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Newborn nutrition and growth


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Newborn nutrition and growth

  1. 1. NewbornNutrition Dr Varsha atul ShahDepartment of NeonatologySingapore General Hospital
  2. 2. Newborn nutrition Newborns adapt rapidly from a relatively constant intrauterine supply of nutrients to intermittent feeding of milk Normal, full-term newborns double their birth-weight by about 5 months of life and triple their birth-weight by 1 year of life
  3. 3. Principles of nutritional support From 24/52 to 39/52 gestation fetal growth increases at a rate of approximately 15 g/kg/D Term neonates loss about 5 to 10% of their birth-weight in the first 10 days to 2weeks of life Preterm infant loss 10 to 20% of their birth-weight because of their immature skin and kidneys, regain BW by 7-14 days Term infants have sufficient glycogen and fat store to meet energy demands while preterm infants rapidly deplete their limited endogenous nutrient store and hence become hypoglycaemic and catabolic
  4. 4. How to assess nutrient requirement in preterm infants? Use intrauterine growth charts Use nutrient accretion rate data
  5. 5. Nutritional GoalTo achieve normal growth and development
  6. 6. Nutrient requirementsEnergy (Eintake = E stored + Eexpended + Eexcreted ) Healthy term babies grow well with intake of 90-120 kcal/kg/D 125 - 140 kcal/kg/D is the energy required by preterm infants to achieve a growth rate of 15 g/kg/D Conditions that result in increased energy requirements include; CLD, steroid therapy and infection etc
  7. 7. Nutrient requirementsWater Infant’s water requirements depend on gestational age, postnatal age and environmental conditions (phototherapy, radiant warmer) Term infants ingest 140-180 mls/kg/D of fluid Preterm infants may require fluid intake of up to 200 ml/kg/ D in the first week of life. Conversely fluid restriction may be necessary for infants with RDS, CLD CHF, PDA or renal insufficiency
  8. 8. Protein Recommended allowance:15-20 % of daily calories If energy intake is low, dietary protein cannot be utilized fully for tissue synthesis hence azotemia can occur Term infants : 2.2 g/kg/D can be achieved through VLBW infants: 3-3.5 g/kg/D protein supplement ELBW infants: 3.6-3.8 g/kg/D eg. Promod
  9. 9. Fat Recommended daily intake: 50% of daily calories for preterm infants <1750 grams, 30-40% for term and more mature infants Fat intake of > 60% of total calories may lead to ketosis EFA must be provided in the diet Preterm infants vulnerable to EFA deficiency because of insufficient fat absorption, increased fat requirement and rapid brain growth and myelinization and limited adipose reserves Fat digestion and absorption is limited in preterm infants because of bile salt deficiency secondary to reduced synthesis and ineffective ileal resorption of bile acids
  10. 10. Carbohydrates Carbohydrate constitute 40-50% of total daily calories Almost all the CHO in the human milk and infant formula is lactose Preterm formula contains 50% lactose and 50% glucose Intestinal mucosal lactase activity is active by the 28th week. Glycosidase activity is also active in preterm infants hence these infants tolerate preterm formula
  11. 11. Minerals Accretion of Ca, Phosphorus, Mg and iron is maximal at the third trimester of pregnancy. Preterm infants are prone to mineral deficiency because of this as well as difficulty in estabilizing aedquate enteral intake of the early weeks of life. The daily recommended allowance for preterm infants : Sodium/Potassium : 2-3 mEq/kg/D Ca : 210 mg/kg/D Phorphorus : 140 mg/kg/D Magnesium : 10 mg/kg/D
  12. 12. The quantity of iron in the breast milk isless compared to infant formula.
  13. 13. Vitamins Are essential metabolic cofactors Toxicity can occur with fat-soluble vitamin because it can be stored in the tissues Toxicity with water-soluble vitamin is unusual because of high renal clearance and low storage capacity Vitamin content in breast milk changes with course of lactation Preterm infants have no reserve for vitamins, hence prone to deficiency
  14. 14. VitaminsDaily recommended intake: Vitamin A : 1500 iu/kg/D Vitamin D : 400 iu/kg/D Vitamin E : 6-12 iu/kg/D Vitamin K : 0.5-1 mg
  15. 15. Trace elements Are accumulated during the third trimester, hence preterm infants are prone to deficiency states Most preterm formula have adequate amount of trace elements.
