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Enteral Feeding in LBW NeonatesEnteral Feeding in LBW Neonates
CHAIRPERSONCHAIRPERSON
Dr. A.G. ShingwekarDr. A.G. Shingwekar, , MD,DCHMD,DCH
Professor & HeadProfessor & Head
Department of Paediatrics, G.R.M.C. & J.A. Group of Hospitals, Gwalior
Presented by
Dr. KISHORE CHANDKI
Guided by :Dr. Ajay Gaur MD, PhD
Dr. G. Das MD
Dr. Y.S. Verma MD
Dr.(Mrs) Neetu MD
Dr. (Mrs) Sunita MD
Enteral Feeding in LBW NeonatesEnteral Feeding in LBW Neonates
IntroductionIndications & Contraindications Goals of Feeding Routes of Enteral Feeding Choice of Milk for Feeding Amount & Schedule of Feeding Minimal Enteral Nutrition Converting Gavage to Oral Feeds Feeding Term LBW neonate
Enteral Feeding in LBW NeonatesEnteral Feeding in LBW Neonates
Judging the adequacy of nutrition Kangaroo Mother Care Micronutrient Supplementation Immunonutrition MCT Oil Post discharge feeding & advice Summary
Enteral FeedingEnteral Feeding
Defined as the “administration of nutrients directly into the gastrointestinal tract.”
If the patient is unable to meet his/her nutritional requirements with oral diet/ nutritional supplements, then enteral feeding is indicated.
Once the gastrointestinal tract is functional, enteral feeding is the optimal method of nutritional support.
Advantages w.r.t. ParenteralAdvantages w.r.t. Parenteral
More Physiologic More safe More nutritionally complete Less expensive
But decision for mode of nutrition is based on :WeightGestational AgeClinical Condition
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
IndicationsIndications
Absent / impaired swallow
Inadequate oral intake
Neonates <1800 gm or < 34 weeks gestation, unable to breast feed
Necessity :
Functioning & accessible gastrointestinal tract
ContraindicationsContraindications
Complete bowel obstruction, Ileus
Intestinal ischemia
Necrotizing Enterocolitis
Complications of Enteral NutritionComplications of Enteral Nutrition
GI : Perforation, stricture, esophagitis, gastritis, nausea, vomiting, bleeding, GER
Mechanical : Dislodgement, tube migration, blockade, inflammation, granulation of skin site, aspiration, nasopharyngeal trauma, sinusitis, otitis media, laryngeal ulceration
Metabolic : Fluid overload, dehydration, hyper- & hypo-glycemia, electrolyte imbalance, azotemia, hypercapnea, hyperphosphatemia, vit. & mineral deficiency
Misc. : Aspiration pneumonia, Feed contamination & resulting infection, Abnormal LFT
Elizabeth K E, ‘Nutrition & Child Development’, 3rd Ed., 2004
Goals Of FeedingGoals Of Feeding
Achieve well-defined short-term growth & nutrient retention Mimic intrauterine growth rates Mimic reference fetal composition
Prevent Neonatal morbidities Improve feeding tolerance Reduce NEC Minimize nosocomial infection
Optimize long-term outcome Optimize neurodevelopmental outcome Reduce rates of allergy & atopic diseases
Ghai O.P., Essential Paediatrics, 2004
What is the Optimal Diet for LBW neonate ?What is the Optimal Diet for LBW neonate ?
“ “ Optimal diet should support a rate of growth Optimal diet should support a rate of growth approximating that of the third trimester approximating that of the third trimester intrauterine life without imposing stress on the intrauterine life without imposing stress on the developing & excretory functions!”developing & excretory functions!”
…the statement encourages mimicking the intrauterine environment by stimulating fetal accretion rates of nutrients & intrauterine growth rates!
Is it possible to extrapolate the extrauterine growth?Is it possible to extrapolate the extrauterine growth?
Thermal Thermal ProtectionProtection
Preferential Preferential nutrient nutrient deliverydelivery
Excretion Excretion handled by handled by placentaplacenta
Oxygen via Oxygen via placentaplacenta
Thermal Thermal instabilityinstability
Exogenous Exogenous nutrientsnutrients
Immature Immature kidneykidney
Birth asphyxiaBirth asphyxia
Is it possible to extrapolate the extrauterine growth?Is it possible to extrapolate the extrauterine growth?
UDPG UDPG prolonged prolonged jaundicejaundice
IVH, cerebral IVH, cerebral anoxiaanoxia
Low glycogen Low glycogen stores/brown fatstores/brown fat
Poor lactate Poor lactate metabolism metabolism acidosisacidosis
Poor immunity Poor immunity sepsis sepsis
Congenital Congenital anomaliesanomalies
Contd…Contd…
Poor Feeding Poor Feeding reflexesreflexes
Low gastric Low gastric acidity, low acidity, low enzyme levels, enzyme levels, low bile secretionlow bile secretion
NECNEC surfactant surfactant
HMDHMD Immature respi. Immature respi.
