Nutrition for Low Infant Birth

8/22/2019 Nutrition for Low Infant Birth

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The management of low-birth weight infantsrequiring intensive care continues to

improve dramaticallyNew technology

Use of surfactant

-A mixture of lipoproteins secreted

by alveolar cells into the alveoli and

respiratory air passages that

contributes to the elastic properties

of pulmonary tissues

- have increased the survival of

preterm infants


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Most LBW OR LOW-BIRTH WEIGHT INFANTS have the

potential for long and productive lives

FACTORS THAT DICTATE THE NUTRITIONAL

REQUIREMENTS OF INFANTSInfants size

Age

Clinical condition

Neonatal Intensive Care System

Registered Dietitian

- trained in neonatal nutrition makes the decisions necessary

to facilitate optimal nutrition

Regionalized Perinatal Care System- The neonatal nutritionist may also consult the healthcare

providers in community hospitals and public health settings


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PHYSIOLOGIC DEVELOPMENT

Weight of infant at birth:

Less than 2500 g Low birth weight

Less than 1500 g Very low birth weight

Less than 1000 g Extremely low birth weight

Low birth weight is attributable to:

shortened period of gestation or prematurity

Retarded intrauterine growth rate

makes infant SGA or small for gestational ageGESTATIONAL AGE the age of an infant at birth as determined by

he length of pregnancy ( the number of weeks since the last

menstrual period) or clinical assessment.


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ESTIMATE OF INFANTS GESTATIONAL AGE IS BASED ON:

Date of mothers last menstrual period

Clinical parameters of uterine fundal heightPresence of quickening

Fetal heart tones or ultrasound evaluation

After birth gestational age is determined by clinical assessment

CLINICAL PARAMETERS:

A series of neurologic signs

depends primarily on posture and tone

A series of external characteristics that reflect thephysical activity if the infant


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SGA OR SMALL FOR GESTATIONAL AGE

- has a birth weight that is lower than the 10th percentile of

the standard weight for that gestational age

IUGR OR INTRAUTERINE GROWTH RETARDATION- a SGA infant whose intrauterine weight gain is poor but

whose linear and head growth are between the 10th and 90th

percentile on the intrauterine growth grid

SYMMETRICAL IUGR- infant whose length and occipital frontal circumference

are also below the 10th percentile of the standards

AGA OR AVERAGE FOR GESTATIONAL AGE

- infant has a birth weight between the 10th

and 90th

percentile on the intrauterine growth chart

LGA OR LARGE FOR GESTATIONAL AGE

- birth weight is above the 90th percentile


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INFANT MORTALITY AND STATISTICS

High incidence of LBW infants

- may result to high infant mortality rate

INVERSE RELATIONSHIP BETWEEN BIRTH RATE AND INFANT

MORTALITY RATE

Risk for infant death

- infants weighing 1500 to 2499 g is 6 times higher than infantsweighing more than 2500 g.

- risk of infants weighing less than 1500 g is 96 times higher

FACTORS AFFECTING INANT MORTALITY

1. TEENAGE PREGNANCY- have a 2.3% to 6% higher incidence of giving birth to LBW

infants

2. INCIDENCE OF MULTIPLE BIRTHS

- are 9 times likely to result in LBW


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CHARACTERISTICS OF IMMATURITY

PREMATURE INFANTS

- high risk for poor nutritional status- physiologic immaturity

- Illness

- Nutrient demands

FETAL NUTRIENT STORES

- are deposited at the last 3 months of pregnancy

LIMITED METABOLIC STORES nutritional support in the

form of parenteral or enteral nutrition

should be initiated as soon as

possible

Preterm infants

Weighing 1000g constitutes only of 1% total fat


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TERM INFANTS has fat percentage of 16%

1000 g AGA PREMATURE INFANT

glycogen fat reserve = 110 kcal per kilogram of bodyweight

basal metabolic needs = approximately 50kcal/kg/day

MOST QUICKLY DEPLETED NUTRIENTS

- Infants with IUGR due to increase in basal metabolic rate

SMALL PREMATURE INFANT particularly vulnerable to undernutrition

UNDERNUTRITION deficient bodily nutrition due to inadequatefood intake or faulty assimilation

MALNUTRITION (PREMATURE INFANTS)

- may increase the risk of infants

- prolong chronic illness

- adversely affect brain growth and function


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Type of milk used for neonatal diet

directly linked to neurodevelopment at 18 mos. of age

HUMAN MILK OR PREMATURE INFANT FORMULA

- fed on 1st month of life resulted in improved development

NUTRITIONAL REQUIREMENTS: PARENTERAL FEEDING

Parenteral feeding intravenous administration of nutrients

Difficulty progressing to full enteral feeding

- 1st several weeks/days of life

WHAT MAKES THE DIFFICULTY?

