Feeding the Preterm Infant

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Feeding the Preterm Infant. Jill-Marie Spence, RD April 2013. Outline. Introduction Human Milk Preterm Formulas Nutritional Needs: Micropreterm SGA Late Preterm Infant Post-discharge Nutrition Growth Conclusion. Estimated Nutritional Requirements. AAP recommends:
Transcript
Feeding the Preterm Infant Jill-Marie Spence, RD April 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 understanding of science to practical application. Nutritional Needs of Preterm Infants Colostrum and Transitional Milk understanding of science to practical application. Improves immune function Promotes gut maturation Benefits of Human Milk understanding of science to practical application.
  • 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 understanding of science to practical application.
  • > 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 understanding of science to practical application.
  • 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 understanding of science to practical application.
  • 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 understanding of science to practical application.
  • 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 understanding of science to practical application.
  • Endocrine
  • Decreases the incidence of type 1 and type 2 diabetes
  • Nutritional content of human milk varies with understanding of science to practical application.
  • 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 breastfeeding
  • 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
  • Many of the benefits of HM are still unknown lymphocytes and other components are removed from HM Human milk is a living tissue that cannot be duplicated
  • Composition of Preterm Transitional, mature, and term mature milk Schanler, Atkinson in Tsang 2005 Unfortified Human Milk 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 milk 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 milk 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 milk
  • 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 infants born < 32 weeks and supplementation may be required for infants 32 -36 weeks of gestation
  • 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 infants born < 32 weeks and supplementation may be required for infants 32 -36 weeks of gestation
  • Promotes gastric emptying and digestion
  • Cysteine and Taurine added
  • Methionine -> Cysteine
  • Cysteine -> Taurine
  • Conditionally essential
  • LCPUFA infants born < 32 weeks and supplementation may be required for infants 32 -36 weeks of gestation
  • 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 diet infants born < 32 weeks and supplementation may be required for infants 32 -36 weeks of gestationAuestad 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.
  • 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
  • Amino-Acid Based Infant Formulas enteral feeding with a higher protein:energy ratio to meet the goal of greater protein gain relative to fat
  • Cow’s milk protein allergy
  • Multiple food protein intolerance
  • Infants unable to tolerate hydrolysate based formulas
  • Short Bowel Syndrome
  • Other GI disorders
  • Current Recommendations enteral feeding with a higher protein:energy ratio to meet the goal of greater protein gain relative to fat
  • 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 enteral feeding with a higher protein:energy ratio to meet the goal of greater protein gain relative to fat
  • 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
  • Enteral Requirements enteral feeding with a higher protein:energy ratio to meet the goal of greater protein gain relative to fat Nutritional Needs of the enteral feeding with a higher protein:energy ratio to meet the goal of greater protein gain relative to fatMicropreterm 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 during the last trimester
  • Fetal intestine capable of digesting and absorbing milk
  • 25 – 30 weeks
  • Disorganized motility
  • Lack of published during the last trimesterdata 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
  • TPN during the last trimester
  • 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 during the last trimester
  • 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 during the last trimester
  • 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 Infants
  • 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
  • Post-discharge Nutrition for SGA resistance
  • 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 metabolic 34 to < 37 weeks Lapillonne J Ped 2013;162:s90-100
  • Difficulty feeding metabolic
  • 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 metabolic
  • 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 metabolic
  • 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 nutritional requirements of late-preterm infants have not been established
  • 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 nutritional requirements of late-preterm infants have not been established< 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 nutritional requirements of late-preterm infants have not been established
  • 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
  • Formula Cost Comparison nutritional requirements of late-preterm infants have not been established How do we measure up? nutritional requirements of late-preterm infants have not been established Postnatal Growth Failure nutritional requirements of late-preterm infants have not been established
  • 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 nutritional requirements of late-preterm infants have not been established
  • Strong evidence exists to support nutritional programming or late effects of early nutritional experiences
  • Improved neurocognitive outcomes Ehrenkranz 2006
  • Growth nutritional requirements of late-preterm infants have not been established
  • 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 monito
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