Center Center apnea, apnea, aspiration, aspiration, pulmonary pulmonary hemorrhagehemorrhage
Is it possible to extrapolate the extrauterine growth?Is it possible to extrapolate the extrauterine growth?Contd…Contd…
So, the answer is probably ‘NO’So, the answer is probably ‘NO’Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Fetal Energy & Fetal Energy & Protein AccretionProtein Accretion
Postnatal Energy & Postnatal Energy & Protein AccretionProtein Accretion
Weight gainWeight gain
18 gm/kg/d (24-28 18 gm/kg/d (24-28 wks)wks)
16 gm/kg/d (32-36 16 gm/kg/d (32-36 wks)wks)
15 gm/kg/d15 gm/kg/d
(During acute phase (During acute phase : Avoid catabolism): Avoid catabolism)
Protein AccretionProtein Accretion ~ 2 gm/kg/d~ 2 gm/kg/d 3 gm/kg/d3 gm/kg/d
Fat AccretionFat Accretion 1.4-1.9 gm/kg/d1.4-1.9 gm/kg/d ~1.5 gm/kg/d~1.5 gm/kg/d
Calorie AccretionCalorie Accretion ~30 kCal/kg/d ~30 kCal/kg/d (>28 wks)(>28 wks)
~50 kCal/kg/d~50 kCal/kg/d
Fluid Requirements For NeonatesFluid Requirements For Neonates
DayDay
Fluid (mL/kg/d)Fluid (mL/kg/d)Birth weight Birth weight
<1000 gm<1000 gmBirthWeight BirthWeight
1001-1500 gm1001-1500 gmBirth Weight Birth Weight
>1500 gm>1500 gm
11 100100 8080 6060
22 115115 9595 7575
33 130130 110110 9090
44 145145 125125 105105
55 160160 140140 120120
66 175175 155155 135135
7+7+ 190190 170170 150150
IAP Textbook of Pediatrics, 2nd Ed. 2002Additional Allowances : Additional Allowances : PPhototherapy : 20-40 ml/kg/d, Radiant Warmer : 40-80 ml/kg/dhototherapy : 20-40 ml/kg/d, Radiant Warmer : 40-80 ml/kg/d
Guidelines for Fluids & Feeding to LBW BabiesGuidelines for Fluids & Feeding to LBW Babies
AgeAge
Category of NeonatesCategory of Neonates< 1200 gm< 1200 gm
<30 weeks<30 weeks1200-1800 gm1200-1800 gm
30-34 weeks30-34 weeks>1800 gm>1800 gm
>34 weeks>34 weeks
InitialInitial
IVF. Try gavage if IVF. Try gavage if not sicknot sick
GavageGavage Breast feeding. If Breast feeding. If unsatisfactory, unsatisfactory, give katori-spoon give katori-spoon feeds.feeds.
After 1-3 After 1-3 days days
GavageGavage Katori-spoonKatori-spoon Breast feedingBreast feeding
Later Later
(2- 4 weeks)(2- 4 weeks)
Katori-spoonKatori-spoon Breast feedingBreast feeding Breast feedingBreast feeding
After After sometime sometime
(4- 6 weeks)(4- 6 weeks)
Breast feedingBreast feeding Breast feedingBreast feeding Breast feedingBreast feeding
Ref. Teaching Aids : NNF
Routes of Administration of Enteral NutritionRoutes of Administration of Enteral Nutrition
TPN
TPN + MENTPN + MEN
PPNPPN
Alternative Feeding
Exclusive Breast Feeding
Least preferredLeast preferred
Most preferredMost preferred
Routes of Administration of Enteral NutritionRoutes of Administration of Enteral Nutrition
Oral- Spoon & katori, etc.
Nasogastric/Orogastric
Nasoduodenal / Nasojujenal
Surgical or Percutaneous Endoscopic gastrostomy
Surgical or Percutaneous Endoscopic jejunostomy
Indian J Pediatr 2002; 69 (5) : 411-415
Inserting a Nasogastric (NG) TubeInserting a Nasogastric (NG) Tube
Normal anatomical Normal anatomical PathPath
Inserting a Gastric TubeInserting a Gastric Tube
Principles of Newborn Baby Care, WHO/UNICEF, 2003
Insert through nostril
Confirming Proper Placement of TubeConfirming Proper Placement of Tube
Air insufflation & auscultation method : with 1 to 2 ml of air - If a whistling sound is heard through the stethoscope as the air is injected, the end of the tube is correctly positioned in the stomach. You should also be able to withdraw the air you pushed in.
Acidity of the aspirate: [Only suitable for babies more than 24 hours old or preterm LBW babies who are more than 48 hours old] If the blue litmus paper turns pink, the fluid is acidic and the tip of the tube is correctly positioned in the stomach.
Inserting a Gastric TubeInserting a Gastric Tube
Signs that the tube may not be placed correctly are:
X Coughing
X Apnea
X Cyanosis
Nasogastric TubeNasogastric Tube
Easy to place
Easy to secure
Lasts longer, Cheaper
No need to pass every time
Risk of nasopharyngeal trauma
Space occupying effect GER, aspiration (Gag reflex should be intact)
Advantages Disadvantages
Agrawal K.N., ‘Pediatrics & Neonatology, 1st Ed., 2000
Nasoenteric TubesNasoenteric Tubes
http://www.nutriciame-clinicalnutrition.com
Properties :Properties :
Has a small diameter available for patient comfortHas a small diameter available for patient comfort Is long enough for nasoenteric feeding Is long enough for nasoenteric feeding Is flexible for easy insertion and removal Is flexible for easy insertion and removal Is radioopaque for X-Ray confirmation of Placement Is radioopaque for X-Ray confirmation of Placement Has several feed outlets at the distal end to prevent clogging Has several feed outlets at the distal end to prevent clogging Has a smooth rounded tip to prevent insertion trauma Has a smooth rounded tip to prevent insertion trauma If a guide wire is used, the guide wire will not dislodge during If a guide wire is used, the guide wire will not dislodge during insertion; it is easy to remove. insertion; it is easy to remove. Is preferably made of premium material, resistant to gut Is preferably made of premium material, resistant to gut secretionssecretions
Nasoenteric TubesNasoenteric Tubes Polyurethane tubes (PUR):Polyurethane tubes (PUR): Soft, flexible and do not Soft, flexible and do not react to gastric juices. Can stay for 6-8 weeks. Some react to gastric juices. Can stay for 6-8 weeks. Some contain a guide wire for easy insertion. contain a guide wire for easy insertion. Polyvinylchloride (PVC):Polyvinylchloride (PVC): Contain a plasticizer to Contain a plasticizer to keep the tube flexible, because the compound is keep the tube flexible, because the compound is sensitive to the low pH, becomes rigid after 7-10 days sensitive to the low pH, becomes rigid after 7-10 days which can lead to irritation of the pharynx and to the which can lead to irritation of the pharynx and to the esophagus. If not replaced after 7 days of usage a esophagus. If not replaced after 7 days of usage a digestion happen to the tube it self which make the digestion happen to the tube it self which make the content of toxic products to be leached and may cause content of toxic products to be leached and may cause nectorizing entercolitis in premature infants. After 7 nectorizing entercolitis in premature infants. After 7 days as the tube become rigid and stiff it may cause days as the tube become rigid and stiff it may cause perforation and intussusception.perforation and intussusception.
