MANAGEMENT OF PRETERM AND LOW BIRTH WEIGHT INFANTS
i. Physiologic development
ii. Nutrition requirements during parenteral feeding
iii. Transition from parenteral to enteral feeding
iv. Nutrition requirements during Enteral feeding
The principles of nutrition for parenteral and enteral feeding in Preterm and Low birth
weight infants
Management of Preterm and Low Birth Weight Infants
Preterm/premature Infant: Infants born before 36 weeks of gestation.
Low Birth Weight (LBW): Infants having weight less than 2.5 kg (5½ lbs) at the time of
birth.
Very Low Birth Weight (VLBW): Infants having weight less than 1.5 kg (31/3 lbs) at the
time of birth.
Extremely Low Birth Weight (ELBW): Infants having weight less than 1.0 kg (2¼ lbs) at
the time of birth.
Small for Gestational Age (SGA): Infants born with growth parameters less than two
standard deviation (SD) from the mean. It is usually defined as birth weight below the 10th
percentile of the standard weight for gestational age.
Intrauterine Growth Retardation (IUGR): Low intrauterine fetal growth rate than the
expected; it may be due to placental insufficiency, infection, malnutrition, etc. IUGR baby
may or may not be a premature one.
Chronological age (CH) or “actual age”: Indicates the time elapsed from the actual day of
birth in days, weeks, months, and years.
Corrected Age (CA): Chronological age minus the number of weeks born before 40 weeks
in weeks, and months. Also known as “adjusted age” and is the more appropriate term used
post discharge to describe children up to 3 years of age who are born preterm
Etiology
Various factors that may lead to preterm delivery includes:
Pregnancy achieved by in vitro fertilization
Little or no prenatal care
Poor nutrition during gestation (and perhaps before)
Cigarette smoking
Younger or older maternal age (eg, < 16, > 35 years)
Untreated infections (eg, bacterial vaginosis, intra-amniotic infection)
Multiple gestation (eg, twins, triplets)
Cervical insufficiency (formerly cervical incompetence)
Preeclampsia
Placental abruption
Certain congenital defects (fetuses with structural congenital heart defects are nearly twice as
likely to be delivered prematurely as fetuses without congenital heart defects).
Symptoms and Signs
The premature infant is small, usually weighing < 2.5 kg, and tends to have thin, shiny,
pink skin through which the underlying veins are easily seen.
Little subcutaneous fat, hair, or external ear cartilage exists.
Spontaneous activity and tone are reduced, and extremities are not held in the flexed
position typical of term infants.
In males, the scrotum may have few rugae (are a series of ridges produced by folding of
the wall of an organ), and the testes may be undescended.
In females, the labia majora ( the larger outer folds of the vulva) do not yet cover the labia
minora (the smaller inner folds of the vulva) .
Reflexes develop at different times during gestation. The Moro reflex ( It is a response to a
sudden loss of support) begins by 28 to 32 wk gestation and is well established by 37 wk.
The palmar grasp reflex starts at 28 wk and is well established by 32 wk. The tonic neck
reflex starts at 35 wk and is most prominent at 1 month post term.
Evaluation
Monitoring in a neonatal intensive care unit (NICU) Screening for complications
Complications of prematurity:
The incidence and severity of complications of prematurity increase with decreasing
gestational age and birthweight.
Some complications (eg, necrotizing enterocolitis, retinopathy of prematurity,
bronchopulmonary dysplasia, intraventricular hemorrhage) are common in preterm infants.
Most complications relate to dysfunction of immature organ systems. In some cases,
complications resolve completely; in others, there is residual organ dysfunction.
Cardiac: The most common cardiac complication is Patent ductus arteriosus (PDA). Patent
ductus arteriosus (PDA) is a condition in which the ductus arteriosus does not close. The word
"patent" means open. The ductus arteriosus is a blood vessel that allows blood to go around the
baby's lungs before birth.
CNS - Poor sucking and swallowing reflexes. nfants born before 34 wk gestation have
inadequate coordination of sucking and swallowing reflexes and need to be fed intravenously
or by gavage (tube feeding).
