Nutritional Support of the VLBW InfantDr Varsha Atul Shah
ObjectivesFollowing self-study of the slide presentation and reading of the NutritionalSupport of the Very Low Birth Weight (VLBW) Infant Toolkit, the participantwill have/be able to: Recognize that nutrition during critical periods in early life may permanently affect the structure and/or function of the infant’s organs and tissues; Identify three physiological goals of VLBW infant nutrition management; List suggested best practices for the major aspects of infant nutrition promotion, including parenteral nutrition, establishing enteral nutrition, human milk/breastfeeding, transition to oral feeding and discharge planning; Recognize that new research has only reinforced prior best practices; Demonstrate knowledge and skills necessary to establish and support breastfeeding.
Gold Standard of Growth for VLBW Infants To approximate the in utero growth of a normal fetus of the same post-conceptional age. – Body weight – Body composition AAP Committee on Nutrition: Nutritional needs of low birth weight infants. Pediatrics 1985;75:976 AAP Committee on Nutrition: Nutritional needs of the preterm infant, in Kleinman RE (ed): Pediatric Nutrition Handbook, ed 5, Elk Grove Village, IL, AAP, 2004, p 23-54.
Unique Nutritional Aspects of the VLBW Infant Higher organ:muscle mass ratio Higher rate of protein synthesis and turnover Greater oxygen consumption during growth Higher energy cost due to transepidermal water loss Higher rate of fat deposition Prone to hyperglycemia
Unique Nutritional Aspects of VLBW infants - Brain Growth Brain Growth over 8 weeks: At 28 wks 100% Increase At term 40% Increase At 3 mo 25% Increase
Preventing Feeding-Related Morbidities in VLBW Infants Necrotizing enterocolitis Osteoporosis Vitamin and mineral deficiencies Feeding intolerance Prolonged TPN and related cholestasis Prolonged hospitalization Lack of full physical and intellectual potential
Optimizing Long Term OutcomeNutritional Programming:Nutrition during critical periods in early life may permanently affect the structure and/or function of organs or tissues. Alan Lucas, 1990
Early Diet Influences Long- term Health and DiseaseBreastfeeding leads to reduction in diastolic blood pressure in later years of 3.2 mmHg, a greater impact that seen by other public health measures including: – Weight loss (-2.8 mmHg) – Alcohol reduction (-2.1 mmHg) – Salt restriction (-1.3) – Exercise (-0.2 mmHg)
Early Diet Influences Long- term Health and DiseaseAdverse effects of growth acceleration in humans include: – Obesity – Elevated blood pressure – Insulin resistance and diabetes – IGF-1 concentrations – Cardiovascular mortality
Nutritional Care/Outcomes in VLBW Infants - Potential Improvements Human milk “Early” TPN – Prevent protein deficit – Prevent EFA deficiency GI priming/MEN/Trophic feeds – Prevent GI atrophy effects – Faster realization of full enteral feeds Fortification/Supplementation – Starting earlier – Continuing longer
Benefits of Human Milk - Reduced Infections Otitis media – with a reduction in the frequency and duration of ear infections in breastmilk versus formula fed newborns Respiratory tract illnesses including respiratory synctial virus infection Gastrointestinal illness Urinary tract infections Infant botulism
Benefits of Human Milk - Reductions in Chronic Diseases Obesity Allergies/atopy Type 1 juvenile onset diabetes Crohn’s disease Lymphoma
Benefits of Human Milk for Preterm Infants Host Defense Gastrointestinal Development Special Nutrition Neurodevelopmental Outcome Physically & Psychologically Healthier Mother
Immunoglobulins : 90% IgA and sIgA More IgA in preterm milk Concentration decreases over time IgA found in stool of breastfed infants unchanged: lines intestine to protect Increased urinary excretion of IgA with breastmilk
Incidence of Necrotizing Enterocolitis by Type of Feed Necrotizing EnterocolitisType of feed Incidence Proportion EBM 1.2 % 3/253EBM + PTF 2.5 % 11/437 PTF 7.2 % 17/236
GI Benefits of Human Milk for the Preterm Infant Gastrointestinal development – Reduces intestinal permeability faster – Induces lactase activity – Multiple factors to stimulate growth, motility and maturation of the intestine – Human milk empties from the stomach faster than artificial milks – Less residuals and faster realization of full enteral feedings
Time Needed to Attain Full Enteral Feeds in 95% of VLBW InfantsType of feed Number of daysExpressed breastmilk 20Standard formula 45Preterm formula 48 Lucas & Cole. Lancet 1990;336:1519
Benefits of Human Milk for the VLBW Infant Special nutritional needs – Different quantity and quality of proteins – Fats: Cholesterol, DHA, ARA – Carbohydrates designed for human infants – Lower osmolality/renal solute load – Other factors: e.g. erythropoietin, EGF
Human Milk and Retinopathy of Prematurity in VLBW Infants 145 VLBW (<1500gm) Jan 1992-Feb 1993 Incidence of ROP – Human Milk 37.3% p<0.005 – Formula 63.8% Incidence of ROP at discharge – Human Milk 22.3% p<0.0007 – Formula 53.4% Multiple Regression Analysis: – feeding correlated with ROP incidence and severity – dose response relationship – even small vol. (<20%) of human milk protective Hylander et al. J Perinatol 2001; 21:356-362
Poor growth during antenatal or postnatal life is associated with increased risk to long-term health. Significant growth restriction occurs during the in-hospital phase of post-natal growth among VLBW infants. Maximizing volume of feeding and nutrient fortification has been shown to improve overall growth. Due to high relative growth rate standardizing the response to poor or suboptimal growth should improve overall growth.