- Infants small stomach capacity

- Immature gastrointestinal tract

- Illness

PARENTERAL NUTRITION

- becomes essential for nutrition support either as a

supplement to enteral feedings or as the total source of nutrition


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FLUID

- fluid balance must be monitored for preterm infants

INADEQUATE INTAKE LEADS TO:

- Dehydration- Electrolyte Imbalance

- Hypotension

EXCESSIVE INTAKE LEADS TO:

- Edema- Congestive heart failure

- Possible opening of the ductus arteriosus

ADDITIONAL CLINICAL COMPLICATION

- Necrotizing entercolitis

- inflammation or death of the gastrointestinal tract- Bronchopulmonary dysplasia

- Intraventricular Hemorrhage

- - - Premature infants have greater % of body water

than the term infant


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REDUCTION OF EXTRACELLULAR WATER

- should be accomplished which is accompanied by a normal loss

of 10% to 15& body weight and improved renal function

ELBW INFANTS lose up to 20% of birth weight

WATER REQUIREMENTS

- estimated by the sum of the predicted losses from the lungs

and skin, urine and stool and water needed for growth

INSENSIBLE WATER LOSS

- highest in the smallest and least mature infants because

longer body surface area relative to body weight

including permeability to skin epidermis to water and

greater skin blood flow relative to metabolic rate.- is increased by radiant warmers and phototherapy by lights

-decreased by heat shields, thermal blankets and humidified

incubators

- can vary from 50 to 100ml/kg/day on 1st day of life and increase

up to 120 to 200ml/kg/day


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DEPENDING ON:

- Infants size

- gestational age

- day of life

- environment

EXRETION OF URINE

- a major route in water loss

- varies from 40 to 85ml/kg/day

- depends on the fluid volume and solute load presented tokidney

ABILITY TO PENETRATE URINE increases with maturity

STOOL WATER LOSS - generally up to 5 to 10ml/kg/day

suggested for optimal growth - 10ml/kg/day

Fluid administered - 80 to 105ml/kg/day (1st day of life)


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FLUID NEEDS EVALUATION:

- assessing fluid intake

- comparing clinical parameters

- urine volume output - creatinine

- specific gravity or osmolality - urea nitrogen levels- serum electrolyte

DAILY ASSESSMENT:

- Weight - Blood Pressure - Peripheral perfusion

- Skin turgor - mucous membrane

DAILY FLUID ADMINISTRATION:

- increases to 10 to 20ml/kg/day

End of 2nd week of life - 140 to 160ml/kg/day

FLUID RESTRICTION-maybe necessary in preterm infants with patent ductusarteriosus or congestive heart failure

---- more fluid is needed by preterm infants placed underphototherapy light


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NUTRITIONAL SUPPORT OF PREMATURE INFANTS

ILLNESS

small

metabolic

Reservesof fat &

glycogen

Small

stomach &

Immature

GI tract

Nutrient

Demands

of growth

High

Nutritional

Risk status

MEDICAL MANAGEMENTNUTRITIONAL MANAGEMENT

Parenteral feeding with

monitoring by

-Nutritionists

- Nurses

- Pharmacists

- Physicians

Enteral feeding by

-Gastric gavage

- Transpyloric tube

- Nipple feeding

- Breast feeding

CAUSE

PATHOPHYSIOLOGY

TRANSITION TO:


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ENERGY

(PRETERM INFANTS)

NITROGEN BALANCE (FIRST 3 WEEKS OF LIFE)

- providing VLBW infants with 1 to 2 g protein and 30 to50

kcal/kg/dayCOMPARISON OF PARENTERAL AND ENTERAL ENERGY NEEDS OF

PREMATURE INFANTS

PARENTERAL ENTERAL

MAINTENANCE

Gradually increase 40 50 cal/kg/day 50kcal/kg/day

Intake to meet energy needs

by the end of the week

GROWTH

Meet energy needs 80 90 cal/kg/day 105- 130kcal/kg/day

As soon as the infants

condition is stable


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GLUCOSE (DEXTROSE)

- is the principal energy source

GLUCOSE TOLERANCE

- limited in premature infants especially VLBW infants

HYPERGLYEMIA- an excess of sugar in the blood

- less likely to happen when glucose is administered with amino

acids than when infused alone

TO PREVENT HYPERGLYCEMIA:

- Glucose should be administered in small amounts

GLUCOSE LOAD

- is a function of the concentration of the dextrose infusion and

the rate at which it is administered

INITIAL GLUCOSE LOAD (PRETERM INFANTS)- less than 6mg/kg/min. with a gradual increase to 11 to 12

mg/kg/min.

ELBW INFANTS

- tolerate a lower glucose load of 4 to 6 mg/kg/min.


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HYPOGLYCEMIA

- an abnormal decrease of sugar in the blood

- may occur if the glucose infusion is abruptly decreased or

interrupted

AMINO ACIDS

PROTEIN

- guidelines range from 2.5 to 3.8g/kg/day

Intrauterine Growth rate of protein accretion

- can be achieved at 3 g/kg/day

ELBW INFANTS

- 3 to 4 g/kg/day

PRETERM INFANTS

- given 1 to 2 g of protein (1st few days of life)

PEDIATRIC SOLUTIONS

- result in plasma amino acid profiles similar to those of healthy

infantsfed breast milk


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2 PEDIATRIC SOLUTIONS IN USE (U.S)

- Trophamine

- Aminosyn PF

FUNCTION:

