Nutritional Management of Premature Infants


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International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)

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Nutritional Management of Premature Infants

  1. 1. Nutritional Management of Premature Infants Ekhard E. Ziegler, M.D. Fomon Infant Nutrition Unit Department of Pediatrics University of Iowa
  2. 2. AcknowledgementDr. Ziegler receives grant support formAbbott, Mead Johnson and NestléDr. Ziegler gives talks, for which he sometimes receives payment, on behalf of Abbott, MeadJohnson and Nestlé
  3. 3. Phases of nutritional supportPhase 1: - Parenteral nutrition - Gut primingPhase 2: Transition feeding: Enteral phased in, parenteral phasedoutPhase 3: Enteral (late)Phase 4: Post-discharge
  4. 4. Early nutrition period
  5. 5. Gut primingDealing with an immature and unused gutObjective: Maturation of immature gut
  6. 6. The immature gut• Diminished cell mass, enzyme activity• Increased permeability• Disordered, immature motility• Susceptibility to NEC• Absent or abnormal microbiota
  7. 7. A Walker J Pediat 2010; 156: S3-7
  8. 8. Small intestinal motility Term infantFrom: C.L.Berseth, J Pediatr 1990;117:777
  9. 9. Small intestinal motility Premature infant (32 weeks)From: C.L.Berseth, J Pediatr 1990;117:777
  10. 10. From: Cormack & Bloomfield, J Paed Child Health 2006;42:458-63
  11. 11. Gastric residuals• Are normal in the first 2 weeks of life• Are sometimes green or yellow• Consist mostly of gastric secretions• Do not indicate "intolerance"• Indicate immature motility• Do not indicate NEC, or impending NEC, unless there are other signs of NEC
  12. 12. Clinical manifestations of GI tract immaturity1. Gastric emptying slow and erratic and strongly dependent on body position2. Duodenal reflux common (bilious residuals)3. Susceptibility to NEC4. Intestinal transit time long5. Bowel movements irregular
  13. 13. Gut primingQ: Start when?A: On day of birth or next dayQ: Why early?A: Delay only postpones maturation and induces atrophyQ: Doesnt early start increase risk of NEC?A: No, it does not increase risk of NEC, it actually decreases it and that of sepsis
  14. 14. Gut primingQ: Priming with what?A: Human milkQ: Why?A: Human milk primes the gut more efficiently and more safely than anything else
  15. 15. Gut primingQ: Priming with how much?A: Very small volumes, 1-2 cc every 8 hrsQ: Start to advance?A: When residuals begin to decrease
  16. 16. Why is human milk so important for gut priming? • Strong trophic effects • Strong anti-infectious effects • Protects against sepsis, NEC and death
  17. 17. Human milk and GI priming Relevant properties• Trophic effects• Anti-infective effects• Ant-inflammatory effects• (Prebiotic effects)• (Anti-NEC effect)
  18. 18. Human milk Trophic factorsEGF (epidermal growth factor)TGFαInsulinIGF-1LactoferrinHeat-stable factor(s)Trefoil factors
  19. 19. Human milk in the VLBW infant Trophic effects• Stimulates cell proliferation• Decreases permeability• Enhances motility maturation• Protects from NEC
  20. 20. Clinical correlates of trophic effects of human milk1. Fewer and smaller residuals2. Rapid feeding advancement, full feeds sooner3. Absence of abdominal distention episodes4. Rapid gastric emptying5. Low susceptibility to NEC
  21. 21. Human milk Anti-infectious components• Cells (macrophages, T and B cells)• Secretory IgA• Lactoferrin• Lysozyme• Bactericidal substances• Fatty acids• Oligosaccharides anti-adhesive• Mucins effects
  22. 22. Human milk oligosaccharides (2) Effects• Anti-infectious: Inhibit pathogen binding• Anti-inflammatory• Prebiotic: Foster colonization by fucose- utlizing bacteria
  23. 23. Human milk & the premature infant SepsisEl-Mohandes et al., 1997Hylander et al., 1998Furman et al., 2003Schanler et al., 2005 not for donor milk Sepsis + NECSchanler et al., 1999Meinzen-Derr et al., 2008
  24. 24. Human milk protects ELBW infants against NEC or deathThe likelihood of NEC or death was decreased by a factor of 0.87 for each 100 ml/kg increase in human milk intake during the first 14 daysMeinzen-Derr et al. for the NICHD Neonatal Research Network
  25. 25. From: J Meinzen-Derr et al., J Perinatol 2009;29:57-62
  26. 26. The huge advantages of human milk for the premature infant1. Protects against sepsis, NEC and death2. Leads to higher IQ later in life3. Primes the gut better than anything else
  27. 27. The disadvantages of human milk for the premature infant1. Nutritionally inadequate2. There is not always enough of it, not all mothers pump3. The nutrient composition is not known
  28. 28. Securing human milkBecause of its important protective effects, wemust make every effort to secure human milk:1. Educate mothers before delivery, explain how expressed milk is stored and used2. Support and encourage mothers after delivery3. Obtain donor milk if the mothers milk supply is insufficient
  29. 29. Feeding advancement in VLBW infants Guidelines1. Start feeds on day 1 or 22. Start with low volume, e.g., 2 cc/8hrs3. Monitor gastric residuals4. Increase feeds slowly in frequency and/or size as residuals subside5. Do not hold feedings because of occasional large residuals6. Pay attention to passage of meconium
