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Nutrition Management of the Premature Infant

Nutrition Management of the Premature Infant. Melissa Nash, MPH, RD Washington County Field Team melissa_nash@co.washington.or.us. Objectives. Describe appropriate growth in premature infants, including growth charts.

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Nutrition Management of the Premature Infant

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  1. Nutrition Management of the Premature Infant Melissa Nash, MPH, RD Washington County Field Team melissa_nash@co.washington.or.us

  2. Objectives • Describe appropriate growth in premature infants, including growth charts. • Describe current practices for feeding and supplementation for premature infants. • Understand how to better support the breastfeeding premature infant. • Recognize potential feeding problems and solutions in premature infants.

  3. Newborn Classifications LBW: Low Birth Weight • <2500g (5 1/2 lbs) VLBW: Very Low Birth Weight • <1500g (3 1/3 lbs) ELBW: Extremely Low Birth Weight • <1000g (2 1/4 lbs) Preterm: <37 weeks GA Late Preterm: 34 0/7 – 36 6/7 weeks GA

  4. Typical Feeding Progression Gestational Age (Weeks) 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 Pacifier Sucking (non-nutritive suck) Gag Reflex Rooting Reflex Early Intermediate Mature Coordinate Suck, Nutritive Suck Swallow, Breathe TPN for 1-2 weeks as enteralGradually start breast/Infant nippling feeds advance via tubebottle per infant cuesall feeds

  5. Post-Discharge Premature Infant Nutritional Issues Switch from ‘super-milks’ to standard milk Slower growth in follow-up Neonatal period critical for ‘programming’ of development and health Limited information/research on post- discharge nutrition

  6. The Underlying Question… “Do you want a smart, tall, fat adult who will die prematurely of cardiovascular disease or a dumb, short, thin adult who will outlive the other?” Richard Schandler, MD Neonatalogist

  7. Developmental Origins of Health & Disease “Fetal Programming” • Under-nutrition during pg & LBW are strongly associated with HTN, obesity, insulin resistance and dyslipidemia later in life • Combination of poor growth & rapid catch-up weight may increase risk • Additional research is needed to determine when catch-up growth is “excess growth”

  8. What does the research say? Weight Gain & Growth • Feeding a post-discharge formula (PDF) for 9-12 months following discharge results in improved wt, lt, & HC • Greatest results in infants <1250-1500g • Greater results in males vs. females • Long-term developmental advantages inconclusive

  9. What does the research say? Bone Mineral Content (BMC) • BMC higher in premies receiving a PDF for 9 months post-discharge • Highest Ca formulas = greatest BMC Chan, J Pediatr 1993;123:439-43 Bishop, Arch Dis Child;1993:573-8 Carver, Pediatr 2001;107:683-689 Cooke, Pediatr Res 2001;49:717-722 Morley, Am J Clin 2001;71:822-8

  10. Growth Charts Recommended growth charts: • 2013 Fenton growth charts from birth to ~50 wks • WHO growth charts from term to 24 months • CDC growth charts from 24 months to 18 yrs old

  11. Fenton Growth Gridshttp://ucalgary.ca/fenton/2013chart

  12. Why should we use the updated Fenton charts? Boys chart Solid lines = 2013 Dashed lines = 2003

  13. Start with correct growth parameters Growth Assessment

  14. Corrected Age Use corrected age for all premature infants <37 weeks until 24 months when assessing: • Growth • Nutritional needs • Feeding (solids, cow’s milk) • Developmental milestones

  15. First Choice Formulas for Premies: Post-Discharge Formula • Post-Discharge (transitional) formulas • Enfamil Enfacare* • Similac Neosure* • Good Start Nourish* *WIC provides with an Rx • Provide add’l vits & nutrients: Ca, Phos & Pro • Whey-dominate, less lactose, 20% MCT oil • Provide add’l calories: 22 vs. 20 kcal/oz • May be mixed to 24 or 27 kcal/oz • May be used to fortify EMM to 22, 24, 27 kcal/oz