- promote adequate weight gain and nitrogen retention

STANDARD AMINO ACID SOLUTION

- are not designed to meet the particular needs pf premature

infants

LOW HIGH- Cysteine Methionine

- Tyrosine Glycine

- Taurine

CYSTEINE

- a sulfur-containing amino acid occurring in many proteins- cannot be effectively synthesized by premature infants

Cysteine supplement - has been suggested

- insoluble and unstable in solution = added as cysteine

chloride when PN is prepared


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METABOLIC PROBLEMS ASSOCIATED WITH AMINO ACID INFUSION

- metabolic acidosis - hyperammonemia - azotemia

LIPIDS ( intravenous fat emulsions)

FUNCTION:- To meet essential fatty acid requirements

- To provide concentrated source of energy

EFA NEEDS provide 0.5 to 1 g/kg/day of lipids

EFA DEFICIENCY

- 1ST week of life in VLBW fed parenterally without fatCLINICAL CONSEQUENCES:

- coagulation abnormalities

- abnormal pulmonary surfactant

- adverse effects on lung metabolism

LIPIDS (PRETERM INFANTS)- should be introduced slowly with periodic monitoring ofplasma triglyceride levels

PLASMA TRIGLYCERIDE LEVELS should remain 150 mg/dl


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LIPID ADMINISTRATION

- over 24 hours at a maximum rate of 0.15 g/kg/hr to prevent a

rise in triglyceride and fatty acid

TOTAL LIPID LOAD

- less than 30 to 40% of non- protein calories but should not

exceed 60%

HEPARIN - commonly administered at 1 U/ml

- prevents thrombosis formation

- with the administration of lipids, prolongs the life of peripheral

veins

- continues administration may improve lipid clearance

CARNITINE

- frequently added to PN solution provided to premature infants- facilitates the mechanism by which fatty acids are transported

across the mitochondrial membrane allowing their oxidation to

provide energy


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CARNITINE SUPPLEMENTATION

- enhanced lipid utilization in LBW infants receiving PN for

longer than 1 month

- can also be helpful to preterm infants who are receiving only

PN at 2 4 weeks of age

ELECTROLYTE (AFTER A FEW DAYS OF LIFE)

- sodium, potassium and chloride are added to parenteralsolutions to compensate for the loss of extracellular fluid

POTASSIUM

- should be withheld until renal flow is demonstrated- to prevent hyperkalemia and arrhythmia

PRETERM INFANT TERM INFANT

SAME ELECTROLYTE REQUIREMENTS

FACTORS THAT AFFECT THE REQUIREMENTS:- Renal function

- State of hydration

- Use of diuretics


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VERY IMMATURE INFANTS - limited ability to conserve sodium

- require increased amounts of sodium to maintain a

normal serum sodium concentration

SERUM ELECTROLYTE LEVELS

- should be monitored periodically

URINE ELECTROLYTES

- should be quantified when serum levels are abnormal to

detect inappropriate electrolyte excretion

GUIDELINES FOR ADMINISTRATION OF PARENTERAL

ELECTROLYTES FOR PREMATURE INFANTSELECTROLYTE AMOUNT (mEq/kg/day)

Sodium 2-3

Chloride 2-3

Potassium 2-3


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MINERALS

Calcium and Phosphorus

-important components of the Parenteral Nutrition solution

PREMATURE INFANTS:

Low Calcium and Phosphorus at risk of developing

osteopenia of prematurity

VLBW INFANTS:

Receive PN for prolonged periods likely to have poor bonemineralization

HOW TO MONITOR CALCIUM & PHOSPHORUS STATUS:

- serum calcium, phosphorus and alkaline phosphatase levels

- radiographic bone studies


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CALCIUM AND PHOSPHORUS

- Have higher amounts of needs in preterm infants than term infants

- Should be provided simultaneously in PN solution

- Not recommended on alternate day infusion

--- because abnormal serum mineral intake and decreased

mineral retention develop

GUIDELINES FOR ADMINISTRATION OF PARENTERAL MINERAL

FOR PREMATURE INFANTS

MINERALS AMOUNT (mg/L)

Calcium 500-600

Phosphate 400-500

Magnesium 50-70


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TRACE ELEMENTS

Zinc

- should be given to all preterm infants receiving PN

Enteral feedings (cannot be started in 2 weeks)- additional trace elements should be added

Amounts of Copper & Magnesium

- should be reduced for infants with obstructive jaundice

Amounts of Selenium, Chromium & Molybdenum

- should be reduced in infants with renal dysfunction

PARENTERAL IRON

- not routinely provided because treated infants often receive

blood transfusion soon afterbirth

- dosage is approximately 10% of the enteral dosage

- guidelines range from 0.1 to 0.2mg/kg/day

ENTERAL FEEDINGS

- provides a source of iron and can often be initiated


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GUIDELINES FOR ADMINISTRATION OF PARENTERAL TRACEELEMENTS FOR PREMATURE INFANTS

TRACE ELEMENTS AMOUNT (g/kg/day)

Zinc 400

Copper 20*

Manganese 1*

Selenium 2+Chromium 0.2+

Molybdenum 0.25+

Iodine 1

*Reduced or not provided for infants with obstructive jaundice

+Reduced or not provided for infants with renal dysfunction


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VITAMINS

After birth - All newborn infants receive:

- an injection of 0.5 to 1 mg of Vitamin K

Vitamin K

- helps prevent hemmorhagic disease of the newborn from Vit.

