nutrition

1. Neonatal and Infant Nutrition:
what should we know ???
Dr mohd zuraizi
Paediatrician, hospital tawau

2. WHY ?
Is nutrition such a big deal?
Nutrition Status and Outcomes

3. • What is Normal nutrition for baby and child
• How do we get it ??
– Assessment, it is enough ??
• What if we get too little ???
• What if we get too much ???

4. Introduction
• What does ‘nutrition’ mean to you?

5. Textbook answer
• Nelson’s Textbook of Paediatrics
–achievement of satisfactory
growth and avoidance of
deficiency states.

6. Objectives
• By the end of this morning, you will ( I
hope)…….
– understand the effects of fetal growth
restriction on short- and long-term health
– understand the principles and importance of
nutrition in the neonatal period including
assessment of nutritional status
– be able to make appropriate
recommendations to address feeding
problems and faltering growth

7. ‘Normal’ Nutrition

8. Fetal nutrition
• Parenteral (mostly!)
• Stores are laid late in gestation
• At 28 weeks, a fetus has:
– 20% of term calcium and phosphorus stores
– 20% of term fat stores
– About a quarter of term glycogen stores

9. Adaptation to nutrition after birth
• Gut adaptation is regulated by
– Endocrine factors
– Intraluminal factors
– Breast milk hormones and growth factors
– Bacteria

10. BreastFEEDING is THE best

11. Feeding the term infant
• Breast feeding achieves
– Nutrition
– Immunological and antimicrobial protection
– Passage of breast milk hormones and growth
factors
– Provision of digestive enzymes
– Facilitation of mother-infant bonding

12. Protection of infant from chronic
diseases:
–Insulin dependent diabetes mellitus
• (OR 0.61)
–Inflammatory bowel disease
–Allergic disease
–Childhood lymphoma (OR 0.91)
–Obesity (OR 0.75-0.87)

13. Protection of mother from:
–Pregnancy
–Postpartum hemorrhage
–Bone demineralization
–Ovarian cancer

14. Supplementing breast milk
• Should be unnecessary, but
– Vitamin K levels are low
– Vitamin D levels are low in areas of little
sunlight
– Iron levels are low (but very well absorbed)

15. Breast Feeding Questions
• Why should I breast feed my baby?
I thought formula was the identical alternative.
• How often and for how long will my baby nurse?
• How do I know if the baby is getting enough?
• How many months can I breast feed the baby
and when can I add formula?

16. Monitoring feeding
• Maternal sensation of engorgement and
emptying
• Frequency of feeding
• Wet nappies
• Stools
• Jaundice
• Weight

17. Normal output
Daily stool and urine output guidance
Day 0 1 wet nappy and meconium at least once a day
Day 1 2 wet nappies and meconium at least once a day
Day 2 & 3 3 or 4 wet nappies and changing stools at least once a day
Day 4+ 5 or 6 heavy wet nappies and yellow stools at least once daily
A baby who is passing meconium at 3 or 4 days old may not be getting enough
milk.
A baby who does not have yellow stools by day 5 may not be getting enough
milk.
A baby who is not doing as many wet nappies each day as expected may not be
getting enough milk.

18. Assessment of
Breast Feeding
• Weight pattern - consistent weight gain.
• Voiding - # wet diapers/day, soaked?
• Stooling - generally more stools than
formula.
• Feed-on-demand ~ every 2-3 hours.
• Duration of feedings - generally 10-20
min/side.
• Need for high fat hind milk.
• Activity and vigor of infant.

19. Supporting Breast Feeding
• Ask patients if they plan to breast feed.
• Give prenatal guidance, materials and support
numbers.
• Support hospital initiatives to encourage
breast feeding, such as lactation counselors.
• Ask about breast feeding support available to
mother.
• Become familiar with how to manage common
problems such as mastitis and inverted
nipples.
• Understand issues related to pumping and
helping moms return to work or wean the

20. Growth in Infants
• Rapid body growth and brain
development during the first
year:
– Weight increases 200%
– Body length increases 55%
– Head circumference increases
40%
– Brain weight doubles

21. Major Determinants of
Caloric Needs
• Basal metabolic rate
(BMR)
• Activity level
• Growth (2x BMR during
first year)
• Stress (infection, surgery,
illness)
• Misc. (thermic effect of
food)

22. Feeding Skills Development
• 4-6 mos - experience new tastes.
– Give rice cereal with iron.
• 6-7 mos - sits with minimal
support.
– Add fruits and vegetables.
• 8-9 mos - improved pincer grasp.
– Add protein foods and finger foods.
• 10-12 mos - pulls to stand,
reaches for food.
– Add soft table food, allow to self-

23. Feeding Skills Development
• 12-18 mos - increased independence.
– Stop bottle, practice eating from a spoon.
• 18 mos -2 yrs - growth slows, less interest
in eating.
– Encourage self-feeding with utensils.
• 2-3 yrs - intake varies, exerts control.

