The management of low-birth weight infants requiring intensive care continues to improve dramatically…
New technology Use of surfactant -A mixture of lipoproteins secreted by alveolar cells into the alveoli and respiratory air passages that contributes to the elastic properties of pulmonary tissues

- have increased the survival of preterm infants

Most LBW OR LOW-BIRTH WEIGHT INFANTS have the potential for long and productive lives FACTORS THAT DICTATE THE NUTRITIONAL REQUIREMENTS OF INFANTS Infant’s size Age Clinical condition Neonatal Intensive Care System Registered Dietitian - trained in neonatal nutrition makes the decisions necessary to facilitate optimal nutrition Regionalized Perinatal Care System - The neonatal nutritionist may also consult the healthcare providers in community hospitals and public health settings

PHYSIOLOGIC DEVELOPMENT Weight of infant at birth: Less than 2500 g Less than 1500 g Less than 1000 g Low birth weight Very low birth weight Extremely low birth weight Low birth weight is attributable to: shortened period of gestation or prematurity Retarded intrauterine growth rate makes infant SGA or small for gestational age GESTATIONAL AGE – the age of an infant at birth as determined by he length of pregnancy ( the number of weeks since the last menstrual period) or clinical assessment. .

ESTIMATE OF INFANT’S GESTATIONAL AGE IS BASED ON: Date of mother’s last menstrual period Clinical parameters of uterine fundal height Presence of quickening Fetal heart tones or ultrasound evaluation  After birth gestational age is determined by clinical assessment CLINICAL PARAMETERS: A series of neurologic signs depends primarily on posture and tone A series of external characteristics that reflect the physical activity if the infant .

SGA OR SMALL FOR GESTATIONAL AGE .infant has a birth weight between the 10th and 90th percentile on the intrauterine growth chart LGA OR LARGE FOR GESTATIONAL AGE .birth weight is above the 90th percentile .infant whose length and occipital frontal circumference are also below the 10th percentile of the standards AGA OR AVERAGE FOR GESTATIONAL AGE .a SGA infant whose intrauterine weight gain is poor but whose linear and head growth are between the 10th and 90th percentile on the intrauterine growth grid SYMMETRICAL IUGR .has a birth weight that is lower than the 10th percentile of the standard weight for that gestational age IUGR OR INTRAUTERINE GROWTH RETARDATION .

risk of infants weighing less than 1500 g is 96 times higher FACTORS AFFECTING INANT MORTALITY 1.may result to high infant mortality rate INVERSE RELATIONSHIP BETWEEN BIRTH RATE AND INFANT MORTALITY RATE Risk for infant death . TEENAGE PREGNANCY .3% to 6% higher incidence of giving birth to LBW infants 2.INFANT MORTALITY AND STATISTICS High incidence of LBW infants .have a 2. . INCIDENCE OF MULTIPLE BIRTHS .are 9 times likely to result in LBW .infants weighing 1500 to 2499 g is 6 times higher than infants weighing more than 2500 g.

physiologic immaturity .Nutrient demands FETAL NUTRIENT STORES .high risk for poor nutritional status .CHARACTERISTICS OF IMMATURITY PREMATURE INFANTS .are deposited at the last 3 months of pregnancy LIMITED METABOLIC STORES nutritional support in the form of parenteral or enteral nutrition should be initiated as soon as possible Preterm infants Weighing 1000g constitutes only of 1% total fat .Illness .

Infants with IUGR due to increase in basal metabolic rate SMALL PREMATURE INFANT – particularly vulnerable to under nutrition UNDERNUTRITION – deficient bodily nutrition due to inadequate food intake or faulty assimilation MALNUTRITION (PREMATURE INFANTS) .TERM INFANTS has fat percentage of 16% 1000 g AGA PREMATURE INFANT glycogen fat reserve = 110 kcal per kilogram of bodyweight basal metabolic needs = approximately 50kcal/kg/day MOST QUICKLY DEPLETED NUTRIENTS .may increase the risk of infants .prolong chronic illness .adversely affect brain growth and function .

becomes essential for nutrition support either as a supplement to enteral feedings or as the total source of nutrition .Type of milk used for neonatal diet – directly linked to neurodevelopment at 18 mos.Infant’s small stomach capacity .fed on 1st month of life resulted in improved development NUTRITIONAL REQUIREMENTS: PARENTERAL FEEDING Parenteral feeding – intravenous administration of nutrients Difficulty progressing to full enteral feeding .Immature gastrointestinal tract .1st several weeks/days of life WHAT MAKES THE DIFFICULTY? . of age HUMAN MILK OR PREMATURE INFANT FORMULA .Illness PARENTERAL NUTRITION .

