LBW FEEDING

1. DR MURTAZA KAMAL
MBBS, MD, DNB
DIVISION OF NEONATOLOGY
DEPARTMENT OF PEDIATRICS
VMMC & SAFDARJUNG HOSPITAL,N DELHI
DOP: 26/10/2012
Feeding in Low Birth
Weight Infants

2. Questions to be answered
 Why are LBW infants different?
 When should feeding be started?
 Which milk should be chosen for feeding them?
 What should be the method of feeding?
 What are the supplements required?
 How is the adequacy of feeds monitored?
 How is feed intolerance suspected and managed?

3. General principles of feeding in LBW infants
 Energy reserves low
 Early feeding :
 shortens the period required to regain birth weight.
 reduced hyperbilirubinemia, hypoglycemia, dehydration
 increased survival rate
 Technique of feeding is determined by birth
weight and gestation
 Optimal feeding in preterm LBW:
neurodevelopmental outcome is unaffected.

4. Basic problems in feeding preterms
 Physiologic handicaps
 Biochemical handicaps

5. Physiologic handicaps
 Inability to co-ordinate sucking and swallowing
before 33-34 weeks of gestation
 Poor lower oesophageal sphincter tone and
unfavourable anatomy, resulting in GER
 Poor gag reflex predisposing to aspiration
 Small gastric capacity
 Gastroparesis and intestinal hypomotility

6. As a result of the physiologic handicaps
It is not possible to feed them by the same,
 route,
 volume and
 frequency
as term babies.

7. Biochemical handicaps
 Greater energy needs
 to sustain greater growth velocity
 to compensate for greater wastage due to various disease
processes
 poorer intestinal absorption
 Greater need for protein per unit body weight
but poorer stomach peptic activity
 Greater fluid requirements
 greater transdermal
 greater urinary losses

8. Biochemical handicaps
 Relative bile acid deficiency
 Relative lactase deficiency
 Very high requirements of calcium and
phosphorus to match intrauterine accretion rates
 Increased need for sodium for tissue growth
 Earlier requirement for iron to compensate for
poor stores
 Increased requirement for almost all minerals
and vitamins, since they are all accrued during
the third trimester

9. Biochemical handicaps
 Incompletely developed amino acid pathways:
cystein, taurine, glycine, histidine become
essential amino acids
 Higher requirement for essential fatty acids:
 retinal maturation
 myelinization

10. Due to the biochemical handicaps
 Greater need for certain nutrients than term
human milk provides
 Inability to handle certain nutrients due to poorly
developed enzymatic pathways and renal and
hepatic immaturity

11. Phases of feeding of preterm and LBW babies
3 phases:
 Transition phase: birth to 7 days or stabilization
 Stable growing phase: from stabilization to
discharge
 Postdischarge phase: from arrival at home
onwards

12. Phases of feeding of preterm and LBW babies
 Transition phase
 Baby is in the process of being stabilized
 Predominantly on IV fluids and feeds are just being
introduced or in the process of being built up
 Aim is to avoid catabolism
 Stable growing phase
 The baby is trying to maintain growth and nutrient
accretion rates that it would have had in the womb
 Postdischarge phase
 The baby is trying to catch up with term babies in terms of
growth and nutrition

13. Which milk should be chosen?
 All LBW infants, irrespective of their initial
feeding method should receive ONLY breast milk
 Expressed breast milk:
 Ideally initiated within hours of delivery
 Thereafter 2-3 hourly
 EBM can be stored for about 6 hours at room temperature
and for 24 hours in the refrigerator

14. When should feeding be started?
 Like term babies feeding should be initiated in
preterm babies soon after birth except:
 Preterm babies with gestation less than 28 weeks
 Sick preterm babies with severe respiratory distress,
shock, convulsions or severe birth asphyxia
 These babies should be started on intravenous
fluids and enteral feeds should be started as soon
as they are hemodynamically stable.

15. Which milk should be chosen?
 If the mother is sick or there is a
contraindication to breastfeeding,options
available are:
 Preterm formula (<1500 gm birth weight)
 Term formula (>1500 gm birth weight)
 Undiluted animal milk

16. Is preterm breast milk adequate?
 High levels of numerous anti-infective factors
and enzymes which cannot be matched by any
other milk
 Higher proteins, sodium chloride, magnesium, IgA
and possibly fat
 Deficiency of calcium, phosphorus, iron, zinc,
copper. Supplementation needed.