Best Practice #1.1Establish consistent, comprehensive, multidisciplinary nutritional monitoring as an integral component of improving nutrition outcomes in the neonatal population.
Best Practice #1.2 Establish standards of nutritional practice based on best evidence or expert opinion if evidence is lacking. Track nutritional continuous qualityimprovement (CQI) data and use it tomodify and improve current practices and outcome.
Implementation Strategies Daily rounds and progress notes should include a specific place for weight and feeding adjustment and should address progress toward daily growth targets. Weekly measurement and plotting of weight, length and head circumference should be done. Standardize response to poor or suboptimal growth. Mother’s milk expression and collection should be encouraged, supported and monitored routinely.
Parenteral Nutrition for VLBW Infants
Sophisticated techniques for providing short and long-term parenteral nutrition to critically ill infants have been developed. In-utero protein and energy gain is more than 4 gm/kg/day. Administration of 3 gm/kg/day of protein immediately after birth is safe and can reduce the early protein deficit cumulated within the first week of life. Early administration of at least 1 gm/kg/day pf intravenous lipids will prevent essential fatty acid deficiency.
Best Practice #2.1 Parenteral nutrition, including protein and lipids, should be started within the first 24 hours of life. Parenteral nutrition should be increased rapidly so infants receive adequate amino acids (3.0-4.0 gm/kg/day) and non-protein calories (80-100 kcal/kg/day) as quickly as possible.
Best Practice #2.2 Start parenteral lipids within the first 24 hours of life. Lipids can be started at doses as high as 2 g/kg/d. Lipids can be increased to doses as high as 3.0-3.5 g/kg/day over the first few days of life.
Best Practice #2.3 Discontinue parenteral nutrition, with removal of central catheters, as soon as adequate enteral nutrition is established.
Implementation Strategies Standardized policies, order sets and TPN solutions should be used to provide balanced, maintenance parenteral nutrition. Amino acids (of at least 2 gm/kg/day) and intravenous lipid administration should be started within the first 24 hours of life – Available pre-mixed TPN /TNA (Total Nutrition Admixture) may simply administration and mixing issues.
Establishing Enteral Feedings
Current research confirms that human milk (with appropriate fortification for the VLBW infant) is the standard of care for preterm as well as term infants. The objective of feeding during the early days of life is to stimulate gut maturation, hormone release and motility. Early introduction of feedings shortens the time to full feeds and discharge and does not increase the incidence of NEC. Benefits of human milk include: key digestive enzymes, immunologic protective factors, immunomodulators, anti-inflammatory factors, anti-oxidants, growth factors, hormones and other bio-active factors.
Best Practice #3.1 Human milk should be used whenever possible as the enteral feeding of choice for VLBW infants.
Best Practice #3.2 Enteral feeds, in the form of trophic or minimal enteral feeds (also called GI priming), should be initiated within 1-2 days after birth, except when there are clear contraindications such as a congenital anomaly precluding feeding (e.g. omphalocele or gastroschisis), or evidence of GI dysfunction associated with hypoxic- ischemic compromise.
Implementation Strategies Create a supportive environment to maximize milk production in the early post-partum period. Teach mothers hand expression and collection techniques to maximize colostrum availability. Establish a relationship with a human milk bank and procedures for obtaining heat-treated donor milk quickly. Specific standardized feeding policies should be available in each NICU. Reasons for withholding feedings should be documented and discussed in rounds.
Best Practice #7: Every mother of an infant admitted to the NICU should be provided with anappropriate breast pump and the support to use it effectively.
Guidelines for advancing feeds have been shown tobe associated with more consistent orders andresponses to residuals between physicians, fasterrates of advancement and lower rates of necrotizingenterocolitis.
Best Practice #3.3 NICU’s should standardize feeding management based on best available evidence. – NICUs should standardize their definition of feeding intolerance, with specific reference to acceptable residual volumes, changes in abdominal girth and the presence of heme- positive stools. – Enteral feeds should usually be given by intermittent bolus, rather than continuously, and by gastric, rather than transpyloric administration.
