphorus supply is associated to a

2. LBM accretion requires some P and compartment (10 mg P/160 mg Nitrocompartment (10 mg P/160 mg Nitrocompartment (1 à 1.5 mmol/10g de

3. Limitation of the initial weight loss im3. Limitation of the initial weight loss imthe first week of life

4. Increase of AA intake reduces or pre

5. The use of a balanced electrolyte intCl–>1‐2 mmol)

parenteral solution

tasis in VLBW infantstasis in VLBW infants

a Na or K intake

K retention for the intracellular ogen) and Na for the e tracell larogen) and Na for the extracellular LBM).

mproves electrolyte homeostasis duringmproves electrolyte homeostasis during

events the non‐oliguric hyperkaliemia

take improves acid base status (Na++K+‐

Kg*d Estimated o

Compounded ready to use or in

Kg dparenteral in

Fluids ml/kg/d -Energy Kcal/kg/d 90-120Protein g/kg/d 3.5-4.0Glucose g/kg/d 13-18Fat g/kg/d 2-4Sodium mmol/kg/d 2-7Potassium mmol/kg/d 2-5Chloride mmol/kg/d 2 7Chloride mmol/kg/d 2-7Calcium mmol/kg/d 1.3-4.0Phosphorus mmol/kg/d 1 0 2 5Phosphorus mmol/kg/d 1.0-2.5Magnesium mmol/kg/d 0.15-0.3

Th Senterre & J Rigo 2011; J.Rigo& al 2012

ptimal Senterre & New NUMETA

dustrial multichamber bag

p

ntakesSenterre &

Rigo 2011

New NUMETA

G13% 3CB

165 130

0 118 118

0 4.1 4.0

8 18.8 17.3

3.0 3.25

2.4 3.25

2.3 2.7

3 0 4 03.0 4.0

0 2.7 1.62

5 2 7 1 635 2.7 1.63

30 0.25 0.20

How to use Standardized ParenMinimal adaptation allows to provide nutritio

early days of

APP 2 1083mOsm/L J1 J2volume 100 ml/kg/d 40 50 60 70

AA 2,7 g/kg/d 1,1 1,4 1,6 1,9

early days of

AA 2,7 g/kg/d 1,1 1,4 1,6 1,9glucose 12,5 gr/kg/jour 5 6,3 7,5 8,8

Lipid 20%* gr/kg/jour 1 1 1 1,5

energy 57 kCal/kg/d 32 38 44 54

Na+ 1,6 mmol/kg/d 0,6 0,8 1 1,1K+ 1,5 mmol/kg/d 0,6 0,8 0,9 1,1Cl- 2 mmol/kg/d 0,8 1 1,2 1,4

Ca++ 72 mg/kg/d 28,8 36 43,2 50,4 5P 55 mg/kg/d 22 27,5 33 38,5

Primene 10%A.A 1 g/kg/d 1 1 1 0,5volume 10 ml/kg/d 10 10 10 5volume 10 ml/kg/d 10 10 10 5energy 3,75 kCal/kg/d 3,8 3,8 3,8 1,9

TOTAL INTAKES volume ml/kg/d 55 65 75 82gAA g/kg/d 2.1 2.4 2.6 2.4energy kCal/kg/d 36 42 48 56

Energy=AA*3.75+* Added separetely

teral Nutrition in VLBWIonal recommendations during the life

J3 J4 J5 ≥ J680 90 100 110 120 130 140 150 1602,2 2,4 2,7 3 3,2 3,5 3,8 4,1 4,3

life

2,2 2,4 2,7 3 3,2 3,5 3,8 4,1 4,310 11,3 12,5 13,8 15 16,3 17,5 18,8 20

1,5 1,5 2 2 2,5 2,5 3 3 3

60 65 76 81 92 97 108 113 120

1,3 1,4 1,6 1,8 1,9 2,1 2,2 2,4 2,61,2 1,4 1,5 1,7 1,8 2 2,1 2,3 2,41,6 1,8 2 2,2 2,4 2,6 2,8 3 3,2

57,6 64,8 72 79,2 86,4 93,6 100,8 108 115,244 49,5 55 60,5 66 71,5 77 82,5 88

0,5 0,5 0 0 0 0 0 0 05 5 0 0 0 0 0 0 05 5 0 0 0 0 0 0 0

1,9 1,9 0 0 0 0 0 0 0

92 102 110 120 132 142 155 165 1752.7 2.9 2,7 3 3,2 3,5 3,8 4,1 4,362 67 76 81 92 97 108 113 120

