Nutrition Support in the NICU

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Nutrition Support in the NICU

Sarah SwaintekDietetic InternSodexo Mid-Atlantic February 4, 2013

+Objectives

To understand the components of TPN/EN neonatal nutrition support.

To assess nutrition support tolerance in a neonatal setting.

To identify similarities and differences between nutrition support in neonatal vs adult acute care setting.

+ Maternal History

34 yo Female G1P000 G1P1 Maternal hx of hyperthyroidism (no treatment) Presented w/

Preterm Premature rupture of membranes (PPROM) and contractions, Rubella immune, RPR non reactive, Hepatitis B negative, GBS status unknown

+ Delivery History

NICU called to Labor and Delivery: NSVD at 31 weeks and 2 days

Via assistance of vacuum Placental infarction during delivery

Baby @ 20 seconds of life: Cyanotic, no cry at birth, no respiratory effort Suctioned, stimulated grunting and retracting

APGAR At minute 1 = 3 At minutes 5 = 7

Welcome to the world BBR! Baby transferred to NICU

+ NICU Admit Date: 12/29/2012

BBR is an ex 31 and 2/7 male admitted to NICU w/ Prematurity Respiratory Distress R/O Sepsis LBW

Birth weight Classification

Weight (gm)

High birth weight >4000gm

Normal birth weight 2500gm – 3999gm

LBW < 2500gm

VLBW < 1500gm

ELBW < 1000gm

+Complications Associated with Prematurity

Intrauterine growth rate

3rd Trimester: Ca, Phos, PRO, fat needs Deposition of Stores

Gut immaturity

Lung immaturity

Need for Nutrition Support!

+ Anthropometrics BW: 1875gm (LBW)

Length: 43.5cm (17.1 inches)

Observations: Appearance: Cachetic, No dysmorphic features, Palate intact Lungs: Increased WOB CV: No murmur Abd: Soft, nondistended Ext: Moves all 4 extremities equally Skin: Translucent

Gestational Age Classification Growth Percentile

Large for Gestational Age (LGA) >90th percentile

Appropriate for Gestational Age (AGA) 10th-90th percentile

Small for Gestational Age (SGA) <10th percentile

+Growth Chart

+ Plan of Action (12.29.12)

Total fluid goal @ 90 mL

NPO

IVF D10W at 7mL per hour

NS Bolus at 18mL over 30

minutes

PPN: D10P2IL1 at 6.7mL per

hourNO LYTES!

D10 = % Dextrose

P2 = Protein in gm/kg

IL1 = Lipid in gm/kg

+ Plan of Action (continued)

Bubble CPAP ABG, Chest and Abdominal X-ray

Labs: Total bilirubin, BMP, Mg, Phos, CBC, Blood Culture, CRP (in

12 hours)

Medications: Antibiotics:

Start Ampicillin and Gentamicin via PIV

+ Nutrition Assessment (12.31.12) BBR is an ex 31(2) week male; now 31(4) weeks.

DOL#2

BW: 1875gm (50th-90th%) AGA as plotted on growth chart. CBW: 1835gm Intrauterine Growth Rate: 25.7gm/d

Length: 43.5cm (50th-90th%)

Meds: ampicillin, gentamicin

Nutrition-focused Physical Findings: Isolette PIV SMIV OG tube in place Phototherapy x1

No stool since admit

+ Estimated Needs Current Intake:

PN (via peripheral line): D10P3IL2 No lytes MVI and TME included

EN: trophic feeds Breastmilk/Premie Good Start (PGS) 24 at 2mL q3hrs

Residuals: 0.5mL (x3)

Estimated Needs/Nutrition Rx: 90-110kcal/kg, 4-4.5gm/kg PRO

Nutrient Currently Receiving

Practice Guideline

Total Fluid Goal 93 mL/kg/d 90-110 mL/kg/d

Total Kcal Intake 53.5 kcal/kg (TPN) 90-120 kcal/kg (TPN)

Total Protein Intake 2.5 gm/kg 4-4.5 gm/kg

+ Labs (12.31.12)

Laboratory Test

Lab Value Reference Range

Na 140 134-146

K+ 4.7 3.7-5.9

Cl- 107 95-110

CO2 26.9 20-28

BUN 21 3-25

Cr 0.8 0.3-1

Glucose 43-70 20-80

Ca 7.1 8-11

Mg 2.4 1.2-2.2

Phos 5.7 5-8

H/H 18.2/51.6 11-17/35-49

CRP 7.3 <5

Tbili 11.9 6-8

Dbili 0.4 <2

+Hyperbilirubinemia

One of the most common problems encountered in newborns. Characterized by yellow-pigmented skin and increased bilirubin

concentrations in the blood.

