Feeding of LBW Infants

Dr. L S Deshmukh
DM (Neonatology)
Feeding the LBW Infant

Objectives :
• Nutrient requirement
• Formula choices
• Options for feeding regimens
• Adjuncts to feeding
 “There is no finer
investment for any
community than putting milk
into babies”

- Winston Churchill (1943)

LBW Nutrition - Introduction

Improved survival of premies & LBWs

Greater morbidity in preterms
Increased risk of growth deficits and
developmental delay
Increased risk of later adult disease
Recent research, marked difference
between LBW versus term AGA nutrition
 Goals of LBW Nutrition
Short term :
- Mimic intrauterine growth/composition
Long term :
- Optimize neurodevelopmental outcome
- Impact adult onset disease
Prevent neonatal morbidities :
- Improve feed tolerance
- Reduce NEC
- Minimize infection
 Problems of Preterm
Physiological Handicaps :
• Poor co-ordination of sucking & swallowing (<33 wks)
• Weak Gag reflex (aspiration)
• Lax esophageal sphincter
• Small gastric capacity
• Gastroparesis & intestinal hypomotility
Biochemical handicaps :
• High energy & micronutrient requirement.
• Higher fluid requirement
• Increase need for proteins, minerals & vitamins
• Relative deficiency of bile acids & lactase

Saili A et al, J Neonatol July-Sept 2002

 Current Feeding Practices : Problems

• Volume restriction
• Uncertainty about proper conc. of
nutrients
• Global undernutrition of LBWs
• Increased volume of feeds only after
weight plateus (inadequate growth).
• Consequences : ↓ no. of brain cells,
deficit in learning, behavior and memory
 Glucose
• 6 to 10 mg/kg/min, higher than term.
• Higher brain to body ratio
• Avoid higher percentage (adiposity &
↑ Co2)
• Hypoglycemia redefined as < 45
mg/dl
 Revised Recommended Protein
Intake for PT Infants

26-30 wks PCA 4.4 g/kg/d

30-36 wks PCA 3.6-4.0 g/kg/d
36-40 wks PCA 3.0-3.4 g/kg/d
(Rigo J,J Pediatr,2006)

positive protein balance requires at least

1.5 g/kg/day – Hay ww et al, Pediatr Neonatol. 2010
 Lipids
• Vital ingredient
• Provision of 40-50% calories in TPN
• LA & ALA
• Lack of AA & DHA
• 0.5 gm/kg/d to prevent EFA deficiency
Controversies :
• Additional LC PUFA to formula/TPN
• Supplemental DHA & AA
 Role of LCPUFA
* Breast milk has adequate conc.
* Present formulae deficient
* Most important DHA & AA
* Major constituents of nerve cell membranes
* Key role in the structural development of
retinal, neural & synaptic membranes.
* Important for visual & neurodevelopment
 LBW Nutrition – LCPUFAs
• 11 RCTs involving PTs
• Many reported beneficial effects on visual,
neural and developmental outcome.
• Some reports of negative effect on growth
• Cochrane Review, Simmer K, 2004
- Increased early rate of visual maturation
- No effect on growth
- No long term benefit
- Use of fish oil & borage oil in PTs

(Fewtrell MS et al, J Pediatr, 2004)

 Ca & P Supplementation
• Two- third body mineral content acquired
in 3rd trimester
• Fetal accretion rates 105 mg/kg/d and 70
mg/kg/d for Ca & P respectively
• PT born with low skeletal stores
• Very high requirement
• Human milk feeding alone-
- Hypophosphatemia
- Poor bone mineralization
- Elevated Alk. Phospatase
- May lead to # & slow growth
 Ca & P Supplementation
 Osteopenia of prematurity, commoner < 1000 g
 Ca & P deficiency, rarely vitamin D deficiency
 Ca & P accretion in utero equal to puberty
 Rates of bone formation equal to adult
 Ca absorption around 60% - 70%

(Hawthorne KM et al, Minerva Pediatr, 2004)

 Ca & P Supplementation
• Recommended intakes –
• Ca : 200-220 mg/kg/d,
• P : 100-110mg/kg/d
• Ca : P ratio > 16 wks GA 1.8:1
• Supplementation with both essential
for postnatal bone mineralization.
• Supplement till 42-43 wks PNA
• Cochrane Review : No studies which met
selection criteria were identified
(Carl A Kuschel , 2009)
 LBW Nutrition - Iron

