Neonatal nutrition

Mohammad khassawneh

Goals

• Ensure continuation of growth by giving enough calories

• Provide balance in fluid homeostasis

• keep electrolytes normal range

• Avoid imbalance in macro-nutrients

• Provide micro-nutrients and vitamins

General facts about neonatal fluid and nutrition

• Last trimester of pregnancy– Fat and glycogen storing– Iron reserves– Calcium and phosphoruos deposits

• Premature babies more fluid (85%-95%), 10% protein, 0.1% fat. No glycogen stores

• Insufficient protein and calories is life threatening to the sick

Guidelines fluid management

• 80 cc/kg/day, increase to 100-120cc/kg/d with increase IWL

• Increase to 100cc/kg/d 2nd day – add sodium 2-4 mEq/kg/d and K= 2 mEq/kg/d.– Calcium may be added

• after 2nd day adjust according to– urine output 2-3cc/kg/hour with 110-140cc/kg/d– Specific gravidity 1.008-1.012,– watch weight change,– total in/out

Nutritional pathway for premature infant

• Day1, parenteral glucose 5-7mg/kg/minute– Watch blood sugar– Electrolytes check at 24 hours – Consider trophic feeding

• Day2, TPN if not feeding• Day 3 or more: enteral feeding slowly increased

20cc/kg/day

– 1.5kg= 30cc/day =2.5cc every 2 hours

• Day10-20, full nutrition

Energy use in body

• Resting energy use 45 kcal/kg/d

• Minimal activity 4 kcal/kg/d

• Occasional cold stress 10 kcal/kg/d

• Fecal loss of energy 15 kcal/kg/d

• Growth 4.5kcal/gm 40-45 kcal/kg/d

• Total 110-120 kcal/kg/d

Distribution of energy sources

• Glucose 16.3gm = 55 kcal/kg/d…. 50%

• Protein 3.1gm =12.5 kcal/kg/d…12%

• Fat 4gm = 40 kcal/kg/d…38%

• Total 108 kcal/kg/d

Total parenteral nutrition (TPN)

• This began 1968 first use

• growth of 10-15gm/kg/day weight gain – 3gm/kg/d protein (amino acid)– 3gm/kg/d fat (Fatty acid)– 16gm/kg/d Dextrose 10-25% (carbohydrate)

• this will give100-120 k.calories/kg/day

others

• Minerals– Zinc, copper, molybdenum, chromium,

selenium– Calcium, phosphorous, Magnesium– Na, K

• Vitamins– Fat soluble– Water soluble

Biochemical testing for patient on TPN

• Urine glucose

• Triglyceride

• BUN, Albumin

• Ca, P, Mg, creatinine, Na, Cl, CO2

• direct (conjugated) bilirubin, ALT

• Trace element level

Complication of TPN

• Infiltration under skin

• Infection

• Liver dysfunction

• Renal overload

Feeding development

• Swallowing first detected at 11 weeks

• Sucking reflex at 24 weeks

• Coordinated suck-swallowing not present till 32-34 weeks

• Swallowing to coordinate with respiration– Respiration>60-80 NG feeding– Respiration>80 high risk for aspiration (NPO)

Methods of feeding

• Oral feeding– >32 weeks– Respiration<60-80– Try 20 minutes

• Naso-gastric (NG) feeding bolus

• NG feeding continuous

• trans-pyloric

• Gastrostomy feeding

Trophic Feeding

• Keeping infant fasting (NPO)– Decrease in intestinal mass– Decrease in mucosal enzyme– Increase in gut permeability

• Trophic feeding:– small amount of feeding to prepare the intestine– release enteric hormones, better tolerance to feeds

Enteral feeding

• 40-45% of calories are coming from carbohydrates (Lactose or glucose polymer)

• Protein requirement of infant is 2.2-4.0 gm/kg/d

• Protein is whey predominant 60:40

Breast feeding

• after delivery baby has metabolic reserves• Hepatic glycogen• Brown fat• Extracellular and extravascular water

• milk production is stimulated• Try to get baby onto the breast within first

1-2 hours of life• Colestrum ; high in protein a nd

immunoglobuline

breastfeeding

• DOL# 1:• Colostrum and transitional milk average volume 35

mL (7-125mL)

• DOL# 3-5:• Increasing milk production

Breast feeding

• Q2-3 hours = 8-12 feeds per day– Quicker gastric emptying– frequent breast stimulation and emptying increase milk supply– Watch for feeding cues

