Neonatal and Infant Nutrition:what should we know ???

Dr mohd zuraiziPaediatrician, hospital tawau

WHY ?Is nutrition such a big deal?

Nutrition Status and Outcomes

• What is Normal nutrition for baby and child• How do we get it ??

– Assessment, it is enough ??• What if we get too little ???• What if we get too much ???

Introduction

• What does ‘nutrition’ mean to you?

Textbook answer

• Nelson’s Textbook of Paediatrics –achievement of satisfactory

growth and avoidance of deficiency states.

Objectives• By the end of this morning, you will ( I hope)

…….– understand the effects of fetal growth

restriction on short- and long-term health – understand the principles and importance of

nutrition in the neonatal period including assessment of nutritional status

– be able to make appropriate recommendations to address feeding problems and faltering growth

‘Normal’ Nutrition

Fetal nutrition

• Parenteral (mostly!)• Stores are laid late in gestation• At 28 weeks, a fetus has:

– 20% of term calcium and phosphorus stores– 20% of term fat stores– About a quarter of term glycogen stores

Adaptation to nutrition after birth

• Gut adaptation is regulated by– Endocrine factors– Intraluminal factors– Breast milk hormones and growth factors– Bacteria

BreastFEEDING is THE best

Feeding the term infant

• Breast feeding achieves– Nutrition– Immunological and antimicrobial protection– Passage of breast milk hormones and growth

factors– Provision of digestive enzymes– Facilitation of mother-infant bonding

Protection of infant from chronic diseases:– Insulin dependent diabetes mellitus

• (OR 0.61)

– Inflammatory bowel disease– Allergic disease– Childhood lymphoma (OR 0.91)– Obesity (OR 0.75-0.87)

Protection of mother from:

– Pregnancy

– Postpartum hemorrhage

– Bone demineralization

– Ovarian cancer

Supplementing breast milk

• Should be unnecessary, but– Vitamin K levels are low– Vitamin D levels are low in areas of little

sunlight– Iron levels are low (but very well absorbed)

Breast Feeding Questions

• Why should I breast feed my baby? I thought formula was the identical alternative.

• How often and for how long will my baby nurse?• How do I know if the baby is getting enough? • How many months can I breast feed the baby

and when can I add formula?

Monitoring feeding

• Maternal sensation of engorgement and emptying

• Frequency of feeding• Wet nappies • Stools• Jaundice• Weight

Normal outputDaily stool and urine output guidanceDay 0 1 wet nappy and meconium at least once a day

Day 1 2 wet nappies and meconium at least once a day

Day 2 & 3 3 or 4 wet nappies and changing stools at least once a day

Day 4+ 5 or 6 heavy wet nappies and yellow stools at least once daily

A baby who is passing meconium at 3 or 4 days old may not be getting enough milk.

A baby who does not have yellow stools by day 5 may not be getting enough milk.

A baby who is not doing as many wet nappies each day as expected may not be getting enough milk.

Assessment of Breast Feeding

• Weight pattern - consistent weight gain.• Voiding - # wet diapers/day, soaked?• Stooling - generally more stools than formula.• Feed-on-demand ~ every 2-3 hours.• Duration of feedings - generally 10-20

min/side.• Need for high fat hind milk.• Activity and vigor of infant.

Supporting Breast Feeding• Ask patients if they plan to breast feed.• Give prenatal guidance, materials and support

numbers.• Support hospital initiatives to encourage breast

feeding, such as lactation counselors.• Ask about breast feeding support available to

mother.• Become familiar with how to manage common

problems such as mastitis and inverted nipples.• Understand issues related to pumping and

helping moms return to work or wean the infant.

Growth in Infants

• Rapid body growth and brain development during the first year:– Weight increases 200%– Body length increases 55%– Head circumference increases

40%– Brain weight doubles

Major Determinants of Caloric Needs

• Basal metabolic rate (BMR)• Activity level• Growth (2x BMR during first

year)• Stress (infection, surgery,

illness)• Misc. (thermic effect of food)

Feeding Skills Development• 4-6 mos - experience new tastes.

– Give rice cereal with iron.• 6-7 mos - sits with minimal support.

– Add fruits and vegetables.• 8-9 mos - improved pincer grasp.

– Add protein foods and finger foods.• 10-12 mos - pulls to stand, reaches

for food.– Add soft table food, allow to self-feed.

Feeding Skills Development

• 12-18 mos - increased independence.– Stop bottle, practice eating from a spoon.