+Glu*3.75+lip*9.3 kcal

Balanced Parenteral Solution Imp

More aggressive nutrition may induin VLBW in

145

150

mm

ol/L

)

14,50

15,00

**

* **


115130

135

140

conc

entra

tion

(

11 5013,00

13,50

14,00*

100

105

110

115

asm

a N

a an

d K

10 00

10,50

11,00

11,50

** *

**

55

6095

100

Pla

5,50

6,009,50

10,00

mm

ol/L

)

*

40

45

50

4,00

4,50

5,00

sma

K c

onc.

(m* *##

Birth 1 2 3 4 5 6 7

Postnatal Age (d)

35 3,50 Pla

s

Th Senterre

roves Electrolyte’s Homeostasis

uce a new metabolic syndrome nfants

147,5

150,0

ol/L

)

15,0

<28 wks GA* *

roves Electrolyte s Homeostasis.

137 5

140,0

142,5

145,0

cent

ratio

n (m

m

14,0

14,5 28-30 wks GA

**

107,5

110,0135,0

137,5

Na

and

Cl

con

11,013,5

***

*

52,5100,0

102,5

105,0

Pla

sma

N

10,0

10,5

ol/L

)

42 5

45,0

47,5

50,0

4,5

5,0

ma

K c

onc.

(mm

Birth 1 2 3 4 5 6 7

Postnatal age (d)

40,0

42,5

4,0 Pla

sm

e JFRN 2012

Consequences of aggressive nutitio

Electrolyte’s Ho

2

3

143

144

mean ± 95% CIBW <1250g, N=102

-2

-1

0

1

n (%

BW

)

141

142

-5

-4

-3

Wei

ght g

ain

138

139

140

0 1 2 3 4 5 6 7-8

-7

-6

136

137

r=-0.33, p<0.001


onal approach in VLBW infants

BW <1250g, BW: 1005 ± 157 g

omeostasis

N=102 GA: 28.5 ± 1.9 weeksMean ± SD

Incidence Literature

Na >150 mmol/L 16% 30 50%m (m

mol

/l)

Na >150 mmol/L 16% 30-50%

Na <130 mmol/L 30% Pla

sma

sodi

u

K >7 mmol/L 0% 20-25%

K 3 l/L 9%K <3 mmol/L 9%

B l d P l S l i I

More aggressive nutrition may induin VLBW in

8

g/d)

8 Sodium

Urinary excretion (mmol/kg*d)


6

7

ss (m

mol

/kg

6

7 Urinary excretion (mmol/kg d) Total intake (PN+ON) (mmol/kg*d)

4

5

urin

ary

los

4

5

Negativeb l

2

3

inta

ke a

nd

2

3balance

0

1

Sod

ium

0

1

0 1 2 3 4 5 6 7Postnatal age (days)

Th Senterre JFRN 2012

El l ’ H i


3,0

)

PotassiumUrinary excretion (mmol/kg*d)

proves Electrolyte’s Homeostasis.

2 0

2,5

s (m

mol

/kg/

d y ( g ) Total intake (*N+EN) (mmol/kg*d)

1,5

2,0

d ur

inar

y lo

ss

Negativebalance Positive

balance

1,0

um in

take

an

0,0

0,5

Pot

assi

u

0 1 2 3 4 5 6 7


0,0

More aggressive nutrition may induin VLBW i

Effect of AA intake on Initial

Three groups of AA intakesThree groups of AA intakes

Decrease of the Initial Weight LossDecrease of the Initial Weight Loss

Bonsante F Iacobelli S& al Eur. J Clin Nutr. 2


weight loss and Plasma K+

Reduction of the plasma K+ Conc.

s Rétention of K↑related to AA Intakes ↑

2011;65:1088-93









30


Influence of AA intakes on glu

0 200,220,240,26

h)