• Duration– 10 minutes or longer– As long as swallowing continues

• Cluster feeds is normal• Growth spurts

– Baby may feeds more frequently for 1-2 days– Many growth spurts at 2wks, 6, wks, 2-3 months, and 5-6

months they feed more during them

Breast feeding

• Ineffective if baby sucks from nipple only

• Nipple and areola must be drawn deeply into baby’s mouth

• Listen for infant swallowing– DOL#1: intermittent swallows– DOL#2 on: 1 swallow : 1-3 jaw excursions

Maternal factor of low milk

• Gestational diabetes• Hypothyroid• Retained placental fragments• Dehydration, hemorrhage, hypertension, infection• Previous breast surgery• Lack of prenatal engorgement• Psychosocial

– Previous unsatisfactory experience– Lack of partner support– Post-partum depression– Separation from infant

Milk is what you eat

• Mom’s need extra 500kcal/day if breast feeding

• Caffeine– Limit to 1-2 cups/day– Babies may become overstimulated, fussy

• Spicy and gassy foods reflects

Infant illness that affect breast feeding

• Prematurity– Co-ordinated suck-swallow-breathing reflexes at 32-34 weeks

• SGA, IUGR• Twins• Cleft lip and Palate, Micrognathia, Ankyloglossia, Macroglossia

• Jaundice• Neuromotor problems• Birth asphyxia• Cardiac lesions• Infection• Surgical problems

Do I have to wake my baby to feed?

• Should wake baby during first 2-3 weeks while milk supply is being established

• Once milk supply good and baby back to birth weight can allow baby to go 5 hours during a 24 hour period without a feed

• If milk supply decreasing should reinstitute night time feed

Is my milk enough???

• 8-12 feeds per day to 6-8 weeks of age• Frequent swallowing• Adequate urine output (2-6 times/day)

• Adequate stooling• Yellow stools by DOL#4• Weight loss no greater than 8% of BWT• Weight gain 15-30 grams/day• Good skin turger, moist mucous membranes• Contentment 1.5-2 hours after feeds

Enough milk

• Breasts feel full before and softer after feeds

• Milk leaks from contralateral breast during suckling

• Sensation of milk ejection pins and needles

• Absent nipple trauma and pain• Profound state of relaxation in mom during

suckling

Human milk

• Human milk is Ideal food for full term infant• Inadequate components for premature

infant <1500gm (human milk fortifier needed to be added)– Protein– Vitamin D– Calcium– Phosphorous– Sodium

Breast feeding

• Foremilk

• Hind milk

Nonnutritive sucking

• Pacifier– In premature

• ?/ no effect (wt gain, hospitalization, improved oxygenation, faster oral feeding)

• May give infant comfort and calm more quickly

• In term infant nipple confusion with bottle and pacifier against breast feeding

Premature formulas

• lack natural standard

• 50% lactose and rest glucose polymer

• Protein– 150% in amount of term formula– Whey predominant

• Fat 50% LCT 50%MCT.

• Higher Ca, P, higher Ca : P ratio of 2:1

• Long chain polyunsaturated fatty acids

Standard infant formula

• 100% lactose

• Fat is all long chain triglyceride

• Protein is whey 60%, casein 40%

• Iron fortified 12mg/liter and low iron versus low 1.5mg/liter (should not give it)

• Ready to feed or prepare from powder

Soy formulas

• Lactose free– Primary and secondary lactase defeciency– Galactosemia

• Carbohydrate is sucrose or corn syrup

• Fat is vegetable oil such as coconut oil

• Not recommended in very low birth weight infant related to weight gain and osteopenia.

Case 1

• 4 kg baby boy d in delivered by C/S and mother interested in bottle feeding.– Type of milk advised

• Sihha, NAN1, similac, S26

– Amount– frequency

Case two

• 3.5 Kg mother wants to breast feed her infant. She is primi-gravida – Is small amount of milk in first 3ds enough– How to encourage her to continue breast

feeding– Signs of successful breast feeding– For how long breast feeding to continue– Discuss AAP guideline – Baby jaundice at 2 weeks

Case 3

• 1.4 kg baby born at 30 week and has RDS– Discuss fluid management in first 3 days– How to feed him

• Amount• Rate of increase• Type of formula• Risks of fast feeding