Apneic episodes - an unexplained episode of cessation of breathing for 20 seconds or longer, or
a shorter respiratory pause associated with bradycardia, cyanosis, pallor, and/or marked
hypotonia. Immaturity of the respiratory center in the brain stem results in apneic spells (central
apnea). Apnea may also result from hypopharyngeal obstruction alone (obstructive apnea). Both
may be present (mixed apnea).
Intraventricular hemorrhage, Developmental and/or cognitive delays. Premature
infants, particularly those with a history of sepsis, necrotizing enterocolitis, hypoxia,
and intraventricular and/or periventricular hemorrhages, are at risk of developmental
and cognitive delays.
These infants require careful follow-up during the first year of life to identify auditory,
visual, and neurodevelopmental delays. Careful attention must be paid to developmental
milestones, muscle tone, language skills, and growth (weight, length, and head
circumference). Infants with identified delays in visual skills should be referred to a
pediatric ophthalmologist.
Infants with auditory and neurodevelopmental delays (including increased muscle tone
and abnormal protective reflexes) should be referred to early intervention programs that
provide physical, occupational, and speech therapy.
Infants with severe neurodevelopmental problems may need to be referred to a pediatric
neurologist.
Eyes - Ocular complications include :
Retinopathy of prematurity (ROP) Myopia (Vision of far away things gets affected) and/or
strabismus (squint). Retinal vascularization is not complete until near term. Preterm delivery may
interfere with the normal vascularization process, resulting in abnormal vessel development and
sometimes defects in vision including blindness (ROP). Incidence of ROP is inversely proportional
to gestational age. Disease usually manifests between 32 wk and 34 wk gestational age.
GI tract - GI complications include : Feeding intolerance, with increased risk of aspiration &
Necrotizing enterocolitis. Feeding intolerance is extremely common because premature infants
have a small stomach, immature sucking and swallowing reflexes, and inadequate gastric and
intestinal motility. These factors hinder the ability to tolerate both oral and NGT feedings and
create a risk of aspiration. Feeding tolerance increases over time, particularly when infants are
able to be given some enteral feedings. Necrotizing enterocolitis is the most common surgical
emergency in the premature infant. Necrotizing enterocolitis usually manifests with bloody
stool, feeding intolerance, and a distended, tender abdomen.
Complications of neonatal necrotizing enterocolitis include bowel perforation with
pneumoperitoneum (presence of air or gas in the abdominal peritoneal cavity),
intra-abdominal abscess formation, stricture formation, short bowel syndrome, septicemia,
and death.
Infection - Infectious complications include:
Sepsis Meningitis -
Sepsis or meningitis is about 4 times more likely in the premature infant, occurring in
almost 25% of VLBW infants.
Kidneys - Renal complications include:
Metabolic acidosis -Renal function is limited, so the concentrating and diluting limits of urine
are decreased. Late metabolic acidosis and growth failure may result from the immature
kidneys’ inability to excrete fixed acids, which accumulate with high protein formula feedings
and as a result of bone growth. Sodium and bicarbonate are lost in the urine.
Lungs - Pulmonary complications include :
Respiratory distress syndrome Respiratory insufficiency of prematurity; Chronic lung
disease (bronchopulmonary dysplasia)
Surfactant production is often inadequate to prevent alveolar collapse and atelectasis
(collapse of one or more areas in the lung), which result in respiratory distress syndrome
(hyaline membrane disease - condition that causes babies to need extra oxygen and help
breathing).
Some infants are successfully weaned off support over a few weeks; others develop
chronic lung disease (bronchopulmonary dysplasia) with need for prolonged respiratory
support using a high-flow nasal cannula, continuous positive airway pressure (CPAP) or
other noninvasive ventilatory assistance, or mechanical ventilation. Respiratory support
may be given with room air or with supplemental oxygen. If supplemental oxygen is
required, the lowest oxygen concentration that can maintain target oxygen saturation
levels of 90 to 95% should be used.