Phototherapy The process of using fluorescent light to aid in the breakdown of

bilirubin into a form the body can more quickly eliminate. Transforms bilirubin into water-soluble isomers that can be

eliminated without conjugation in the liver. To be considered:

Maximizing skin exposure Eye protection and care Thermoregulation

Nutrition Implications: Increased fluid loss Jaundice babies typically don’t feed well Hypocalcemia

+ Phototherapy

+ Nutrition Diagnosis

Inadequate energy intake related to prematurity and recent delivery AEB infant currently meeting <70% of estimated kcal and protein needs.

+ Nutrition Interventions Nutrient Delivery –

Continue TPN, titrate to meet estimated needs Trophic feeds with Breastmilk as feasible

Coordination of Care – Maternal lactation support and education

GOAL: Regain BW by DOL #7

+ Monitoring & Evaluation

Indicator Criteria

PN tolerance Labs WNL

Adequacy of nutrient regimen, weight gain

Weekly growth parameters WNL

+ Nutrition Risk

Moderate RD to f/u in 6-8 days

+Nutrition Follow-Up (01.03.13) BBR is now an ex 31(2) week male; now 32 weeks.

DOL#5

BW: 1875gm (50th-90th%) CBW: 1780gm Intrauterine Growth Rate: 27.1gm/d

Length: 43.5cm (50th-90th%)

Meds: ampicillin, gentamicin, caffeine, s/p glycerin

Biochemical: Tbili-11.1, Dbili-2.9

Nutrition-focused Physical Findings: Isolette CPAP OG tube in place PIV Pacifier Phototherapy x2

Stool x1

+ Labs (01.03.13)Laboratory Test Lab Value Reference

Range

Na 136 136-143

K+ 3.8 4.1-5.6

BUN 35 3-25

Cr 0.5 <1.3

Glucose 67 20-80

Ca 10.7 8-11

Mg 2.4 1.5-2.2

Phos 4 6.1-11.7

Alk Phos 35 ≤400

TG 49 ≤250

GGT 303 15-75

AST 42 16-74

ALT 28 1-25

Tbili 11.1 6-8

Dbili 2.9 <0.2

+ Estimated Needs Current Intake:

PN (via peripheral line): D10P4.5IL2.5 EN: Breastmilk

6mL q3hr via OG (advancing by 1mL q6hr) Residuals: 0.5-3mL (x6)

Estimated Needs: 90-110kcal/kg (TPN), 4-4.5gm/kg PRO

Nutrient Currently Receiving

Practice Guideline

Total Fluid Goal 151 mL/kg/d 120-150 mL/kg/d

Total Kcal Intake 110 kcal/kg 90-120 kcal/kg (EN)

Total Protein Intake 4.8 gm/kg 4-4.5 gm/kg

+ Nutrition Diagnosis

Inadequate oral intake related to prematurity AEB dependence on parenteral and enteral nutrition support

+ Nutrition Interventions Nutrient Delivery –

Continue parenteral nutrition until enteral nutrition reaches 75% of goal volume/calories

Taper PPN as EN increases (decrease protein to 4gm/kg)

Hold Trace Mineral elements until direct bili is <2 Add back Zinc

Coordination of Care – Maternal lactation support and education D/w team on Rounds today

GOAL: Regain BW by DOL #7

+ Monitoring & Evaluation

Indicator Criteria

PN tolerance BMP, Mg, Phos, LFTs, TG, Bilirubin

EN tolerance Residuals, emesis, feed advance

Growth Average daily wt gain WNL, weekly growth parameters, growth chart WNL, weekly growth matches intrauterine growth

+ Nutrition Risk

High RD to f/u in 3-5 days

+ Nutrition Reassessment (01.08.13) BBR is an ex 31(2) week male; now 32(5) weeks;

DOL#10 CBW: 1910gm (35gm increase) Intrauterine Growth Rate: 27.1gm/d Length: 43.5cm (50-90th %)

Meds: None currently

Biochemical Data: Tbili-10.4 (direct 0.6)