K deficiency

- limited in newborns

- little intestinal bacteria production of Vit. K occurs until

bacterial colonization takers place

INTRAVENOUS MULTIVITAMIN PREPARATIONS

- recently approved and designed for use in infants should be

given to provide the appropriate vitamin intake and prevent toxicity from

additives used in adult multivitamin injections


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VITAMIN A- large supplemental doses had been suggested for the

prevention of BPD (Bronchopulmonary dysplasia)

BPD (Bronchopulmonary Dysplasia)- involves abnormal development of lung tissuecharacterized by inflammation and scarring in the lungs- facilitating tissue repair

intramuscular injection of Vitamin A at 5000 IU per day 3 times aweek

1st month of life--- decreases the incidence of BPD


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Inositol

- present in human milk and infant formula

- present in low concentration in PN solutions

- additon of this to PN solutions increased survival and adecreased incidence of BPD and retinopathy of prematuriy in

preterm infants with respiratory disease syndrome

Respiratory Disease Syndrome

- a lung disease that is caused buy a surfactant deficiency,develops shortly after birth and common in preterm infants

--- However Inositol is not used clinically because its

effectiveness has not yet been established


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TRANSITION FROM PARENTERAL TO ENTERAL FEEDING

Enteral feeding delivery of a nutritionally complete feed directlyinto the stomach, duodenum or jejunum

- beneficial for preterm infants as early as possible

REASONS:

- stimulates gastrointestinal enzymatic development andactivity

- promotes bile flow

- increase villous growth in the small intestine

- promotes mature gastrointestinal motility

- decrease the incidence of cholestatic jaundice

- improve subsequent feeding tolerance in preterm infants

Cholestatic jaundice

occurs when essentially normal liver cells are unable to

transport bilirubin through capillary membrane of the liver

because of damage in that area


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- It is important to maintain parenteral feeding until enteral

feeding is well established

VLBW INFANTS- it may take 7 -14 days to provide a full enteral feeding

- May take longer with infants having feeding intolerance or

illness

Small sickest infants receive increments of onlyb10ml/kg/day

Larger more stable preterm infants may tolerate incrementsof 20 to 30 ml/kg/day

ENTERAL ALIMENTATION

- preferred for preterm infants

- more physiologic and nutritionally superior


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CONSIDERATIONS IN PROVIDING ENTERAL FEEDINGS:

- degree of prematurity - history of perinatal insults

- current medical condition - function of gastointestinal tract

- respiratory status- In general, enteral nutrient requirements are different fromparenteral requirements

ENERGY

- the energy requirements of premature infants vary withindividual biologic and environmental factors

Energy needs may be increased by:

- stress - illness - rapid growth

Intake of 50kcal/kg/day required to meet maintenance energyneeds

105 to 130 kcal/kg/day needed for growth


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Some premature infants may need 130 to 150 kca/kg/day

- to achieve appropriate growth

PROTEIN

Amount and quality of protein intake - must be balance to avoid

inducing amino acid or protein toxicity

AMOUNT

advisable protein intake is 3.5 to 4g.kg.day well tolerated by stableinfants growing rapidly

- may increase stress in sick infants who are not growing

TYPE

- breastmilk or formulas containing predominantly whey protein

should be chosen whenever possibleWhey Protein - the essential amino acid Cysteine is more concentrated


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TAURINE

- is a sulfuric amino acid that may be important for preterm

infants

Sources:

- human milk - added to infant formula

Inadequate protein intake: Excessive intake:

- growth limiting - elevated plasma amino acid levels

- azotemia - acidosis

LIPIDS

Growing preterm infant needs an adequate intake of well

absorbed dietary fiber

To meet essentially fatty acid needs:

LINOLEIC ACID should comprise 3.1% of the total calories

Arachidonic acid & Docosahexonic acid present in human milk

and are added to standard infant

formula for term infants


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TYPE

LIPASES are enzymes needed for trygliceride breakdown

BILE SALTS solubize fat for ease in digestion and

absorption

EFA linoleic acid found in human milk and vegetable oil

Infants absorb vegetable oil more efficiently than saturated animal

fat

PREMATURE INFANT FORMULA MUST CONTAIN:

- vegetable oil- MCT oil (medium-chain trygliceride) to provide long chain fatty

acidCARBOHYDRATES (important source of energy)

AMOUNT

Human milk & standard infant formula approx. 40% of totalcalories is derived from carbohydrates

Too little carbohydrates may lead to hypoglycemia

Too much carbohydrates may lead to osmotic diuresis/loosestool


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TYPE

Lactose

- a disaccharide composed of glucose and galactose

- predominant carbohydrate in all mammalian milk

- important to neonates for glucose homeostasisSucrose

- a disaccharide commonly found in commercial infant

formula products

Glucose Polymers

- common carbohydrates in the preterm infants diet- consist mainly of 5 to 9 glucose units linked together

VITAMINS AND MINERALS

Calcium & Phosphorus

- required for optimal bone mineralization

Recommended intake:-175mg/100kcal/day of calcium - 91.5mg/100kcal/day of

phosphorus


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Osteopenia of prematurity in preterm infants develop when:

- poor mineral stores - low dietary intake

OSTEOPENIA:

- is a disease characterized by demineralization of growing

bones and documented by radiologic evidence of washed out or

thin bones

OSTEOPENIA IS MOST LIKELY TO DEVELOP IN PRETERM

INFANTS WHO ARE:1. Fed infant formula that is not specifically formulated for

preterm infants

2. Fed human milk that is not supplemented with calcium and

phosphorus

3. Receiving long term PN without enteral feedings


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VITAMIN D (recommended intake)

- range from 150 to 400 IU/day for preterm infants

VITAMIN E

- protects biologic membranes against oxidative lipid

breakdown

Recommended intake:

- 0.7 IU/100kcal of Vit. E per kilogram of linoleic acid

--- A premature infant with Vit. E deficiency mayexperience hemolytic anemia

Hemolytic anemia anemia caused by oxidative destruction of

mature red blood cells

HIGH DOSES OF VITAMIN E MAY LEAD TO:- intraventricular hemmorhage - sepsis

- necrotizing entercolitis - liver & renal failure

- death


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RECOMMENDATIONS FOR ENTERALADMINISTRATION OF

VITAMINS IN THE PREMATURE INFANT

VITAMIN AMOUNT (kg/day)

VITAMIN A 700-1500IU

VITAMIN D 150-400IU

VITAMIN E 6-12IU

VITAMIN K 8-10g

ASCORBIC ACID 18-24g

THIAMIN 180-240gRIBOFLAVIN 250-360g

PYRIDOXINE 150-210g

NIACIN 3.6-4.8mg

PANTOTHENATE 1.2-1.7G

BIOTIN 3.6-6gFOLATE 25-50 g

VITAMIN B12 0.3g


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IRON (RECOMMENDED INTAKE)

- 2 to 4mg/kg/day

--- Infants fed with human milk should be given ferrous sulfate

drops

FOLIC ACID- premature infants have higher folic acid needs than term infants

DAILY FOLIC ACID INTAKE- 25 to 50g

(effectively maintains normal serum folate concentration)

SODIUMDAILY SODIUM INTAKE:

- 4 to 8 mEg/kg or more

--- may be required by some infants to prevent

hyponatremia

Hyponatremia lower than normal concentration of sodium in the

blood

--- Milk can be supplemented with sodium if repletion is necessary


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Goal in Feeding:

- To feed the infant via the most physiologic method

possible and supply nutrients for growth without creating clinical

complications.

FEEDING METHODS:

A. GASTRIC GAVAGE (by the oral route)

- often chosen for infants who are unable to suck because

of immaturity or problems with the CNS

- a soft feeding tube is inserted through the infants mouth

and into the stomach

Infant less than 32 to 34 weeks of GA :

- expected to have poorly coordinated sucking and

swallowing abilities because of developmental immaturity .MAJOR RISKS:

- aspiration - gastric distention


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TO MINIMIZE THE RISK:

- electronic monitoring of vital functions

- proper positioning of the infant during feeding

POTENTIAL PROBLEMS (delivering on intermittent bolus schedule)

- gastric distention - vagal nerve stimulation w/ resultant bradycardia

Continuous Drip Feedings

- are sometimes preferred for tiny immature infants whose

small gastric capacity and slow intestinal motility may

impede the tolerance of large bolus feeds

BOLUS- a mass of chewed food moving through the digestive tract

Randomized control trial - was conducted in premature infants of 26 to

30 weeks gestation to compare continuous and bolus feedingsBolus Feedings

- resulted in better weight gain and feeding tolerance than

continuous infusion of feedings


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NASAL GASTRIC GAVAGE

- sometimes better tolerated than oraltube feedings

- helpful for infants who are learning to nipple-feed

- however , may compromise the nasal airway

B. TRANSPYLORIC FEEDING

- indicated for infants who are at risk for aspirating formula into the

lungs or who have slow gastric emptying

- also used for infants whose respiratory function is compromised &

who are at risk for formula aspiration

- requires considerable expertise & radiographic confirmation of the

catheter tip location

Goal:

- to circumvent the often slow gastric emptying of the immatureinfant by passing the feeding tube through the stomach and pylorus

- and placing its tip within the duodenum or jejunum


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POSSIBLE DISADVANTAGES:

- decreased fat absorption

- diarrhea

- dumping syndrome (rapid gastric emptying)

- alterations of the intestinal microflora- intestinal perforation

- bilious fluid in the stomach

C. NIPPLE FEEDING

- maybe attempted with infants where gestational age is greaterthan 32 weeks

- should be initiated only when the infant is under minimal

stress & is sufficiently mature and strong to sustain the

sucking effort

Ability to feed on a nipple:- indicated by evidence of an established sucking reflex and

sucking motion

STANDARDIZED ORAL STIMULATION PROGRAM


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STANDARDIZED ORAL STIMULATION PROGRAM

- help infants successfully nipple feed more quickly before

oral feedings begin

INITIAL ORAL FEEDINGS-may be limited to 1 to 3 times a day to prevent undue fatigue

Healthy premature infants (younger than 32 weeks)