Bronchopulmonary dysplasia .Electrolyte Imbalance .inflammation or death of the gastrointestinal tract .Hypotension EXCESSIVE INTAKE LEADS TO: ..Possible opening of the ductus arteriosus ADDITIONAL CLINICAL COMPLICATION .Dehydration .Congestive heart failure .FLUID .Intraventricular Hemorrhage .fluid balance must be monitored for preterm infants INADEQUATE INTAKE LEADS TO: .Edema .Necrotizing entercolitis .Premature infants have greater % of body water than the term infant ..

thermal blankets and humidified incubators .REDUCTION OF EXTRACELLULAR WATER .should be accomplished which is accompanied by a normal loss of 10% to 15& body weight and improved renal function ELBW INFANTS – lose up to 20% of birth weight WATER REQUIREMENTS .is increased by radiant warmers and phototherapy by lights -decreased by heat shields. urine and stool and water needed for growth INSENSIBLE WATER LOSS .estimated by the sum of the predicted losses from the lungs and skin. .can vary from 50 to 100ml/kg/day on 1st day of life and increase up to 120 to 200ml/kg/day .highest in the smallest and least mature infants because longer body surface area relative to body weight including permeability to skin epidermis to water and greater skin blood flow relative to metabolic rate.

depends on the fluid volume and solute load presented to kidney ABILITY TO PENETRATE URINE – increases with maturity STOOL WATER LOSS .generally up to 5 to 10ml/kg/day suggested for optimal growth .environment EXRETION OF URINE .day of life .Infant’s size .gestational age .varies from 40 to 85ml/kg/day .DEPENDING ON: .a major route in water loss .10ml/kg/day Fluid administered 80 to 105ml/kg/day (1st day of life) .

Skin turgor .creatinine .Peripheral perfusion .urine volume output .increases to 10 to 20ml/kg/day End of 2nd week of life .urea nitrogen levels .140 to 160ml/kg/day FLUID RESTRICTION -maybe necessary in preterm infants with patent ductus arteriosus or congestive heart failure ---.comparing clinical parameters .more fluid is needed by preterm infants placed under phototherapy light .specific gravity or osmolality .Blood Pressure .serum electrolyte DAILY ASSESSMENT: .Weight .mucous membrane DAILY FLUID ADMINISTRATION: .assessing fluid intake .FLUID NEEDS EVALUATION: .

NUTRITIONAL SUPPORT OF PREMATURE INFANTS CAUSE small metabolic Reserves of fat & glycogen ILLNESS Small stomach & Immature GI tract Nutrient Demands of growth High Nutritional Risk status PATHOPHYSIOLOGY MEDICAL MANAGEMENT Parenteral feeding with monitoring by -Nutritionists .Physicians TRANSITION TO: NUTRITIONAL MANAGEMENT Enteral feeding by -Gastric gavage .Breast feeding .Pharmacists .Nurses .Transpyloric tube .Nipple feeding .

providing VLBW infants with 1 to 2 g protein and 30 to50 kcal/kg/day COMPARISON OF PARENTERAL AND ENTERAL ENERGY NEEDS OF PREMATURE INFANTS PARENTERAL MAINTENANCE Gradually increase 40 – 50 cal/kg/day 50kcal/kg/day ENTERAL Intake to meet energy needs by the end of the week GROWTH Meet energy needs As soon as the infant’s condition is stable 80 – 90 cal/kg/day 105.130kcal/kg/day .ENERGY (PRETERM INFANTS) NITROGEN BALANCE (FIRST 3 WEEKS OF LIFE) .

Glucose should be administered in small amounts GLUCOSE LOAD .less likely to happen when glucose is administered with amino acids than when infused alone TO PREVENT HYPERGLYCEMIA: .less than 6mg/kg/min. .limited in premature infants especially VLBW infants HYPERGLYEMIA . with a gradual increase to 11 to 12 mg/kg/min.is a function of the concentration of the dextrose infusion and the rate at which it is administered INITIAL GLUCOSE LOAD (PRETERM INFANTS) .an excess of sugar in the blood .is the principal energy source GLUCOSE TOLERANCE .GLUCOSE (DEXTROSE) . ELBW INFANTS .tolerate a lower glucose load of 4 to 6 mg/kg/min.

HYPOGLYCEMIA - an abnormal decrease of sugar in the blood - may occur if the glucose infusion is abruptly decreased or interrupted AMINO ACIDS PROTEIN - guidelines range from 2.5 to 3.8g/kg/day Intrauterine Growth rate of protein accretion - can be achieved at 3 g/kg/day

ELBW INFANTS - 3 to 4 g/kg/day PRETERM INFANTS - given 1 to 2 g of protein (1st few days of life)
PEDIATRIC SOLUTIONS - result in plasma amino acid profiles similar to those of healthy infants fed breast milk