17. How much feed should a newborn receive?

18. Tube Feeding Guidelines
(Manual of Neonatal Care,7th edision:John P Cloherty)
Birth wt.(g) Initial rate(mL/kg/day) Volume
increase(mL/kg/every
12 hours)
<1000 10 10
1001-1250 10-20 10
1251-1500 20-30 10-15
1501-1800 30 15
1801-2500 30-40 15-20

19. Which method should be used to feed LBW
babies?

20. Maturation of
oral feeding
skills
Breastfeeding
requires effective
sucking, swallowing,
proper coordination
between suck/swallow
and breathing
Gestational age Maturation of
feeding skills
Initial feeding
method
<28 weeks No proper
sucking efforts,
no propulsive
motility of the
gut
IV fluids
28-31 weeks Sucking bursts
develop
Orogastric or
nasogastric
feeding with
occasional
spoon/paladai
feeding
32-34 weeks Slightly mature
sucking pattern,
coordination
between
breathing and
swallowing begins
Feeding by
spoon/paladai/
cup
>34 weeks Mature sucking
pattern, more
coordination
between sucking
and swallowing
Breastfeeding

21. Method of feeding
 At 30 weeks:
 Ability to co-ordinate swallowing with respiration
 No suck-swallow coordination
 Tube fed to avoid aspiration
 At 34 wks
 Suck-swallow coordination gained
 >1800 gm can be breastfed
 1200-1800 fed by katori spoon/paladai
 Presence or absence of sickness
 Individual feeding efforts of the baby

22. Newborns that require assisted feeding
 Preterm babies <34 weeks or birth weight <1800
gm
 Babies having mild respiratory distress
 Babies with inability to feed at breast or by
katori/spoon or paladai
 Orofacial defects/malformation (cleft lip or
palate)

24. Progression of oral feedings in preterm LBW
infants

25. Technique of gavage feeds
 Place oro-gastric feeding
catheter size 5-6 fr
 Check correct placement
 Attach 10 ml syringe
(without plunger), pour
measured amount of milk
and let it trickle by gravity
 Place baby in left lateral
position for 15-20 minutes
 Avoid flushing the tube with
water after feed
 Pinch the orogastric tube
during removal
 Measure pre-feed abdominal
girth, do not attempt pre-
feed aspirates

26. Orogastric or nasogastric
 There is no difference in tolerance and complications
between the two
 In VLBW infants with apnea or respiratory
problems, orogastric route may be preferred

27. Two hourly or three hourly feeding
 LBW babies should be fed every 2 hours starting
as soon as possible after birth.
 American Academy of Pediatrics

28. Katori-spoon/ paladai feeds
 Place the baby in a semi-
upright posture
 Place the milk filled spoon
at the corner of the
mouth
 Allow milk to flow into the
baby’s mouth slowly,
allowing him to actively
swallow
 Try gentle stimulation if
doesn’t actively accept
and swallow feed
 If unsuccessful, switch
back to gavage feeds

29. Special situations
 Extremely low birth infants: Usually minimal
enteral nutrition (MEN) is initiated once the
infant is hemodynamically stable
 Severe IUGR with antenatally detected absent
or reversed end-diastolic flow in umilical
artery: feeds are delayed up to 48-72 hours in
preterm infants (<35 wks)
 Infants on CPAP/ventilation: Can be started on
orogastric feeds once hemodynamically stable.
Leave the tube open intermittently to prevent
gastric distention.

30. Minimal Enteral Nutrition (MEN)
 Small volumes of EBM (12-24 ml/kg/day every 1-3
hours)
 Delivered intra-gastric
 Advantages
 Enhance gut growth
 Less feed intolerence
 Improved weight gain
 Improved calcium and phosphorus retention
 Enhance hormonal secretion
 Enhance motility in a LBW neonate
 Reduction in days required for attaining full feeds
 Decreased hospital stay

31. Non-nutritive sucking
 All stable LBW infants, irrespective of their
initial feeding method should be put on their
mothers’ breast
 The immature sucking observed in preterm
infants born before 34 weeks:
 Might not meet their daily fluid and nutritional
requirements
 Helps in rapid maturation of their feeding skills
 Improves the milk secretion in their mothers
 Decreases length of hospital stay

32. Supplements
 Vitamin K
 <1000 gms :0.5 mg IM of Vitamin K at birth
 Others: 1 mg IM Vitamin K at birth
 Vitamin D
 All LBW infants who are exclusively breastfed should
receive 400 IU daily of vitamin D from first few days of
life once they accept full feeds.
 Continue until 6 months of age.
 Larger doses (800-1000IU) may benefit smaller babies
(<1500 gms).
 Most available vitamin D drops contain 400IU/ml.
 Multivitamin drops
 0.3ml /day from 2 weeks of age.
American Academy of Pediatrics

33. Supplements
 Calcium and Phosphorous:
 All infants <2000 gm : calcium 120-140mg/Kg/day and
phosphorous at and 60-90mg/ Kg/day
 Continued till 40 wk post conceptual age.
 For optimal supplementation: calcium and phosphorous in 2:
1 ratio
 Iron
 2-3 mg/Kg/day starting at 6-8 wks,
 As early as 2 wks in <1500 gms
 Needs to be continued till one year of age.
American Academy of Pediatrics

34. Growth monitoring
 Check for weight daily
 Head circumference weekly
 Check length weekly or fortnightly

35. Weight gain
 Key measure of optimal feeding
 Preterm baby
 Loses up to 1-2% weight every day
 Cumulative weight loss 10% during 1st week of life
 Birth weight regained by 14th day
 SGA-LBW babies if otherwise healthy
 No appreciable weight loss
 Should start gaining weight early
 LBW babies should gain 18-24 gm/kg/day