• Total body iron low at birth

• Further decrease in iron, phlebotomy
losses / Epo
• Early iron deficiency – Late cognitive
effects
• Dose 2-4 mg/kg/d started between 2 wks
to 2 mo PNA
• 6 mg/kg/d for Epo / IDA
(Rao R et al, Semin Neonatol. Oct. 2001)
 Zinc Supplementation
* Preterm HM has less conc. & LBW may be zinc
deficient
* Better weight gain
* May improve immune function
* Improves mental development & behaviour ?
(Lira PI et al, Eur J Clin Nutr, 1998)
Sazwal et al, Indian Study, Pediatr 2001
- Decreased risk of death due to diarrhea
- Zinc deficiency more in SGA babies
Effect on growth
- Better weight & height gain
- Dose : 2 mg/kg/d x 6 wks
Islam MN et al. indian pediatr, 2010
 Vit.A Supplementation
 Regulates & promotes growth of many cells
 Maintains integrity of respiratory epithelial tract
 Important for visual pigment, human function and as
antioxidant.
 1000 IU / kg/d for all VLBW
Theraupeutic use
 ↓ O2 requirement & BPD
 ↓ ROP
 ↓ Nosocomial sepsis
 Dose : 5000 IU IM 3 times a wk x 4 wks.
Oral - 4000 IU/kg/d
( Darlow BA, Cochrane Review, 2002)
Vitamin E in LBW Nutrition
•Routine supplementation, ↑ses Hb marginally
•↓ risk of IVH,
•↓ risk of severe ROP
•RD for LBW - 0.7 IU/100 kcal + 1 IU/gm
PUFA
•Recommended 10 mg/d (Oral)
IM 20 mg/kg/d x 3 d
•Side effects : sepsis, NEC, thrombocytosis

(Brian LP, Cochrane Review, 2006)

Enteral feeding - Early Gut Development

• Int. mucosal development by IInd

trimester.
• Organize motility develops till 28-30
wks.
• Motility – rate limiting
• Poor esophageal motility – GER
• Gastric emptying slower
• Only 50% <28 wks. pass mec. within
3 d.
Maturation of oral feeding skills in LBW infants

GA Maturation of feeding skills Initial feeding

method
< 28 wks No proper sucking efforts Intravenous fluid
No propulsive motility in the gut
28-31 wks Sucking bursts develop Oro-gastric (or naso-
No coordination between gastric) tube feeding
suck/swallow and breathing with occasional
spoon/paladai feeding
32-34 wks Slightly mature sucking pattern Feeding by
Coordination between breathing & spoon/paladai/cup
swallowing begins
>34 wks Mature sucking pattern Breast feeding
More coordination between breathing
and swallowing
 Enteral feeding - issues
• what milk to feed
• what nutritional supplements
• how to feed
• how much and how frequently
• what support
• how to monitor
 What to feed
• Nutritional sources for LBW infants
 Human milk
 Breastmilk substitutes
 Locally prepared animal milks
Nutrient guidelines Milk Selections (Per100
Kcal)

Nutrient Am Acad Pediatr Consen. Recomm.

Protein (g) 2.9-3.3 2.5-3.2

Calcium (mg) 175 100-192

Phos. (mg) 92 52-117

Sodium (mEq) 2.1-2.9 1.7-2.5

Vit. D (IU) 270 125-133

Iron (mg) 1.7-2.5 1.7

Zinc (µg) >500 833

Recommended dietary allowance in preterm VLBW
infants and the estimated intakes with
fortified/unfortified human milk
RDA At daily intake of 180 ml/kg
(Units/kg/d)
Only expressed EBM fortified EBM fortified
Breast milk with lactodex- with preterm
HMF formula
(4g/100mL) (4g/100mL)
Energy (kcal) 105-130 117 144 153
Protein (g) 305-4.0 2.46 3.2 3.4
Carbohydrates (g) 10-14 11.6 16.84 15.58
Fat (g) 5.4-7.2 6.8 7.1 9.06
Calcium (mg) 210 43.2 223 103
Phosphorus (mg) 110 22.2 112 52
Vit. A (IU) 90-270 680 3308 980
Vit. D (IU/d) 400 3.5 903 40
Vit.E (IU) >1.3 1.9 6.3 3.6
Vit B1 (mcg) >48 36.2 79.4 231
Vit B2 (mcg) >72 84.2 156.2 564.2
Bit. B6 (mcg) >42 25.7 115.7 221
Folic acid (mcg) 39.6 6 150 36
Zinc (mg) >0.6 0.6 0.96 0.96
 Recommended and Actual Intake of

