The principles of feeding for infants with normal and complicated delivery

Kardana, I Made Division of Neonatology Sanglah Hospital, Denpasar

TERM HEALTHY INFANTS

Rapidly adapt from relatively constant intrauterine supply Should be breast-fed as soon as possible within the first hour

Preterm infants
Are at increased risk of potential nutritional compromise Unable to feed and has a GI system less ready to receive enteral nutrition

Nutrition problems of preterm

Imaturity organ

Increased diseases and anomaly

Rapid Growth rate

Increase nutrient demands

Limited nutrient reserve

ENTERAL NUTRITION

Infant > 1500 g

Usually > 32 weeks gestation First feed 1-3 hours of age, 3 hourly feed Total volume 60 ml/kg/day (first day), if

tolerated volume is increased 30 ml/kg/day up to a maximum of 160-180 ml/kg/day

Feeds orogastric / nasogastric tube

34-36 weeks gestation

show signs of sucking, swallowing

reflexes early introduction to the breast-feeds Early feeding may allow the release of enteric hormones with exert a trophic effect on GI system

Infant < 1500 g

Less able to adapt

Less well tolerate volumes of feed Incomplete digestive and absorptive capacities Slower gastric and gut emptying times nutritional requirements More complex in infants < 1000 g

When to feed??

Depend on the infants condition

- Stable CV and respiratory status - Evidence of gut function - Take several days to achieve stability

iv dextrose should be initiated PN if feed not within 3 days

How to feed???

Infant 1-1.5 kg 2 hourly feed, intermittent orogastric/nasogastric

Infant < 1 kg hourly feed or by continuous drip

How much to feed??

First day 60 ml/kg/day Daily volume increased 20 or 30 ml/kg/day Eventual feed volume 180 ml/kg/day two weeks to achieve depend on degree of tolerance

Type of feeding EBM is the best

EBM advantages
1.

Provides species-specific nutrients to support normal infant growth

2. Gastrointestinal GIT growth factors

Oligopeptides promote motility

Protection against NEC 3. Host defence / immunity Against infection, Decrease in atopy

EBM advantages
4. Developmental outcome
Higher score on developmental testing 5. Psychological benefit for mother and baby

Alternative (artificial) feeds

Standard formula Preterm formula Banked human expressed milk Special feed : soy formula, elemental formula

Fluid management

First few days :

Loss of water BW 5-10% in term infant and 15-20% in very preterm infant

Water losses : IWL , Urine , abnormal loss

fluid management
Guidelines for water requirement
Days of life Ml/kg/day 1 60 2 90 3 120 4 150 5+ 150+

fluid management
Sick babies no need to increased fluid

requirement at this rate as long as there are : No sign of dehydration Normal serum sodium Normal glucose

PARENTERAL NUTRITION

Containdications to enteral feeding

Impending or recent extubation Respiratory distress Metabolic acidosis Hypotension and shock, use of IV inotropes Pre and postoperatively Serious infections, especially if paralitic ileus suspected NEC Severe asphyxia Before and after exchange transfusion

Parenteral nutrition (PN)

Prevent protein catabolism Promote positive nitrogen balance

Improve growth
Prevent essential nutrient deficiencies

parenteral nutrition

Expensive Complicated

Serious complication

Indication PN

Infants with BW < 1,500 g, in conjunction with slowly advancing enteral nutrition Infants with BW > 1,500 g for whom significant enteral intake is not expected for > 3 days

indication PN

Post severe asphyxia Severe respiratory disease

Necrotizing enterocolitis
Major GI anomalies Major surgery Instability cardiovascular

Composition of PN
Carbohydrates (glucose) Proteins (amino acids) Fats/lipids Vitamins Trace elements Electrolytes

parenteral nutrition glucose

First day 4 6 mg/kg/min of glucose

10% glucose and 60 ml/kg/day provide 4.2 mg/kg/min glucose Glucose higher rates

by the fluid infusion rate

by the glucose concentration

Glucose utilization rate (mg/kg/min)

= rate (ml/h) x % dextrose Wt (kg) x 6

parenteral nutrition protein

1 g protein = 4 Kcal
Promotes weight gain Positive nitrogen balance Start at 1 g/kg/day, advance by 0.5 g/kg/day maximum 2.5 g/kg/day

parenteral nutrition

lipid

Start at 1 g/kg/day, advance by 1 g/kg/day maximum 3 g/kg/day Monitoring lipid tolerance

- Serum triglyceride levels < 150 mg/dl

Electrolytes

Sodium

2-3 mmol/kg/day Normal concentration 135-145 mmol/L First few days : - relative haemoconcentration - sodium does not need to be added

Electrolytes

Potassium

2-3 mmol/kg/day Added when renal function and urine output normal Normal concentration : - 3.5 5 mmol/L (venous blood) - 4 - 6 mmol/L (capillary blood)

Calcium

Requirement 1-2 mmol/kg/day

Hypocalcaemia preterm, SGA, sick infant, diabetic mother Normal concentration : 2.25 2.75 mmol/L Sick infant 2 ml of 10% calcium

gluconate/100 ml iv fluid prevent

hypocalcaemia

Route of administration PN

Peripheral veins : Less expensive, fewer complication, limited number of veins,

maximum glucose concentration 12.5%

Central veins

Long term infusion Hypertonic solution Maximum concentration 20-25% Expensive More complication

Monitoring parenteral nutrition

Test Glycosuria Blood glucose Sodium, potassium, acid-based Frequency Twice daily Daily (more often in the first days of life, or with glycosuria) Daily initially, then 3 times per week 3 times per week 2 times per week 2 times per week Daily, or more often, if jaundiced If billrubin substantially conjugated Daily if using intralipid

Calcium, magnesium Urea, creatinine Platelet count Bilirubin Liver function test
Triglyceride

Complications PN

Glucose hyperglycaemia, glycosuria, osmotic dehydration, thrombophlebitis Amino acid blood urea , hyperammonaemia, liver cell damage, metabolic acidosis

Intralipid reduced platelet adhesiveness, diminished pulmonary blood flow, liver cell damage, and competition with bilirubin for albumin binding sites.

complications
Of the infusion equipment

Systemic infection

Thrombosis
Hemorrhage

Dislodgement with extravasations

Assessing nutritional adequacy

Anthropometric measurements
To compare growth rate with approximate intrauterine growth rate standards

Expected mean weight gain <1 kg BW : Gain 15-18 g/kg/d, > 2-4 weeks

1-2 kg BW : Gain 12-15 g/kg/d, 10-14 days

> 2 kg BW : Gain 8-12 g/kg/d, 7-10 days

assessing nutritional adequacy

Clinical tolerance
Vomiting Excessive residual Marked abdominal distention Diarrhea NEC

assessing nutritional adequacy

Indications of inappropriate nutrition

- Poor growth energy intake << - Metabolic acidosis protein intake >> - ALP , Ca & P , Ca & P intake vitamin D deficiency - Tryglyceride level fat intolerance - Bilirubin, ALP, transaminase cholestasis