  16. Second Choice Formulas for Premies: Term Formulas • Standard Term Formulas • Enfamil Premium • Good Start Gentle; Good Start Protect • Similac Advance (WIC) • Reduced/No Lactose and/or Partially Hydrolyzed • Enfamil Gentlease • Good Start Sooth, GS Gentle, GS Protect • Similac Sensitive, Similac Total Comfort (19 kcal/oz) Uses: GI upset, constipation, lactose sensitivity Provides 20 kcal/oz Can fortify EMM or be prepared to 22, 24, 27 kcal/oz

  17. Contraindicated Formulas for Premies: Soy Formula AAP does not recommend soy formula for preterm infants born <1800g • Lower serum albumin levels • High amts of phytates • Lower levels of markers for bone formation • Risks for aluminum toxicity • Concerns w/ disruption of thyroid fct, suppression of testosterone, & phytoestrogen-like effect Examples: Isomil & Prosobee (WIC) Bhatia, Pediatrics 2008;121:1062

  18. Contraindicated Formulas for Premies: Thickened Formulas These “reflux” formulas contain rice starch with thicken upon entering the stomach. Contraindicated for premature infants <38 weeks GA due to risk of the formation of lactobezoars (hard clumps of undigested milk curds) Examples: Enfamil AR* & Similac for Spit-Up* *Available thru WIC w/ Rx

  19. EMM & Formula Comparison

  20. Breastfeeding the Premature Infant “The potent benefits of human milk are such that all preterm infants should receive human milk.” “Human milk should be fortified, with protein, minerals, and vitamins to ensure optimal nutrient intake for infants weighing <1500 g at birth.” Policy Statement: Breastfeeding and the Use of Human Milk, Pediatrics 2012; 129:e827 In general, the smaller infant, the higher the nutritional needs & the longer they may need fortification.

  21. Breastfeeding the Preterm Infant There are several significant short & long-term benefits to feeding a preterm infant human milk: • ↓ rates of sepsis & NEC • Fewer hospital readmissions • ↑ intelligence thru adolescents • ELBW infants fed ↑ of human milk show significantly ↑ scores for mental, motor, & behavior ratings at ages 18 months and 30 months • Even after adjusting for cofounders • Outcomes assoc. w/ predominant human milk, not exclusive • Lower rates of metabolic syndrome Policy Statement: Breastfeeding and the Use of Human Milk, Pediatrics 2012;129:e827

  22. Goals for Breastfeeding the Premature Infant • Promote adequate wt gain, including catch-up • Ensure good nutritional status • Maintain & increase breast milk supply • Sustain or improve feedings at the breast • Limit bottle & formula feedings

  23. Guidelines for Initiating & Maintaining Milk Supply First 2-3 weeks • Use hand expression & compression w/ pumping • http://newborns.stanford.edu/Breastfeeding/MaxProduction.html • http://newborns.stanford.edu/Breastfeeding/HandExpression.html • Pump w/ double electric pump • Empty breasts at every pumping • Pump q 2-3 hrs/day & 1x/night (not to exceed 4 hrs) • Pump 7-10x/24 hours while establishing supply After first 2-3 weeks (if adequate milk supply) • Pump q 4hr/day & 1x/night (not to exceed 5 hrs) • Pump 6-8x/24 hours

  24. Ideas for Increasing Milk Supply • Increase skin-to-skin contact • Ensure adequate fluid intake • Ensure optimal pump and/or flange • Increase frequency of pumping, up to 10x/d • Use breast massage/compression while pumping • Discuss ways to decrease tension • Try power or cluster pumping • Discuss use of galactagogues/meds w/ LC

  25. Breastfeeding the Premature Infant The ability to BF is multi-factorial, depends on: • MOB’s milk supply & willingness to pump • Birth weight & gestational age • Complexity of NICU course • Infant maturity

  26. Breastfeeding the Premature Infant Typical plan of BF premature infant at discharge: • BF 2x/d (with time limit) • Offer bottle of fortified EMM q feeding • Give MVI w/ iron daily • MOB pumps q feeding

  27. Breastfeeding the Premature Infant Progression of BF plan: • Add one additional BF q week • Consider nipple shield • Cont. to offer fortified bottles q feeding & after BF • Give 1 ml MVI w/ iron daily • MOB to continue to pump at q feeding & after BF until at least 40-44 weeks GA • Support, support, support!!!