0 120,140,160,180,20

ke (g

/kg*

h

0,040,060,080,100,12

AA

inta

k

0,0 0,2 0,4 0,6

Glucose intak

0,000,02

Glucose intak

Blood glucose = 0.85* glucose in


ucose tolerance

> 1,9

Glycémie g/l

< 1,9 < 1,8 < 1,7 < 1,6

1 5< 1,5 < 1,4 < 1,3 < 1,2 < 1 1< 1,1

< 1 < 0,9 < 0,8 < 0 7

0,8 1,0 1,2

e (g/kg*h) < 0,7 e (g/kg h)

ntake – 1.23* AA intake + 0.93


M di ti i l l i lMedian creatinemia levels in low birth weight neonates from peak creatinemia until the fourth week of

ol/l)

postnatal life (1,000–1,500 g, 1,501–2,000 g, 2,001–2,500 g, and term neonates were extracted from the at

inine, μmo

neonates were extracted from the paper of Guignard‐ grey discontinuous line), the observations in ELBW neonates (i e <1 000 g)

serum crea

in ELBW neonates (i.e., <1,000 g) (black continuous line)


/)

,μ

postnatal age, weeks

George I et al, Pediatr Nephrol 2011, 26: 1843‐9


1 6 144

1,2

1,4

1,6

L)

108

126

144

L)

Mean ± SD

0,8

1,0

tinin

e (m

g/dL

72

90

tinin

e (µ

mol

/L

0,2

0,4

0,6

Cre

at

18

36

54

Cre

at

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Day of life (d)

0,0 0


90

105

120

mg/

dl)

15,0

17,5

20,0

mol

/L)

Mean ± SD

60

75

Ure

a C

onc.

(m

10,0

12,5

rea

Con

c.(m

m

15

30

45

Pla

sma

U2,5

5,0

7,5

Pla

sma

Ur

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Day of life (d)

0 0,0

BUN is not related to protein intake dis related to Renal


1801000 (N 48)

is related to Renal

140

160

mg/

dL)

<1000g (N=48) r=0.77, p<0.001

1000-1249g (N=54) r=0.73, p<0.001

80

100

120

sma

Con

c(m

40

60

Ure

a P

las

0,0 0,3 0,6 0,9C ti i

0

20

Creatinine p

uring the first weeks of age but immaturity


immaturity.

1,2 1,5 1,8 2,1 2,4l C ( /dL)plasma Conc (mg/dL)


1,8

2,0

2,2

mg/

dL)

Serum Creatinine Conc.=1.40 - 1.39* Prot intake(g/kg*d)

P<0.0001

1,0

1,2

1,4

1,6

nine

Con

c.(m

0,4

0,6

0,8

1,0

Ser

um C

reat

in

0,5 1,0 1,5 2,0 2,5 3,0 3,5 4,0 4,5 5,0 5,5 6,0

Protein intake (PN+EN) (g/kg*d)

0,0

0,2

S


140

160

180

dL)

Serum urea conc mg/dL=78.5 -6.68*Prot intake(g/kg*d)P<0.0001

80

100

120

ea c

onc

(mg/

d40

60

80

Ser

um u

re

1,0 2,0 3,0 4,0 5,0 6,0

Protein intake (PN+EN) (g/kg*d)

0

20

RiskRisk of of ProteinProtein overloadoverload

ff f k800

N Intake

Effect of nitrogen intake on nitrogen

600

700

g/d)

N Intake N Retention N Urinary

400

500

gen

(mg/

kg

200

300

Nit

rog

PT HM PT HMF PTF LP PTF MP P0

100

Pretem

dd in in pretermpreterm infantsinfants

fn urinary excretion in VLBW infants

Putet & al 1984,1987

Rigo &al 1995, 1999

Cooke & al 2006

PTF HP T HM TF

Term

1. Positive nitrogen balance from the

Conclusions1. Positive nitrogen balance from the

matabolic use of potassium and ph2. Optimal nutrition from birth with h

4.5 g of protein during the first weemetabolic syndrome associating hyand hypokaliemiaand hypokaliemia .

3. Parenteral guidelines need to be reparenteral solution providing adeqparenteral solution providing adeqthe first day of life.

4. In enteral nutrition, the use of PTF requirements for phosphorus and p

5. PTF with a Ca/P ratio of 2 are at risVLBW i fVLBW infants.

6. Ca/P ratio and K guidelines need to

first day of life, improves thefirst day of life, improves the hosphorus available for LBM gain. high AA >2.5g/kg*d increasing to 4‐ek of life could induce a new ypophosphatemia, hypercalcemia,

evised to provide well balanced quate minerals and electrolytes fromquate minerals and electrolytes from

with high P/E ratio increases the potassium.sk to induce hypophosphoremia in

o be revised

What is the Divine feeding reegimen for Preterm Infants?

sap - pn nutrition in vlbw infants: improvement of postnatal … neonatologia... · 2016. 7....

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