Metabolic problems - Metabolic complications include:
Hyperbilirubinemia, Metabolic bone disease (osteopenia of prematurity)
Hyperbilirubinemia occurs more commonly in the premature as compared to the term
infant, and kernicterus (brain damage caused by hyperbilirubinemia) may occur at serum
bilirubin levels as low as 10 mg/dL (170 μmol/L) in small, sick, premature infants.
The higher bilirubin levels may be partially due to inadequately developed hepatic
excretion mechanisms, including deficiencies in the uptake of bilirubin from the serum,
its hepatic conjugation to bilirubin diglucuronide, and its excretion into the biliary tree.
Decreased intestinal motility enables more bilirubin diglucuronide to be deconjugated
within the intestinal lumen by the luminal enzyme beta-glucuronidase, thus permitting
increased reabsorption of unconjugated bilirubin (enterohepatic circulation of bilirubin).
Conversely, early feedings increase intestinal motility and reduce bilirubin reabsorption
and can thereby significantly decrease the incidence and severity of physiologic
jaundice.
Uncommonly, delayed clamping of the umbilical cord may increase the risk of
hyperbilirubinemia by allowing the transfusion of RBCs thus increasing RBC breakdown
and bilirubin production.
Metabolic bone disease with osteopenia is common, particularly in extremely
premature infants. It is caused by inadequate intake of calcium, phosphorus, and vitamin
D and is exacerbated by administration of diuretics and corticosteroids. Breast milk also
has insufficient calcium and phosphorus and must be fortified. Supplemental vitamin D
is necessary to optimize intestinal absorption of calcium and control urinary excretion.
Congenital hypothyroidism, characterized by low thyroxine (T4) and elevated
thyroid-stimulating hormone (TSH) levels, is much more common among premature
infants than full-term infants. In infants with a birthweight of < 1500 g, the rise in TSH
may be delayed for several weeks, necessitating repeated screening for detection.
Temperature regulation– Hypothermia. Premature infants have an exceptionally large
body surface area to volume ratio. Therefore, when exposed to temperatures below the
neutral thermal environment, they rapidly lose heat and have difficulty maintaining body
temperature. The neutral thermal environment is the environmental temperature at
which metabolic demands (and thus calorie expenditure) to maintain normal body
temperature (36.5 to 37.5° C rectal) are lowest.
Growth Patterns:
The growth patterns of preterm, very low birth weight infants are known to be considerably
different from those of higher birth weight term infants. All parameters (weight, length and
head circumference) used to assess nutritional status should be corrected for gestational age
until 2 years of age. Growth data should be plotted according to the infant’s age corrected for
prematurity.
There are a number of ways to calculate corrected age (also known as adjusted age). The
most common way to calculate corrected age is by subtracting the number of weeks
premature from the chronological or actual age:
Corrected age = Chronological age – (40 weeks – weeks gestational age at birth)
Acute and Long-Term Outcomes for Infants Born Preterm
🠶 Although the mortality rate for preterm infants and the gestational age-specific
mortality rate have improved dramatically over the last three to four decades, preterm
infants remain vulnerable to many complications.
🠶 These complications often arise from still immature organ systems that are
not yet prepared to support extrauterine life.
🠶 There is a progressive increase in the risk for complications of prematurity and
acute neonatal illness with decreasing gestational age, reflecting the fragility and
immaturity of the brain, lungs, immune system, kidneys, skin, eyes, and
gastrointestinal system.
🠶 In general, the more immature the preterm infant is, the greater the degree of life
support required.
🠶 The outcomes for preterm infants are also influenced by the extrauterine
environment, which includes the neonatal intensive care unit (NICU), the home,
and the community.
🠶 Among the earliest concerns about the health of premature infants is the increased risk
for neurodevelopmental disabilities.
🠶 The spectrum of neurodevelopmental disabilities includes cerebral palsy,mental
retardation,visual impairment, and hearing impairment.
🠶 The more subtle disorders of central nervous system function include language
disorders, learning disabilities,attention deficit hyperactivity disorder, minor
neuromotor dysfunction or developmental coordination disorders,behavioral problems,
and social-emotional difficulties.