Various Nutrients

Nutrient P-RNI Intake from FHM

kg/d Mother’ milk

Energy (Kcal) 105-135 88-145 104-174

Sodium (mmol) 2.5-4.0 1.3-2.2 1.7-2.8
Zinc (µmol) 17.0 7.7-12.3 20.6-34.3
Vit. D (IU/d) 400 4.8-8.0 257-428
Proteins (g) 3-3.5 2.0-3.4 2.9-4.8
Calcium (mg) 160-240 36-60 144-240
Phosph. (mmol) 2.5-3.8 0.5-0.9 2.3-3.8
Iron (mg) 2.0-3.0 0.04-0.06 0.04-0.06
 Human milk
• Mother’s own milk and donor milk
• Fore milk and hind milk
• Drip milk and expressed milk

Storage of human milk

HUMAN MILK SUPPLEMENTS
 Promotes int.
adoptation
sIgA, Growth factor,
hormones,
oligosaccharides
Compensate for Prevents Infection
immaturity of the & Inflammation
intestine sIgA, Lactoferrin,
Neocleotides, PAF- Beneficial Lysozyme,
AH, cytokines Cytokines,
growth factors
effects of oligosaccharides
bioactive
agents in
HM
Promotes Enhance function
establishment of poorly expressed
beneficial microbiota in the infants

sIgA, Lactoferrin, α-LA, Lipids, cytokines,

Oligosaccharides hormones
Human milk supplementation
• Individual vitamins or minerals
— Vitamin A
— Vitamin D
— Vitamin K
— Iron
— Zinc
— Calcium and phosphorus
• Multivitamins
• Multicomponent fortifiers
 Multicomponent Fortifier

• facilitate more rapid catch-up

growth
• May improve neurodevelopmental
outcomes.
• logistically difficult for infants
fed directly
McCormick FM et al, 2010
 Fortified Breast Milk : Safety

• HM – sterile product
• EBM contamination at various points.
- Pumping
- Storage
- Transportation
- Addition of fortifier
- Setup & administration of feed
• Effect of iron content on bacterial growth
(Dalidowitz C, J Am Diet Asso, Oct, 2005)
 Breastmilk substitutes
• Pre-term infant formulas
• Standard infant formulas
• Nutrient enriched “post-discharge”
formulas
• Soy-based formulas
ENTERAL FEEDING – Time of initiation

• Early Vs Delayed feeding

• Early feeding < 4 d
• Delayed > 5-7 d
• Feeds delayed to dec. NEC
• No evidence that delayed introduction
of progressive enteral feeds prevents
NEC (Morgan J et al , cochrane, 2011 )
 Delayed Feeding : Consequences

• Fewer mucosal antibody cells.

• Reduction in the local immune response.
• Decreased enzyme levels.
• Damage to mucosal barriers.
• Increased susceptibility to infections.
• Morphologic injury.
• Decreased secretion of IgA.
• Bacterial overgrowth.
 Minimal Enteral Nutrition
(MEN) Benefits

- Stimulates secretion of GI hormones

- Improved glucose tolerance
(enteroinsular axis)
- Stimulates motor activity
- Stimulation of bile flow & ↓ cholestasis
AIIMS- NICU protocols 2008
Minimal Enteral Nutrition (MEN)
•Dilute / full strength feeds < 10 to 15mL/Kg/day
or no enteral nutrient intake (water only)
•“Trophic” feedings

•↓ feed intolerance
•? ↓ NEC
•↓ hospital stay
Tyson JE, Cochrane Review, 2006,
 MEN - essentials