2 PEDIATRIC SOLUTIONS IN USE (U.S) - Trophamine - Aminosyn PF FUNCTION: - promote adequate weight gain and nitrogen retention STANDARD AMINO ACID SOLUTION - are not designed to meet the particular needs pf premature infants LOW HIGH - Cysteine Methionine - Tyrosine Glycine - Taurine CYSTEINE - a sulfur-containing amino acid occurring in many proteins - cannot be effectively synthesized by premature infants Cysteine supplement - has been suggested - insoluble and unstable in solution = added as cysteine chloride when PN is prepared

METABOLIC PROBLEMS ASSOCIATED WITH AMINO ACID INFUSION - metabolic acidosis - hyperammonemia - azotemia

LIPIDS ( intravenous fat emulsions) FUNCTION: - To meet essential fatty acid requirements - To provide concentrated source of energy EFA NEEDS provide 0.5 to 1 g/kg/day of lipids EFA DEFICIENCY - 1ST week of life in VLBW fed parenterally without fat CLINICAL CONSEQUENCES: - coagulation abnormalities - abnormal pulmonary surfactant - adverse effects on lung metabolism LIPIDS (PRETERM INFANTS) - should be introduced slowly with periodic monitoring of plasma triglyceride levels PLASMA TRIGLYCERIDE LEVELS – should remain 150 mg/dl

protein calories but should not exceed 60% HEPARIN .with the administration of lipids.less than 30 to 40% of non. prolongs the life of peripheral veins .prevents thrombosis formation .over 24 hours at a maximum rate of 0.facilitates the mechanism by which fatty acids are transported across the mitochondrial membrane allowing their oxidation to provide energy .LIPID ADMINISTRATION .commonly administered at 1 U/ml .15 g/kg/hr to prevent a rise in triglyceride and fatty acid TOTAL LIPID LOAD .continues administration may improve lipid clearance CARNITINE .frequently added to PN solution provided to premature infants .

CARNITINE SUPPLEMENTATION .to prevent hyperkalemia and arrhythmia PRETERM INFANT TERM INFANT SAME ELECTROLYTE REQUIREMENTS FACTORS THAT AFFECT THE REQUIREMENTS: .Renal function . potassium and chloride are added to parenteral solutions to compensate for the loss of extracellular fluid POTASSIUM .State of hydration .should be withheld until renal flow is demonstrated .Use of diuretics .can also be helpful to preterm infants who are receiving only PN at 2 – 4 weeks of age ELECTROLYTE (AFTER A FEW DAYS OF LIFE) .enhanced lipid utilization in LBW infants receiving PN for longer than 1 month .sodium.

require increased amounts of sodium to maintain a normal serum sodium concentration SERUM ELECTROLYTE LEVELS .should be quantified when serum levels are abnormal to detect inappropriate electrolyte excretion GUIDELINES FOR ADMINISTRATION OF PARENTERAL ELECTROLYTES FOR PREMATURE INFANTS ELECTROLYTE Sodium Chloride Potassium AMOUNT (mEq/kg/day) 2-3 2-3 2-3 .should be monitored periodically URINE ELECTROLYTES .limited ability to conserve sodium .VERY IMMATURE INFANTS .

radiographic bone studies .serum calcium.MINERALS Calcium and Phosphorus -important components of the Parenteral Nutrition solution PREMATURE INFANTS: Low Calcium and Phosphorus VLBW INFANTS: Receive PN for prolonged periods at risk of developing osteopenia of prematurity likely to have poor bone mineralization HOW TO MONITOR CALCIUM & PHOSPHORUS STATUS: . phosphorus and alkaline phosphatase levels .

Not recommended on alternate day infusion --.CALCIUM AND PHOSPHORUS .Have higher amounts of needs in preterm infants than term infants .because abnormal serum mineral intake and decreased mineral retention develop GUIDELINES FOR ADMINISTRATION OF PARENTERAL MINERAL FOR PREMATURE INFANTS MINERALS Calcium Phosphate Magnesium AMOUNT (mg/L) 500-600 400-500 50-70 .Should be provided simultaneously in PN solution .

should be given to all preterm infants receiving PN Enteral feedings (cannot be started in 2 weeks) .not routinely provided because treated infants often receive blood transfusion soon afterbirth .TRACE ELEMENTS Zinc .should be reduced for infants with obstructive jaundice Amounts of Selenium.additional trace elements should be added Amounts of Copper & Magnesium .1 to 0.dosage is approximately 10% of the enteral dosage . Chromium & Molybdenum .2mg/kg/day ENTERAL FEEDINGS .provides a source of iron and can often be initiated .guidelines range from 0.should be reduced in infants with renal dysfunction PARENTERAL IRON .

25+ Iodine 1 *Reduced or not provided for infants with obstructive jaundice +Reduced or not provided for infants with renal dysfunction .GUIDELINES FOR ADMINISTRATION OF PARENTERAL TRACE ELEMENTS FOR PREMATURE INFANTS TRACE ELEMENTS AMOUNT (µg/kg/day) Zinc 400 Copper 20* Manganese 1* Selenium 2+ Chromium 0.2+ Molybdenum 0.

