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Nutrition Support in the NICU

Nutrition Support in the NICU. Sarah Swaintek Dietetic Intern Sodexo Mid- Atlantic February 4, 2013. Objectives. To understand the components of TPN/EN neonatal nutrition support. To assess nutrition support tolerance in a neonatal setting.

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Nutrition Support in the NICU

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  1. Nutrition Support in the NICU Sarah Swaintek Dietetic Intern SodexoMid-Atlantic February 4, 2013

  2. Objectives • To understand the components of TPN/EN neonatal nutrition support. • To assess nutrition support tolerance in a neonatal setting. • To identify similarities and differences between nutrition support in neonatal vs adult acute care setting.

  3. Maternal History • 34 yo Female • G1P000  G1P1 • Maternal hx of hyperthyroidism (no treatment) • Presented w/ • Preterm Premature rupture of membranes (PPROM) and contractions, Rubella immune, RPR non reactive, Hepatitis B negative, GBS status unknown

  4. Delivery History • NICU called to Labor and Delivery: • NSVD at 31 weeks and 2 days • Via assistance of vacuum • Placental infarction during delivery • Baby @ 20 seconds of life: • Cyanotic, no cry at birth, no respiratory effort • Suctioned, stimulated  grunting and retracting • APGAR • At minute 1 = 3 • At minutes 5 = 7 • Welcome to the world BBR! • Baby transferred to NICU

  5. NICU Admit Date: 12/29/2012 • BBR is an ex 31 and 2/7 male admitted to NICU w/ • Prematurity • Respiratory Distress • R/O Sepsis • LBW

  6. Complications Associated with Prematurity • Intrauterine growth rate • 3rd Trimester: • Ca, Phos, PRO, fat needs • Deposition of Stores • Gut immaturity • Lung immaturity • Need for Nutrition Support!

  7. Anthropometrics • BW: 1875gm (LBW) • Length: 43.5cm (17.1 inches) • Observations: • Appearance: Cachetic, No dysmorphic features, Palate intact • Lungs: Increased WOB • CV: No murmur • Abd: Soft, nondistended • Ext: Moves all 4 extremities equally • Skin: Translucent

  8. Growth Chart

  9. Plan of Action (12.29.12)

  10. Plan of Action (continued) • Bubble CPAP • ABG, Chest and Abdominal X-ray • Labs: • Total bilirubin, BMP, Mg, Phos, CBC, Blood Culture, CRP (in 12 hours) • Medications: • Antibiotics: • Start Ampicillin and Gentamicin via PIV

  11. Nutrition Assessment (12.31.12) • BBR is an ex 31(2) week male; now 31(4) weeks. • DOL#2 • BW: 1875gm (50th-90th%) • AGA as plotted on growth chart. • CBW: 1835gm • Intrauterine Growth Rate: 25.7gm/d • Length: 43.5cm (50th-90th%) • Meds: ampicillin, gentamicin • Nutrition-focused Physical Findings: • Isolette • PIV • SMIV • OG tube in place • Phototherapy x1 • No stool since admit

  12. Estimated Needs • Current Intake: • PN (via peripheral line): D10P3IL2 • No lytes • MVI and TME included • EN: trophic feeds • Breastmilk/Premie Good Start (PGS) 24 at 2mL q3hrs • Residuals: 0.5mL (x3) • Estimated Needs/Nutrition Rx: 90-110kcal/kg, 4-4.5gm/kg PRO

  13. Labs (12.31.12)

  14. Hyperbilirubinemia • One of the most common problems encountered in newborns. • Characterized by yellow-pigmented skin and increased bilirubin concentrations in the blood. • Phototherapy • The process of using fluorescent light to aid in the breakdown of bilirubin into a form the body can more quickly eliminate. • Transforms bilirubin into water-soluble isomers that can be eliminated without conjugation in the liver. • To be considered: • Maximizing skin exposure • Eye protection and care • Thermoregulation • Nutrition Implications: • Increased fluid loss • Jaundice babies typically don’t feed well • Hypocalcemia

  15. Phototherapy

  16. Nutrition Diagnosis • Inadequate energy intake related to prematurity and recent delivery AEB infant currently meeting <70% of estimated kcal and protein needs.