- may tolerate the introduction of 1 nipple feeding per day

D. BREASTFEEDING

- nursing at the breast should begin as soon as the infants is

ready

Premature breast-fed infants- have better sucking, swallowing and breathing coordination

and less breathing disruption than bottlefed infants


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KANGAROO BABY CARE

- allows the mother to maintain skin to skin contact while

holding her infant

- facilitates her lactation- promotes continuation of breast feeding

- enhances the mothers confidence in carrying for her

high- risk infant

Feeding infants with cups to supplement breast feeding

- prevents nipple confusion

POSSIBLE PROBLEMS:

- Milk aspiration

- Refusal to breast feed

- Low- volume intakes


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TOLERANCE OF FEEDINGS

Vomiting of Feedings

- usually signals the infants inability to retain the provided

amount of milk- may also indicate that feeding volumes were increased

too quickly or are exclusively for the infants size and

maturity

Bile stained emesis

- may indicate the infant has an intestinal blockage andneeds additional evaluation or that the feeding tube has

slipped into the intestine

Abdominal distention

- maybe caused by excessive feeding, organic obstruction,

excessive swallowing of air, resuscitation or sepsis- often indicates the need to interrupt feeding until its

cause is determined and the abdomen becomes soft and is

not distended


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Gastric residuals

- measured by aspiration of the stomach contents

- should be determined routinely before each bolus gavage

feeding and intermittently in all continuous drip feedings

SIGNIFICANCE OF VOLUME IN RELATION TO TOTAL VOLUME OF

FEEDING

Ex. A residual volume of more than 50% of a bolus feeding or

equal to the continuous infusion rate might be a sign of feeding

intolerance

The frequency and consistency of bowel movements- should be constantly monitored when feeding preterm infants

SELECTION OF ENTERAL FEEDING


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SELECTION OF ENTERAL FEEDING

Initial feeding period

-premature infants may often require additional time to

adjust to enteral nutrition feedings

Primary Goal: - to establish tolerance to the milk being provided

( Infants need a period of adjustment to be able to assimilate a

large volume and concentration of nutrients)

THUS - enteral feedings often require supplementation with

parenteral fluids until infants can tolerate adequate amounts of

feeding by mouths

After initial period of adjustment

GOAL: - to provide complete nutritional support for growth and

rapid organ development

(All essential nutrients should be provided in quantities that

support sustained growth)


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FOLLOWING FEEDING CHOICES:

1. Human milk supplemented with human milk fortifiers and iron

Human milk fortifiers

- supplements of protein, carbohydrates, fat, minerals &

vitamins added to human milk to meet the increased nutrient

needs of premature infants

2. Iron fortified premature infant formula for infants who weigh

less than 2 kg

3. Iron fortified standard infant formula for infants who weigh

more than 2 kg

Discharged premature infants- can be given a transitional formula unless they have

osteopenia


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Infants with osteopenia

- need calcium & phosphorus enriched premature infants

formula until the condition improves

Breastfed infants w/ osteopenia Breastfed infants w/out osteopenia

- should also receive supplement - should receive a multivitamin &

with bottles of fortified human milk mineral supplement that contains

or premature infant formula Vitamin D & Iron

HUMAN MILK

- is the ideal food for healthy term and premature infants

- although it requires nutrient supplementation to meet the needs ofpremature infants

- its benefits for the infants are numerous because of its unique mixof amino acids and long chain fatty acids


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1st month of lactation ( composition of milk of mothers)

birth to premature infant differ from those who gave birth to term infant

PREMATURE INFANTS

- have higher concentration of protein and sodium in breastmilkwhen fed with their own mothers milk

- they grow more rapidly than infants fed banked or mature

breastmilk

ZINC & IRON ( HUMAN MILK)- are more readily absorbed

FAT

- is more easily digested because of presence of lipases

Lipase is an enzyme that catalyzes the breakdown of fats and

lipoproteins usually into fatty acids and glycene

FACTORS IN HUMAN MILK (NOT PRESENT IN FORMULAS)


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FACTORS IN HUMAN MILK (NOT PRESENT IN FORMULAS)

Components include:

1. Live cells, macrophages, T & B lymphocytes

Macrophages a phagocytic tissue cell of the immune system

that maybe fixed or freely motile, function in the destructionof foreign antigens such as bacteria or viruses.

T cell lymph several lymphocytes that differentiate in the thymus,

possess highly specific cell- surface antigen receptor associated with

the initiation of a cell-mediated humoral immunity

B Cell have antigen binding antibody molecules on the surface that

comprise the antibody secreting plasma cells when mature

2. Antimicrobial factors, secretory immunoglobulin A, lactoferin

3. Hormones

- a product of living cells that circulates in body fluids and

produces a specific often stimulatory effect on the activity of cells

usually remote from its point of origin


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4. Enzymes

- any of numerous complex proteins that we produced by living

cells and catalyze specific biochemical reactions at body temp.