K occurs until bacterial colonization takers place INTRAVENOUS MULTIVITAMIN PREPARATIONS . K deficiency .little intestinal bacteria production of Vit.recently approved and designed for use in infants should be given to provide the appropriate vitamin intake and prevent toxicity from additives used in adult multivitamin injections .All newborn infants receive: .an injection of 0.limited in newborns .VITAMINS After birth .5 to 1 mg of Vitamin K Vitamin K .helps prevent hemmorhagic disease of the newborn from Vit.

decreases the incidence of BPD .VITAMIN A .facilitating tissue repair intramuscular injection of Vitamin A at 5000 IU per day 3 times a week – 1st month of life --.large supplemental doses had been suggested for the prevention of BPD (Bronchopulmonary dysplasia) BPD (Bronchopulmonary Dysplasia) .involves abnormal development of lung tissue characterized by inflammation and scarring in the lungs .

present in low concentration in PN solutions .present in human milk and infant formula .additon of this to PN solutions increased survival and a decreased incidence of BPD and retinopathy of prematuriy in preterm infants with respiratory disease syndrome Respiratory Disease Syndrome .However Inositol is not used clinically because its effectiveness has not yet been established . develops shortly after birth and common in preterm infants --.a lung disease that is caused buy a surfactant deficiency.Inositol .

duodenum or jejunum .decrease the incidence of cholestatic jaundice .promotes mature gastrointestinal motility .increase villous growth in the small intestine .improve subsequent feeding tolerance in preterm infants Cholestatic jaundice – occurs when essentially normal liver cells are unable to transport bilirubin through capillary membrane of the liver because of damage in that area .TRANSITION FROM PARENTERAL TO ENTERAL FEEDING Enteral feeding – delivery of a nutritionally complete feed directly into the stomach.beneficial for preterm infants as early as possible REASONS: .stimulates gastrointestinal enzymatic development and activity .promotes bile flow .

preferred for preterm infants .May take longer with infants having feeding intolerance or illness Small sickest infants receive increments of onlyb10ml/kg/day Larger more stable preterm infants may tolerate increments of 20 to 30 ml/kg/day ENTERAL ALIMENTATION ..it may take 7 -14 days to provide a full enteral feeding .It is important to maintain parenteral feeding until enteral feeding is well established VLBW INFANTS .more physiologic and nutritionally superior .

respiratory status .degree of prematurity .function of gastointestinal tract .In general.stress .the energy requirements of premature infants vary with individual biologic and environmental factors Energy needs may be increased by: .illness .history of perinatal insults . enteral nutrient requirements are different from parenteral requirements … ENERGY .CONSIDERATIONS IN PROVIDING ENTERAL FEEDINGS: .rapid growth Intake of 50kcal/kg/day 105 to 130 kcal/kg/day required to meet maintenance energy needs needed for growth .current medical condition .

to achieve appropriate growth PROTEIN Amount and quality of protein intake .5 to 4g.the essential amino acid Cysteine is more concentrated .must be balance to avoid inducing amino acid or protein toxicity AMOUNT advisable protein intake is 3.breastmilk or formulas containing predominantly whey protein should be chosen whenever possible Whey Protein .day well tolerated by stable infants growing rapidly .may increase stress in sick infants who are not growing TYPE .Some premature infants may need 130 to 150 kca/kg/day .kg.

TAURINE .growth limiting .added to infant formula Inadequate protein intake: Excessive intake: .human milk .acidosis LIPIDS Growing preterm infant needs an adequate intake of well absorbed dietary fiber To meet essentially fatty acid needs: LINOLEIC ACID should comprise 3.1% of the total calories Arachidonic acid & Docosahexonic acid present in human milk and are added to standard infant formula for term infants .azotemia .elevated plasma amino acid levels .is a sulfuric amino acid that may be important for preterm infants Sources: .

TYPE LIPASES are enzymes needed for trygliceride breakdown BILE SALTS solubize fat for ease in digestion and absorption EFA linoleic acid found in human milk and vegetable oil Infants absorb vegetable oil more efficiently than saturated animal fat PREMATURE INFANT FORMULA MUST CONTAIN: . 40% of total calories is derived from carbohydrates Too little carbohydrates may lead to hypoglycemia Too much carbohydrates may lead to osmotic diuresis/loose stool .MCT oil (medium-chain trygliceride) to provide long chain fatty acid CARBOHYDRATES (important source of energy) AMOUNT Human milk & standard infant formula approx.vegetable oil .

a disaccharide composed of glucose and galactose .important to neonates for glucose homeostasis Sucrose .required for optimal bone mineralization Recommended intake: -175mg/100kcal/day of calcium .common carbohydrates in the preterm infant’s diet .a disaccharide commonly found in commercial infant formula products Glucose Polymers .TYPE Lactose .5mg/100kcal/day of phosphorus .predominant carbohydrate in all mammalian milk .91.consist mainly of 5 to 9 glucose units linked together VITAMINS AND MINERALS Calcium & Phosphorus .

