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Infant Nutrition

Infant Nutrition. Jennifer Levy, MD Children’s Hospital of Oakland. Overview. Fetal Energy Expenditure & Sources Neonatal Energy Expenditure & Requirements Proteins Fats Carbohydrates Vitamins Human Milk Formulas Parenteral Nutrition. Fetal Energy.

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Infant Nutrition

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  1. Infant Nutrition Jennifer Levy, MD Children’s Hospital of Oakland

  2. Overview • Fetal Energy Expenditure & Sources • Neonatal Energy Expenditure & Requirements • Proteins • Fats • Carbohydrates • Vitamins • Human Milk • Formulas • Parenteral Nutrition

  3. Fetal Energy • Estimated Fetal Energy Expediture = 35 to 55 kcal/kg/day • Energy Sources 1. Maternal glucose (2/3) 2. Placental lactate (1/4) 3. Maternal amino acids

  4. Neonatal Energy Form of Energy Caloric Expenditure Resting Metabolic Rate* 50 kcal/kg/day Activity 15 kcal/kg/day Cold Stress 10 kcal/kg/day Nutrition Processing 50 kcal/kg/day Total 120 kcal/kg/day

  5. Proteins

  6. Fats • Placental transfer of essential and non-essential fatty acids • Fat stores are formed by lipogenesis from glucose • Most poorly digested macronutrient

  7. Fats Types of Fatty Acids • Stearic, Oleic, and Palmitic are common • Linoleic and Linolenic are the most common • Long-chain polyunsaturated (LCPUFA) • Short and Medium Chain Triglycerides (MCT)

  8. Carbohydrates Lactose • Enhances absorption of calcium and magnesium • Promotes intestinal growth of lactobacilli

  9. Vitamins Water Soluble Vitamins • Vitamin B Complex and Vitamin C • Generally not formed from precursors • Daily intake required • No accumulation (except Vitamin B12) • Cross placenta by active transport

  10. Vitamins Fat-soluble vitamins • Vitamins A, D, E, K • Synthesized from precursors • Daily intake not usually required • Not easily excreted and can accumulate • Placental transfer by simple or facilitated diffusion

  11. Vitamin Deficiencies Vitamin B12 and Folate • Vitamin B12 is synthesized by GI microorganisms and is required for folate metabolism • Risk of B12 deficiency in breast-fed infants of vegetarian mothers who do not ingest dairy or eggs • Risk of folic acid deficiency in infants fed evaporated or goat’s milk • Megaloblastic anemia and hypersegmented neutrophils

  12. Vitamin Deficiencies Vitamin D Deficiency • Vitamin D regulates the concentration of calcium and phosphorus in the bloodstream and bone • Important for bone mineralization and growth • Deficiency results in osteopenia -> rickets • Hypocalcemia -> tetany, seizures

  13. Vitamin Deficiencies Vitamin E Deficiency • Vitamin E has antioxidant properties and is recommended to be taken concurrently with iron administration to protect from iron-induced hemolysis • Manifests with anemia and reticulocytosis

  14. Vitamin Deficiencies Vitamin K • Required for carboxylation of prothrombin into the active form • Newborns are predisposed: - Initial lack of microorganisms that synthesize Vitamin K - Immature newborn liver • Maternal medications • Breast fed infants • Associated with hemorrhagic disease of the newborn

  15. Iron Deficiency • Microcytic anemia • Associated with short term and long term neurodevelopmental deficits • Preterm infants more susceptible due to small iron stores at birth, high growth velocity, and phlebotomy loss

  16. Human Milk Physiology • Prolactin is secreted by maternal anterior pituitary throughout pregnancy • At delivery, the decrease in estrogen and progesterone leads to increased milk production and delivery • Milk ejection is mediated by oxytocin from the posterior pituitary

  17. Human Milk Immunologic and Antibacterial Factors • Secretory IgA • Protective and bactericidal enzymes • Lactobacilli growth is increased • Colostrum has increased lymphocytes, macrophages, and immunoglobulins

