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Neonatal nutrition

Mohammad khassawneh
Goals
Ensure continuation of growth by giving
enough calories
Provide balance in fluid homeostasis
keep electrolytes normal range
Avoid imbalance in macro-nutrients
Provide micro-nutrients and vitamins

General facts about neonatal fluid
and nutrition
Last trimester of pregnancy
Fat and glycogen storing
Iron reserves
Calcium and phosphoruos deposits
Premature babies more fluid (85%-95%),
10% protein, 0.1% fat. No glycogen stores
Insufficient protein and calories is life
threatening to the sick

Guidelines fluid management
80 cc/kg/day, increase to 100-120cc/kg/d with
increase IWL
Increase to 100cc/kg/d 2
nd
day
add sodium 2-4 mEq/kg/d and K= 2 mEq/kg/d.
Calcium may be added
after 2
nd
day adjust according to
urine output 2-3cc/kg/hour with 110-140cc/kg/d
Specific gravidity 1.008-1.012,
watch weight change,
total in/out
Nutritional pathway for premature
infant
Day1, parenteral glucose 5-7mg/kg/minute
Watch blood sugar
Electrolytes check at 24 hours
Consider trophic feeding
Day2, TPN if not feeding
Day 3 or more: enteral feeding slowly increased
20cc/kg/day
1.5kg= 30cc/day =2.5cc every 2 hours
Day10-20, full nutrition
Energy use in body
Resting energy use 45 kcal/kg/d
Minimal activity 4 kcal/kg/d
Occasional cold stress 10 kcal/kg/d
Fecal loss of energy 15 kcal/kg/d
Growth 4.5kcal/gm 40-45 kcal/kg/d

Total 110-120 kcal/kg/d
Distribution of energy sources
Glucose 16.3gm = 55 kcal/kg/d. 50%
Protein 3.1gm =12.5 kcal/kg/d12%
Fat 4gm = 40 kcal/kg/d38%
Total 108 kcal/kg/d
Total parenteral nutrition (TPN)
This began 1968 first use
growth of 10-15gm/kg/day weight
gain
3gm/kg/d protein (amino acid)
3gm/kg/d fat (Fatty acid)
16gm/kg/d Dextrose 10-25% (carbohydrate)
this will give100-120 k.calories/kg/day
others
Minerals
Zinc, copper, molybdenum, chromium,
selenium
Calcium, phosphorous, Magnesium
Na, K
Vitamins
Fat soluble
Water soluble
Biochemical testing for patient on
TPN
Urine glucose
Triglyceride
BUN, Albumin
Ca, P, Mg, creatinine, Na, Cl, CO2
direct (conjugated) bilirubin, ALT
Trace element level
Complication of TPN
Infiltration under skin
Infection
Liver dysfunction
Renal overload
Feeding development
Swallowing first detected at 11 weeks
Sucking reflex at 24 weeks
Coordinated suck-swallowing not
present till 32-34 weeks
Swallowing to coordinate with respiration
Respiration>60-80 NG feeding
Respiration>80 high risk for aspiration (NPO)
Methods of feeding
Oral feeding
>32 weeks
Respiration<60-80
Try 20 minutes
Naso-gastric (NG) feeding bolus
NG feeding continuous
trans-pyloric
Gastrostomy feeding

Trophic Feeding
Keeping infant fasting (NPO)
Decrease in intestinal mass
Decrease in mucosal enzyme
Increase in gut permeability
Trophic feeding:
small amount of feeding to prepare the intestine
release enteric hormones, better tolerance to feeds
Enteral feeding
40-45% of calories are coming from
carbohydrates (Lactose or glucose
polymer)
Protein requirement of infant is 2.2-4.0
gm/kg/d
Protein is whey predominant 60:40
Breast feeding
after delivery baby has metabolic reserves
Hepatic glycogen
Brown fat
Extracellular and extravascular water
milk production is stimulated
Try to get baby onto the breast within first
1-2 hours of life
Colestrum ; high in protein a nd
immunoglobuline

breastfeeding
DOL# 1:
Colostrum and transitional milk average volume 35
mL (7-125mL)
DOL# 3-5:
Increasing milk production