Osteopenia of prematurity in preterm infants develop when: .is a disease characterized by demineralization of growing bones and documented by radiologic evidence of washed out or thin bones OSTEOPENIA IS MOST LIKELY TO DEVELOP IN PRETERM INFANTS WHO ARE: 1. Fed human milk that is not supplemented with calcium and phosphorus 3.low dietary intake OSTEOPENIA: . Fed infant formula that is not specifically formulated for preterm infants 2.poor mineral stores . Receiving long – term PN without enteral feedings .

E per kilogram of linoleic acid --.7 IU/100kcal of Vit.intraventricular hemmorhage .range from 150 to 400 IU/day for preterm infants VITAMIN E .0.sepsis . E deficiency may experience hemolytic anemia … Hemolytic anemia – anemia caused by oxidative destruction of mature red blood cells HIGH DOSES OF VITAMIN E MAY LEAD TO: .protects biologic membranes against oxidative lipid breakdown Recommended intake: .necrotizing entercolitis .liver & renal failure .death .VITAMIN D (recommended intake) .A premature infant with Vit.

8mg 1.6-6µg 25-50 µg 0.7µG 3.3µg .6-4.RECOMMENDATIONS FOR ENTERALADMINISTRATION OF VITAMINS IN THE PREMATURE INFANT VITAMIN VITAMIN A VITAMIN D VITAMIN E VITAMIN K ASCORBIC ACID THIAMIN RIBOFLAVIN PYRIDOXINE NIACIN PANTOTHENATE BIOTIN FOLATE VITAMIN B12 AMOUNT (kg/day) 700-1500IU 150-400IU 6-12IU 8-10µg 18-24µg 180-240µg 250-360µg 150-210µg 3.2-1.

2 to 4mg/kg/day --.4 to 8 mEg/kg or more --.Milk can be supplemented with sodium if repletion is necessary … .premature infants have higher folic acid needs than term infants DAILY FOLIC ACID INTAKE .IRON (RECOMMENDED INTAKE) .may be required by some infants to prevent hyponatremia Hyponatremia – lower than normal concentration of sodium in the blood --.25 to 50µg (effectively maintains normal serum folate concentration) SODIUM DAILY SODIUM INTAKE: .Infants fed with human milk should be given ferrous sulfate drops… FOLIC ACID .

To feed the infant via the most physiologic method possible and supply nutrients for growth without creating clinical complications.Goal in Feeding: .often chosen for infants who are unable to suck because of immaturity or problems with the CNS .aspiration .expected to have poorly coordinated sucking and swallowing abilities because of developmental immaturity …. GASTRIC GAVAGE (by the oral route) . FEEDING METHODS: A.gastric distention .a soft feeding tube is inserted through the infant’s mouth and into the stomach Infant less than 32 to 34 weeks of GA : . MAJOR RISKS: .

a mass of chewed food moving through the digestive tract Randomized control trial .are sometimes preferred for tiny immature infants whose small gastric capacity and slow intestinal motility may impede the tolerance of large bolus feeds… BOLUS.TO MINIMIZE THE RISK: .proper positioning of the infant during feeding POTENTIAL PROBLEMS (delivering on intermittent bolus schedule) .resulted in better weight gain and feeding tolerance than continuous infusion of feedings .electronic monitoring of vital functions .vagal nerve stimulation w/ resultant bradycardia Continuous Drip Feedings .gastric distention .was conducted in premature infants of 26 to 30 weeks gestation to compare continuous and bolus feedings Bolus Feedings .

requires considerable expertise & radiographic confirmation of the catheter tip location Goal: .indicated for infants who are at risk for aspirating formula into the lungs or who have slow gastric emptying .helpful for infants who are learning to nipple-feed . may compromise the nasal airway B. TRANSPYLORIC FEEDING .also used for infants whose respiratory function is compromised & who are at risk for formula aspiration .sometimes better tolerated than oral –tube feedings .to circumvent the often slow gastric emptying of the immature infant by passing the feeding tube through the stomach and pylorus .and placing its tip within the duodenum or jejunum .however .NASAL GASTRIC GAVAGE .

intestinal perforation .diarrhea .maybe attempted with infants where gestational age is greater than 32 weeks .alterations of the intestinal microflora .bilious fluid in the stomach C.should be initiated only when the infant is under minimal stress & is sufficiently mature and strong to sustain the sucking effort Ability to feed on a nipple: . NIPPLE FEEDING .indicated by evidence of an established sucking reflex and sucking motion .POSSIBLE DISADVANTAGES: .dumping syndrome (rapid gastric emptying) .decreased fat absorption .