  28. Breastfeeding the Premature Infant Evaluation of readiness to reduce fortification: • Ability to sustain growth • Ability to sustain appropriate ad lib milk intake • Lab values are WNL (ck’d one mo post-discharge) Methods to decrease fortification: • Decrease by 2 bottles q 4-6 days or • Drop fort bottles at night * Check weight WEEKLY during transition

  29. Vitamin/Mineral Supplementation *Poly vitamin = A, C, D, E, B vitamins + iron? *Tri vitamin = A, C, D + iron?

  30. Osteopenia of Prematurity Condition of decreased bone density in premature, LBW infants. Characterized by low Ca, low P, and high ALP Risk for bone fractures & growth stunting

  31. Osteopenia of Prematurity Risk factors: • VLBW infants (<1500 g) • Any IUGR infant with a BW <1800g • Infants with CLD or BPD • Infants requiring long-term TPN (>4 weeks) • Infants on certain meds that affect mineral absorption • Infants starting feeds of unfortified breastmilk or standard/soy formula

  32. Osteopenia of Prematurity Indications for reassessment of bone labs: • 1 mo post discharge for infants w/ BW <1500g • 1 mo post discharge if any labs at discharge were abnormal • An infant <3 mo CA who is transitioning to breast or term formula • Infant with marginal intake & slow growth

  33. Osteopenia of Prematurity Some very small premature infants gain weight well while taking only breastmilk, despite having abnormal bone labs. Tribasic: • Ca/P supplement • Standard dose is 1/8 tsp BID, up to TID • Bone labs should be monitored q 4-6 wks while on Tribasic • Infant continues w/ Tribasic for 2-3 mo while EBF

  34. Late Preterm Infant Infants born between 34 0/7 – 36 6/7 weeks GA Birth weights ~ 2000-3000g (4 ½ -6 ½ lbs) No current recommendations for additional nutrient requirements, besides a multivitamin. At risk of inadequate nutrient intake due to: • Immature gastrointestinal function • Immature neural function • Lower stamina • Lower oral-motor tone

  35. Late Preterm Infants Breastfeeding: • Many discharged home before MOB’s milk supply established • Late preterms may not be able to provide enough stimulation to bring in adequate supply • MOB will usually have to pump after BF for several weeks to ensure adequate supply • Infants can EBF, BF + bottle of EMM, BF + bottle of fortified EMM to 22-24 kcal/oz • Offer MVI until 12 mo CA

  36. Late Preterm Infants Formula Feeding: • Offer TERM infant formula • Offer MVI until volume reaches 32 oz/d • May start/increase to 22-24 kcal/oz if infant unable to consume enough volume to provide adequate growth. Usually need inc. calories for first month.

  37. Feeding Progression/Solids Feeding recommendations for premature infants should be based on corrected age: • Breastmilk/formula until at least 12 mo CA • Solids may be introduced between 4-6 mo CA (based on developmental stage & feeding skill) • Withhold cow’s milk until 12 mo CA

  38. Common Concerns in the Premature Infant • Constipation • Spit-up &/or GERD • Inadequate weight gain • Rapid weight gain

  39. Constipationin the Premature Infant Stools that are dry, hard & difficult to pass, independent of frequency Causes/Assessment: • Immature GI tract • Medications • Inadequate fluid intake • Calorie-dense formulas • Improper formula preparation • Transitioning from breastmilk to formula • Early intro to cereals in bottle • Neurological delays