Nutrition-focused Physical Findings: Isolette CPAP OG tube in place Pacifier

Stool x7

+Nutrition Support Summary

12/31/12 01/03/13 01/08/13

Nutrition Support PN via PIVEN via OG

PN via PIVEN via OG

EN via OG(PN d/c 01/04/13

Nutrition Composition

PN = D10P3IL2EN = Breastmilk/PGS22

PN = D10P4.5IL2.5EN = Breastmilk

Breastmilk/Premie Good Start 24

Rate PN = ContinuousEN = Tropic

PN = ContinuousEN = 6mL q3hr

40mL q3hr over 45 min

Residuals 0.5mL (x3) 0.5-3mL (x6) 0.8-12mL (x8)

24-Hour Nutrient Provision

TFG: 93mL/kg/dKcal: 53.5kcal/kg/dPRO: 2.5gm/kg/d

TFG: 151mL/kg/dKcal:110kcal/kg/dPRO: 4.8gm/kg/d

TGF: 151mL/kg/dKcal: 108kcal/kg/dPRO: 3gm/kg/d

+ Nutrition Reassessment (cont) Nutrition Rx: 120-130kcal/kg, 3.5-4gm/kg PRO

Nutrition Diagnosis: Inadequate oral intake related to prematurity AEB dependence on EN

nutrition support (on-going dx, new s/s) Inadequate kcal and protein intake related to marginal TF tolerance AEB high

residual volumes and inability to reach goal feed volumes (new dx)

Nutrition Interventions: Nutrient Delivery:

Continue EN feeds, advance as tolerated Fortify breastmilk to 22kcal/oz w/ HMF to help meet needs

Coordination of Care: Maternal lactation support and education d/w team

Nutrition Goals: Regain BW by DOL#7 (goal met) Infant to tolerate current feed volume and continue to advance w/ residuals

<20% of feed volume, 16-20gm/d wt gain; over 7 days (new goal)

+Nutrition Follow-Up (01.10.13) Ex 31(2) week male; now 33 weeks; DOL#12

CBW: 2045gm Average Daily Weight Gain: 37.8gm/d Intrauterine Growth Rate: 30gm/d Length: 45cm (50th-90th%) Head Circumference: 29cm

Meds: IV antibiotics (ampicillin,vancomycin), nystatin, caffeine

Biochemical Data: Alk Phos-587

Nutrition-focused Physical Findings: Isolette CPAP PIV OG tube in place Pacifier

Stool x7


12/31/12 01/03/13 01/08/13 01/10/13

Nutrition Support

PN via PIVEN via OG

PN via PIVEN via OG


EN via OG





Breastmilk (HMF22)/PGS24





Residuals 0.5mL (x3) 0.5-3mL (x6) 0.8-12mL (x8) 2-5mL (x6)





TFG: 156mL/kg/dKcal: 123kcal/kg/dPRO: 3.7gm/kg/d

+ Nutrition Follow-Up (cont) Nutrition Rx: 120-130kcal/kg, 3.5-4gm/kg PRO

Nutrition Diagnosis: Inadequate oral intake related to prematurity AEB dependence

on EN support (ongoing dx) Increased nutrient needs related to prematurity AEB elevated

Alk Phos and need for breastmilk fortification (for adequate kcal/Ca/Phos) (new dx)

Nutrition Interventions: Nutrient Delivery:

Continue EN feeds, advance as tolerated Fortify breastmilk to 24 kcal/oz with HMF to help meet needs

Coordination of Care d/w team today in Rounds

Nutrition Goals: Infant to tolerate current feed volume and continue to advance

w/ residuals <20% of feed volume, 16-20gm/d wt gain; over 7 days (new goal)

+Nutrition Follow-Up (01.17.13) Ex 31(2) week male; now 34 weeks; DOL#19

CBW: 2275gm (10th-50th%) Average Daily Weight Gain: 32.8gm/d (1/10-1/17),

comparative 31.4gm (1/09-1/16) given 90gm weight gain overnight

Intrauterine Growth Rate: 31.4gm/d Length: 48cm (90th-97th%) Head Circumference: 30.5cm (10th-50th%)

Meds: caffeine, Lasix (last dose 1/16)

Biochemical Data: Alk Phos-458 (trending down), Ca-9.6, Phos-7.4

Nutrition-focused Physical Findings: Isolette (open-crib trial today) CPAP PIV (d/c 01/17) OG tube in place