swallowing and breathing coordination and less breathing disruption than bottlefed infants .STANDARDIZED ORAL STIMULATION PROGRAM .have better sucking.may tolerate the introduction of 1 nipple – feeding per day D.nursing at the breast should begin as soon as the infants is ready Premature breast-fed infants . BREASTFEEDING .help infants successfully nipple feed more quickly before oral feedings begin INITIAL ORAL FEEDINGS -may be limited to 1 to 3 times a day to prevent undue fatigue Healthy premature infants (younger than 32 weeks) .

volume intakes .Refusal to breast feed .KANGAROO BABY CARE .enhances the mother’s confidence in carrying for her high.Low.facilitates her lactation .promotes continuation of breast feeding .Milk aspiration .risk infant Feeding infants with cups to supplement breast feeding .prevents nipple confusion POSSIBLE PROBLEMS: .allows the mother to maintain skin to skin contact while holding her infant .

maybe caused by excessive feeding. resuscitation or sepsis .often indicates the need to interrupt feeding until its cause is determined and the abdomen becomes soft and is not distended .TOLERANCE OF FEEDINGS Vomiting of Feedings . organic obstruction. excessive swallowing of air.may also indicate that feeding volumes were increased too quickly or are exclusively for the infant’s size and maturity Bile stained emesis .may indicate the infant has an intestinal blockage and needs additional evaluation or that the feeding tube has slipped into the intestine Abdominal distention .usually signals the infant’s inability to retain the provided amount of milk .

should be constantly monitored when feeding preterm infants . A residual volume of more than 50% of a bolus feeding or equal to the continuous infusion rate might be a sign of feeding intolerance The frequency and consistency of bowel movements .measured by aspiration of the stomach contents .Gastric residuals .should be determined routinely before each bolus gavage feeding and intermittently in all continuous drip feedings SIGNIFICANCE OF VOLUME IN RELATION TO TOTAL VOLUME OF FEEDING Ex.

SELECTION OF ENTERAL FEEDING Initial feeding period -premature infants may often require additional time to adjust to enteral nutrition feedings Primary Goal: .to establish tolerance to the milk being provided ( Infants need a period of adjustment to be able to assimilate a large volume and concentration of nutrients) THUS .enteral feedings often require supplementation with parenteral fluids until infants can tolerate adequate amounts of feeding by mouths After initial period of adjustment GOAL: .to provide complete nutritional support for growth and rapid organ development (All essential nutrients should be provided in quantities that support sustained growth) .

supplements of protein. minerals & vitamins added to human milk to meet the increased nutrient needs of premature infants 2. carbohydrates. Iron – fortified standard infant formula for infants who weigh more than 2 kg Discharged premature infants . Iron – fortified premature infant formula for infants who weigh less than 2 kg 3.FOLLOWING FEEDING CHOICES: 1.can be given a transitional formula unless they have osteopenia . Human milk supplemented with human milk fortifiers and iron Human milk fortifiers . fat.

need calcium & phosphorus enriched premature infants formula until the condition improves Breastfed infants w/ osteopenia .Infants with osteopenia .its benefits for the infants are numerous because of its unique mix of amino acids and long chain fatty acids .is the ideal food for healthy term and premature infants .although it requires nutrient supplementation to meet the needs of premature infants .should receive a multivitamin & mineral supplement that contains Vitamin D & Iron HUMAN MILK .should also receive supplement with bottles of fortified human milk or premature infant formula Breastfed infants w/out osteopenia .

1st month of lactation ( composition of milk of mothers) birth to premature infant differ from those who gave birth to term infant PREMATURE INFANTS .is more easily digested because of presence of lipases Lipase – is an enzyme that catalyzes the breakdown of fats and lipoproteins usually into fatty acids and glycene .are more readily absorbed FAT .have higher concentration of protein and sodium in breastmilk when fed with their own mother’s milk .they grow more rapidly than infants fed banked or mature breastmilk ZINC & IRON ( HUMAN MILK) .

secretory immunoglobulin A. T & B lymphocytes Macrophages – a phagocytic tissue cell of the immune system that maybe fixed or freely motile. T cell lymph – several lymphocytes that differentiate in the thymus. possess highly specific cell. macrophages.surface antigen receptor associated with the initiation of a cell-mediated humoral immunity B Cell – have antigen – binding antibody molecules on the surface that comprise the antibody secreting plasma cells when mature … 2.a product of living cells that circulates in body fluids and produces a specific often stimulatory effect on the activity of cells usually remote from its point of origin . function in the destruction of foreign antigens such as bacteria or viruses. Antimicrobial factors. lactoferin 3.FACTORS IN HUMAN MILK (NOT PRESENT IN FORMULAS) Components include: 1. Live cells. Hormones .