http://www.nutriciame-clinicalnutrition.com
Inserting an Orogastric (OG) TubeInserting an Orogastric (OG) Tube
Orogastric TubeOrogastric Tube
No space occupying effect
Larger bore tube can be passed easily
Difficult to secure, dislodgement
Lasts shorter
Need to pass with every feed
Advantages Disadvantages
Agrawal K.N., ‘Pediatrics & Neonatology, 1st Ed., 2000
Routes of Enteral FeedingRoutes of Enteral Feeding
Nasoduodenal feeding Nasojejunal feeding
Nasoduodenal or Nasojejunal TubesNasoduodenal or Nasojejunal Tubes
Length : From tip of nose to knee joint
Less aspiration
Less expensive & safer than TPN
Less chances of reflex bradycardia
Less risk of dislodgement
Requires fluoroscopic or endoscopic control for insertion
Expensive tubes wrt NG/NJ
Risk of gut perforation
Frequent supervision
Advantages Disadvantages
Agrawal K.N., ‘Pediatrics & Neonatology, 1st Ed., 2000
Transpyloric FeedingTranspyloric Feeding
Candidates :
Intolerance to naso/orogastric feeding owing to gastric retention or regurgitation
Neonates at increased risk for aspiration
Anatomic abnormalities of GI tract e.g. microgastria
Problems :
Must be delivered continuously
Fluoroscopic control required for placemnent
Increased risk for fat malabsorption because of by passing of lipases
Cloherty, Eichenwald, Stark, ‘Manual of Neonatal Care’; 5 th Ed, 2004
Transpyloric FeedingTranspyloric Feeding
No difference in short/long term growth, rather increase in GI disturbance & increased mortality
Hence, avoided as far as possible
Indian J Pediatr 2002; 69 (5) : 401-404
Routes of Enteral FeedingRoutes of Enteral Feeding
Gastrostomy (GT) feeding Jejunostomy (JT) feeding
Enterostomy TubesEnterostomy Tubes
Less aspiration ( with jejunostomy)
Less chances of reflex bradycardia, trauma to air passages
Less risk of dislodgement
No interference with breathing
Requires endoscopic control/anesthesia for insertion
Expensive tubes wrt NG/NJ
Peristomal infection, peritonitis, tube blockage, inadvertent removal, tube fracture and leakage
Advantages Disadvantages
Postgraduate Medical Journal 2002;78:198-204
Enterostomy TubesEnterostomy Tubes
Indications : Congenital anomalies of the mouth, jaw, pharynx,
gastrointestinal tract, and/or airway (ie, esophageal fistula, tracheoesophageal fistula, cleft lip and palate, intestinal atresia, and abdominal wall defects)
Prolonged enteral nutrition (>6 weeks)
http://www.naspghan.org/sub/ENTERAL_AND_PARENTERAL_NUTRITION.htm
Contraindications :
Abdominal wall infection
Coagulopathy
Massive ascites
Choice of Milk for FeedingChoice of Milk for Feeding
Human milk alone (Term/Preterm) Human Milk + Calcium Phosphate & Vit.
Supplements Human Milk (EBM) + Preterm formula Human milk + Fortifier (HMF) Top milk with or without Fortifier
Contd…
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Choice of Milk for FeedingChoice of Milk for Feeding
Human milk alone (Term/Preterm) : Expressed breast milk
Contd…
Besides usual advantages, has Immunological advantages Better neurodevelopmental and visual outcomes (possibly
because of LC-PUFA) Reduced incideence of NEC
But it does have short comings :- Does not have enough protein and calorie to ensure optimal
EARLY growth at 20 kCal/Oz- Does not have enough sodium to compensate for high sodium
losses. - Does not have enough calcium or phosphate
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Choice of Milk for FeedingChoice of Milk for Feeding
Human milk alone (Term/Preterm) : Expressed breast milk
Contd…
- Is deficient in vitamins and iron relative to the needs of a preterm infant who will have mixed out on the last trimester placental transfer.
- Composition varies- Losses A/W collection, storage,
feeding procedures, esp. fats & vitamins.
Because of this, many units routinely supplement EBM with HMF upto 24 kCal/Oz in babies <32 weeks or <1500 gm (when the baby is tolerating 150ml/kg/day)
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Choice of Milk for FeedingChoice of Milk for Feeding
Human Milk + Calcium Phosphate & Vit. Supplements
Contd…
Has : All the biological advantages of Breast Milk!