5. Growth factors

Human milk fed to preterm infants

- reduce the incidence of necrotizing entercolitis & sepsis and

improves neurodevelopment

Necrotizing entercolitis - inflammation or death of the gastrointestinal

tractDISADVANTAGE:

- human milk does not meet the calcium & phosphorus needs for

normal bone mineralization in premature infants

Calcium & phosphorus supplements

- are recommended for rapidly growing infants

3 HUMAN MILK FORTIFIERS:


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3 HUMAN MILK FORTIFIERS:

Similac Natural (liquid form)

Similac & Enfamil human milk fortifiers (powdered form)

- contain calcium, phosphorus, protein, carbohydrates, fat,

vitamins and mineralsProviding human milk to a premature infant

- can be a very positive experience for the mother

- promotes involvement and interaction

PREMATURE INFANT FORMULA- these preparations have been developed to meet the unique

nutritional & physiologic needs of growing preterm infants

Quantity & Quality

- promote growth at intrauterine rates

- have caloric densities of 20 & 24kcal/oz

- are available only in a ready to feed form


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- the types of carbohydrates, protein,& fat differ to facilitate

digestion & absorption of nutrients

- have higher concentrations of protein, minerals & vitamins

TRANSITIONAL INFANT FORMULA- contain 22kcal/oz & are designed or premature infants

- nutrient content is less than that of the nutrient dens prematureinfant formulas & more than that of the standard infant formula

- can be introduced when the infant reaches a weight of 1800 g or

more & can be used throughout the 1st

year of life- available in powder form for home use

- ready to feed form for hospital use

POTENTIAL BENEFICIARIES:

- infants who weigh less than 1250 g and do not consume enoughnutrients when hospitalized

- those who cannot consume adequate amount of standard formulato grow when discharged

COMPARISON OF THE NUTRITIONAL CONTENT OF HUMAN MILK & FORMULAS


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COMPARISON OF THE NUTRITIONAL CONTENT OF HUMAN MILK & FORMULAS

HUMAN FORTIFIED STANDARD TRANSITIONAL PREMATURE

MILK MILK FORMULA FORMULA FORMULA

Caloric density 20 24 20 22 20,24

(kcal/oz)

Protein whey, 70:30 whey 60:40, 48:52, 100:0 60:40, 50:50 60:40

Casein ratio predominant

Protein (g/L) 9-14 19-20 14-16 19-21 18-24

Carbohydrate Lactose Lactose, glucose Lactose or lactose Lactose/glucose Lactose/glucose

polymers & glucose polymers polymers polymers

Carbohydrate 66-73 77-88 73-74 77-79 72-90

(g/L)Fat Human fat human fat, MCTs vegetable veg., MCT oil veg., MCT oil

Fat(g/L) 39-42 44-52 34.1 36.5 39-41 34.5- 43.8

Calcium(mg/L) 248-280 1180 1141 429-530 784-890 1115- 1452

Phosphorus 128-147 650-790 241-360 463-490 561-806

(mg/L)

Vitamin D 20-21 1190-1520 402-410 522-590 1014-2200

(IU/L)

Vitamin E 2.8-10.7 34-49 10.1- 13.5 26.9-30 27-51

(IU/L)

Folic acid 33-85 30.6-33.5 60-108 187-192 237-298

(g/L)

Sodium(mEq/L) 7.9-10.8 14-15 7-8 10.7-11.3 11.5-15.1

FORMULA ADJUSTMENTS


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FORMULA ADJUSTMENTS

(occasionally increasing the energy content of formulas fed to small

infants)

- maybe appropriate when infant is not growing quick enough &

is already consuming as much as possible during feedings

CONCENTRATION

Providing hypercaloric formula - prepare the formula w/ less water

Concentrated infant formula w/ energy contents of 24kcal/oz- are available to hospitals as ready to feed nutrients

- consider the infants fluid intake & fluid losses in relation to

the renal solute load of the concentrated feeding, to ensure a positive

water balance is maintained

Transitional formula can be concentrated from 24 to 30 kcal/oz

- should be provided in amounts that can be tolerated by the

infant & caloric supplements can be added as needed

Infants consume less due to illness


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Infants consume less due to illness

- infant formula powder is often added to provide more calories

& nutrients

- provide enough calcium, phosphorus, magnesium,& Vit. D to

treat osteopenia

Caloric supplements

- an approach to increasing the energy content of a formula

- Corn oil - MCT oil - glucose polymers ex. Polycose

- increase the formulas caloric density w/out markedly alteringsolute load or osmolality

- alter the relative distribution of total calories derived from

protein, carbohydrate & fat

--- Adding these supplements to human milk of standard infant formula

is not advised- should be used only when a formula already meets all nutrient

requirements other than energy or when the renal solute load is a

concern

WHEN A HIGH ENERGY FORMULA IS NEEDED


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WHEN A HIGH ENERGY FORMULA IS NEEDED:

- MCT oil & Polycose can be added to a base that has a

concentration of 24kcal/oz or greater

- could either be a full strength premature formula or a

concentrated standard formula w/ a maximum of 50% totalcalories from fat

- a minimum of 9% total calories from protein

For infant who can tolerate long chain fatty acid- an emulsified fatty acid product (Microlipid) may beappropriate because it stays in solution better than MCT oil

GROWTH & NUTRITIONAL ASSESSMENT


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GROWTH & NUTRITIONAL ASSESSMENT

- All neonates typically lose some weight after birth

PRETERM INFANTS

- are born with more extracellular water than term infants &thus tend to lose more weight than term infants