  17. Nutrition Interventions • Nutrient Delivery – • Continue TPN, titrate to meet estimated needs • Trophic feeds with Breastmilk as feasible • Coordination of Care – • Maternal lactation support and education • GOAL: Regain BW by DOL #7

  18. Monitoring & Evaluation

  19. Nutrition Risk • Moderate • RD to f/u in 6-8 days

  20. Nutrition Follow-Up (01.03.13) • BBR is now an ex 31(2) week male; now 32 weeks. • DOL#5 • BW: 1875gm (50th-90th%) • CBW: 1780gm • Intrauterine Growth Rate: 27.1gm/d • Length: 43.5cm (50th-90th%) • Meds: ampicillin, gentamicin, caffeine, s/p glycerin • Biochemical: • Tbili-11.1, Dbili-2.9 • Nutrition-focused Physical Findings: • Isolette • CPAP • OG tube in place • PIV • Pacifier • Phototherapy x2 • Stool x1

  21. Labs (01.03.13)

  22. Estimated Needs • Current Intake: • PN (via peripheral line): D10P4.5IL2.5 • EN: Breastmilk • 6mL q3hr via OG (advancing by 1mL q6hr) • Residuals: 0.5-3mL (x6) • Estimated Needs: 90-110kcal/kg (TPN), 4-4.5gm/kg PRO

  23. Nutrition Diagnosis • Inadequate oral intake related to prematurity AEB dependence on parenteral and enteral nutrition support

  24. Nutrition Interventions • Nutrient Delivery – • Continue parenteral nutrition until enteral nutrition reaches 75% of goal volume/calories • Taper PPN as EN increases (decrease protein to 4gm/kg) • Hold Trace Mineral elements until direct bili is <2 • Add back Zinc • Coordination of Care – • Maternal lactation support and education • D/w team on Rounds today • GOAL: Regain BW by DOL #7

  25. Monitoring & Evaluation

  26. Nutrition Risk • High • RD to f/u in 3-5 days

  27. Nutrition Reassessment (01.08.13) • BBR is an ex 31(2) week male; now 32(5) weeks; DOL#10 • CBW: 1910gm (35gm increase) • Intrauterine Growth Rate: 27.1gm/d • Length: 43.5cm (50-90th %) • Meds: None currently • Biochemical Data: • Tbili-10.4 (direct 0.6) • Nutrition-focused Physical Findings: • Isolette • CPAP • OG tube in place • Pacifier • Stool x7

  28. Nutrition Support Summary

  29. Nutrition Reassessment (cont) • Nutrition Rx: 120-130kcal/kg, 3.5-4gm/kg PRO • Nutrition Diagnosis: • Inadequate oral intake related to prematurity AEB dependence on EN nutrition support (on-going dx, new s/s) • Inadequate kcal and protein intake related to marginal TF tolerance AEB high residual volumes and inability to reach goal feed volumes (new dx) • Nutrition Interventions: • Nutrient Delivery: • Continue EN feeds, advance as tolerated • Fortify breastmilk to 22kcal/oz w/ HMF to help meet needs • Coordination of Care: • Maternal lactation support and education • d/w team • Nutrition Goals: • Regain BW by DOL#7 (goal met) • Infant to tolerate current feed volume and continue to advance w/ residuals <20% of feed volume, 16-20gm/d wt gain; over 7 days (new goal)

  30. Nutrition Follow-Up (01.10.13) • Ex 31(2) week male; now 33 weeks; DOL#12 • CBW: 2045gm • Average Daily Weight Gain: 37.8gm/d • Intrauterine Growth Rate: 30gm/d • Length: 45cm (50th-90th%) • Head Circumference: 29cm • Meds: IV antibiotics (ampicillin,vancomycin), nystatin, caffeine • Biochemical Data: • Alk Phos-587 • Nutrition-focused Physical Findings: • Isolette • CPAP • PIV • OG tube in place • Pacifier • Stool x7

  31. Nutrition Support Summary

  32. Nutrition Follow-Up (cont) • Nutrition Rx: 120-130kcal/kg, 3.5-4gm/kg PRO • Nutrition Diagnosis: • Inadequate oral intake related to prematurity AEB dependence on EN support (ongoing dx) • Increased nutrient needs related to prematurity AEB elevated Alk Phos and need for breastmilk fortification (for adequate kcal/Ca/Phos) (new dx) • Nutrition Interventions: • Nutrient Delivery: • Continue EN feeds, advance as tolerated • Fortify breastmilk to 24 kcal/oz with HMF to help meet needs • Coordination of Care • d/w team today in Rounds • Nutrition Goals: • Infant to tolerate current feed volume and continue to advance w/ residuals <20% of feed volume, 16-20gm/d wt gain; over 7 days (new goal)