* Can be started on ventilator and /or

receiving TPN
* In severe birth asphyxia, after 48-72
hours
* VLBW infants born with antenatal
diagnosis of altered umbilical arterial
blood flow delayed for 2 to 3 days.
Initiation of Enteral Feeding : Issues
NG V/s OG Feeding :
Nasogastric feeding
- Pulmonary compromise
- Higher A & B
Orogastric Feeding :
- Grooved palate
- Sialadenitis
No large RCTs available, insufficient
data
(Cochrane Review, 2006)
Initiation of Enteral Feeding : Issues

Feeding tube placement :

Size of feeding tube : Problems with larger
tube
• Nasal inflammation
• Throat irritation
• Pressure necrosis
• Pulmonary compromise
• GER
• Apnea & bradycardia
Use smaller feeding tubes
Initiation of Enteral Feeding : Issues
Intermittent Bolus Feed
Benefits :
- Promotes cyclical surge of gut
hormones
- Promotes gut development
Risk :
- Feeding intolerance
- Delayed gastric empty / intestinal
transit
- Difficult metabolic homeostasis
Initiation of Enteral Feeding : Issues

Continuous Feeding :
Benefits :
- Energy efficient
- Improved nutrient absorption
- Reduced feed intolerance
- Improved growth
Risk :
- Alters cyclical pattern of release of
hormones
- Potential to affect metabolic homeostasis
− ↑ GER
Continuous vs. intermittent feeding

• There is no difference in time to

achieve full feedings
(Premji SS et al, Cochrane,2008 )
 Enteral feeding - interval
• ad libitum or demand/semi demand
Vs Scheduled
• Some evidence - earlier hospital
discharge
(McCormick FM, Cochrane, 2010 )
 Feeding volumes and frequency
Birth Starting Volume Maximum Frequency
weight volume increment volume of feeds
(g) (ml/kg/d) each day (ml/kg/d)
(ml/kg/d)

<1200 10-20 20 180 2 hrly

1200- 60 30 180 2 hrly
1600
>1600 60 30 150 3 hrly
Cup feeding versus Bottle / spoon
• cup fed more likely to be exclusively
breastfed at hospital discharge
• no difference at 3 / 6 mo
• one study feed by cup spent ten days
longer in hospital
• cannot recommend cup feeding.

Flint A et al , Cochrane , 2008

Initiation of Enteral Feeding : Issues

Enteral Feeding with Umbilical Lines :

• Fear of feeding problems & NEC
• A prospective, RCT of 60 PT infants
with low UAC – no feeding problems
• Monitor infants for signs of feeding
problems.
Breast Feeding LBW - Challenges

• Fortification of preterm HM
• Establishing a milk supply
• Maintaining milk supply
• Transition from gavages to
breast feed
• Incidence and duration of BF
• Barrier to BF in PT
Initiation of Breast Feeding : When ?
• Traditional Criteria :
• Physiologic stability
• Ability to tolerate bolus feeds
• GA > 34 wks & BW > 1500 g

• Behaviorally based criteria :

• Mother – Caregiver observations
• Infant sucks on pacifier / tube
• Makes rooting motions
• Has brief periods of active / quiet alert state
 feeding intolerance
•Significant abdominal distension or
discoloration
•Signs of perforation
•Obvious blood in stool
•Gastric residuals 25% to 50% of interval
volume for 2 to 3 feedings
•Bilious gastric residual or emesis
•Significant apnea/bradycardia
•Significant cardiopulmonary instability

(The Vermont Oxford Network "Got Milk" focus group ,2003)

 Gastric residuals

• Prefeed aspirate, milky & > 50%, omit

feeds & evaluate
• 25-50%, omit feed & monitor (AC)
• < 25% aspirate, push back, monitor &
continue feeding.
(Saili A, J Neonatol, 2002)
Non-nutritive Sucking (NNS)

•Different from nutritive sucking

•During gavage feeds
•Pacifier (thumb size) / empty breast
•Facilitates development of sucking.
•Improves digestion
•Decreased hospital stay
(Source : Pinelli J. Chochrane Review, 2010)
•Calming as well as analgesic effect
(Source : Symington A, Chochrane Review, 1998)
Kangaroo Mother Care (KMC)
Possible Benefits:
• Promotes & Prolongs Breastfeeding
• Physiologic stability ( A&B, quiet sleep)
• Maternal confidence & Bonding
• Decreased Infection
• Cost Savings
(Kirsten GF, PCNA,2001)
 Oil Application / Massage
• Greater weight gain
• ? Greater length gain
• Better neurobehavior
• Better thermoregulation
(Ramji S et al, 2005; Modkar JA et al, 2005)