  16. 16. Types of enteral feedsHuman milk (provides 67 kcal/100 ml)Infant formula (provides 67 kcal/100ml)Preterm formula (provides 81 kcal/100 ml)Transitional formulaSpecialized formula eg. PregestimilAnti-reflux formulaSoy formulaLactose free formula
  17. 17. Soy protein-based formula is NOT indicated in: baby <1800g
  18. 18. Additives to Infant Formula Nucleotides LCPUFAs Taurine Iron Prebiotics Probiotics (bifidobacteria, lactobacillus, saccharomyces, streptococcus thermophilus)
  19. 19. Enteral feeding method Breast feeding Bottle feeding Oral gastric feeding Naso-gastric feeding Transpyloric feeding
  20. 20. Human milk It is the preferred milk for term infant When fortified, it is also the nutritionally optimal diet for preterm infants Milk produced by women who delivered prematurely contains increased amount of protein, sodium and zinc but decreased amount of Vitamin A. The composition changes to approach that of term milk after a few weeks Human milk contain factors protective of infection – leucocytes, immunoglobulins, lactoferrin, lysozymes and complement
  21. 21. Human milk Human milk has growth and differentiation factors that may promote intestinal maturation (epidermal growth factor) Human milk also contain enzymes eg bile salt-stimulated lipase Composition of breast milk varies with mother’s health and nutritional status Protein, sodium, mineral and immunoglobulin contents are highest in colostrum, intermediate in transitional milk and lowest in the mature milk ‘Hindmilk’ (milk expressed at the end of a feeding) has the highest fat
  22. 22. AAP Recommendations for Breastfeeding Human milk for all infants from 0-6 months Breastfeeding to begin within 1 hour of delivery Frequent nursing 8-12x/day No supplements unless medically indicated Start weaning after 4-6 months Introduce each food type gradually Human milk plus solid food from 6-12 months Reduce milk feeds correspondingly
  23. 23. Benefits of Breastfeeding Infant  Nutritional composition-less obesity  Growth and development-improves cognitive function  Acute illness-reduces diarrhoea,otitis media, pneumonia  Chronic diseases-reduces atopy, allergies Maternal effects  Body composition and metabolism  Reduces breast and ovarian cancer  Reduces perimenopausal osteoporosis and fracture  Child spacing Economic factors Psychosocial aspects-skin to skin contact, bonding
  24. 24. Contraindications to Breastfeeding Miliary TB Cancer of breast Galactosemia Maternal drug abuse Maternal medication eg. chemotherapy Maternal HIV infection
  25. 25. Problems associated with Breastfeeding Underfeeding Vitamin K low- higher incidence of hemorrhagic disease of the newborn Iron low- need to supplement if still on full breastfeeding after 6 months Prolonged unconjugated hyperbilirubinemia
  26. 26. Recognised benefits of breastfeeding include all ofthe following EXCEPT:Lesser risk of haemorrhagic disease of thenewborn.
  27. 27. Nursing Feeding Guidelines Choice of nutrition for newborn is in accordance to the parent’s wishes Breastfeeding should always be encouraged Consult mother before offering formula milk to infant
  28. 28. Feeding of Healthy Newborn
  29. 29. Full term healthy baby required  90 – 120 kcal / kg / day Intake of fluid targeted at  140 – 180 ml / kg / day
  30. 30. Benefits of breast milk to the baby Breast milk and human colostrum are made for babies and is the best first food Easily digested and well absorbed Contains essential amino acids Rich in polyunsaturated essential fatty acids Carbohydrate content in human milk is higher than cow’s milk. Better bioavailability of iron and calcium Lesser risk of haemorrhagic disease of the newborn The quantity of iron in the breast milk is less compared cow’s milk formula.