  30. 30. Transition feeding IssuesHow fast to advanceWhen to start fortificationWhen to stop TPN
  31. 31. Advancement of feedings1. Kennedy & Tyson 2009 Cochrane 3 studies; 10 – 20 cc/kg/d vs 30 – 35 cc/kg/d No effect on NEC, reached full feeds sooner2. Morgan et al. 2011 Cochrane 4 studies; 15-20 cc/kg/d vs 30 – 35 cc/kg/d No effect on NEC or mortality; full feeds sooner (2-5 days)3. At least 2 newer studies, same findings
  32. 32. Early feeding advancement Härtel et al., J Ped Gast Nutr 2009;48:464-470 Slow p RapidLate-onset sepsis 20.4% 0.002 14.0%Central line 48.6% <0.001 31.1%Antibiotics 92.4% <0.001 77.7%
  33. 33. Ronnestad, A. et al. Pediatrics 2005;115:e269-e276 Copyright ©2005 American Academy of Pediatrics
  34. 34. When to start fortification1. At Iowa we start when the feeding volume reaches 25 ml/day (= 1 packet of powder fortifier)2. Most commonly started at 100 ml/kg/day. Why so late?
  35. 35. Fortification of human milk Initiation1. Most commonly at 80 or 100 cc/kg/day enteral feeding volume2. At Iowa: At feeding volume of 25 cc/kg/d Advantages: - Probably decreases need for PN - Baby still has gastric residuals
  36. 36. Transition feedingQ: When to stop parenteral nutrition?A: When enteral feeds are >90% of full
  37. 37. Late enteral feedingEnteral feedings are sole source of nutrients
  38. 38. Late enteral feedingObjective: Deliver adequate amounts of nutrients for normal* growthMain problem: Fortification of human milk* normal = like fetus +- catch-up
  39. 39. Late enteral feeding The key issue:How to consistently provide adequate protein intakes
  40. 40. Human milk fortification Why fortification?Human milk provides about 1/3 of the protein and only a fraction of most other nutrients needed by the premature infantMeeting the need for protein with human milk alone would require feed volumes of >300 ml/kg/d and provide 3x the amount of energy needed, and would still not meet the needs for most other nutrients
  41. 41. Human milk fortification ObjectiveIncrease concentration of protein and minerals so that we can meet the requirements for protein and minerals without feeding huge amounts of calories
  42. 42. Data of Lemons et al., Ped. Res. 16:113 (1982)
  43. 43. Fortified Human Milk Protein (g/100 mL) Human milk, 2 weeks 1.5 Fortifier 1.0 Total 2.5Protein/energy = 3.1 g/100 kcalProtein intake = 3.4 g/kg/d (at 110 kcal/kg/d)
  44. 44. Fortification of Mother’s Milk Protein (g/100 mL) Mother’s milk, 4 weeks 1.1 Powder fortifier 1.0 Total 2.1Protein/energy = 2.6 g/100 kcalProtein intake = 3.1 g/kg/d (at 120 kcal/kg/d)
  45. 45. Fortification of Mother’s Milk Protein (g/100 mL) Mother’s milk, 4 weeks 1.1 Powder fortifier 1.0 Extra fortifier 0.5 Total 2.6Protein/energy = 3.25 g/100 kcalProtein intake = 3.9 g/kg/d (at 120 kcal/kg/d)
  46. 46. Human milk fortifiers(amounts of nutrients added to each100 ml human milk) Powder A Powder B LiquidCalories (kcal) 14 14 14Protein (g) 1.0 1.1 1.8Na (meq) 0.65 0.5 0.5Ca (mg) 117 90 90Iron (mg) 0.35 1.4 1.4Plus all other minerals, trace minerals and vitamins in adequate amounts
  47. 47. Alternative to fortificationAlternate feeding of mothers milk with feeding of formula (HiPro)
  48. 48. Formulas for premature infantsCaloric density: Standard 80 kcal/dl (some also available at 90 kcal/dl and 100 kcal/dl)Protein: 3.0 or 3.3g/100 kcalLipid: 40% MCT oil; DHA, ARACarbohydrate: 40% lactose, 60% glucose polymersMinerals (per 100 kcal): Ca 165, P 83Iron: 14 mg/L (or 4 mg/L)
  49. 49. Formulas for preterm infants protein content (g/100 kcal)Body weight Requir. Formula Formula (g) Standard Hi-protein 500-700 3.8 3.0 3.3 3.5 700-900 3.7 3.0 3.3 3.5 900-1200 3.4 3.0 3.3 3.51200-1500 3.1 3.0 3.31500-1800 2.8 3.01800-2200 2.6 3.02200-2800 2.5 2.82800-3500 2.3 2.83500+ 1.8 2.2
  50. 50. What can you do to ensure adequate nutrition?Monitor protein intakesMonitor growth: Plot infant weight on chart (or use target weight gains), make sure growth runs parallel to fetal percentiles, or crosses them upwards
  51. 51. Fenton chart
  52. 52. Human milk fortificationAdding calories alone to mothers milk lowers the protein/energy ratio to <1.6 g/100 kcal Therefore Fat (canola oil, MCT oil) or carbohydratemust never be added to mothers milk
  53. 53. Going homeWhen the premature infant leaves the hospital, his/her protein needs are still much higher than those of the term infantAlso, the infant has almost always undermineralized bonesHence the infant needs more protein and more minerals than plain mothers milk or term formula can provide
  54. 54. Selected Nutrient Levels of Formulas (per 100 kcal) Premature Post- Term formula discharge formula formulaKcal/dl 80 74 67Protein 3.0-3.5 2.8 2.1Vitamin A 1250 460 300Vitamin B6 250 100 60Ca 180 105 78Fe 1.8 1.8 1.8
  55. 55. Post-discharge nutritional management of the VLBW infant Summary• Formula-fed infants: Special post-discharge formulas (provide adequate protein, Ca, P; Fe)• Breast-fed infants: Fortification (supplementation) indicated, but not practiced regularly, difficult to perform; special attention to Fe supplementation
  56. 56. Good nutrition does not save lives It saves brains