This document provides guidance on nutritional assessment and management for preterm infants. It outlines the ABCDE approach: A) Anthropometry - Regularly monitor weight, head circumference, and length and plot on a growth chart. Look for weight maintenance or gain. B) Biochemistry and bloods - Monitor glucose, electrolytes, and minerals. Serum ferritin indicates iron status. C) Clinical examination and status - Consider individual needs based on conditions. Check for edema. D) Dietary intake - Calculate protein and energy intake and compare to targets of 3-4.5 g/kg/day protein and 110-135 kcal/kg/day energy. E) Environment

1. azad82d@gmail.com
azad.haleem@uod.ac
Dr.Azad A Haleem AL.Mezori
MRCPCH,DCH, FIBMS
Assistant Professor
University Of Duhok
College of Medicine
Pediatrics Department
ABCDE; approach to nutritional
assessment in preterm infants
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3. Introduction
• The last 20 years has seen dramatic improvements in the survival of preterm infants
due to improved antenatal and neonatal care.
• Closer attention to nutrition means early parenteral nutrition and mother’s own milk
are considered as standard of care.
• While many healthcare professionals (HCPs) are aware of several key nutritional
concepts on the neonatal intensive care unit (NICU), many HCPs lack a concise,
systematic approach.
• Patient monitors on the neonatal intensive care unit (NICU) provide second-by-
second feedback on cardiorespiratory status, but no such colourful monitoring
devices or alarms exist for nutritional status.

4. • A number of principles and concepts guide nutrition in preterm
infants.
• The most obvious is that they have limited nutrient stores and high
demands

5. • At 24 weeks of gestation, 85%–90% of an infant’s weight is water, meaning
a 500 g preterm infant only has around 50–60 g ‘dry tissue’.
• Preterm infants have no fat stores and very little stored energy as glycogen
in muscles and liver.
• Minerals only account for around 1% of body weight.
• The main component of body weight is protein, but in the absence of
sufficient dietary energy this will be catabolised to provide energy.
• Organs suffering catabolic loss of protein may not function optimally: liver
protein synthesis may be impaired; diaphragmatic muscle may be
weakened.
• Survival without exogenous dietary energy could be estimated by
assuming no more than 20% of body protein could be catabolised before
irreversible metabolic decompensation.
Facts on protein, energy ?

6. • A 500 g infant with total 50 g dry lean mass could convert
no more than 10 g protein (20%) into just 50 kcal of energy.
• Resting energy expenditure in a preterm infant is around 50
kcal/kg/day, meaning death from malnutrition would occur
within 2–3 days without dietary supply.
• At 24 weeks of gestation, fetal protein accretion is
approximately 2 g/kg/day, but to enable similar accretion
ex utero requires around 3.5 g/kg/day dietary protein due
to inevitable nitrogen losses in urine, stool and secretions,
as well as metabolic ‘inefficiency’.

7. • A similar protein intake in an adult would require the
consumption of 20 beef burgers per day.
• Energy requirements in preterm infants are around
110–135 kcal/kg/ day.
• To place this in context, a Tour de France cyclist
consumes around 7000 kcal/day or around 100
kcal/kg/day.
• Newborn preterm infants therefore expend 20% more
energy than the most energy-intense sporting activity
known to man!

8. • When to Start feeding
• Almost all stable LBW neonates can be initiated on enteral feeding soon after birth.
• How to feed
• Birth weights > 2000g. Most of these neonates are capable of breastfeeding. Some
amongst them may require assisted feeding with cup/spoon.
• Birth weights 1600-2000g. Those amongst them who have good sucking can be
allowed breast feeds. Those with slow suck may require assistance with
cup/spoon/paladai
• Birth weight 1200-1599g. These infants would generally require tube feeding.
Those who have fair sucking may also be allowed to suckle on the breast.
• Birth weights <1200g. These infants would initially be predominantly on
intravenous fluids, but if stable can be initiated on trophic or minimal enteral
feeding and with time the enteral feeding volumes can be scaled up.

9. • Trophic or minimal enteral feeding is provided by giving the infant about
10 ml/kg/day of breast milk for the first 48 hrs of life and then scaling up
the feed volumes to the desired limit.

