In the name of Allah

Enteral Nutrition of Preterm Baby
Mohamed Khashaba Prof. of Pediatrics/Neonatology Head of NICU, MUCH


Stress the importance and challenges of preterm nutrition. Focus or general guidelines to feeding in preterm and high risk babies.


Improved perinatal care has resulted in survival of large number of LBWT infants requiring prolonged nutritional support.

Nutrition of LBWT infants represents a continuing challenge.


Why is nutrition of preterm baby important?


What are the general guidelines to enteral feedings?


Feeding in selected situations


Why is nutrition of

preterm baby important?

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Unmatched rate of fetal growth. Nutritive & energy stores are laid down in the 3rd trimester. Immaturity of digestive, absorptive, metabolic and excretory functions. Adverse effects of malnutrition. Potential catastrophic diseases. Unanswered questions.


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1- Unmatched rate of fetal growth

Fetal Growth Rate
• • •

Weight of 22 weeks fetus: Weight of 27 weeks fetus: Weight of 31 weeks fetus:

500 gms 1000 gms 1500 gms

TPN is not the sole logic continuation of fetal nutrition through placenta in utero. Swallowed amniotic fluid has a role in nutrition of the fetus especially during 3rd trimester.

2- Nutritive & energy stores are laid

down in the 3rd trimester.

Between 29 and 40 weeks gestation:
• • •

Protein content rises from 8.8% to 12% F at content rises from 1% to 13.1% Glycogen stores rise from 10 mg/gm liver to 50 mg/gm.

3-Immature digestive, absorptive, metabolic and excretory functions.

Functional Immaturity of GIT

Immature suck pattern: short bursts followed by swallows. Poor tone of inferior esophageal sphincter.

Functional Immaturity of GIT
Gastric activity and emptying
1. 2. 3. 4.

Diminished smooth muscle mass. Reduced propulsive activity. Less mature autonomic innervations. Blunted hormonal & enzymatic response.

4- Adverse effects of malnutrition

Many LBWT infants & almost all ELBWT babies




retardation during NICU stay

(Lemons et al.,

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Nutritional inadequacies have long term neuro developmental outcome Lucas et al., 1990. Under nutrition affects pulmonary maturity, growth and immunity. Impaired insulin secretion leading to hyperglycemia.

Vitamin A

Deficiency predispose to CLD & susceptibility to sepsis.

Vitamin E
• • • •

Antioxidant. Facilitate phagocytosis & heme synthesis. Important for ROP prevention. Protective role in IVH & BPD.

Trace Minerals
• • •

Preterms have low stores at birth. 8 trace elements are essential. Deficiency affect cell growth, enzyme system & heme synthesis.

5- Potential catastrophic diseases as NEC

and acute conditions e.g respiratory distress, hypoxia.

6- Many questions remain partially or completely unanswered.


How quickly should enteral feeding be advanced, and in what manner?


How should feeding protocols be altered by specific factors.


General guidelines to enteral feedings.


Parenteral nutrition should begin early and continue till full enteral feeds are reached. Minimal enteral feeds should be started early. Breast milk is preferable “fortified”. Slow advancement of feeds. Observation of signs of intolerance. Attention to sensory needs. Keep accurate records of intake.

2. 3. 4. 5. 6. 7.

Contraindications of enteral feeding
Downs’s score > 6 Hypotension Gastrointestinal obstruction or NEC A 5 minute Apgar score of 4

Method of feeding
.Cup feeding .Syringe feeding Nasogastric versus orogastric .feeding .Direct breast feeding

2. Minimal Enteral Feeds
(Gut priming-trophic feeds)
1. 2. 3.

Reduces feeding intolerance. Reduces incidence of jaundice. Reduces time to full enteral feeds attainment.

2.Minimal Enteral Feeds
(Gut priming- trophic feeds)
4. Induces release of intestinal hormones. 5. Direct trophic effects on GIT.

Indications of gut priming
Extremely LBW Umbilical artery catheter in place Unstable baby with sepsis Unstable baby with asphyxia

3- Breast Milk
A. B. C.

Incidence of NEC is 6 times higher in formula fed. Better cognitive & intellectual development. LC-PUFA may have important role in brain & retinal development. Better tolerance.


4- Advancement of Feeds

Rapid advancement (>20 ml/kg/day) is associated with increased risk of NEC.

4- Advancement of Feeds
1. 2. 3.

Assess the nurse’s report. Feeding order : precise & clear. Avoid advancing both volume & number of feeds at the same time. Nasogastric tube need not be removed for early enteral feeding.


5- Feeding Problems
Indicate possible GI pathology:
2. 3. 4. 5. 6.

Bile-stained residuals. Distended abdomen. Guiac positive stool. Significant residuals. Significant systemic symptoms.

Abnormal gastric residual volume
Abnormal gastric residual volume has been defined as follows: >2 mL/kg per feeding OR >50 percent of the volume of feeds over the last three hour

quality of the gastric residual

Gastric residuals that are green, or bilious, could indicate intestinal obstruction, but more often indicate overdistention and retrograde reflux of bile into the stomach.

quality of the gastric residual

A blood tinged residual could indicate an inflammatory process, but may only be due to a slight mucosal irritation from the indwelling gastric tube.

Possible Causes of Feeding Intolerance
1. 2. 3. 4. 5. 6.

NEC. Sepsis. Hemodynamic problems. Hypoxemia. Electrolyte disturbances. High theophylline serum levels.

Feeding Intolerance
Possible Options
1. 2. 3. 4. 5. 6.

Decrease amount of each feed. Switch to more dilute formula. Change the interval between feeds. Switch to predigested formula. Change to continuous gastric drip. Start parenteral nutrition & NPO.

6- Attention to Sensory Needs

Feeding should represent a pleasurable experience. Use of non nutritive sucking. Rocking the baby between feeds.

• •

7- Non Nutritive Sucking

May have an effect on weight gain & gastric motility & metabolic rate.


Facilitate transition to oral feeding.
(Pinelli, 2000)

When the infant tolerates at least 100 mL/kg per day or has fed unfortified human milk for at least one week, the caloric density of milk is increased by either switching to preterm formula. or adding human milk fortifier.

Average daily energy requirements for enteral fed premature infants are 120 kcal/kg per day Total energy needs in infants with chronic illness, such as bronchopulmonary dysplasia, increase up to 150 kcal/kg per day

Growth Parameters

Weight minimum increment of 15/kg per day. Once the infant reaches 2.0 kg, the daily weight gain of 20 to 30 g/d should be the goal Length minimum increment of 1 cm per week. Head circumference minimum increment of 1 cm per week

Biochemical assessment

Bone mineral status: serum calcium, phosphorus, and alkaline phosphatase activity. Protein status: serum albumin and urea nitrogen. The hemoglobin and reticulocyte count


Feeding in Selected Situations

Feeding of Ventilated Babies

Babies kept NPO until need for ventilatory assistance is minimized & baby stable. Post-extubation NPO (4-12 hrs.). Low UAC is a relative contraindication.

2. 3.

Feeding of Perinatal Asphyxia Babies

NPO until stability:
2. 3. 4. 5.

Bowel sounds are present. Abdominal examination is benign. Passed meconium. Stable hemodynamically.

Feeding After Exchange Transfusion

NPO for 24 hrs. after line is removed.

Necrotizing Enterocolitis

Feeding should be withheld for 2 weeks minimum. Total parenteral nutrition should be

immediately started.


Stress the importance and challenges of preterm nutrition. Focus or general guidelines to feeding in preterm and high risk babies.