Best Practice # 3.3 continued– Pumps delivering breastmilk should be oriented so that the syringe is vertically upright, and the tubing (smallest caliber and shortest possible) should be positioned and cleared to prevent sequestration of fat.– Enteral feeds should be advanced until they are providing adequate nutrition to sustain optimal growth (2% of body weight/day). For infants fed human milk this could mean as much as 170 - 200+ mL/kg/day.
Best Practice # 3.4 VLBW infants fed human milk should be supplemented with protein, calcium, phosphorus and micronutrients. Multinutrient fortifiers may be the most efficient way to do this when feeding human milk. Formula fed infants may also require specific caloric and micronutrient supplementation.
Implementation Strategies Each NICU should discuss and agree on a definition of feeding intolerance. Staff should be educated on policies, plans and practice changes. NICU feeding policy should specify modes and methods of feeding as well as fortification – Reason for variance should be discussed and documentation.
Human Milk and Breastfeeding
Maximal human milk exposure for the vulnerable preterm infants during hospitalization is essential. A concerted effort of a multidisciplinary team is an excellent strategy to improve human milk exposure along with the development of a strong unit culture in support of human milk. Early milk production is correlated with later maintenance milk volume and lactation success. Human milk is a body substance and therefore carries risks of transmission of infectious agents. Safe handling should minimize the risk to the VLBW infant.
Best Practice # 4.1 Educate & advocate for human milk for NICU infants. – Obstetric, perinatal, neonatal and pediatric professionals should have the knowledge, skills and attitudes necessary to effectively support the provision of breastmilk to the VLBW infant. – Mothers and families should be given accurate information about human milk for VLBW infants, and their decisions respected.
Breastfeeding Resources International – ABM (Academy of Breastfeeding Medicine) – WHO/UNICEF – ILCA (International Lactation Consultant Association) – IBLCE (International Board of Lactation Consultant Examiners) – Wellstart International – WABA (World Alliance for Breastfeeding Advocacy) National – AAP (American Academy of Pediatrics) – ACOG (American College of Obstetricians & Gynecologists) – AAFP (American Academy of Family Physicians) – DHHS: Office of Women’s Health/Maternal-Child Health Bureau) – March of Dimes – WIC (Women, Infant, Children Supplemental Nutrition Program)/USDA – NIH (National Institutes of Health) – CDC (Centers for Disease Control & Prevention)
Academy of Breastfeeding Medicine Academy of Breastfeeding Medicine www.bfmed.org
Best Practice #4.2 Mothers’ milk supply should be established and maintained.
Best Practice # 4.3 Human milk should be handled to ensure safety and maximal nutritional benefit to the infant.
Best Practice # 4.4 Obstetric, perinatal, and neonatal professionals should counsel mothers when breastfeeding may be of concern or contraindicated.
Implementation Strategies Hold regular CME, CEU and other inservice activities related to lactation issues. Develop competencies regarding human milk handling and usage. Designate a Director of Lactation as a resource person. Risk factors for insufficient lactation should be communicated to perinatal and post-partum staff as well as to perinatal staff of referring facilities. Routine and standardized patient education should begin during pre-pregnancy OB/GYN visits and continue through pregnancy. Remove formula company influences from the perinatal area.
Transition to Oral Feedings
Early attachment is beneficial for milk production and mother-child bonding. Skin-to skin contact may strengthen the mother-infant dyad and lead to longer breastfeeding periods over the first two years of life. Non-nutritive breastfeeding can stimulate milk volume and improve breastfeeding success rates.
Best Practice #5.1 Infants should be transitioned from gavage to oral feedings when physiologically capable, not based on arbitrary weight or gestational age criteria.
Best Practice # 5.2 A definitive protocol for transition to oral feedings of human milk or formula does not currently exist. NICU healthcare providers should make use of safe techniques for which some evidence exists (skin-to- skin care, non-nutritive breastfeeding, test-weighing, alternate feeding methods) to effectively facilitate transition to full oral feeding.
Implementation Strategies Implement and encourage routine skin-to- skin time. Measure lactation time Measure breastfeeding frequency and breastfeeding status at the time of discharge.
Discharge Planning andPost-Discharge Nutrition
In the weeks prior to discharge fromthe NICU an individualized nutritional plan should be prepared. These plans should be coordinated between the family, neonatology, lactation consultants, dieticians, nursing staff and if possible the primary care physician continuing to provide care following discharge. Post-discharge nutrition, including the need for special diets, frequency of visits and monitoring of growth and biochemical markers is required. VLBW infants grow faster and have higher bone mineral content up to 1 year of age if provided with additional nutrients including
Best Practice #6.1 Nutritional discharge planning should be comprehensive, coordinated and initiated early in the hospital course. Planning should include appropriate nutrient fortification and nutritional follow-up.
Best Practice #6.2 Mothers should be encouraged to eventually achieve exclusive breastfeeding after discharge while ensuring appropriate growth for the infant.
The EndQuestions?Review the CPQCCToolkit: NutritionalSupport of the VeryLow Birth WeightInfant.Available at:www.cpqcc.org