  18. Human Milk Electrolytes • Decreased Na, K, Ca, Ph, Cl, and Mg Protein • As breast milk matures, protein decreases • Amino acids are lower Fats • 50% calories • Triglycerides are variable

  19. Human Milk Premature Milk • Increased protein • Increased electrolytes • Inadequate protein, calcium, phosphorus, and vitamin D for premies • Need to supplement with human milk fortifier (2 packets/ 50ml = 24kcal/30mL)

  20. Human Milk Benefits • Decreased IDDM, IBD, NEC, obesity • Decreased infections • Improved neurodevelopmental outcome Contraindications (in US) • Infection • Galactosemia • Drugs

  21. Nutritional Supplements PretermFull term BM P. Form BM Formula IRON 2w-2mos Fe Fortified 6mos Fe Fortified (2-4 mg/kg/day) Vitamins HMF (ICN) None Vit D None (200IU/day) Fluoride ----------after 6 months--------------- (0.25-0.5 mg/day)

  22. Formulas Classification by Carbohydrate Source

  23. Premature Formulas Similac Special Care and Enfamil Premature Lipil • 24kcal/30 mL or 20kcal/30mL • Reduced lactose (50%) and glucose polymers • 50% MCT, ARA and DHA added • Higher protein content • Higher calcium and phosphorus content • Increased caloric density • Use in infants less than 1800g or 32 weeks GA

  24. Premature Discharge Formulas Neosure or Enfacare Lipil • 22 kcal/30mL • Increased protein • Increased calcium and phosphorus content • Increased caloric content • Give until 9 months PCA

  25. TPN • Recommend 80-90 kcal/kg/day • Most calories are provided by lipids and glucose • Glucose infusion rate: 6-8mg/kg/min GIR: 0.167 x concentration x rate weight

  26. TPN Carbohydrates • Mostly glucose • 1g CHO provides 3.4 kcal • With increasing glucose concentration, increasing osmolarity • Should provide 55-65% of total kilocalories • Maximum concentration is 12.5% peripherally

  27. TPN Fats • 1 g fat provides 9 kcal (20% solution provides 2 kcal/1 ml) • Should provide 30-50% of total calories • Limit to 3g/kg/day • Monitor serum TG levels

  28. TPN Proteins • Goal is to prevent negative energy and nitrogen balance • Required early in life to achieve goals • 1g of protein provides 4 kcal • Should provide 7-10% of total calories Calcium and Phosphorus • Ratio should be 1.3:1 to 1.7:1 • Risk of bone demineralization • Cysteine prevents precipitation

  29. Sample TPN for Just Born LBW InfantsAdapted from Nutrition and Gastroenterology Clinical Review Committee, 2002

  30. Monitoring Parenteral Nutrition Daily • Weight • Urine for glycosuria • Intake and Output • Serum electrolytes (initially) • Serum glucose (advanced dextrose) • Serum triglycerides (advancing lipids)

  31. Monitoring Parenteral Nutrition Weekly • Serum glucose, electrolytes, Ca, Phos, and Mg • Serum albumin and total proteins • Liver function tests, bilirubin (T & D) • Serum triglycerides • Complete blood count

  32. TPN Supplements for Premature Infants • Insulin infusions • Vitamin A • Cysteine hydrochloride • Carnitine • Glutamine

  33. TPN Complications • Cholestasis • Metabolic Acidosis • Hyperglycemia • Metabolic Bone Disease • Nosocomial Infections • Complications of fat

  34. Early Feeding for Preterm and Sick Infants • Begin at day 2-3 if stable • Human milk 12-24 mL/kg/day • Reduced hospital stay • Reduced sepsis and sepsis evaluations • Reduced days to full feedings • Increased calcium and phosphorus absorption • No increased incidence of NEC • Fewer infants with central venous catheters

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