Treatment
Supportive care
General supportive care of the premature infant is best provided in a neonatal ICU or special
care nursery and involves careful attention to the thermal environment, using servo-controlled
incubators. Infants are continually monitored for apnea, bradycardia( decreased breathing), and
hypoxemia until 34.5 or 35 wk gestation.
Parents should be encouraged to visit and interact with the infant as much as possible
within the constraints of the infant’s medical condition. Skin-to-skin contact between the
infant and mother (kangaroo care) is beneficial for infant health and facilitates maternal
bonding. It is feasible and safe even when infants are supported by ventilators and
infusions.
Feeding
Feeding should be by NGT until coordination of sucking, swallowing, and breathing is
established at about 34 wk gestation, at which time breastfeeding is strongly encouraged.
Most premature infants tolerate breast milk, which provides immunologic and nutritional
factors that are absent in cow’s milk formulas.
However, breast milk does not provide sufficient calcium, phosphorus, and protein for very
low-birth-weight infants (ie, < 1500 g), for whom it should be mixed with a breast milk
fortifier.
Alternatively, specific premature infant formulas that contain 20 to 24 kcal/oz (2.8 to 3.3
joules/mL) can be used.
In the initial 1 or 2 days, if adequate fluids and calories cannot be given by mouth or NGT
because of the infant’s condition, IV parenteral nutrition with protein, glucose, and fats is
given to prevent dehydration and undernutrition.
Breast milk or preterm formula feeding via NGT can satisfactorily maintain caloric intake in
small, sick, premature infants, especially those with respiratory distress or recurrent apneic
spells. Feedings are begun with small amounts (eg, 1 to 2 mL q 3 to 6 h) to stimulate the GI
tract. When tolerated, the volume and concentration of feedings are slowly increased over 7 to
10 days. In very small or critically sick infants, total parenteral hyperalimentation via a
peripheral IV or a percutaneously or surgically placed central catheter may be required for a
prolonged period of time until full enteral feedings can be tolerated.
Hospital discharge criteria:
Premature infants typically remain hospitalized until their medical problems are under
satisfactory control and they Are: Taking an adequate amount of milk without special
assistance, Gaining weight steadily, Able to maintain a normal body temperature in a crib.
FEEDING PRETERM INFANTS
Infants who are preterm, low birth weight or small for gestational age are highly susceptible
to infections, ill health, morbidities and mortality. Breastfeeding is very important for such
infants as it not only provides required nutrients but also warmth of mother’s body. However,
very often such infants may present feeding problems such as poor suck/swallow/breathe
coordination, impaired swallowing mechanism and poor oral-motor coordination.
Consequently individualised feeding strategies need to be planned depending upon their
degree of prematurity and developmental readiness for feeding.
Due to poor sucking ability, preterm, LBW and VLBW infants may need expressed breast
milk. Therefore expressed breast milk can be given through intra-gastric tube or
usingkatori/cup and spoon. Generally these infants are not able to consume adequate feed at a
time.Therefore they should be fed every two hourly during the day as well as night (IYCF,
2004; IYCF, 2010).Breastfeeding should be supplemented with fortified breastmilk or a
postdischarge (transitional) formula until infant is able to sustain growth with ad libitum
(without restriction) milk intake. If breastmilk is not available, iron fortified infant formulas
should be given until one year corrected age.
Preterm mother’s milk is best suited to the baby due to its unique composition having a
combination of nutrients, enzymes, hormones and immunological protective components.
Preterm milk is higher in calories and protein than term milk for the first two to four
weeks.Feeding recommendations for infants born < 37 weeks gestation should be based on
the corrected age. Recommendations for feeding need to take into consideration an infant’s
current level of development, their birth weight, discharge weight and, nutritional status.
Feeding progression for most preterm infants is the same as for infants born at term when
corrected age is used.
FEEDING PRETERM and LBW INFANTS
Term infants with normal birth weight require minimal assistance for feeding in
the immediate postnatal period - they
are able to feed directly from mothers’ breast. In contrast, feeding of LBW infants is
relatively difficult because of the
following limitations:
1. Though majority of them are born at term, a significant proportion are born
premature with inadequate feeding skills. They might not be able to breastfeed and
would require other methods of feeding such as spoon or gastric tube feeding.