5.reduce the incidence of necrotizing entercolitis & sepsis and improves neurodevelopment Necrotizing entercolitis .inflammation or death of the gastrointestinal tract DISADVANTAGE: . Enzymes .are recommended for rapidly growing infants .human milk does not meet the calcium & phosphorus needs for normal bone mineralization in premature infants Calcium & phosphorus supplements . Growth factors Human milk fed to preterm infants .4.any of numerous complex proteins that we produced by living cells and catalyze specific biochemical reactions at body temp.

promotes involvement and interaction PREMATURE INFANT FORMULA . fat.can be a very positive experience for the mother . protein.contain calcium.promote growth at intrauterine rates . carbohydrates. phosphorus.have caloric densities of 20 & 24kcal/oz .are available only in a ready to feed form .these preparations have been developed to meet the unique nutritional & physiologic needs of growing preterm infants Quantity & Quality .3 HUMAN MILK FORTIFIERS: Similac Natural (liquid form) Similac & Enfamil human milk fortifiers (powdered form) . vitamins and minerals Providing human milk to a premature infant .

& fat differ to facilitate digestion & absorption of nutrients .contain 22kcal/oz & are designed or premature infants .the types of carbohydrates.infants who weigh less than 1250 g and do not consume enough nutrients when hospitalized .ready to feed form for hospital use POTENTIAL BENEFICIARIES: .have higher concentrations of protein..can be introduced when the infant reaches a weight of 1800 g or more & can be used throughout the 1st year of life . minerals & vitamins TRANSITIONAL INFANT FORMULA .available in powder form for home use .nutrient content is less than that of the nutrient – dens premature infant formulas & more than that of the standard infant formula . protein.those who cannot consume adequate amount of standard formula to grow when discharged .

43.3 veg. MCTs 44-52 1180 – 1141 650-790 1190-1520 34-49 30. 70:30 Casein ratio Protein (g/L) 9-14 Carbohydrate Lactose Carbohydrate (g/L) Fat Fat(g/L) Calcium(mg/L) Phosphorus (mg/L) Vitamin D (IU/L) Vitamin E (IU/L) Folic acid (µg/L) Sodium(mEq/L) 66-73 Human fat 39-42 248-280 128-147 20-21 2. 50:50 60:40 predominant 19-20 14-16 19-21 18-24 Lactose.5 60-108 7-8 veg.1 .24 whey 60:40.1 – 36. MCT oil 34.7-11.. glucose Lactose or lactose Lactose/glucose Lactose/glucose polymers & glucose polymers polymers polymers 77-88 73-74 77-79 72-90 human fat.5-15.COMPARISON OF THE NUTRITIONAL CONTENT OF HUMAN MILK & FORMULAS HUMAN Caloric density (kcal/oz) Protein whey.13.1452 561-806 1014-2200 27-51 237-298 11.8 1115.6-33.1.7 33-85 7.5.5 429-530 241-360 402-410 10.8-10..8 MILK 20 FORTIFIED MILK 24 STANDARD FORMULA 20 TRANSITIONAL FORMULA 22 PREMATURE FORMULA 20.5 14-15 vegetable 34.9-10. MCT oil 39-41 784-890 463-490 522-590 26. 48:52.9-30 187-192 10. 100:0 60:40.

are available to hospitals as ready to feed nutrients .FORMULA ADJUSTMENTS (occasionally increasing the energy content of formulas fed to small infants) .maybe appropriate when infant is not growing quick enough & is already consuming as much as possible during feedings CONCENTRATION Providing hypercaloric formula .should be provided in amounts that can be tolerated by the infant & caloric supplements can be added as needed .consider the infant’s fluid intake & fluid losses in relation to the renal solute load of the concentrated feeding. to ensure a positive water balance is maintained Transitional formula can be concentrated from 24 to 30 kcal/oz .prepare the formula w/ less water Concentrated infant formula w/ energy contents of 24kcal/oz .

Corn oil .an approach to increasing the energy content of a formula .should be used only when a formula already meets all nutrient requirements other than energy or when the renal solute load is a concern .provide enough calcium.glucose polymers ex.alter the relative distribution of total calories derived from protein.increase the formula’s caloric density w/out markedly altering solute load or osmolality .& Vit. magnesium.infant formula powder is often added to provide more calories & nutrients .MCT oil . D to treat osteopenia Caloric supplements .Adding these supplements to human milk of standard infant formula is not advised… . Polycose . carbohydrate & fat --.Infants consume less due to illness . phosphorus.

an emulsified fatty acid product (Microlipid) may be appropriate because it stays in solution better than MCT oil .WHEN A HIGH ENERGY FORMULA IS NEEDED: .could either be a full – strength premature formula or a concentrated standard formula w/ a maximum of 50% total calories from fat .MCT oil & Polycose can be added to a base that has a concentration of 24kcal/oz or greater .a minimum of 9% total calories from protein For infant who can tolerate long – chain fatty acid .