• 18 mos -2 yrs - growth slows, less interest in eating.– Encourage self-feeding with utensils.

• 2-3 yrs - intake varies, exerts control.

Nutrition for the preterm or sick baby

CASE SENARIO: Mrs Oak

• 28 year old primigravida• 5’2, 80kg• Smokes 5 cigarettes daily• Concerns about growth from 20 weeks• Latest ‘dopplers’ show absent EDF• Proteinuria and hypertension

• How will you counsel the family?• Consider particularly:

– Risks of preterm delivery vs risk of continuing pregnancy

– Short term risks– Approach to feeding– Long term outcome

Short term risks of IUGR

• Obstetric– Intrauterine death– Intrapartum asphyxia

Short term risks of IUGR

• Paediatric– Hypoglycaemia – Necrotising enterocolitis– Increased risk of problems of prematurity– (hypothermia)– (polycythaemia)

NEC and IUGR

• Case-control study (n=74) – at 30-36 weeks GA, birth weight <10th centile is a

significant risk factor– OR 6 (1.3-26)1

• Observational study (n= 69) – At 30-36 weeks 71% of cases were <10th centile2

• 1 Beeby and Jeffrey. 1991, ADC:67:432-5• 2 McDonnell and Wilkinson. Sem Neonatol 1997

NEC and IUGR: Why?

• Pathogenesis of NEC requires – enteral feeding – gut ischaemia – bacterial infection

• Abnormal gut blood flow recognised in IUGR

• Ischaemic damage or reperfusion injury?

Normal doppler flow in umbilical artery

Absent end diastolic flow

Reversed end-diastolic flow

Abnormal dopplers and NEC

• In 9 of 14 studies, AREDF led to an increased risk of NEC

• OR 2.13 (95%CI 1.49 to 3.03)

• Dorling J, Kempley S, Leaf A. Feeding growth restricted preterm infants with abnormal antenatal Doppler results. Arch. Dis. Child. Fetal Neonatal Ed. 2005; 90: F359-F363

So how to feed?

• Delay start?• Use non-nutritive feeds?• Increase slowly?• Use friendly bacteria?

Cochrane review: early vs late feeding

• 72 babies in 2 studies• Early feeders had

– Fewer days parenteral nutrition– Fewer investigations for sepsis

• No difference in– NEC– Weight gain

Cochrane review: rapid vs slow increase

• 369 babies in 3 studies • Rapid: 20 to 35 ml/kg/day• Slow: 10 to 20 ml/kg/day• Rapid group:

– reached full enteral feeds and regained birthweight faster

– No difference in NEC rate or length of stay

Cochrane review: minimal enteral nutrition

• 380 babies in 8 studies• 12 to 24 ml/kg/day for 5 to 10 days• MEN group

– Faster to full enteral feeds– Shorter length of stay– No difference in NEC

Probiotics for preventing NEC

• Systematic review of 1393 VLBW infants treated with a variety of organisms

• Reduced risk of – NEC (RR 0·36, 95% CI 0·20–0·65) – Death (RR 0·47, 0·30–0·73)

• Achieved full feeds faster• No difference in rates of sepsis

– Deschpande et al, Lancet 2007

Preventing NEC: what works?

Strategy Absolute RR NNTEnteral antibiotics 0.089 11

Judicious fluid administration 0.084 12

Human milk feeds 0.069 15

Enteral IgG and IgA 0.066 15

Enteral Probiotics 0.025 40

Antenatal corticosteroids 0.019 54

Delayed or slow feeding Not effective -

Enteral IgG only Not effective -

Feeding small or preterm infants: Choices

• Human milk– Mother’s own– Banked donor milk– Fortified

• Artificial– Term formula– Preterm formula

• Parenteral Nutrition

Milk Feeds

Human milk advantages

• Protection from NEC• Improved host defences• Protection from allergy and eczema• Faster tolerance of full enteral feeds• Better developmental and intellectual

outcome

Human milk shortcomings if preterm

• Human milk may not provide enough– Protein– Energy– Sodium– Calcium, phosphorus and magnesium– Trace elements (Fe, Cu, Zn)– Vitamins (B2,B6,Folic acid, C,D,E,K)

Breast milk fortifiers

• Improved– short term growth– nutrient retention– bone mineralisation

• Concerns– trend towards increased NEC

Term vs preterm formulas

• Term formulas do not provide for preterm protein, calcium, sodium and phosphate requirements, even at high volumes

• Term formula (vs preterm formula) fed infants– Grow more slowly– Have lower developmental score and IQ at follow up