  40. Constipation – Feeding Plan • Maximize breastmilk • Warm bath, infant massage, bicycle movements • Iron: • Iron supplements may cause constipation • Check hematocrit -if formula is meeting iron needs & hct is WNL: Switch to MVI w/o iron • Juice (if infant is >40 weeks): • Mix ½ oz prune, pear or apple juice with ½ oz water • Start 1 oz diluted jc qod, inc to 1 oz diluted jc qd prn • Max 1 oz full-strength jc qd

  41. Constipation – Feeding Plan • If taking PDF mixed >24 kcal/oz: • Decrease from 27 kcal/oz to 24 kcal/oz to 22 kcal/oz • If infant BW >1500-1800g & if gaining weight well, consuming good vol, and nutritional needs met: • D/C fortifier & offer 100% breastmilk • Change to routine term formula • Always check wt gain/intake wkly after making change • If infant BW <1500g & <3 mo CA: • Talk w/ RD who has experience with premature infants • Always check bone labs before making a formula change • If constipation continues, talk to MD re: stool softeners

  42. Spit-up and/or GERD in the Premature Infant Assessment: • Assess weight gain • Assess nipple flow • Assess feeding behaviors and positioning • Back arching? • Volume in bottle slowly increasing or decreasing? • Volume of spit-up • Parental concerns

  43. Spit-up and/or GERDin the Premature Infant Feeding Plan: • Parental reassurance if growth ok • Smaller, more frequent feeds • Keep upright for 20 min after a feeding • Educate on proper positioning • No solids in bottle • Limited use of added starch formula & only if > 40 wks CA • Reflux meds needed? Poets, Pediatr 2004;112:212-217 Carroll, Arch Pediatr Adolesc Med 2002;156:109-11 Lightdale, Pediatr 2013; 131:1684-95

  44. Inadequate Weight Gain in the Premature Infant Assessment: • Infrequent bottle feeding (> Q 3-4 hr) • Improper mixing formula/fortifying EMM • Lower kcal/oz formula • Easily exhausted or not interested in breast, bottle • Slow nipple flow on bottle, tight suction on cap • Minimal BF skills • Constipation affecting volume consumed • GERD affecting volume consumed • Neurological delays & limited coordination • Recent illness

  45. Inadequate Weight Gainin the Premature Infant Feeding Plan: • Observe feeding, trial of nipples • If trying to transition to breast, make sure baby is offered bottle after BF, put time-limit on BF • Switch to 24-27 kcal/oz • Calculate catch-up needs • Give parents a goal intake volume • Parents to keep diary for 2 weeks • Weekly weight checks • Discuss plan w/ MD

  46. Rapid Weight Gain in the Premature Infant Assessment: • Improperly mixing formula • Improperly fortifying EMM • Large volumes consumed • Feeding schedule vs. hunger cues • Cereals in bottle • After successful BF reached, cont. to offer bottle after BF

  47. Rapid Weight Gain in the Premature Infant Feeding Plan: • Discuss feeding cues & volumes w/ family • Switch kcal level down • 27-24-22 kcal/oz • If >1500g-2000g BW & if growth ok: • Switch to term formula • If <1500 BW & if growth ok, ck bone labs: • If WNLs, switch to term formula; re-ck labs in 1 mo • If abnormal, continue w/ PDF & re-ck labs in 1 mo

  48. Coordination of Care • Family • Pediatrician • Nurses: PMD office & PHN • Dietitians: NICU, out-patient, WIC • Lactation consultants • Neurodevelopmental/ Feeding clinic • Get involved!

  49. Nutrition Practice Care Guidelines for Preterm Infants in the Community http://public.health.oregon.gov/HealthyPeopleFamilies/WIC/Pages/index.aspx • Click on “For Medical Providers” • Double click on “Nutrition Practice Care Guidelines…” OR • Click on “For Oregon WIC Staff” on left-side column • Click on “WIC Staff Resources” • Scroll down to “Nutrition Information” header • Double-click on “Nutrition Guidelines: Preterm Infants” & “Oregon Appendix”

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