2. These infants are prone to have significant illnesses in the first few weeks of
life; the underlying condition often precludes enteral feeding.
3. Preterm very low birth infants (VLBW) infants have higher fluid requirements in
the first few days of life due to excessive insensible water loss.
4. Since intrauterine accretion of nutrients occurs mainly in the later part of the third
trimester, VLBW infants (usually born before 32 weeks gestation) have low body stores at
birth. Hence, they require supplementation of various nutrients. Even term LBW infants
who are likely to be growth restricted need higher calories for ‘catch-up’ growth.
5. Because of the gut immaturity, they are more likely to experience feed
intolerance necessitating adequate monitoring and treatment.
Enteral feeding should be initiated immediately after birth in healthy LBW infants with the
appropriate feeding method determined by their gestation and oral feeding skills.
Maturation of oral feeding skills: Breastfeeding requires effective sucking, swallowing and
a proper coordination between suck/swallow and breathing. These complex skills mature
with increasing gestation .
A mature sucking pattern that can adequately express milk from the breast is not present until
32-34 weeks gestation.5 However, the coordination between suck/swallow and breathing is not
fully achieved until 37 weeks of gestation.
The maturation of oral feeding skills and the choice of initial feeding method at different gestational ages
are summarized below:
Maturation of oral feeding skills and the choice of initial feeding method in LBW infants
Gestational age Maturation of feeding skills Initial feeding method
< 28 weeks No proper sucking efforts
No propulsive motility in the gut
Intravenous fluids
28-31 weeks Sucking bursts develop
No coordination between suck/swallow and breathing
Oro-gastric (or naso-gastric)
tube feeding with occasional
spoon/paladai feeding
32-34 weeks Slightly mature sucking pattern
Coordination between breathing and swallowing begins
Feeding by spoon/paladai/cup
>34 weeks Mature sucking pattern
More coordination between breathing and swallowing
Breastfeeding
How to decide the initial feeding method
The feeding ability depends largely on gestation rather than the birth weight.
However, it is important to remember that not all infants born at a particular gestation
would have same feeding skills.
Hence the ideal way in a given infant would be to evaluate if the feeding skills expected for
his/her gestation are present and then decide accordingly.
All stable LBW infants, irrespective of their initial feeding method should be put on their
mothers’ breast.
The immature sucking observed in preterm infants born before 34 weeks might not meet
their daily fluid and nutritional requirements but helps in rapid maturation of their feeding
skills and also improves the milk secretion in their mothers (‘Non-nutritive sucking’).
Deciding the initial feeding method in LBW infants Intra-gastric tube feeding
The smaller the infant, the less body stores (protein, fat, and glycogen) are available to provide
nutrients for metabolic needs.
The metabolic and thus nutrient requirements of the newborn are equal to or greater than
those of the fetus of the same gestational age. It is reasonable, therefore, to provide the
preterm infant with at least what the fetus of the same gestational age receives for nutrition
to maintain normal metabolism.
i. NUTRITION REQUIREMENTS DURING PARENTERAL FEEDING
IV feeding, including amino acids, should be started right after birth at rates that are
appropriate for the gestational age of the infant. For several proven reasons, IV nutrition is
fundamental in all infants who cannot tolerate full enteral feedings. Metabolic and thus
nutritional requirements do not stop with birth; this includes protein accretion. IV feeding is
always indicated when normal metabolic needs are not met by normal enteral feeding. The
smaller the infant, the less body stores (protein, fat, and glycogen) are available to provide
nutrients for metabolic needs.