10. • Nasogastric or orogastric feeding
• Feeding can be done using either indwelling nasogastric or orogastric tubes.
• There is no difference in tolerance/complications between indwelling nasogastric or
orogastric tubes.
• However, in VLBW (<1500g) who have apnea or respiratory problems, orogastric route
may be preferred.
• Some units instead of indwelling tubes, place feeding tubes during feeding and remove it
after delivery of feeds.
• Cup/spoon/paladai feeding
• Expressed breast milk/an appropriate milk can be fed to LBW neonates who have some
sucking using a variety of devices – spoon, paladai, small cups or other
traditional/culturally accepted devices.
• Care must be taken to teach mothers the correct technique, so that excess spillage of milk
does not occur.
• Breast feeding
• Adequate efforts must be made to ensure that mothers are available to feed their LBW
infants.
• Since these neonates are small and often have slow suck, the nursing personnel must be
around to supervise breastfeeding and provide adequate support to the mothers.

11. • How much to feed
• Birth weight < 1200g: Start with 10-20 ml/kg/day 2 hrly for 2-3 days (trophic or
minimal enteral feeding). Increase by 20 ml/kg/day thereafter till max of 180
ml/kg/day
• Birth weight >1200g: Start with 60ml/kg/day 2 hrly. Increase each day by 30 ml/kg
till maximum of 180 ml/kg/day in infants <1600g and up to 150 ml/kg /day in those
more than 1600g, provided the infant is showing adequate weight gain.

12. • What to feed
• Breast milk is the preferred choice.
• Hind milk feeding helps in weight gain ; Breast milk is often associated with slower
weight gain than formula, but improved developmental and cognitive outcomes, the
so-called ‘breastfeeding paradox’.
• If breast milk insufficient or non-available (first few days of life/mother not
available or sick) consider using an appropriate preterm formula till adequate breast
milk available.

13. • Transition to breast feeding
o Non-nutritive sucking (NNS)
• Sucking activity is a physiologic reflex dependent on maturity, but is capable
of being enhanced with learning experience.
• Preterm infants are unable to coordinate sucking with swallowing and
breathing till about 32 weeks of post-conceptional age.
• The preterm neonate at 28 weeks has mostly mouthing activity with single
sucks but by 31 weeks rhythmic bursts of sucking with pauses can clearly
be seen.
• The development of this reflex can be enhanced by allowing the preterm
neonate to suck on the empty breast – non-nutritive sucking.
• Transition to breast feeds can achieved by gradual introduction of spoon
feeds in NG fed babies along with NNS and then introduction of breast
feeds.
• Neonates with gestation > 32 weeks, fair sucking and clinically stable can all
be allowed to transit to breast feeding.

14. • Supplements
• All neonates < 35 weeks need some mineral and vitamin supplementation
since breast milk does not meet the recommended nutrition intakes for
preterm neonates.
• Mineral supplements
• Calcium and phosphorous
• These infants should be supplemented with approx. 100 mg/kg/d of
elemental calcium and about 40-50 mg/kg/day of phosphorous.
• This may be started when the infant has reached about 150ml/kg/day of
enteral feeding.
• Iron
• Iron supplement must started at about 4 weeks at a dose of 2-4 mg/kg/day.
• It is advisable to use ferrous salts for iron supplementation.

15. • Vitamin supplements
• Neonates should be given a standard multivitamin preparation to provide the
recommended daily needs.
• The supplement should provide the vitamins in the following amounts each day:
• Vitamin A 1000-1500 IU
• Vitamin D 400 IU
• Vitamin E 25 IU
• Vitamin C 40-50 mg
• Vitamin B1 1000 μg
• Vitamin B12 3-5 μg
• Niacin 5-10 mg
• Folic acid 50 μg
• Oral vitamin supplementation should be started when the infant has reached an
enteral intake of 150 ml/ kg/day.
• How long should they continue?
• Mineral and vitamin supplementation should continue till baby reaches term gestation.
The need for further continuation should be assessed.
• The preterms may need supplementation till 6-9 months of postnatal age (the age by
when the infant is expected to be on complimentary feeds).

16. • Normal growth and development requires every single macronutrient and
micronutrient to be provided in a balanced diet.
• Despite concerns regarding later metabolic risks of rapid growth in early
life, the most important adverse outcome following preterm birth is
neurocognitive impairment, so remember that preterm infants have ‘one
brain for life’.

17. • Nutrition is a ‘complex intervention’ with
multiple interacting elements, often with a
long lag time between exposure and
functional effects, but can be grouped into
four key areas:
Nutrients ,
Functional components,
Microbiomic aspects and
Sociobehavioural and technical aspects .

19. THE NUTRITIONAL ASSESSMENT
• Given the importance of good nutritional status it is helpful to have a simple practical
approach that can be used in a busy NICU. The ABCDE approach has been widely used:

20. A—Anthropometry
• Anthropometry requires minimal training and accurate equipment.
• Weight must be regularly monitored, every 1–3 days depending on clinical
circumstances.
• Head circumference and length can be measured weekly.
• Plot all measures on a valid growth chart either by hand or ideally by using
electronic medical record software.
• Most infants lose some weight in the first few days due to the inevitable
contraction of extracellular fluid, but most infants should then maintain that
weight centile during NICU stay.