  33. Nutrition Follow-Up (01.17.13) • Ex 31(2) week male; now 34 weeks; DOL#19 • CBW: 2275gm (10th-50th%) • Average Daily Weight Gain: 32.8gm/d (1/10-1/17), • comparative 31.4gm (1/09-1/16) given 90gm weight gain overnight • Intrauterine Growth Rate: 31.4gm/d • Length: 48cm (90th-97th%) • Head Circumference: 30.5cm (10th-50th%) • Meds: caffeine, Lasix (last dose 1/16) • Biochemical Data: • Alk Phos-458 (trending down), Ca-9.6, Phos-7.4 • Nutrition-focused Physical Findings: • Isolette(open-crib trial today) • CPAP • PIV (d/c 01/17) • OG tube in place • Stool x2

  34. Nutrition Support Summary

  35. Growth Chart

  36. Nutrition Follow-Up (continued) • Nutrition Rx: • Estimated Needs: 120-130kcal/kg, 3.5-4gm/kg PRO • Nutrition Diagnosis: • Inadequate kcal and protein intake related to current EN rate AEB total kcal intake not meeting estimated needs. • Inadequate oral intake related to prematurity AEB dependence on parenteral and enteral nutrition support (revised) • Increased nutrient needs related to prematurity AEB elevated Alk Phos and need for breastmilk fortification (for adequate kcal/Ca/Phos) (ongoing dx). • Nutrition Intervention: • Nutrient Delivery – continue EN feed, advance as tolerated, increase volume of EN feeds to 44mL q 3 hr • Nutrient Delivery – continue breastmilk fortification to 24kcal/oz with HMF to help meet kcal needs. • Coordination of Care – maternal lactation support and education, consider non-nutritive breastfeeding practices as medically feasible. • Coordination of Care – d/w team today in Rounds • GOAL: • Infant to tolerate current feed volume and continue to advance with residuals <20% feed volume • 16-20gm/day weight gain (over 7 days)

  37. So What?!?! • Challenges in NICU setting • Volume tolerance • Ca/Phos needs • Mimicking the intrauterine growth • Nutrition Support in NICU setting • Access site • Hyperglycemia • TPN induced cholestasis • Increased Ca/Phos needs • Overlap in modalities • Similarities and Differences from Adult Care • Initiation of Nutrition Support • Tolerance/Residuals • Speed of happenings • Less evidence-based research on practice guidelines • Shortages advantage

  38. References: Academy of Nutrition and Dietetics. Nutrition Care Manual, accessed January 9, 2013. Ben, XM. Nutritional management of newborn infants: Practical guidelines. World Journal of Gastroenterology, 2008: 14(40): 6133-6139. EIHassan,NO, Kasier, JR. Parenteral Nutrition in the Neonatal Intensive Care Unit. NeoReviews, 2011: v 12: 130-140. George Washington University Hospital. Inpatient Nutrition Practice Guidelines: NICU, 2011. Groh-Wargo, et al, Eds. Nutritional Care for High Risk Newborns, Revised 3rd Edition. Precept Press, Chicago, Illinois, 2000. Groh-Wargo S, Sapford, A. Enteral Nutrition Support of the Preterm Infant in the Neonatal Intensive Care Unit. Nutrition in Clinical Practice. June/July 2009: 363-376. Hay, WW. Strategies for Feeding the Preterm Infant. Neonatology, 2008: 94(4): 245-254. Marconi, AM, Ronzoni, S, Vailati, S, Bozzetti, P, Morabito, A, and Battaglia, F. Neonatal Morbidity and Mortality in Intrauterine Growth Restricted (IUGR) Pregnancies Is Predictaed Upon Prenatal Diagnosis of Clinical Severity, 2009: 16: 373. Thureen, P, Heird, WC. Protein and Energy Requirements of the Preterm/Low Birthweigh (LBW) Infant. Pediatric Research, 2005: v 57: 95R-98R. Tsang, RC, Lucas, A, Uauy, R, Zlotkin, S. Nutritional Needs of the Preterm Infant: Scientific Basis and Practical Guidelines, 1993: 135-149, 217-220. Yadav, RK, Sethi, RS, Sethi, AS, Kumar, L, Chaurasia OS. The Evaluation of Effect of Phototherapy on Serum Calcium Level. People’s Journal of Scientific Research, 2012: v 5(2). Szeszycki, E, Cruse, W, Strup, M. Evaluation and Monitoring of Pediatric Patients Receiving Specialized Nutrition Support. A.S.P.E.N 2010, accessed January 20, 2013. www.nutritioncare.org.

  39. Questions?

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