But : Still will have LESS protein than the required
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Choice of Milk for FeedingChoice of Milk for Feeding
Preterm formula
Contd…
Has : Adequate calories, calcium, phosphate & vitamins
fed at the rate of 150-180 mL/kg/d
But : Does not have any of biologically active immune
substances, or enzymes of growth factors May still require supplements of sodium, chloride, vitamin A &
D and iodine More chances of contamination while preparation
Hence: Not preferred in general If required, given until neonate reaches a weight of 2-2.5 kg or
on full breast feeds!Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Breast Milk Substitute : Formula MilkBreast Milk Substitute : Formula Milk
Managing Newborn Problems, WHO/UNICEF, 2003
• Use when the mother cannot breastfeed or express breast milk.
• Use a breast-milk substitute designed for premature or small babies.
• Once the container is open, use within the recommended time according to the manufacturer’s instructions.
• Check the expiry date of the breast-milk substitute.
• Use aseptic technique to prepare the breast-milk substitute from liquid concentrates or powders, using high-level disinfected or sterile utensils and containers, and sterilized or boiled and cooled water.
Breast Milk Substitute : Formula MilkBreast Milk Substitute : Formula Milk
Managing Newborn Problems, WHO/UNICEF, 2003
• Wash hands with soap and water.
• Determine the required volume of milk for the feed.
• Measure the breast-milk substitute and water, mix them, and feed the baby using a cup, cup and spoon, or other device. Have the mother do this whenever possible.
• Store remaining milk in a labelled container in a refrigerator for a maximum of 24 hours.
• Breast-milk substitute is not available, have the mother use a breast-milk substitute that is based on animal milk and prepared at home.
Choice of Milk for FeedingChoice of Milk for Feeding
Ref. : Deptt. of Agriculture, United States
• Top Milk :Term Term
Breast MilkBreast MilkCow’s Cow’s MilkMilk
Buffalo’s Buffalo’s MilkMilk
Goat’s Goat’s MilkMilk
Calories (Kcal/dl)Calories (Kcal/dl) 6767 6767 117117 7272
Protein (gm/dl)Protein (gm/dl) 1.11.1 3.23.2 4.34.3 3.33.3
Fat (gm/dl)Fat (gm/dl) 4.54.5 4.14.1 6.56.5 4.54.5
Carbohydrate (gm/dl)Carbohydrate (gm/dl) 7.17.1 4.44.4 5.15.1 4.44.4
Calcium (mg/dl)Calcium (mg/dl) 3333 120120 169169 134134
Phosphorus (mg/dl)Phosphorus (mg/dl) 1515 9090 117117 111111
Iron (mg/dl)Iron (mg/dl) 0.030.03 0.20.2 0.120.12 0.050.05
Vitamin A (IU/dl)Vitamin A (IU/dl) 250250 70-22070-220 178178 185185
Sodium (mEq/dl)Sodium (mEq/dl) 0.80.8 0.760.76 0.520.52 0.500.50
Folic Acid (mcg/dl)Folic Acid (mcg/dl) 55 55 66 11
Choice of Milk for FeedingChoice of Milk for Feeding
• Top Milk :
Animal milk and term formula milk are unsuitable for feeding preterm as composition does not meet recommended nutrient intake and it predisposes to late hypocalcemia as phosphate contains high.
Animal milk with human milk fortifier is not yet studied.
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Human Milk Fortifier (HMF) Human Milk Fortifier (HMF)
Is the nutritional supplement product that may be added to breast milk to supplement its nutrient content
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Cochrane review
Short term benefitsGreater weight gainGreater length gainGreater HC gainIncreased N2 balanceIncreased bone mineral content
Long term benefit (at 18 mo)No benefit in terms of :-xWeightxLengthxHCxNeurodevelopmental x outcome
Adverse effectsNo increase in NECFeed intolerance
Currently available HMF have low protein, low sodium, high soluble calcium & phosphate, high osmolality and difficulty in mixing leading to separation of fat and disruption of fat globules with addition of calcium
Composition of various feedsComposition of various feeds
Mineral & Mineral & Vitamin per Vitamin per 100 Kcal100 Kcal
Preterm-Preterm-RNI RNI (AAPCON (AAPCON 1998)1998)
Preterm-Preterm-EBM (per EBM (per 100 ml)100 ml)
Preterm Preterm EBM + HMF EBM + HMF (Per 100 ml)(Per 100 ml)
Preterm Preterm Formula (Per Formula (Per 100 ml)100 ml)
Calories Calories (Kcal/kg/d)(Kcal/kg/d)
105-130105-130 6767 8181 8080
Protein Protein (gm/kg/d)(gm/kg/d)
3.5-43.5-4 1.61.6 22 22
Carbohydrate Carbohydrate (gm/kg/day)(gm/kg/day)
11-15.511-15.5 7.37.3 9.79.7 9.19.1
Calcium Calcium (mg)(mg)
175175 2525 125125 128128
Phosphorus Phosphorus (mg)(mg)
9191 1414 6464 6464
Iron (mg)Iron (mg) 1.7-2.51.7-2.5 0.090.09 0.090.09 0.80.8
Contd…
Composition of various feedsComposition of various feeds
Mineral & Mineral & Vitamin per Vitamin per
100 Kcal100 Kcal
Preterm-Preterm-RNI RNI
(AAPCON (AAPCON 1998)1998)
Preterm-Preterm-EBM (per EBM (per
100 ml)100 ml)
Preterm Preterm EBM + HMF EBM + HMF (Per 100 ml)*(Per 100 ml)*
Preterm Preterm Formula (Per Formula (Per
100 ml)100 ml)
Vitamin A Vitamin A (IU)(IU)
75-22575-225 4848 15081508 241241
Vitamin D Vitamin D (IU)(IU)
270270 88 508508 7272
Sodium Sodium (mEq)(mEq)
2.1-2.92.1-2.9 1.261.26 1.561.56 2.22.2
Vitamin E Vitamin E (IU)(IU)
>1.1>1.1 11 33 44
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
* 1 Sachet (2 gm) of HMF is added to 50 ml of expressed breast milk.