Feeding preterm infants: aim

“To provide nutrient intakes that permit the rate of postnatal growth and the composition of weight gain to approximate that of a normal fetus of the same gestational age, without producing metabolic stress”

American Academy of Pediatrics Committee on Nutrition

Evidence Based Nutrition

• RA Ehrenkranz, Seminars in Perinatology 2007 (31): 48-55

Post-Discharge Nutrition

Post discharge nutrition

• Preterm infants tend to be small at discharge, and remain small into adolescence

• Limited evidence for what rate of growth is optimal

The evidence

• Comparison of ‘post-discharge’ formula with standard term formula– No consistent difference in growth parameters

or body composition– Z-score reduces in both groups– Term formula needs supplementing with

vitamins and iron to achieve targets

The evidence

• Comparison of breast milk with term formula– Calcium and phosphate deficiency in breast

milk fed infants in first year resolves by age two

– Little difference in growth (although small numbers)

Catch-up Growth

• Enhanced nutritional intake sufficient to allow ‘catch-up’ growth improves long term neurodevelopmental outcome

IUGR baby

• Definition ??/• IUGR vs SGA baby• Rapid catch up growth…..

The long range forecast with IUGR

• Does the in-utero environment or early feeding permanently change organ structure, function and metabolism?

Developmental Origins theory

• Geographically, coronary heart disease correlates with past neonatal mortality

• In epidemiological studies, adult cardiovascular disease is associated with:– low birthweight– rapid early postnatal growth

Is rapid catch-up growth bad?

• Postnatal weight gain is associated with BMI and waist circumference at 19 years

• IUGR infants are at increased risk of the metabolic syndrome

• Preterm infants fed breast milk rather than preterm formula– had lower BP at 13-16yrs– were less insulin resistant– had a better LDL:HDL ratio

Nutrition Assessment

How best to assess growth and nutrition?

• Weight– Reflects mass of lean tissue, fat, intra- and extra-

cellular fluid compartments• Length

– More accurately reflects lean tissue mass• Head circumference

– Correlates well with overall growth and developmental achievement

Monitoring Growth• Use updated growth charts

– www.cdc.cov • Monitor trends in growth not one value

using wt, ht, HC (< 2 yrs), BMI.• In general, normals fall within 5th-95th%ile.• Evaluate changes in %iles.• Malnutrition results in:

– Decreased weight (acute), then height, then head circumference (chronic).

GIRLSBirth to 36 mo

BOYSBirth to 36 mo

Laboratory assessment

• TPN requires regular monitoring of acid base status, liver function, bone profile and electrolytes

• In enterally fed infants, monitoring albumin, transferrin, total protein, urea, alkaline phosphatase and phosphate may be useful

Faltering Growth

‘Failure to Thrive’ @ FTT

• Term first used to describe delayed growth and development, – also called maternal deprivation syndrome.

• “A failure of expected growth and well being”

• Only growth can be objectively measured

Crossing centiles?

• 5% of normal infants cross 2 intercentile spaces from birth to 6 weeks.

• 5% of normal infants cross 2 intercentile spaces from 6 weeks to 1 year.

• Infants regress to the mean

• Hence development of ‘thrive lines’

Causes and correlates

• Organic disease

• Abuse and Neglect

• Deprivation

• Undernutrition

Causes and correlates

• Organic disease– <5%, usually suggestive symptoms and signs

• Abuse and Neglect– increased risk, but a small proportion

• Deprivation– may influence referral

• Undernutrition

The Energy Balance Equation

Undernutrition

• Most are underweight for height• Fastest decline in weight gain when

energy needs are highest• Poor appetite• Delayed progression to solid foods• Limited range of foods

Faltering Growth over time

Consequences

• Lasting deficit in growth• Lasting effects on appetite and feeding• Low maternal self esteem• Developmental delay at 1 year

– 7-10 DQ points• Small (not statistically significant) IQ

difference at 8-9 years

Management

• Few trials of intervention• One RCT found health visitor led

intervention useful• One non randomised trial found dietary

advice useful• Management is therefore based on

‘accepted best practice’

Screening or Case Finding?

• Up to 50% of children with FTT are never identified

• Recommendations for frequency of weighing suggest paying more attention to fewer weights.

Growth Monitoring

Primary or Secondary care?