36. Human milk fortifier
 By about 4 weeks, as the composition of a
preterm milk approaches term milk, the baby may
fail to thrive (<15gm/kg/day wt gain and
<1cm/week length gain)
 Rule out sepsis, cold stress, anemia and
inadequate intake
 Increase feed to maximum tolerated amount
(about 240ml/kg)
 If persists, add human milk fortifier

37. Human milk fortifier
 It is a nutritional supplemnt 2 grams per 50 ml human
milk
 Gives additional 0.2 gm protein, 0.19 gm fat, 1.2 gm
carbohydrate and significant amount of calcium,
phosphorus, vitamins, mineral and trace elements
 Preterm babies on expressed breast milk fortified
with HMF do not require any other supplementation
except for iron.
 Continue fortification of expressed breast milk with
HMF till baby reaches 40 weeks of PMA or attains
weight of 2 kg whichever is later

38. Human milk fortifier
 Routine use should be avoided
 Best reserved for preterm infants <32 weeks
gestation or <1500 gm birth weight who fail to
gain weight despite full volumes of breastmilk
feeding (National Neonatology Forum).

39. Feeding intolerance
 When to supect feeding intolerance?
 Baby is vomiting (altered milk/bile/blood stained)
 Abdominal girth increases by 2cm from baseline.
 Prefeed gastric aspirate is more than 25% of last feed.
 Routine prefeed aspirates are not recommended

40. Causes and management of feeding intolerance
 Causes
 immature intestinal motility,
 immaturity of digestive enzymes,
 medical conditions e.g. sepsis, NEC etc.
 Management
 Suspend oral feeds till abdominal distension improves
 Evaluate for any medical illness and manage accordingly
 For gastrointestinal immaturity conservative management
only option

42. Energy requirement
 ESPGAN (European Society for Pediatric
Gastroenterology and Nutrition): 130 kcal/kg/d
 AAP (American Academy of Pediatrics) and CPS
(Canadian Pediatric Society): 120-130 kcal/kg/d
 Total energy intake is a sum of energy required
for growth and for basal metabolism, activity,
thermoregulation and energy excreter.

43. Carbohydrates
 Predominant carbohydrate in mammalian milk is
lactose
 Apart from lactose, human milk also contains trace
amounts of alphaglucosides
 Preterms have a developmental lactase deficiency,
but abundance of alpha-glucosidases
 Hence, alpha-glucosides (glucose polymers, maltose
alpha-limit dextrins) are being increasingly added to
preterm infant formulas to supplement calories
 Carbohydrates should provide for 35-40% of the
total calories

44. Fats
 Preterm infant has low levels of pancreatic lipase, bile
salt, lingual lipase in addition to low bile acid pool
 Lingual lipase: able to penetrate the core of human
milk fat globule and hydrolyzing the triglyceride core
without disrupting the globule membrane
 Human milk also provides lipases which continue
lipolysis in the small intestine
 The absorption of fatty acids increases with
decreasing chain length and with the degree of
unsaturation
 Medium chain triglycerides can be absorbed without
the need for lipase or bile salts
 Fats should provide 50% of the total calories

45. Fats
 Preterm milk has almost 2X MCTs as compared to
term milk
 Long chain polyunsaturated fatty acids (e.g.
arachidonic acid, docosahexanoic acid): important
role in the development of infant brain and retina
during the last trimester of pregnancy and the
first month of life

46. Proteins
 Term infants should receive 2.0-2.2 gm/kg/d
 Preterm with birth wt 1200-1800 gm should
receive 2.7-3.5 gm/kg/d
 Preterm with birth wt < 1200 gm probably require
even higher amounts of protein
 A total of 7-16% of daily calories should be
obtained from proteins to provide adequate
weight gain and nitrogen retention

47. Calcium, phosphorus
 The peak of foetal mineral accretion occurs after
34 weeks of gestation
 Preterm infants require very high level of
supplementation
 Calcium: 148-175mg /100kcal(3-4.5x that supplied
by human milk)
 Phosphorus : 102-120 mg/100kcal (5-6x that
supplied by human milk)
 Unfortified human milk by preterm infants
results in bone mineral deficits that persist
throughout the first year of life

48. Iron
Preterms are at increased risk of iron deficiency
because:
 They deplete their iron stores in half the time as a
term infant (2 months)
 They lose iron due to repeated sampling
 Iron transfused through blood does not provide
storage iron
Iron supplementation should begin no later 2 months of
life
 Should continue throughout the first year
 Dose: 2-3mg/kg/d

49. Trace elements
 Less than 0.01% of total body weight
 Important constituents of metalloenzymes,
cofactors for metal ion activated enzymes and
components of vitamins, hormones and proteins
 Iron, zinc, copper, selenium, manganese,
chromium, molybdenum, fluoride, iodine:
established physiologic importance

50. Thanks for
your kind
attention