The principles of feeding for infants

with normal and complicated delivery

Kardana, I Made
Division of Neonatology
Sanglah Hospital, Denpasar
PRINCIPLES FEEDING
Gestational age
term ?
preterm ?

Condition of infants
healthy infants ?
sick infants ?
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


Imaturity
organ
Increased
diseases
and
anomaly
Increase
nutrient
demands
Nutrition problems of preterm
Limited
nutrient
reserve

Rapid
Growth rate
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

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

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
parenteral nutrition lipid
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 Frequency
Glycosuria Twice daily
Blood glucose Daily (more often in the first days
of life, or with glycosuria)
Sodium, potassium, acid-based Daily initially, then 3 times per
week
Calcium, magnesium 3 times per week
Urea, creatinine 2 times per week
Platelet count 2 times per week
Bilirubin Daily, or more often, if jaundiced
Liver function test If billrubin substantially
conjugated
Triglyceride Daily if using intralipid
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