are born with more extracellular water than term infants & thus tend to lose more weight than term infants --.Ehrenkranz growth chart .GROWTH & NUTRITIONAL ASSESSMENT .Ehrenkranz growth chart is commonly used to assess weight progress Birth weight assessment charts: 1.may become dehydrated .The post natal loss should not be excessive Those who lose more than 15% to 20% .All neonates typically lose some weight after birth PRETERM INFANTS .longitudinally depicts daily weight changes & actual growth curves of 1660 infants who were born with a weight of 501 to 1500g .birth weight should be regained by the 2nd or 3rd weeks of life FIRST 98 DAYS OF LIFE .

can be achieved before 38 weeks of gestation 3.have also been developed using birth weight data of infants born at several successive weeks of gestation .however. length. these do not depict the initial period of postnatal weight loss & probably set unrealistic goals for preterm infants in the neonatal period After infant’s condition stabilizes: .infant may be able to grow at a rate that parallels these c curves Intrauterine weight gain of 15g/kg/day .has a built in correction factor for prematurity 7 the infant’s growth can be followed on one chart through the 1st year of corrected age . INTRAUTERINE GROWTH CURVES .2. head circumference .can be used to evaluate the adequacy of growth in areas such as: weight. Growth curve .

Bone mineralization .can also be used for preterm infants after 40 weeks of gestation.from birth to 3 years of age . as long as the age is adjusted LABORATORY INDICES (usually involve measuring the ff) .PN tolerance .Fluid & electrolyte balance .Hematologic status DISCHARGE CARE Establishment of successful feeding .pivotal factor in determining whether an infant could be discharged .(CDC) Center for Disease Control Growth Charts .

every 2 to 3 hours for breast fed infants 3.helps build confidence in their duty to care for a high – risk ifant Preterm infants .usually 3-4 hours during the day for bottle – fed infants .PRETERM INFANTS MUST BE ABLE TO: 1. Tolerate their feedings & usually obtain all of their feedings from the breast or bottle 2.to stay with the infant all day & night in the nusery before discharge .weigh less than 5 ½ lb during discharge Small preterm infants .should be followed very closely during 1st month after discharge . Grow adequately on a modified demand feeding schedule .parents are permitted to “room in” Room in . Maintain their body temperature without the help of an incubator Neonatal intensive care unit .

variable heart rate physiologic events .shaking or shivering of the muscles Infants weighing less than 51/2 lb have poor muscle tone .tremulousness with feeding Tremulousness .can be extremely helpful educationally .can provide eary intervention for developing problems FACTORS AFFECTINTG FEEDING SKILLS PHYSICAL FACTORS .rapid respiratory rate that interfere .1ST WEEK OF DISCHARGE (home visit by nurse or nutritionist or both & office visit to the pediatrician) .

repeating this pattern until infant is fully awake . The caregiver should provide one type of gentle stimulation for a few minutes and then change to a different type.Position infants in a manner that supports normal body flexion & ensures proper alignment of the head & neck during feedings --.is often difficult for infants who have limited muscle flexion & strength & poor head and neck control w/c are needed to maintain a good feeding posture --.tend to sleep more than larger & term infants --.FEEDING .It is much easier for preterm infants to feed effectively if they are fully awake TO AWAKEN A PRETERM INFANT: 1.Premature infants may also need their chin & cheeks supported while bottle feeding SMALL INFANTS .

Lightly swadling infants and then placing them in a semiupright position may also help Feeding environment .should be as quiet as possible ---Infants may tire quickly & show subtle signs of distress parents should recognize these cues to provide rest or comfort AFTER DISCHARGE (most preterm infants may need:) .transitional formula w/ a concentration of 22kcal/oz can be provided at a rate of 160ml/kg/day .approximately 180ml/kg/day of breast milk or standard infant formula containing 20kcal/oz .2.this amount of milk provides 120 kcal/day Alternatively: .

Weight is appropriate for length 4.weight .height .head circumference Patterns of growth should be assessed to determine whether: 1.Some infants may need a formula that provides 24kcal/oz Evaluate needs based on the 3 growth parameters: . Individual curves at least parallel reference curves 2.Determining the adequacy of amounts for individual infants .compare their intakes with their growth progress over time --. Growth is proportional in all three areas NEURODEVELOPMENTAL OUTCOME ---More tiny premature infants are surviving than ever before because of adequate nutritional support & recent advances in neonatal intensive care technology . Growth curves are shifting inappropriately across growth percentiles 3.

has increased concerns about their short & long term neurodevelopmental outcomes As a rule: .have an increased risk of developing handicapped central nervous system conditions.VLBW infants should be referred to a follow. which vary in severity & type of functional impairment = Many of these premature infants reach childhood w/ no evidence of any disability .Increased survival rate of VLBW infants .up clinic to evaluate their development & growth & begin early intervention Surviving ELBW infants (particularly w/ birth weight less than 750g) .

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