21. A—Anthropometry
• Weight, head or length gain in g/kg/day or cm/week can be calculated but
these rates change during the third trimester so tracking an infant’s centile
on a growth chart is always preferable.

22. B—Biochemistry and bloods
• There are no useful biochemical tests of global nutritional status, and serum total
protein and albumin are unhelpful nutritional indicators because of long plasma half
lives.
• Furthermore, homeostatic mechanisms will ensure that plasma concentrations of
many nutrients such as calcium will be maintained despite whole body depletion.
• Monitor glucose and electrolytes at least daily in the first few days, thereafter,
measure one to two times weekly depending on clinical status.
• Watch haemoglobin concentrations as infants with significant anaemia may not
grow optimally.

23. • Serum ferritin is a useful indicator of iron status: iron supplements are not
needed if ferritin is >300 ng/ mL.
• Only infants on prolonged PN (over 3–4 weeks) or with liver impairment
require measurement of trace elements or vitamins.
• Infants on steroids or diuretics need careful attention to bone mineral
status.
• Low serum phosphate after the first 1–2 weeks may indicate inadequate
phosphorus intakes (commonly seen with unfortified breast milk) and is
more useful than alkaline phosphatase which may be normal despite
profound mineral loss, or be appropriately raised where there is active
bone growth.
• A degree of mineral bone deficiency is inevitable in most preterm infants
and many will also need extra calcium (provided as supplements or in
breast milk fortifiers).
• There is no benefit in routinely measuring vitamin D: all preterm infants
require supplementation.
B—Biochemistry and bloods

24. C—Clinical examination and status
• There are few visible signs of malnutrition in preterm infants which is why it is so
easy to allow them to become malnourished.
• However, the occasional baby may have poor wound healing due to zinc
deficiency.
• Consider how individual infant’s needs may differ: severe lung disease may
need additional energy, additional losses due to intestinal stoma may require more
sodium and minerals and higher needs due to malabsorption may occur with short
bowel syndrome.
• Infants should be examined to determine the degree of oedema and whether this
may contribute to ‘inappropriate’ weight gain.
• Infants who are acutely sick due to necrotising enterocolitis (NEC) or sepsis may
not have the metabolic capacity to process high amino acid intakes and may also
develop hyperglycaemia or hyperlipidaemia.

25. D—Dietary intake
• Develop a simple table for your NICU with the energy and protein contents
of all commonly used PN solutions, milks and fortifiers.
• Calculate the actual (not prescribed) protein intake over the preceding 24
hours by summating the protein received in PN, milk and fortifiers.
• Aim for protein 3–3.5 g/kg/day if PN, and around 3.5–4.5 g/kg/day if
enterally fed.
• Calculate the actual total energy intake by summating all the energy in
carbohydrates (4 kcal/g), lipids (9 kcal/g) and protein (4 kcal/g) aiming to
provide 110–135 kcal/kg/ day.
• Target the lower range for more mature babies, and the upper range in
the most immature, enterally fed infants.
• Some infants may need higher intakes.
• If standardised solutions are used there is no need to calculate
micronutrient intakes unless the infant is especially complex.

26. E—Environment and evaluation
• Consider the wider environment:
• Is the NICU quiet enough to facilitate kangaroo care?
• Is the mother receiving support for breast milk expression?
• Do dietary intakes meet the needs?
• What does the growth chart look like?
• Discuss your evaluation with the clinical team including
nurses, pharmacists, dietitians, doctors and other members
of the multidisciplinary team.
• Explain the rationale for the use of any supplements and
fortifiers and provide an interpretation of the growth
trajectory for parents.

27. NUTRITIONAL ASSESSMENT IN THE
FUTURE
• The ABCDE approach can be completed at the bedside and used for every
infant on the NICU.
• Despite the importance of good nutritional status for all infants, technical
advances in NICU care rarely address nutrition.
• Newer software could record dietary intakes by simply scanning the bar
code for the fluid (PN or milk) and calculate nutrient intakes by multiplying
by the volume delivered on a syringe pump.
• Intakes could be presented graphically.
• In the next 10 years, we may see the integration of metabolomic techniques
using stool and urine to predict disease such as NEC, as well as bedside
assessment of energy expenditure and body composition.
• Until then, pen, paper and a calculator are all that are needed.

29. THANKS FOR YOUR Attention