Adamkin Protein VNJC Slides - Mead Johnson · decreasing postnatal growth failure in preterm...
Transcript of Adamkin Protein VNJC Slides - Mead Johnson · decreasing postnatal growth failure in preterm...
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Learning Objectives
• At the end of this presentation the learner will:- Understand the nutritional challenges of preterm
infants- Recognize the role of early TPN amino acids in
decreasing postnatal growth failure in preterm infants- Be able to discuss the importance of preterm
formulas with higher P/E ratios in promoting growth and lean body mass development in preterm infants
- Understand the benefits of human milk fortification in providing protein and other essential nutrients for the preterm infant
Protein Outline
• Standardized early parenteral nutrition
• Higher protein preterm formulas
• Early and exclusive human milk with
various fortifiers
• Lactoengineering
PTF 24 HP
Human
Milk
FortifierEarly TPN
High Protein
Preterm
Formula
ELBW Nutritional Challenge
Zeigler. J Peds Gastro 2007
Inadequate
nutrition
Postnatal
growth failure
Impaired
neurocognitive
development
Protein (80%)
Energy (20%)
ELBW Nutritional Challenge Prevent Inadequate Nutrition
Zeigler. J Peds Gastro 2007
Inadequate
nutrition
Postnatal
growth failure
Impaired
neurocognitive
development
Protein (80%)
Energy (20%)
ELBW Vulnerability to Inadequate Nutrition
The Reference Fetus Available Energy Stores in the Fetus
and Newborn
Reference fetus: Ziegler, Growth, 1976.
Postnatal Weight Loss Has Two Components
POSTNATAL WEIGHT LOSS
A. Excess ECF: (50%)‐Adaptation to extrauterine life
‐Of no consequence nutritionally
B. Endogenous Protein / Fat Stores (50%)‐
ICF
‐
Nutritional
fetus in uteroglucose alone
105
100
95
90
85
80
75
70birth 1 2 3 4 5 6 7
days of age
gram
s of bod
y protein
Change In Body Protein Stores (ELBW)
Denne, Prot & Energy Req in PT infants 2001.
(2%)
(‐1.5%)
(‐21gm)
Enteral
(29gm)
26 weeks
Proteolysis despite receiving energy
Parenteral Nutrition and Growth
Louisville Early TPN Experience TPN‐related Data
*first five days (average) Radmacher P and Adamkin DH J of Peri 2009
Protein Dose in Stock TPN (g/k/d)
• If you start with 5% AA you can’t increase the fluid rate!
• Additional fluids can be co‐infused if glucose and/or
electrolyte requirements change
AA
60ml/k/d
80ml/k/d2% 1.2 1.64% 2.4 3.25% 3.0 4.0
Enteral Feeding VLBW
PROTEIN REQUIREMENTSFactorial Approach•Estimates Protein and Energy•Does not estimate catch‐up
Empirical Method•Physiologic response to graded intakes•Tends to exclude ELBW•Does not measure energy•Includes catch‐up
Protein Requirement (Factorial Method) Enteral
4.0 g/kg/d3.7 g/100 kcal P/E
*With allowance for efficiency of conversion (90%).
Ziegler et al. Growth. 1976;40:329‐341.
Enteral Protein and Energy Requirements of Preterm Infants
(Protein increases, P/E decreases)
Ziegler E. J Pediatr Gastroenterol Nutr 2007;45:S170‐4.
P/E = Ratio of protein to energy, expressed as grams of protein per 100 kcal.
Requirement
(g/kg/d)
<1000 g 3.5 – 4.51000–1500 g 3.5 – 4.0
Unfortified preterm breast milk 2.7Fortified preterm breast milk
3.7 – 4.8
Fortified donor breast milk
3.0 – 4.1
Preterm formula 24 3.6Preterm formula 24 high protein
4.0 – 4.2
Comparison of Protein Requirements and Enteral Options*
g/kg/d when fed at 120 kcal/kg/d
Hay WW. Neonatal Nutrition and Metabolism.1st ed. Saint Louis, MO: Mosby Year Book; 1999.
*Includes factorial and empirical methods
Revised Recommended Protein Intake and Protein‐Energy Ratio for Premature Infants According to Postconceptional Age and the Need for Catch‐up
“EUGR”
Rigo J, Senterre J. J Pediatr. 2006;149:S80‐S88.PER = gram of protein/100cal
Weight gain decreases with sharper decrease in LBM gain and protein retention during last month of gestation
Adapted from Revised Recommended Protein Intake/
P/E Ratio/PCA and Catch‐Up Needs
PCA Protein (g/k/d) P/E (g/100cal)26 – 30 4.4
3.3
30 – 36 3.6 – 4.0 3.0
36 – 40 3.0 – 3.4 2.6 – 2.8
Impact of Protein/Energy Ratio (P/E) on Body Composition
To increase LBM accretion and limit fat mass deposition, an
increase in P/E is mandatory
Lean Body Mass
Weight Gains
Fat Mass Gain
P/EProtein
Energy(-)
(+)
Adapted from Rigo J, Senterre J. J Pediatr. 2006;149:S80‐S88.