--- The post natal loss should not be excessive

Those who lose more than 15% to 20%

- may become dehydrated- birth weight should be regained by the 2nd or 3rd weeks of life

FIRST 98 DAYS OF LIFE

- Ehrenkranz growth chart is commonly used to assess weightprogress

Birth weight assessment charts:1.Ehrenkranz growth chart

- longitudinally depicts daily weight changes & actual growth curvesof 1660 infants who were born with a weight of 501 to 1500g

2 INTRAUTERINE GROWTH CURVES


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2. INTRAUTERINE GROWTH CURVES

- have also been developed using birth weight data of

infants born at several successive weeks of gestation

- however, these do not depict the initial period of

postnatal weight loss & probably set unrealistic goals for

preterm infants in the neonatal period

After infants condition stabilizes:

- infant may be able to grow at a rate that parallels these c

curvesIntrauterine weight gain of 15g/kg/day

- can be achieved before 38 weeks of gestation

3. Growth curve

- can be used to evaluate the adequacy of growth in areas

such as: weight, length, head circumference- has a built in correction factor for prematurity 7 the

infants growth can be followed on one chart through the

1st year of corrected age


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(CDC) Center for Disease Control Growth Charts

- from birth to 3 years of age

- can also be used for preterm infants after 40 weeks of

gestation, as long as the age is adjusted

LABORATORY INDICES (usually involve measuring the ff)

- Fluid & electrolyte balance

- PN tolerance

- Bone mineralization

- Hematologic status

DISCHARGE CARE

Establishment of successful feeding

- pivotal factor in determining whether an infant could be

discharged

PRETERM INFANTS MUST BE ABLE TO:


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PRETERM INFANTS MUST BE ABLE TO:

1. Tolerate their feedings & usually obtain all of their feedings from the

breast or bottle

2. Grow adequately on a modified demand feeding schedule

- usually 3-4 hours during the day for bottle fed infants- every 2 to 3 hours for breast fed infants

3. Maintain their body temperature without the help of an incubator

Neonatal intensive care unit

- parents are permitted to room inRoom in

- to stay with the infant all day & night in the nusery before discharge

- helps build confidence in their duty to care for a high risk ifant

Preterm infants

- weigh less than 5 lb during discharge

Small preterm infants

- should be followed very closely during 1st month after discharge


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1ST WEEK OF DISCHARGE

(home visit by nurse or nutritionist or both & office visit to the

pediatrician)

- can be extremely helpful educationally

- can provide eary intervention for developing problems

FACTORS AFFECTINTG FEEDING SKILLS

PHYSICAL FACTORS

- variable heart rate physiologic events

- rapid respiratory rate that interfere- tremulousness with feeding

Tremulousness

- shaking or shivering of the muscles

Infants weighing less than 51/2 lb have poor muscle tone

FEEDING


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FEEDING

- is often difficult for infants who have limited muscle flexion &

strength & poor head and neck control w/c are needed to maintain a

good feeding posture

--- Position infants in a manner that supports normal body flexion &

ensures proper alignment of the head & neck during feedings

--- Premature infants may also need their chin & cheeks supported

while bottle feeding

SMALL INFANTS

- tend to sleep more than larger & term infants

--- It is much easier for preterm infants to feed effectively if they are fully

awake

TO AWAKEN A PRETERM INFANT:1. The caregiver should provide one type of gentle stimulation for a

few minutes and then change to a different type, repeating this

pattern until infant is fully awake


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2. Lightly swadling infants and then placing them in a semi-

upright position may also help

Feeding environment

- should be as quiet as possible

---Infants may tire quickly & show subtle signs of distress

parents should recognize these cues to provide rest or

comfort

AFTER DISCHARGE (most preterm infants may need:)

- approximately 180ml/kg/day of breast milk or standard

infant formula containing 20kcal/oz

- this amount of milk provides 120 kcal/day

Alternatively:- transitional formula w/ a concentration of 22kcal/oz can

be provided at a rate of 160ml/kg/day

Determining the adequacy of amounts for individual infants


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- compare their intakes with their growth progress over time

--- Some infants may need a formula that provides 24kcal/oz

Evaluate needs based on the 3 growth parameters:

- weight - height - head circumference

Patterns of growth should be assessed to determine whether:

1. Individual curves at least parallel reference curves

2. Growth curves are shifting inappropriately across growthpercentiles

3. Weight is appropriate for length

4. Growth is proportional in all three areas

NEURODEVELOPMENTAL OUTCOME---More tiny premature infants are surviving than ever before

because of adequate nutritional support & recent advances in

neonatal intensive care technology

Increased survival rate of VLBW infants


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Increased survival rate of VLBW infants

- has increased concerns about their short & long term

neurodevelopmental outcomes

As a rule:

- VLBW infants should be referred to a follow- up clinic to

evaluate their development & growth & begin early

intervention

Surviving ELBW infants

(particularly w/ birth weight less than 750g)- have an increased risk of developing handicapped

central nervous system conditions, which vary in severity & type

of functional impairment

= Many of these premature infants reach childhood w/ noevidence of any disability

Documents

Nutrition for Low Infant Birth