There are special challenges in implementing parenteral nutrition (PN) in paediatric patients,
which arises from the wide range of patients, ranging from extremely premature infants up to
teenagers weighing up to and over 100 kg, and their varying substrate requirements. Age and
maturity-related changes of the metabolism and fluid and nutrient requirements must be
taken into consideration along with the clinical situation during which PN is applied. The
indication, the procedure as well as the intake of fluid and substrates are very different to
that known in PN-practice in adult patients, e.g. the fluid, nutrient and energy needs of
premature infants and newborns per kg body weight are markedly higher than of older
paediatric and adult patients. Premature infants <35 weeks of pregnancy and most sick term
infants usually require full or partial PN. In neonates the actual amount of PN administered
must be calculated (not estimated). Enteral nutrition should be gradually introduced and
should replace PN as quickly as possible in order to minimise any side- effects from
exposure to PN. Inadequate substrate intake in early infancy can cause long-term detrimental
effects in terms of metabolic programming of the risk of illness in later life. If energy and
nutrient demands in children and adolescents cannot be met through enteral nutrition, partial
or total PN should be considered within 7 days or less depending on the nutritional state and
clinical conditions.
Indications for parenteral nutrition
Neonatal patients
● All premature infants <35 weeks of pregnancy and most ill term infants require full
or partial PN whilst enteral nutrition is gradually introduced (IV).
● The percentage of PN should be reduced as quickly as possible by the introduction of
enteral nutrition (partial PN) and finally be replaced completely by enteral nutrition
in order to minimise any side-effects from exposure to PN (II).
Premature infants
Energy requirements – 110-120 kcal/kg/day
Protein requirement-
Premature infants, who are physiologically in approx. week 30 of pregnancy, have a
maximum rate of protein synthesis with protein requirements of approx. 2.7 g/kg body
weight/day, which returns to <2.0 g/kg body weight/day until week 40 of pregnancy. A
positive nitrogen balance can usually be attained in premature infants with an amino acid
intake of 2.5 g/kg body weight/day and 60–90 kcal/kg body weight/day. In individual cases
an amino acid intake of up to 3.5–4 g/kg body weight/day may be necessary in order to
achieve protein synthesis according to the intrauterine ratio.
Lipids -
To prevent a deficiency of essential fatty acids, a minimum intake of 0.25 g/kg body weight
and day of linoleic acid is recommended in premature infants and a minimum intake of 0.1
g/kg body weight and day linoleic acid is recommended in full-term newborns and children
(C).
Protein and energy requirements of preterm infants.
FEED INTOLERANCE
The inability to tolerate enteral feedings in extremely premature infants is a major concern
for the pediatrician / neonatologist caring for such infants. Often, feed intolerance is the
predominant factor affecting the duration of hospitalization in these infants.
There are no universally agreed-upon criteria to define feed intolerance in preterm infants.
Various clinical features that are usually considered to be the indicator(s) of feed intolerance
are summarized below (Panel 5):
Indicator(s) of feed intolerance
* Common signs
Of these, vomiting, abdominal distension, and increased gastric residual volume form the
‘triad’ for defining feed intolerance.
Vomiting: The characteristic of vomitus is important in assessing the cause: while altered
milk is usually innocuous, bile- or blood-stained aspirate should be thoroughly investigated.
Abdominal distension: It is essential to serially monitor the abdominal girth in all preterm
LBW infants admitted in neonatal nursery. This helps in early identification of feed
intolerance and eliminates the need for routine gastric
aspirate.
Gastric residual volume: It indicates the rapidity of gastric emptying. Since several factors
(both systemic and local) influence the gastric emptying, the residual volume is a poor and
non-specific indicator of fed intolerance. Measures to enhance the specificity - by quantifying
the volume and by using different cut-offs for defining feed intolerance - have not been found
to be much useful. Moreover, repeated gastric aspiration to look for residuals could injure the
delicate mucosa aggravating the local pathology.
Monitor the abdominal girth every 2 hours in all preterm LBW infants admitted in the
nursery. Routinely aspiration of the gastric contents before giving next feed is not done. It is
done only if there is an increase in abdominal girth by >2 cm from the baseline.
Management of feed intolerance
The common factors attributed to feed intolerance in preterm infants are: immature intestinal
motility, immaturity of digestive enzymes, underlying medical conditions such as sepsis,
inappropriate feed volume, and giving hyperosmolar medications/feedings, and importantly,
necrotizing enterocolitis (NEC).
While issues such as feed volume and osmolality can be controlled to an extent, feed
intolerance due to immaturity is rarely amenable to any intervention; conservative
management till the gut attains full maturity is often the only option left.