Breast feeding
Q2-3 hours = 8-12 feeds per day
Quicker gastric emptying
frequent breast stimulation and emptying increase milk supply
Watch for feeding cues
Duration
10 minutes or longer
As long as swallowing continues
Cluster feeds is normal
Growth spurts
Baby may feeds more frequently for 1-2 days
Many growth spurts at 2wks, 6, wks, 2-3 months, and 5-6
months they feed more during them

Breast feeding
Ineffective if baby sucks from nipple only
Nipple and areola must be drawn deeply
into babys mouth
Listen for infant swallowing
DOL#1: intermittent swallows
DOL#2 on: 1 swallow : 1-3 jaw excursions
Maternal factor of low milk
Gestational diabetes
Hypothyroid
Retained placental fragments
Dehydration, hemorrhage, hypertension, infection
Previous breast surgery
Lack of prenatal engorgement
Psychosocial
Previous unsatisfactory experience
Lack of partner support
Post-partum depression
Separation from infant
Milk is what you eat
Moms need extra 500kcal/day if breast
feeding
Caffeine
Limit to 1-2 cups/day
Babies may become overstimulated, fussy

Spicy and gassy foods reflects

Infant illness that affect breast
feeding
Prematurity
Co-ordinated suck-swallow-breathing reflexes at 32-34 weeks
SGA, IUGR
Twins
Cleft lip and Palate, Micrognathia, Ankyloglossia, Macroglossia
Jaundice
Neuromotor problems
Birth asphyxia
Cardiac lesions
Infection
Surgical problems

Do I have to wake my baby to
feed?
Should wake baby during first 2-3 weeks
while milk supply is being established
Once milk supply good and baby back to
birth weight can allow baby to go 5 hours
during a 24 hour period without a feed
If milk supply decreasing should reinstitute
night time feed


Is my milk enough???
8-12 feeds per day to 6-8 weeks of age
Frequent swallowing
Adequate urine output (2-6 times/day)
Adequate stooling
Yellow stools by DOL#4
Weight loss no greater than 8% of BWT
Weight gain 15-30 grams/day
Good skin turger, moist mucous membranes
Contentment 1.5-2 hours after feeds

Enough milk
Breasts feel full before and softer after
feeds
Milk leaks from contralateral breast during
suckling
Sensation of milk ejection pins and
needles
Absent nipple trauma and pain
Profound state of relaxation in mom during
suckling


Human milk
Human milk is Ideal food for full term infant
Inadequate components for premature
infant <1500gm (human milk fortifier
needed to be added)
Protein
Vitamin D
Calcium
Phosphorous
Sodium
Breast feeding
Foremilk
Hind milk
Nonnutritive sucking
Pacifier
In premature
?/ no effect (wt gain, hospitalization, improved
oxygenation, faster oral feeding)
May give infant comfort and calm more
quickly
In term infant nipple confusion with bottle
and pacifier against breast feeding

Premature formulas
lack natural standard
50% lactose and rest glucose polymer
Protein
150% in amount of term formula
Whey predominant
Fat 50% LCT 50%MCT.
Higher Ca, P, higher Ca : P ratio of 2:1
Long chain polyunsaturated fatty acids
Standard infant formula
100% lactose
Fat is all long chain triglyceride
Protein is whey 60%, casein 40%
Iron fortified 12mg/liter and low iron versus
low 1.5mg/liter (should not give it)
Ready to feed or prepare from powder
Soy formulas
Lactose free
Primary and secondary lactase defeciency
Galactosemia
Carbohydrate is sucrose or corn syrup
Fat is vegetable oil such as coconut oil
Not recommended in very low birth weight
infant related to weight gain and
osteopenia.

Case 1
4 kg baby boy d in delivered by C/S and
mother interested in bottle feeding.
Type of milk advised
Sihha, NAN1, similac, S26
Amount
frequency
Case two
3.5 Kg mother wants to breast feed her
infant. She is primi-gravida
Is small amount of milk in first 3ds enough
How to encourage her to continue breast
feeding
Signs of successful breast feeding
For how long breast feeding to continue
Discuss AAP guideline
Baby jaundice at 2 weeks
Case 3
1.4 kg baby born at 30 week and has RDS
Discuss fluid management in first 3 days
How to feed him
Amount
Rate of increase
Type of formula
Risks of fast feeding