24. Nutrition for the preterm or
sick baby

25. CASE SENARIO: Mrs Oak
• 28 year old primigravida
• 5’2, 80kg
• Smokes 5 cigarettes daily
• Concerns about growth from 20 weeks
• Latest ‘dopplers’ show absent EDF
• Proteinuria and hypertension

26. • How will you counsel the family?
• Consider particularly:
– Risks of preterm delivery vs risk of continuing
pregnancy
– Short term risks
– Approach to feeding
– Long term outcome

27. Short term risks of IUGR
• Obstetric
– Intrauterine death
– Intrapartum asphyxia

28. Short term risks of IUGR
• Paediatric
– Hypoglycaemia
– Necrotising enterocolitis
– Increased risk of problems of prematurity
– (hypothermia)
– (polycythaemia)

29. NEC and IUGR
• Case-control study (n=74)
– at 30-36 weeks GA, birth weight <10th centile is a
significant risk factor
– OR 6 (1.3-26)1
• Observational study (n= 69)
– At 30-36 weeks 71% of cases were <10th centile2
• 1
Beeby and Jeffrey. 1991, ADC:67:432-5
• 2
McDonnell and Wilkinson. Sem Neonatol 1997

30. NEC and IUGR: Why?
• Pathogenesis of NEC requires
– enteral feeding
– gut ischaemia
– bacterial infection
• Abnormal gut blood flow recognised in
IUGR
• Ischaemic damage or reperfusion injury?

31. Normal doppler flow in umbilical
artery

32. Absent end diastolic flow

33. Reversed end-diastolic flow

34. Abnormal dopplers and NEC
• In 9 of 14 studies, AREDF led to an
increased risk of NEC
• OR 2.13 (95%CI 1.49 to 3.03)
• Dorling J, Kempley S, Leaf A. Feeding growth restricted
preterm infants with abnormal antenatal Doppler results.
Arch. Dis. Child. Fetal Neonatal Ed. 2005; 90: F359-F363

35. So how to feed?
• Delay start?
• Use non-nutritive feeds?
• Increase slowly?
• Use friendly bacteria?

36. Cochrane review: early vs late
feeding
• 72 babies in 2 studies
• Early feeders had
– Fewer days parenteral nutrition
– Fewer investigations for sepsis
• No difference in
– NEC
– Weight gain

37. Cochrane review: rapid vs slow
increase
• 369 babies in 3 studies
• Rapid: 20 to 35 ml/kg/day
• Slow: 10 to 20 ml/kg/day
• Rapid group:
– reached full enteral feeds and regained
birthweight faster
– No difference in NEC rate or length of stay

38. Cochrane review: minimal enteral
nutrition
• 380 babies in 8 studies
• 12 to 24 ml/kg/day for 5 to 10 days
• MEN group
– Faster to full enteral feeds
– Shorter length of stay
– No difference in NEC

39. Probiotics for preventing NEC
• Systematic review of 1393 VLBW infants treated
with a variety of organisms
• Reduced risk of
– NEC (RR 0·36, 95% CI 0·20–0·65)
– Death (RR 0·47, 0·30–0·73)
• Achieved full feeds faster
• No difference in rates of sepsis
– Deschpande et al, Lancet 2007

40. Preventing NEC: what works?
Strategy Absolute RR NNT
Enteral antibiotics 0.089 11
Judicious fluid administration 0.084 12
Human milk feeds 0.069 15
Enteral IgG and IgA 0.066 15
Enteral Probiotics 0.025 40
Antenatal corticosteroids 0.019 54
Delayed or slow feeding Not effective -
Enteral IgG only Not effective -

41. Feeding small or preterm infants:
Choices
• Human milk
– Mother’s own
– Banked donor milk
– Fortified
• Artificial
– Term formula
– Preterm formula
• Parenteral Nutrition

42. Milk Feeds

43. Human milk advantages
• Protection from NEC
• Improved host defences
• Protection from allergy and eczema
• Faster tolerance of full enteral feeds
• Better developmental and intellectual
outcome

44. Human milk shortcomings if
preterm
• Human milk may not provide enough
– Protein
– Energy
– Sodium
– Calcium, phosphorus and magnesium
– Trace elements (Fe, Cu, Zn)
– Vitamins (B2,B6,Folic acid, C,D,E,K)

45. Breast milk fortifiers
• Improved
– short term growth
– nutrient retention
– bone mineralisation
• Concerns
– trend towards increased NEC

46. Term vs preterm formulas
• Term formulas do not provide for preterm
protein, calcium, sodium and phosphate
requirements, even at high volumes
• Term formula (vs preterm formula) fed infants
– Grow more slowly
– Have lower developmental score and IQ at follow up

