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Neonatal nutrition

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.

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Neonatal nutrition

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  1. Neonatal nutrition Mohammad khassawneh

  2. 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

  3. 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

  4. Guidelines fluid management • 80 cc/kg/day, increase to 100-120cc/kg/d with increase IWL • Increase to 100cc/kg/d 2nd day • add sodium 2-4 mEq/kg/d and K= 2 mEq/kg/d. • Calcium may be added • after 2nd 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

  5. 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

  6. 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

  7. Distribution of energy sources • Glucose 16.3gm = 55 kcal/kg/d…. 50% • Protein 3.1gm =12.5 kcal/kg/d…12% • Fat 4gm = 40 kcal/kg/d…38% • Total 108 kcal/kg/d

  8. 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

  9. others • Minerals • Zinc, copper, molybdenum, chromium, selenium • Calcium, phosphorous, Magnesium • Na, K • Vitamins • Fat soluble • Water soluble

  10. 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

  11. Complication of TPN • Infiltration under skin • Infection • Liver dysfunction • Renal overload

  12. 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)

  13. 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

  14. 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

  15. 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

  16. 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

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

  18. 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

  19. Breast feeding • Ineffective if baby sucks from nipple only • Nipple and areola must be drawn deeply into baby’s mouth • Listen for infant swallowing • DOL#1: intermittent swallows • DOL#2 on: 1 swallow : 1-3 jaw excursions

  20. 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

  21. Milk is what you eat • Mom’s need extra 500kcal/day if breast feeding • Caffeine • Limit to 1-2 cups/day • Babies may become overstimulated, fussy • Spicy and gassy foods reflects

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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

  27. Breast feeding • Foremilk • Hind milk

  28. 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

  29. 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

  30. 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

  31. 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.

  32. 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

  33. 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

  34. 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

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