Contd…
Human Milk provides the ‘Gold Standard’ for feeding LBW neonates!
Gut Starvation : Need for early feeding ?Gut Starvation : Need for early feeding ?
Morphological ChangesMorphological Changes
Mucosal massMucosal mass Cell productionCell production Villus heightVillus height
Functional ChangesFunctional Changes
PermeabilityPermeability Amino acid absorption Amino acid absorption
EnzymesEnzymes
Sucrase Sucrase LactaseLactase
ImmunityImmunity
Number of lymphocytesNumber of lymphocytes IgA secretionIgA secretion
Bacterial translocationBacterial translocation
Zeigler,Lucas,Moro ‘Nutrition of the VLBW Infant’, 1999
Cloherty, Eichenwald, Stark, ‘Manual of Neonatal Care’, 5 th Ed, 2004
Minimal Enteral Nutrition (MEN)Minimal Enteral Nutrition (MEN)
Syn. Trophic feeding, Gut priming feeding, minimal feeds, gut Syn. Trophic feeding, Gut priming feeding, minimal feeds, gut stimulation, early feeding, or hypocaloricstimulation, early feeding, or hypocaloric feedingsfeedings
Def. :
Feedings that are delivered in very small amounts ( 10 mL/kg/d) for the purpose of induction of gut maturation rather than nutrient delivery!
Advantages :
Improved levels of gut hormones Trophic effects on mucosa
Improved peristalsis
Improved calcium & phosphorus retention
Minimal Enteral Nutrition (MEN)Minimal Enteral Nutrition (MEN)
Less feeding intolerance
Earlier progression to full enteral feedings, Fewer days on parenteral nutrition
Improved weight gain
Reducation in episodes of culture positive sepsis
Low serum bilirubin levels
No increased risk of NEC
Cochrane review, Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Contd…
Minimal Enteral Nutrition (MEN)Minimal Enteral Nutrition (MEN)
……No consensus guideline as when to start, how to progress, No consensus guideline as when to start, how to progress, how long to continue MEN & when to advance to full how long to continue MEN & when to advance to full
nutritive feedingnutritive feeding
Recommended for all babies Sick babies with significant respiratory distress & Sick babies with significant respiratory distress &
hemodynamic instability remain NPO till they are hemodynamic instability remain NPO till they are stable, ideally by 1stable, ideally by 1stst – 2 – 2ndnd day of life day of life
Donot use in suspected or confirmed NEC or evidence Donot use in suspected or confirmed NEC or evidence of ileus.of ileus.
Can be started with EBM at a volume of Can be started with EBM at a volume of 10 mL/kg/d 10 mL/kg/d @ 3-8 hourly intervals@ 3-8 hourly intervals
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Contd…
Rapid (Vs Slow) AdvancementsRapid (Vs Slow) Advancements
Better gain in weight, length & HC
Shorter hospital stay
Risk of GER, aspiration
Risk of NEC with very fast advancements
Indian J Pediatr 2002; 69 (5) : 401-404
Recommendation
You can make rapid enhancements upto 30 ml/kg/d in stable LBW infants without increased risk of NEC, esp. after day 4/5 of life!
Cloherty, Eichenwald, Stark, ‘Manual of Neonatal Care’; 5 th Ed, 2004
Guidelines for Tube FeedingGuidelines for Tube FeedingBirth weight (gm)Birth weight (gm) Initial rate Initial rate
(mL/kg/day)(mL/kg/day)Volume Increase Volume Increase
(mL/kg/day)(mL/kg/day)
< 800< 800 1010 10-2010-20
800-1000800-1000 10-2010-20 10-2010-20
1001-12501001-1250 2020 20-3020-30
1251-15001251-1500 3030 3030
1500-18001500-1800 30-4030-40 30-4030-40
1801-25001801-2500 4040 40-5040-50
>2500>2500 5050 5050
Feeding MUST always be individualized depending on neonate’s condition!
Intermittent Bolus Vs ContinuousIntermittent Bolus Vs Continuous
More physiological Risk of GER
Risk of aspiration
Advantages Disadvantages
Preferred in general! May be used for :
GER
Bolus feeding Intolerance
Indian J Pediatr 2002; 69 (5) : 401-404
Expressing Breast MilkExpressing Breast Milk
Principles of Newborn Baby Care, WHO/UNICEF, 2003
• Teach the mother how to express breast milk herself. The mother should:
- obtain a clean (washed, boiled or rinsed with boiling water, and air-dried) cup or container to collect and store the milk;
- wash her hands thoroughly;- sit or stand comfortably and hold the container
underneath her breast;- express the milk- support the breast with four fingers and place the
thumb above the areola;- squeeze the areola between the thumb and fingers
while pressing backwards against the chest;
Expressing Breast MilkExpressing Breast Milk
- express each breast for at least four minutes, alternating breasts until the flow of milk stops (both breasts are completely expressed).