47. Feeding preterm infants: aim
“To provide nutrient intakes that permit the
rate of postnatal growth and the
composition of weight gain to approximate
that of a normal fetus of the same
gestational age, without producing
metabolic stress”
American Academy of Pediatrics Committee on Nutrition

48. Evidence Based Nutrition
• RA Ehrenkranz, Seminars in Perinatology 2007 (31): 48-55

49. Post-Discharge Nutrition

50. Post discharge nutrition
• Preterm infants tend to be small at
discharge, and remain small into
adolescence
• Limited evidence for what rate of growth is
optimal

51. The evidence
• Comparison of ‘post-discharge’ formula
with standard term formula
– No consistent difference in growth parameters
or body composition
– Z-score reduces in both groups
– Term formula needs supplementing with
vitamins and iron to achieve targets

52. The evidence
• Comparison of breast milk with term
formula
– Calcium and phosphate deficiency in breast
milk fed infants in first year resolves by age
two
– Little difference in growth (although small
numbers)

53. Catch-up Growth
• Enhanced nutritional intake sufficient to
allow ‘catch-up’ growth improves long term
neurodevelopmental outcome

54. IUGR baby
• Definition ??/
• IUGR vs SGA baby
• Rapid catch up growth…..

55. The long range forecast with
IUGR
• Does the in-utero environment or early
feeding permanently change organ
structure, function and metabolism?

56. Developmental Origins theory
• Geographically, coronary heart disease
correlates with past neonatal mortality
• In epidemiological studies, adult
cardiovascular disease is associated with:
– low birthweight
– rapid early postnatal growth

57. Is rapid catch-up growth bad?
• Postnatal weight gain is associated with BMI and
waist circumference at 19 years
• IUGR infants are at increased risk of the
metabolic syndrome
• Preterm infants fed breast milk rather than
preterm formula
– had lower BP at 13-16yrs
– were less insulin resistant
– had a better LDL:HDL ratio

58. Nutrition Assessment

59. How best to assess growth and
nutrition?
• Weight
– Reflects mass of lean tissue, fat, intra- and extra-
cellular fluid compartments
• Length
– More accurately reflects lean tissue mass
• Head circumference
– Correlates well with overall growth and developmental
achievement

60. Monitoring Growth
• Use updated growth charts
– www.cdc.cov
• Monitor trends in growth not one value
using wt, ht, HC (< 2 yrs), BMI.
• In general, normals fall within 5th-95th
%ile.
• Evaluate changes in %iles.
• Malnutrition results in:
– Decreased weight (acute), then
height,
then head circumference (chronic).

61. GIRLS
Birth to 36 mo

62. BOYS
Birth to 36 mo

63. Laboratory assessment
• TPN requires regular monitoring of acid
base status, liver function, bone profile
and electrolytes
• In enterally fed infants, monitoring
albumin, transferrin, total protein, urea,
alkaline phosphatase and phosphate may
be useful

64. Faltering Growth

65. ‘Failure to Thrive’ @ FTT
• Term first used to describe delayed growth
and development,
– also called maternal deprivation syndrome.
• “A failure of expected growth and well
being”
• Only growth can be objectively measured

66. Crossing centiles?
• 5% of normal infants cross 2 intercentile
spaces from birth to 6 weeks.
• 5% of normal infants cross 2 intercentile
spaces from 6 weeks to 1 year.
• Infants regress to the mean
• Hence development of ‘thrive lines’

67. Causes and correlates
• Organic disease
• Abuse and Neglect
• Deprivation
• Undernutrition

68. Causes and correlates
• Organic disease
– <5%, usually suggestive symptoms and signs
• Abuse and Neglect
– increased risk, but a small proportion
• Deprivation
– may influence referral
• Undernutrition

69. The Energy Balance Equation

70. Undernutrition
• Most are underweight for height
• Fastest decline in weight gain when
energy needs are highest
• Poor appetite
• Delayed progression to solid foods
• Limited range of foods

71. Faltering Growth over time

72. Consequences
• Lasting deficit in growth
• Lasting effects on appetite and feeding
• Low maternal self esteem
• Developmental delay at 1 year
– 7-10 DQ points
• Small (not statistically significant) IQ
difference at 8-9 years

73. Management
• Few trials of intervention
• One RCT found health visitor led
intervention useful
• One non randomised trial found dietary
advice useful
• Management is therefore based on
‘accepted best practice’

74. Screening or Case Finding?
• Up to 50% of children with FTT are never
identified
• Recommendations for frequency of
weighing suggest paying more attention to
fewer weights.