Stool x2


12/31/12 01/03/13 01/08/13 01/10/13 01/17/13

Nutrition Support

PN via PIVEN via OG

PN via PIVEN via OG


EN via OG EN via OG





Breastmilk (HMF22)/PGS24

Breastmilk (HMF24)






Residuals 0.5mL (x3) 0.5-3mL (x6) 0.8-12mL (x8) 2-5mL (x6) 1mL (x1)





TFG: 156mL/kg/dKcal: 123kcal/kg/dPRO: 3.7gm/kg/d

TFG: 148mL/kg/dKcal: 118mL/kg/dPRO: 3.5gm/kg/d

+Growth Chart

+Nutrition Follow-Up (continued) Nutrition Rx:

Estimated Needs: 120-130kcal/kg, 3.5-4gm/kg PRO

Nutrition Diagnosis: Inadequate kcal and protein intake related to current EN rate AEB total

kcal intake not meeting estimated needs. Inadequate oral intake related to prematurity AEB dependence on

parenteral and enteral nutrition support (revised) Increased nutrient needs related to prematurity AEB elevated Alk Phos and

need for breastmilk fortification (for adequate kcal/Ca/Phos) (ongoing dx).

Nutrition Intervention: Nutrient Delivery – continue EN feed, advance as tolerated, increase

volume of EN feeds to 44mL q 3 hr Nutrient Delivery – continue breastmilk fortification to 24kcal/oz with HMF

to help meet kcal needs. Coordination of Care – maternal lactation support and education, consider

non-nutritive breastfeeding practices as medically feasible. Coordination of Care – d/w team today in Rounds

GOAL: Infant to tolerate current feed volume and continue to advance with

residuals <20% feed volume 16-20gm/day weight gain (over 7 days)

+So What?!?!

Challenges in NICU setting Volume tolerance Ca/Phos needs Mimicking the intrauterine growth

Nutrition Support in NICU setting Access site Hyperglycemia TPN induced cholestasis Increased Ca/Phos needs Overlap in modalities

Similarities and Differences from Adult Care Initiation of Nutrition Support Tolerance/Residuals Speed of happenings Less evidence-based research on practice guidelines Shortages advantage

+References:Academy of Nutrition and Dietetics. Nutrition Care Manual, accessed January 9, 2013.

Ben, XM. Nutritional management of newborn infants: Practical guidelines. World Journal of Gastroenterology, 2008: 14(40): 6133-6139.

EIHassan,NO, Kasier, JR. Parenteral Nutrition in the Neonatal Intensive Care Unit. NeoReviews, 2011: v 12: 130-140.

George Washington University Hospital. Inpatient Nutrition Practice Guidelines: NICU, 2011.

Groh-Wargo, et al, Eds. Nutritional Care for High Risk Newborns, Revised 3rd Edition. Precept Press, Chicago, Illinois, 2000.

Groh-Wargo S, Sapford, A. Enteral Nutrition Support of the Preterm Infant in the Neonatal Intensive Care Unit. Nutrition in Clinical Practice. June/July 2009: 363-376.

Hay, WW. Strategies for Feeding the Preterm Infant. Neonatology, 2008: 94(4): 245-254.

Marconi, AM, Ronzoni, S, Vailati, S, Bozzetti, P, Morabito, A, and Battaglia, F. Neonatal Morbidity and Mortality in Intrauterine Growth Restricted (IUGR) Pregnancies Is Predictaed Upon Prenatal Diagnosis of Clinical Severity, 2009: 16: 373.

Thureen, P, Heird, WC. Protein and Energy Requirements of the Preterm/Low Birthweigh (LBW) Infant. Pediatric Research, 2005: v 57: 95R-98R.

Tsang, RC, Lucas, A, Uauy, R, Zlotkin, S. Nutritional Needs of the Preterm Infant: Scientific Basis and Practical Guidelines, 1993: 135-149, 217-220.

Yadav, RK, Sethi, RS, Sethi, AS, Kumar, L, Chaurasia OS. The Evaluation of Effect of Phototherapy on Serum Calcium Level. People’s Journal of Scientific Research, 2012: v 5(2).

Szeszycki, E, Cruse, W, Strup, M. Evaluation and Monitoring of Pediatric Patients Receiving Specialized Nutrition Support. A.S.P.E.N 2010, accessed January 20, 2013. www.nutritioncare.org.

http://www.nutritioncare.org/

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Nutrition Support in the NICU