Neonatal nutrition By Mili


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Neonatal nutrition By Mili

  1. 1. Neonatal nutrition MILI SARKAR Dietician
  2. 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. 3. General facts about neonatal fluid and nutrition• Last trimester of pregnancy – Fat and glycogen storing – Iron reserves – Calcium and phosphorous deposits• Premature babies more fluid (85%-95%), 10% protein, 0.1% fat. No glycogen stores• Insufficient protein & calories is life threatening to the sick
  4. 4. Guidelines fluid management• 80 cc/kg/day, increase to 100-120cc/kg/d with increase 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
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. Total parenteral nutrition (TPN)• 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
  9. 9. others• Minerals – Zinc, copper, molybdenum, chromium, selenium – Calcium, phosphorous, Magnesium – Na, K• Vitamins – Fat soluble – Water soluble
  10. 10. 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
  11. 11. Complication of TPN• Infiltration under skin• Infection• Liver dysfunction• Renal overload
  12. 12. 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)
  13. 13. WHO – BREAST FEEDING RecommendationThe World Health Organization recommendsexclusive breastfeeding for the first six monthsof life, with solids gradually being introducedaround this age when signs of readiness areshown. Supplemented breastfeeding isrecommended until at least age two, as longas mother and child wish.
  14. 14. 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
  15. 15. 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
  16. 16. 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 predominant 60:40
  17. 17. Breast feeding• after delivery baby has metabolic reserves • Hepatic glycogen • Brown fat • Extracellular and extra vascular water• milk production is stimulated• Try to get baby onto the breast within first 1-2 hours of life• Colestrum ; high in protein & immunoglobulin
  18. 18. 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
  19. 19. 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
  20. 20. Maternal factor of low milk• Gestational diabetes• Hypothyroid• Retained placental fragments• Dehydration, hemorrhage, hypertension, infection• Previous breast surgery• Lack of prenatal engorgement• Psychosocial – Previous unsatisfactory experience – Lack of partner support – Post-partum depression – Separation from infant
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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 turger, moist mucous membranes• Contentment 1.5-2 hours after feeds
  25. 25. Enough milk• Breasts feel full before and softer after feeds• Milk leaks from contralateral breast during suckling• Sensation of milk ejection ⇒ pins and needles• Absent nipple trauma and pain• Profound state of relaxation in mom during suckling
  26. 26. 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
  27. 27. Breast feeding• Foremilk• Hind milk
  28. 28. 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
  29. 29. Breast milk substitutesExactly there is no equal substitute for Mothers MilkOccasionally the artificial milk have to be given to adopted babies or those who lost mother .Liquid milk consumed by the family should be utilized, the powder should be strongly discouraged.
  30. 30. 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
  31. 31. 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
  32. 32. 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.
  33. 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. 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
  35. 35. ConclusionI have insufficient milk to feed my child" or "my baby ishaving an aversion to breast. He simply turns his faceaway "Scientists have proven from time to time that thesestatements are not true.Many mothers expect that breast milk must flow just likebottle milk.THEY OFTEN FORGET THAT BOTTLE MILK ISLIFELESS & BREAST Milk ARE FULL OF LIFE."IF THERE IS A WILL THERE IS MILK ALWAYS" is a ALWAYSmedical dictum
  36. 36. The end !Thank you forcompleting thismodule