• Common problem, often resolves with simple interventions

• Ill children or those losing weight need referral

• Home visitor assessment– Dietary history– Simple explanation and advice

• Second port of call should be dietician

Strategies

The Role of the US

• Investigations (if necessary) should be completed promptly

• FBC, ferritin, U+Es, TFTs, LFT, MSU• Chromosome analysis in girls• CXR and sweat test in young infants or

history of respiratory infections.

Pathway of care

If not improving?

• Nursery nurse involvement or nursery placement

• Help with other behavioural problems• Treat illness in mother• Social work input• Almost never need food supplements or

hospital admission

Feeding difficulties in ex-prems

• Feeding issues are common, especially in those born before 28 weeks

• Risk of– Disordered oral-motor functioning– Significant gastro-oesophageal reflux– Oral hypersensitivity– Neurological impairment affecting feeding

The Classic Definition of colic

• “crying lasting 3 or more hours per day, on more than 3 days a week, for at least 3 weeks and resolving around 3 months”.

– Wassell, Pediatrics 1954

The impact on parents

• Resistance to soothing causes anxiety• Learned helplessness, causing anxiety

and depression• Stress can cause parental coping crises• 10% of mothers experience a depressive

disorder postnatally

Temperament

• Some reports link excessive crying to later difficult behaviours– few studies only– based on maternal recall– possible that quality of care in later childhood

is influenced by early patterns of behaviour

Colic and difficulties with feeding

• 19 with colic v 24 without• Assessment:

– colic symptom checklist – neonatal oral assessment score– clinical feeding evaluation

Outcomes

• Colic group showed:– more disorganised feeding behaviours, – less rhythmic nutritive and non-nutritive

sucking, – more discomfort during feeds, – lower responsiveness during feeding

interactions.• Miller-Loncar, Arch Dis Child 2004; 89 908-12

Organic causes of a ‘colicky’ baby

• congenital heart disease

• CNS abnormalities• NAI • fever eg UTIs• maternal drug

ingestion

• gastro-oesophageal reflux

• cows milk protein intolerance

• malabsorption • gut dysmotility

Gut hormones

• Motilin initiates migrating motor complexes• Vagus stimulation increases number and force

of contractions• Raised motilin in 2 small studies of infantile colic • Smokers have higher motilin levels

Systematic review of treatment

• Lucassen et al, BMJ, 1998• 50 complete studies, 27 controlled

reviewed.

Treatments for colic

• Results as effect size– Behavioural: (reducing stimulation) 0.48– Dicycloverine: 0.46, but serious side effects– Hydrolysate milks: 0.22– Herbal tea: 0.32 (single small study)– Low lactose and soya milks: no effect– Simethicone: no effect

Treatments for colic

obesity• Calorie intake over excessive of body

expenditure• weight More than 95’ centile population or

BMI more 30

Obesity in Childhood and Adolescents

• >20% of children/adolescents are overweight.• Increased by 50-100% over last 20-30 years:

– More sedentary lifestyle and behavior (TV/video games)..

• Obese children and adolescents become obese adults.

• Recent reports indicate 8-45% of newly diagnosed pediatric pts with diabetes are diagnosed with type 2.

Obesity:Health Consequences

• Cardiovascular disease risk• Type 2 diabetes (epidemic)• Hypertension• Orthopedic• Sleep apnea• Gall bladder

disease/steatohepatitis• Psychosocial problems

Pediatric ObesityEtiology and Treatment

• Etiology: – Genetic predisposition: 80% risk if both

parents obese– Environment– Dietary intake– Physical activity / sedentary activity

–Pathological : hypothyroid, panhypopituitarism, pseudohypoparathyroid, syndromic child

• Treatment:– Multidisciplinary and comprehensive– Formal behavior modification– Family-based

Prevention of CVDCurrent Recommendations

• NCEP guidelines apply to children over 2 yrs.• Diet: <30% fat, <10% sat. fat,

<300 mg cholesterol/day.• Check fasting lipid profile when there is a

positive family history of early CVD, or elevated cholesterol (hyperlipidemia) in a 1st degree relative.

• Combine dietary intervention with healthy lifestyle for maximum benefits.

Any Questions?

Summary

• Optimal growth for neonates and infants requires careful thought about nutrition

• Interventions (or lack of them) may have long term consequences

• There is a limited evidence base to guide current practice

• Colic is not uncommon• Feeding difficulties are common

HOPE IS NOT A METHOD!

• Who? Is you, screening all your patients• Why? They’ll do worse if you don’t• When? The sooner the better• What? Enteral better, even trophic better

than TPN alone• Where? PO>NG>NJ > IV