(+)
(+)
(+)
(+)
Advantages of a Higher Protein 24 Cal Preterm Formula
INCREASED P/E RATIO
Preterm Formulas Reaching 4g/kg/d Protein
LSRO Protein > 5.0g/k/d may be undesirable
Protein and Weight Gain
For each gm/kg of additional protein weight gain increases:
3.4 g/kg/d
4.1 g/kg/d
4.3 g/kg/d
Kashyapl/Heard 1994Olsen 2002Ernst/Radmacher/Adamkin 2003
Species Specific Milk
Protein, Calcium, and Sodium Requirements for VLBW Infants and Human Milk
Fomon SJ 1977Groh‐Wargo S 2000Ziegler E 2007
*0.9g/dl @ 200ml/k/d**1.5g/dl @ 150ml/k/d
Rickets Diagnosis• Identify high
risk patients
• Term infant formulas, unfortified human milk• ELBW long‐term TPN use, steroids, cholestasis, fluid
restricted • SAP > 1000 IU/L• Serum P < 4mg/dl• High serum alkaline phosphatase activity – most
sensitive and specific marker, but not diagnostic• Low serum phos relatively sensitive, not specific• Serum Ca, PTH and 25 (OH) D levels are usually normal
Osteocalcin not usually helpful• Evaluate with wrist/knee radiograph if indicated.
Rickets is radiological, not biochemical, diagnosis
Peak Alkaline Phosphatase in <1000 g Infant
Peak alk phos: 1078+356 IU/L in 18 infants with rickets
If peak alk phos > 1000 IU/L, 10/19 had rickets
But, if peak alk phos 600‐800 IU/L, 3/29 with rickets
Mitchell et al. BMC Pediatrics 2009, 9:47
Preterm Infants Fed Fortified Human Milk Receive Less Protein Than They Need
• Fortified human milk is assumed to provide adequate amounts of nutrients for premature
infants• Assumption “may”
be true if:
- Composition of milk is expressed during weeks 2 to 3 of lactation
- Not true for DBM or expressed milk >3 weeks of lactation
- (DECREASED PROTEIN)
Arslanoglu, Ziegler et al J of Peri 2009
Assumed and Actual Protein, Fat and Energy Content of the Fortified Human Milk and
Assumed and Actual Protein, Energy Intakes of the Infants
STD
ADJ (BUN<9,>14)
Assumed values Actual values Assumed values Actual values
Intakes
Protein intake (g/kg/d)
First week 3.4±0.1 2.9±0.4 3.7±0.1 2.9±0.3
Second week 3.5±0.1 2.9±0.3 4.0±0.4 3.2±0.4
Third week 3.5±0.1 2.8±0.2 4.2±0.3 3.4±0.5
Energy intake (kcal/kg/d)
First week 126.1±5.2 125.9±7.9 132.2±1.8 127.2±12.1Second week 128.4±2.4 126.6±11.8 135.2±4.2 125.6±11.6Third week 127.6±2.4 120.5±8.3 135.9±2.7 128.0±8.3
N=32600 –
1750gProtein Δ
STD 0.5 to 0.7g/k/d Protein Δ
ADJ 0.8g/k/d Arslanoglu, Ziegler et al J of Peri 2009
Human Milk Fortification
• Caloric density of expressed PT human milk on average does
not differ from term DMBM
• Can assume 67 cal/100ml with PT human milk
• Protein content of PT human milk changes during lactation
and is > term DMBM
• Manufacturers of fortifiers assume expressed milk has
1.5g/100ml (lactation at 2 – 3 weeks). Term DMBM protein
has 0.8 to 0.9g/dl
• Energy intakes at 90 –
100 kcal/k/d are seldom limiting for
growth
Mid‐Infrared Spectrophotometry (MIRSA)
• Point‐of‐care• Accurate• Measures protein,
fat, energy and carbohydrates
• Uses only a small volume of milk
• Affordable• Fast• Small footprint
• Wavelength spectrum 1200 to 2400 nm
• Commercially available— validated for bovine milk
Lacto‐engineering
Human Milk Fortification
Powder
Liquid
Human MilkHuman Milk Human MilkHuman Milk
Bovine HMFBovine HMF HumanHMF
HumanHMF
Standard Exclusively Human
Composition of Feedings Using HMF per 100 mL
* No additional minerals or vitamins ( ) per 150 mL
Liquid HumanMilk Fortifier
Summary
• Early TPN amino acids decreases postnatal growth failure
• Preterm formulas with higher P/E ratios promote growth and lean body mass
• Human milk fortification may require increase amounts of protein dependent on the protein content of the mother’s milk or donor breast
milk