• If the milk does not flow well:
- ensure that the mother is using the correct technique;
- have the mother apply warm compresses to her breasts
Expressing Breast MilkExpressing Breast Milk
While feeding, baby’s lips should cover areola in addition to nipple!
www.breastfeeding.orgwww.breastfeeding.org
Recommendations for storage of Breast MilkRecommendations for storage of Breast Milk
Duration of Storage with respect to temperatureDuration of Storage with respect to temperature
Room TemperatureRoom Temperature 6-8 hours6-8 hours
Refrigerator (<4Refrigerator (<4°C; 39ºF)°C; 39ºF) 24 hours24 hours
Freezer Compartment, or Deep Freezer Compartment, or Deep Freezer ( <-20 Freezer ( <-20 °C; <-4 °F)°C; <-4 °F)
6 months6 months
Store in hard plastic or glass containers with well-fitting tops. Warm frozen or refrigerated milk in a warm water bath (~40 °C).°C). Use the rewarmed milk promptly. Discard the remaining once Use the rewarmed milk promptly. Discard the remaining once
warmed.warmed.
Feeding by Alternative MethodsFeeding by Alternative Methods
• Ensure that the mother can properly express breast milk
• Feed the baby using a cup, a cup and spoon, or other suitable device (e.g. paladai)
• Use clean (washed, boiled or rinsed with boiled water, and air-dried) utensils and feeding devices for each feed.
• Feed the baby immediately after the milk is expressed, if possible. If the baby does not consume all of the milk, store the remaining milk
Feeding by Alternative MethodsFeeding by Alternative Methods• Have the mother feed the baby unless she is not
available. The mother should:
- measure the volume of breast milk in the cup
- hold the baby sitting semi-upright on her lap;
- rest the cup (or paladai or spoon) lightly on the baby’s lower lip and touch the outer part of the upper lip with the edge of the cup;
- tip the cup (or paladai or spoon) so the milk just reaches the baby’s lips;
- allow the baby to take the milk; do not pour
- end the feeding when the baby closes her/his mouth and is no longer interested in feeding.
Feeding by Gastric TubeFeeding by Gastric Tube
• Ensure that the mother can properly express breast milk
• Insert a gastric tube, if one is not already in place.
• Confirm that the tube is properly positioned before EACH feeding.
• Encourage the mother to hold the baby and participate in feedings.
• Determine the required volume of milk for the feed according to the baby’s age
Feeding by Gastric TubeFeeding by Gastric Tube• Remove the plunger of a high-level
disinfected or sterile syringe or a clean (washed, boiled or rinsed with boiled water, and air-dried) syringe and connect the barrel of the syringe to the end of the gastric tube:
• Pour the required volume of milk into the syringe with “tip” of the syringe pointed downward.
• Have the mother hold the syringe 5 to 10 cm above the baby or suspend the tube above the baby and allow the milk to run down the tube by gravity. Do not force by plunger.
Feeding by Gastric TubeFeeding by Gastric Tube
o You may apply slight pressure with the plunger initially (just to start the feeding)
o When the feeding is completed, clear the tube with some of water. Try not to put extra air into the stomach.
o There is no need to burn the baby after feeding
o Place the baby on his or her right side or hold upright after feeding
Feeding by Gastric TubeFeeding by Gastric Tube
Right-side lying position after feedingWhaley & Wong’s Essentials of Pediatric Nursing, 5th Ed, Mosby, 1997
Feeding by Gastric TubeFeeding by Gastric Tube• Using this method, each feeding should
take 10 to 15 minutes.
• When the feeding is finished, remove, wash, and high-level disinfect or sterilize the syringe, and cap the tube until the next feeding.
• Progress to feeding by cup/spoon when the baby can swallow without coughing or spitting milk.
• Replace the gastric tube with another clean gastric tube after 2-3 days, or earlier if it is pulled out or becomes blocked.
Feeding by Gastric TubeFeeding by Gastric Tube
Continuous Feeding :
Set up feeding pump and give the feeding
Flush the feeding tube with water every 4 hours.
Change the feeding bag every 24 hours
Feeding the Term LBW neonatesFeeding the Term LBW neonates
Constitute 2/3rd of LBW neonates in India Growth retarded Have inadequate transplacental transfer of nutrients like
Calcium, phosphate & multivitamins
“No guidelines available yet about how to provide them optimum nutrition”.
But, if inadequate weight gain on full breast feeds, may be supplemented with extra calories or proteins with fortifiers or preterm formulas!
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Feeding the baby : Standards of CareFeeding the baby : Standards of Care
Encourage & teach the mother to express breast milk at least eight times in 24 hours
Assess the feeding ability TWICE DAILY, and encourage & support the mother to begin breast feeding as soon as the baby shows signs of readiness to suckle
Record the following EACH TIME the baby is fed : Time of feeding Amount & kind of milk given Any feeding difficulty
Assess the baby’s growth frequently.
MonitoringMonitoring
Indian Pediatrics, Vol. 41, May, 2004: 436
Monitor :
Abdominal girth >2 cm is significant
Pre feed gastric aspirate Compare with amount of previous feed
<30% of pre feed volume
30-50% of pre feed volume/vomiting / abd. distension.
>50% of pre feed volume, or 3 mL/kg (whichever greater)
Continue
with same
Stop feeding, IVF for 12 hrs.
Continue IVF for another 12 hrs & reassess
Restart at same rate as last feed & observe
Not improvingNot improvingImprovingImproving
MonitoringMonitoring
Indian Pediatrics, Vol. 41, May, 2004: 436 2003
>50% of pre feed volume, or 3 mL/kg (whichever greater)
Discontinue feeding for next 24 hours, then reassess
Investigate for Sepsis & NEC
Continue with management of the condition
Restart feeding at half the volume at the time of discontinuation
PositiveNegative
Contd...Contd...