75. Growth Monitoring

76. Primary or Secondary care?
• Common problem, often resolves with
simple interventions
• Ill children or those losing weight need
referral
• Home visitor assessment
– Dietary history
– Simple explanation and advice
• Second port of call should be dietician

77. Strategies

78. The Role of the US
• Investigations (if necessary) should be
completed promptly
• FBC, ferritin, U+Es, TFTs, LFT, MSU
• Chromosome analysis in girls
• CXR and sweat test in young infants or
history of respiratory infections.

79. Pathway of care

80. If not improving?
• Nursery nurse involvement or nursery
placement
• Help with other behavioural problems
• Treat illness in mother
• Social work input
• Almost never need food supplements or
hospital admission

81. Feeding difficulties in ex-prems
• Feeding issues are common, especially in
those born before 28 weeks
• Risk of
– Disordered oral-motor functioning
– Significant gastro-oesophageal reflux
– Oral hypersensitivity
– Neurological impairment affecting feeding

82. The Classic Definition of colic
• “crying lasting 3 or more hours per day, on
more than 3 days a week, for at least 3
weeks and resolving around 3 months”.
– Wassell, Pediatrics 1954

83. The impact on parents
• Resistance to soothing causes anxiety
• Learned helplessness, causing anxiety
and depression
• Stress can cause parental coping crises
• 10% of mothers experience a depressive
disorder postnatally

84. Temperament
• Some reports link excessive crying to later
difficult behaviours
– few studies only
– based on maternal recall
– possible that quality of care in later childhood
is influenced by early patterns of behaviour

85. Colic and difficulties with
feeding
• 19 with colic v 24 without
• Assessment:
– colic symptom checklist
– neonatal oral assessment score
– clinical feeding evaluation

86. Outcomes
• Colic group showed:
– more disorganised feeding behaviours,
– less rhythmic nutritive and non-nutritive
sucking,
– more discomfort during feeds,
– lower responsiveness during feeding
interactions.
• Miller-Loncar, Arch Dis Child 2004; 89 908-12

87. Organic causes of a ‘colicky’
baby
• congenital heart
disease
• CNS abnormalities
• NAI
• fever eg UTIs
• maternal drug
ingestion
• gastro-oesophageal
reflux
• cows milk protein
intolerance
• malabsorption
• gut dysmotility

88. Gut hormones
• Motilin initiates migrating motor complexes
• Vagus stimulation increases number and force
of contractions
• Raised motilin in 2 small studies of infantile colic
• Smokers have higher motilin levels

89. Systematic review of treatment
• Lucassen et al, BMJ, 1998
• 50 complete studies, 27 controlled
reviewed.

90. Treatments for colic
• Results as effect size
– Behavioural: (reducing stimulation) 0.48
– Dicycloverine: 0.46, but serious side effects
– Hydrolysate milks: 0.22
– Herbal tea: 0.32 (single small study)
– Low lactose and soya milks: no effect
– Simethicone: no effect

91. Treatments for colic

92. obesity
• Calorie intake over excessive of body
expenditure
• weight More than 95’ centile population or
BMI more 30

93. Obesity in Childhood
and Adolescents
• >20% of children/adolescents are overweight.
• Increased by 50-100% over last 20-30 years:
– More sedentary lifestyle and behavior
(TV/video games)..
• Obese children and adolescents become
obese adults.
• Recent reports indicate 8-45% of newly
diagnosed pediatric pts with diabetes are
diagnosed with type 2.

94. Obesity:
Health Consequences
• Cardiovascular disease risk
• Type 2 diabetes (epidemic)
• Hypertension
• Orthopedic
• Sleep apnea
• Gall bladder
disease/steatohepatitis
• Psychosocial problems

95. Pediatric Obesity
Etiology and Treatment
• Etiology:
– Genetic predisposition: 80% risk if both
parents obese
– Environment
– Dietary intake
– Physical activity / sedentary activity
–Pathological : hypothyroid,
panhypopituitarism,
pseudohypoparathyroid, syndromic child

96. • Treatment:
– Multidisciplinary and comprehensive
– Formal behavior modification
– Family-based

97. Prevention of CVD
Current Recommendations
• NCEP guidelines apply to children over 2
yrs.
• Diet: <30% fat, <10% sat. fat,
<300 mg cholesterol/day.
• Check fasting lipid profile when there is a
positive family history of early CVD, or
elevated cholesterol (hyperlipidemia) in a
1st degree relative.
• Combine dietary intervention with healthy
lifestyle for maximum benefits.

98. Any Questions?

99. Summary
• Optimal growth for neonates and infants requires
careful thought about nutrition
• Interventions (or lack of them) may have long
term consequences
• There is a limited evidence base to guide current
practice
• Colic is not uncommon
• Feeding difficulties are common

100. HOPE IS NOT A METHOD!
• Who? Is you, screening all your patients
• Why? They’ll do worse if you don’t
• When? The sooner the better
• What? Enteral better, even trophic better
than TPN alone
• Where? PO>NG>NJ > IV