• Better skin barrier function

∀ ↓ sepsis (use of sunflower seed oil)
(Darmstadt GL et al, 2005)
Feed Intolerance : Oral Erythromycin

• Potent prokinetic activity

• Acts through motilin receptors
• Improves feed tolerance
• Cochrane review, 2008- not enough evidence
to show any benefit
• high-dose erythromycin probably justifiable
(Lam HS et al, Curr Opin Pediatr. 2011 Apr;23(2):156-60 )
 Lactase Treated Feeds
• Last of the disaccharidases to develop in PT.
• first detectable in the fetal intestine by 10
weeks' gestation
• At 28 to 34 weeks, lactase activity is only ~30%
• often managed with soy protein, protein
hydrolysate, low lactose, or lactose-free formulas
• Lactase to hydrolyse lactose for promotion of
growth & feed intolerance.
• greater rate of weight gain and higher serum
albumin- indicative of improved nutritional status
(J Pediatr, Oct. 2002)
• Single RCT, no significant benefit.
(Ohlsson A et al, cochrane 2006),
 Feed Intolerance : Adjuncts
• Enteral insulin - accelerates GI develop.
- stimulates intestinal activity
- increases lactate activity
Pilot study, Shulman RJ, 2002
Limitation : Historic controls, need RCT
• Enteral solution (like human amniotic fluid)
- Phase I trial, significant increase in milk
feeding.
- May be related to growth factors
(Barney CK et al, Adv Neo Care, April, 2006)
• Cisapride : RCT, Kohl M et al, Biol Neonate, 2005
- No benefit (only in ELBW)
- More vulnerable to side effects
• Metoclopramide : No role, adverse effects
 Role of Glutamine
•Increased feed tolerance
•Decreased sepsis
•Decreased nosocomial infections
•Better short term outcome
•Dose – 0.3 gm/kg/d
Van Den Berg et al, Am J Clin Nutr, 2005
• No effect on mortality, serious
infection, gut complications or long term
development.Tubman TRJ et al, Cochrane Review,
2006
•may lead to significant improvements
in growth Korkmaz A, Turk J Pediatr. 2007
 Role of Arginine

• RCT
• 152 PT infants
• L-arginine (1.5 mmol/kg/d)
• Significant decrease in all
stage of NEC
(Amin HJ et al, J Pediatr 2002)
 Role of probiotics
• Two Meta-analyses
• reduced the risk of death due to
all causes
• Significant decrease in NEC
• No effect on sepsis
• No significant adverse effects
• strain specific
Szajewska H, Early Hum Dev. 2010
 Prebiotic supplementation

• galacto-oligosaccharides
• fructo-oligosaccharides
• supplementation appears safe
• may benefit enteral tolerance in the
most immature infants.
Modi N et al, Pediatr Res. 2010 Nov;
 Antenatal corticosteroids –

Role in PT nutrition.
• Early introduction of enteral feeding
• Enhanced intestinal motility, integrity
and growth
• Maturation of intestinal arginine
synthesis
• Shortened hospital stay

Wu G et al, J Nutr Biochem Aug. 2004.

Feeding of LBW : Poor Weight Gain

Diet Considerations :
• Incorrect calculations of actual
intakes
• Milk prepared incorrectly
• Volume intakes not advanced for
weight gain.
• Increased nutrient demands
• Feed intolerance
Feeding of LBW : Poor Weight Gain

Use of Human Milk Consideration :

• Greater vol. production than intake
(foremilk V/s hindmilk)
• Incorrect proportion of HMF
• Need for sodium supplementation
• Need for increased vol. or protein
supple.
Approximate Daily Weight Gain for Infants
Gestational age g/kg/d
24-28 wk 15-20
29-32 wk 17-21
33-36 wk 14-15
37-40 wk 7-9