MonitoringMonitoring
Managing Newborn Problems, WHO/UNICEF, 2003
• Assess hydration daily:
- If there are signs of dehydration (e.g. sunken eyes or fontanelle, loss of skin elasticity, or dry tongue and mucous membranes), increase the volume of fluid by 10% of the baby’s body weight on the first day;
- If there are signs of over hydration (e.g. excessive weight gain, puffy eyes, or increasing oedema over lower parts of the body), reduce the volume of fluid by half for 24 hours.
• Weigh the baby daily. If the daily weight loss is more than 5%, increase the total volume of fluid by 10 ml/kg body weight for one day to compensate for inadequate fluid administration.
• Monitor Hb/PCV, Serum sodium weekly till 4-6 weeks
• Monitor serum calcium, phosphate and alkaline phosphatase fortnightly till discharge, and at term corrected age before stopping calcium supplements.
Managing Newborn Problems, WHO/UNICEF, 2003
Judging the adequacy of NutritionJudging the adequacy of Nutrition
Weight Pattern :Weight Pattern : Not >10-15% cumulative weight loss during first week of lifeNot >10-15% cumulative weight loss during first week of life Birth weight regained between 10-14Birth weight regained between 10-14thth day of life day of life Starts gaining weight by second week of life at Starts gaining weight by second week of life at 15-20 gm/day15-20 gm/day. .
(SFD neonates may start without any appreciable weight loss (SFD neonates may start without any appreciable weight loss at all) unless sick. at all) unless sick.
For this weigh the baby :For this weigh the baby :o Daily when in the hospitalDaily when in the hospitalo At 2 weeks, 4 weeks & then monthly after discharge!At 2 weeks, 4 weeks & then monthly after discharge!
Baby should gain Baby should gain 0.75 cm0.75 cm of HC per week till 40 weeks of of HC per week till 40 weeks of gestationgestation
Baby should gain Baby should gain 1.1 cm1.1 cm of length per week between 28-40 of length per week between 28-40 weeks of gestationweeks of gestation
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Weight Gain & FeedingWeight Gain & Feeding
Managing Newborn Problems, WHO/UNICEF, 2003
• If the baby still requires feeding using an alternative feeding method but is on full milk feeds:
- Increase the volume of milk in increments of 20 ml/kg body weight per day until the baby reaches 180 ml/kg body weight of breast milk per day;
- Continue to increase the volume of milk as the baby’s weight increases to maintain a volume of 180 ml/kg body weight of breast milk per day.
Weight Gain & FeedingWeight Gain & Feeding
Managing Newborn Problems, WHO/UNICEF, 2003
• If weight gain is inadequate (less than 15 g/kg body weight per day over three days):
- Increase the volume of milk to 200 ml/kg body weight per day;
- You can have the mother express breast milk into two different cups. Have her give the contents of the second cup, which contains more of the fat-rich hind milk, to the baby first, and then supplement with whatever is required from the first cup.
- If weight gain is inadequate for more than one week and the baby has been taking 200 ml/kg body weight breast milk per day, treat for inadequate weight gain
Inadequate weight gain / Excessive Inadequate weight gain / Excessive Weight LossWeight Loss
Inadequate calorie provided/consumed Cold stress Anemia Underlying systemic illness, e.g. sepsis. Urinary tract infection Late hyponatremia Late metabolic acidosis
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Recording & Monitoring WeightRecording & Monitoring Weight
Converting Gavage to Oral FeedsConverting Gavage to Oral Feeds
Candidates Neonate of ~34 wk gestation with coordinated suck-swallow-breathe pattern & respiratory rate 60/min
Transition should be slow At first, give a supervised spoon feed & if the baby accepts well
I.e. can finish the measured amount within 20-30 min without any sign of fatigue (apnea, vomiting, color changes, poor weight gain & slow to finish the full volume), then, number of spoon feeds can be increased over next few days like :
o One spoon feed every 6 feedso One spoon feed per 2 gavage feedso Alternate spoon & gavage feedo 2 spoon feeds per gavage feedo And finally to full spoon feeds
Always try NNS while on gavage from 30-32 weeks gestation
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Non Nutritive Sucking (NNS)Non Nutritive Sucking (NNS)
Used In transition from gavage to breast feeding During gavage feeding
Rationale Facilitates the development of sucking behaviour Improves digestion of enteral feeding
Benefits Early transition from gavage to breast feeding Decrease length of hospital stay
Method Done with empty breast or with a pacifier Burping is a MUST because aerophagia is likely
Combining IV Fluid & FeedingCombining IV Fluid & Feeding
Managing Newborn Problems, WHO/UNICEF, 2003
• If the baby tolerates the feed and there are no problems, continue to increase the volume of feeds while decreasing the volume of IV fluid to maintain the total daily fluid volume according to the baby’s daily requirement
• Feed the baby every three hours, or more frequently if necessary, adjusting the volume at each feeding accordingly.
• Add the total volume of feeds and fluid given each day. Compare this volume with the required daily volume, and adjust the volume that the baby receives accordingly.
• Discontinue the infusion of IV fluid when the baby is receiving more than two-thirds of the daily fluid volume by mouth and has no abdominal distension or vomiting.
• Encourage the mother to breastfeed exclusively as soon as the baby is receiving 100% of the daily fluid volume by mouth.
Kangaroo Mother Care (KMC)Kangaroo Mother Care (KMC)
Kangaroo mother care (KMC) is care of a baby who is continuously carried in skin-to-skin contact by the mother and exclusively breastfed (ideally). It is the best way to keep a small baby warm and it also helps establish breastfeeding.
