Neonatal nutrition

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. 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)

4. 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

5. 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

6. 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 : casein 60:40

7. Breast feeding Term 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 and immunoglobuline

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

9. 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

10. 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

11. Maternal factor causing low milk Gestational diabetes Hypothyroid Retained placental fragments Dehydration, hemorrhage, hypertension, infection Previous breast surgery Psychosocial Previous unsatisfactory experience Lack of partner support Post-partum depression Separation from infant

12. 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

13. 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

14. 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

15. 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 turgor, moist mucous membranes Contentment 1.5-2 hours after feeds

16. Enough milk Breasts feel full before and softer after feeds Milk leaks from contra-lateral breast during suckling Sensation of milk ejection ? pins and needles Absent nipple trauma and pain Profound state of relaxation in mom during suckling

17. 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

18. Breast feeding Foremilk Less fat and less calories Hind milk More fat and calories

19. 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

20. 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

21. 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

22. 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.

23. Indication for Parenteral intake Respiratory distress Severely ill patient Abdominal pathology Prematurity advancement of feeding

24. Guidelines fluid management 80 cc/kg/day, increase to 100-120cc/kg/d with increase insencible water loss (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

25. 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

26. 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

27. 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

28. 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

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

30. 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

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

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