Corrected age g/d

40 wk – 3 mo 30
3-6 mo 20
6-9 mo 15
9-12 mo 10
12-24mo 6
Care of high-risk infant, Klaus,2000
LBW Daily Weight Chart
Ehrenkranez RA et al, Pediatrics 1999
 MCT oil for wt gain

• primarily of energy
• Increased weight-length ratio
• producing obesity
• RCT, PE Vs MCT oil’
• Significantly higher protein intake
• better growth
Brumberg HL et al, J Perinatol. 2010
 Postdischarge Nutrition
• Often neglected
• Mostly only breast fed
• More attention beneficial
Important for :
 Who can’t consume ad libitum quantities
 Poor growth
 Abnormal biochemical screen of nutritional
status
Important – monitor just before and at least one
month after discharge and consider
fortification
Lucas A et al, Pediatr 2001.
 Weaning Preterm Infants
• Early onset of weaning

• Use of foods with higher energy and

protein

• Foods rich in iron and zinc

• Beneficial effect on length & iron

status

Marriott LD et al, Arch Dis Child Fetal Neonatal ed.

Nov. 2003
 Feeding Options for PTs
During stable growth phase
First Choice : preterm human milk +
Lactodex – HMF (if affordable) + Fe
supplements from 2 wks.
OR
Preterm human milk + Ca/P +
multivitamins, Zinc + Fe supplement.
Second Choice : LBW formula milk +
multivitamins, Zinc + Fe supplements.
Third Choice : Undiluted cow’s milk +
mltivitamins, Zinc + Fe supplement.
 Potentially Better Practices

• Monitoring of growth & nutrition

• Early initiation of enteral nutrition
• Consistent systematic advancement of feeds.
• Uniformity & clarity as to withholding feeds.
• HM is the preferred nutrient for PT
• Use of appropriate enteral products
• Early initiation of TPN, when feasible

(The Vermont Oxford Network "Got Milk" focus group ,2003 )

Thank You
 Developmental signs that show readiness for feeding

Behaviour at Response when Range of Feeding Range of birth

the breast offered gestational or readiness weight
expressed post-menstrual
breat mild by age (wks)
cup

No definite No extrusion of < 28 No readiness < 1000 g

mouthing tongue, no IV feeding
licking needed
Intragastric tube
may be possible
 Developmental signs that show readiness
for feeding
Behaviour at Response when Range of Feeding readiness Range of birth
the breast offered gestational weight
expressed or post-
breast milk by menstrual
cup age (wks)

Occasional, Opning mouth, 28-31 First signs of oral 1000-1500g

ineffective tongue out of readiness.
suckling the mouth, Intragastric feeding
attempts licking milk. appropriate Can try
Not able to small amount of
coordinate direct expression or
breathing and cup feeding to gain
swallowing well oral experience
 Developmental signs that show readiness
for feeding
Behaviour at Response when Range of Feeding readiness Range of birth
the breast offered gestational weight
expressed breast or post-
mild by cup menstrual
age (wks)

May root and Opening mouth, 32-34 Can now use cup or 1300-1800g
attach to tongue forward, other alternative
breast. Weak licking milk feeding method for
suckling Able to most feeds.
attempts coordinate Allow baby to
breathing and attach to breast for
swallowing well part of feed or for
some feeds
 Developmental signs that show readiness
for feeding
Behaviour at Response when Range of Feeding Range of birth
the breast offered expressed gestational or readiness weight
breast mild by cup post-
menstrual
age (wks)

Able to root Opening mouth, 33-35 Breast feed for 1600-2000g

and attach to tongue forward, part of feedor
the breast licking milk, some complete
coordinating feeds
breasting and
swallowing
Coordinating Cup or
May have breathing and
periods of alternative
swallowing well
organized supplement
An now able to most feeds to
suckling with
long pauses suck at the milk ensure
from the cup and adequate intake
other alternatives
 Developmental signs that show readiness
for feeding
Behaviour at Response when Range of Feeding Range of birth
the breast offered expressed gestational or readiness weight
breast mild by cup post-
menstrual
age (wks)

Able to suckle Able to suck at milk 34-36 Breastfeed, and 1800-2200g

effectively at from the cup and may need some
the breast other alternative supplements by
feeding methods cup or other
alternative