Kangaroo In-Hospital AdaptationKMC can be started in the hospital
as soon as the baby’s condition permits (i.e. the baby does not require special treatment, such as oxygen or IV fluid). KMC, however, requires that the mother stay with the baby or spend most of the day at the hospital.
Kangaroo Mother Care (KMC)Kangaroo Mother Care (KMC)
•Ensure that the mother is fully recovered from any childbirth complications before she begins KMC.
•Ensure that the mother has support from her family to stay at the hospital or return when the baby is ready for KMC and to deal with responsibilities at home.
• Explain to the mother that KMC may be the best way for her to care for her baby once the baby’s condition permits:- the baby will be warm;- the baby will feed more easily;- episodes of apnea will be less frequent.
Kangaroo Mother Care (KMC)Kangaroo Mother Care (KMC)
• Take the baby away from the mother only to change napkins (diapers), bathe, and assess for clinical findings.
• Babies can be cared for using KMC until they are about 2.5 kg or 40 weeks post-menstrual age.
Sodium Supplementation Sodium Supplementation
Preterms especially <34 weeks are often hyponatremic due to excessive sodium loss in urine.
Hence monitor serum sodium weekly till post conceptional age of 34 weeks.
If serum sodium <130 mEq/L, extra sodium supplementation given.
o 3% NaCl (1ml = 0.5 mEq), or
o 0.9% NaCl (1ml = 0.15 mEq). Supplement should be orally diluted with feeds to maintain
serum sodium between 135-140 mEq/L.
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Iron Supplementation Iron Supplementation
Although iron stores are low in preterms & term-SFDs, requirements are minimum in first few weeks of life!
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Birth weight 1000 gm Birth weight >1000 gm
Iron @ 3-4 mg/kg/d Iron @ 2-3 mg/kg/d
Start at 4-6 weeks of life when active erythropoiesis starts
Start earlier at 4 weeks of life if baby had frequent phlebotomies
How long to continue How long to continue supplements ? supplements ?
Stop the HMF or Preterm formula when the baby reaches 2 kg or starts accepting full breast feeds, and start calcium-phosphate and vitamin supplements.
If the baby was only on breast milk continue calcium-phosphate till baby reaches corrected age of term (wt. ~3-3.5 kg) check serum calcium, phosphate and alkaline phosphatase before stopping especially in ELBW babies to rule out any osteopenia or prematurity.
Stop multivitamins when the baby reaches 6 months or 4.5 kg. Continue iron for atleast 1 year, and if weaning is not adequate
continue till 2-3 year of age.
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
ImmunonutritionImmunonutrition
Diets that are specifically designed to enhance immune function.
• Glutamine
• L-arginine
• N-acetyl Cysteine
• Glutathione
• MCT & LCT
• n3 fatty acid
• Vitamin A, E, C, Zinc, Selenium Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
ImmunonutritionImmunonutrition
Use of specific nutrients supplements singly or in combination, stimulate the immune response and should result in fewer infections, particularly in LBW infants.
Maximum benefit of immune enhancement has been shown to occur in postoperative adult patients. Whether overall mortality is actually improved still remains to the established.
Present Status : More studies are needed for their use in low birth babies.
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
MCT OilMCT Oil
Indian J Pediatr 2001; 68 (4) : 333-337
Primarily has caprylic & capric fatty acids and is a yellow, odorless, and translucent liquid.
Human milk contains 3-7% of fat as MCT. Cow’s milk has 1% and formula milk has ~10%
Rapidly absorbed into blood stream from lacteals without biliary binding
Exhibit rapid mitochondrial uptake
Rapidly cleared from blood stream
MCT OilMCT Oil
When added to enteral feeds, significantly increases the caloric density without increasing much osmolar load
Does not contain any EFA. Excessive use of MCT i.e. >60% of total fat intake decreases the uptake of EFA.
Growth is not improve.
Expensive, however coconut oil can be used in place
Can be added as 2 kCal/Oz to the milk (has 7.8 kCal/ml)
Present status : Routine use is not recommended.
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Advice on DischargeAdvice on Discharge
Explain the mother that Her milk is best for the baby Breast feeding is especially important for a small baby It may take longer for a small baby to establish breast
feeding It is usually normal if the baby :
Tires easily & suckles weakly at first Suckles for shorter periods of time before resting Falls asleep during feeding Pauses for long periods between suckling
Contd…
Advice on DischargeAdvice on Discharge
Assure the mother that
Breast feeding will become easier once the baby becomes bigger
Ensure that the baby is fed frequently
If the baby weighs 1250 to 2500 gm, feed the baby at least eight times in twenty four hours (I.e. every 3 hours).
If the baby weighs less than 1250 gm, feed the baby at least twelve times in twenty four hours (i.e. every 2 hours).
Contd…
Advice on DischargeAdvice on Discharge
Danger signals (Early detection & referral) :
Lethargy, refusal to feed.
Hypothermia
Tachypnoea, Grunting, Gasping
Seizures, Vacant Stare.
Abdominal distension
Bleeding, icterus over palms / soles.
Contd…
Ref. : Teaching Aids, NNF-India.
SummarySummary
Appropriate & adequate nutrition to Appropriate & adequate nutrition to LBW Babies. LBW Babies.
Early nutrition for long term growth Early nutrition for long term growth and neurodevelopment.and neurodevelopment.
Breast milk provides the gold Breast milk provides the gold standard for feeding. standard for feeding.
Role of non nutritive sucking, KMC Role of non nutritive sucking, KMC and micronutrient supplementation. and micronutrient supplementation.
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