  31. 31. Problems associated with Breastfeeding Underfeeding Vitamin K low- higher incidence of hemorrhagic disease of the newborn Iron low- need to supplement if still on full breastfeeding after 6 months Prolonged unconjugated hyperbilirubinemia
  32. 32. Contraindications to Breastfeeding  Miliary TB  Galactosemia  Maternal drug abuse  Maternal medication eg. chemotherapy  Maternal HIV infection
  33. 33. Nursing Feeding Guidelines Choice of nutrition for newborn is in accordance to the parent’s wishes Breastfeeding should always be encouraged Consult mother before offering formula milk to infant
  34. 34. Benefits of breast milk (contd.) Protects against infection Prevents allergies Better intelligence Promotes emotional bonding Less heart disease, diabetes and lymphoma
  35. 35. Protection against infection 1. WBC in 1. Mother mother’s infected body make antibodies to protect mother 1. Some WBCs go to breast1. Antibody to and make mother’s infection antibodies secreted in milk to there protect baby
  36. 36. Benefits to mother Helps in involution of uterus Delays pregnancy Decreases mother’s workload, saves time and energy Lowers risk of breast and ovarian cancer Helps regain figure faster
  37. 37. Benefits to family Contributes to child survival Saves money Promotes family planning Environment friendly
  38. 38. Anatomy of breast Myoepithelial cells Epithelial cells ducts Lactiferous sinus Nipple Areola Montgomery gland AlveoliSupporting tissueand fat
  39. 39. Physiology of lactation Hormonal secretions in the mother  Prolactin helps in production of milk  Oxytocin causes ejection of milk Reflexes in the baby – rooting, sucking & swallowing
  40. 40. Prolactin productionEnhanced by How early the baby is put to the breast How often and how long baby feeds at breast How well the baby is attached to the breast
  41. 41. Prolactin reflexHindered by Delayed initiation of breastfeeds Prelacteal feeds Making the baby wait for feeds Dummies, pacifiers, bottles Certain medication given to mothers Painful breast conditions
  42. 42. Prolactin “milk secretion” reflex Enhancing factors Hindering factors Emptying of breast Bottle feeding, Sucking Incorrect positioning, Painful breastExpression of milk Night feeds Prolactin in Sensory impulse blood from nipple
  43. 43. Oxytocin “milk ejection” reflexOxytocin contractsmyoepithelial cells Sensory impulse from nipple to brain Baby sucking
  44. 44. Oxytocin reflex Stimulated by Inhibited by•Thinks lovingly of baby •Worry•Sound of the baby •Stress•Sight of the baby •Pain•CONFIDENCE •Doubt
  45. 45. Feeding reflexes in the baby Rooting reflexMother learns to position Sucking reflexbaby Baby learns to take breast Swallowing reflex
  46. 46. Composition of preterm and full term milk (g/dl) Full Term Preterm Fat 3.5 3.5 1.0 Protein 2.0 7.0 Lactose 6.0
  47. 47. How breast milk composition varies Colostrum Foremilk Hindmilk FatProtein Lactose
  48. 48. For successful breastfeeding A willing and motivated mother An active and sucking newborn A motivator who can bring both mother and newborn together ( health professional or relative )
  49. 49. Successful breastfeeding Have a written breastfeeding policy Motivate mother from antenatal period Put to breast within 30 minutes of birth Promote rooming -in of mother and baby Promote frequent breastfeeding
  50. 50. Successful breastfeeding (contd.) Don’t give prelacteal feeds Don’t use bottle to feed Support mother in breastfeeding the baby Arrange mother craft classes in health facilities Treat breastfeeding problems early Exclusive breastfeeding till 6 months Addition of home-based semisolids after 6 months
  51. 51. Position of baby in relation to the mother The baby’s whole body should face the mother and be close to her The baby’s head and neck should be supported, in a straight line with his body, to face the breast Baby’s abdomen should touch mother’s abdomen, to be as close as possible to his mother
  52. 52. Signs that a baby is attached well at the breast  The baby’s mouth is wide open  The baby’s chin touches the breast  The baby’s lower lip is curled outward  Usually the lower portion of the areola is not visible
  53. 53. Signs that a baby is attached well at the breast lower lip is curled outward baby’s mouth is wide openchin touches lower portion ofthe breast the areola is not visible
  54. 54. Treatment of inverted nippleTreatment should begin after birth Syringe suction method Manually stretch and roll the nipple between the thumb and finger several times a day Teach the mother to grasp the breast tissue so that areola forms a teat, and allows the baby to feed
  55. 55. Sore nippleCauses Incorrect attachment : Nipple suckling Frequent use of soap and water Candida (fungal) infectionTreatment Continue breastfeeding and correct the position & attachment Apply hind milk to the nipple after a breastfeed Expose the nipple to air between feeds
  56. 56. Breast engorgementCauses Delayed and infrequent breastfeeds Incorrect latching of the babyTreatment Give analgesics to relieve pain Apply warm packs locally Gently express milk prior to feed Put the baby frequently to the breast
  57. 57. Causes of “Not enough milk” Not breastfeeding often enough Too short or hurried breastfeeding Night feeds stopped early Poor suckling position Poor oxytocin reflex (anxiety, lack of confidence) Engorgement or mastitis
  58. 58. Management of “Not enough milk” Put baby to breast frequently Baby to be correctly attached to breast Build mother’s confidence Use galactogogues judiciously Adequate weight gain and urine frequency 5-6 times a day are reliable signs of enough milk intake
  59. 59. Expressed breast milkIndications Sick mother, local breast problems Preterm / sick baby Working motherStorage Clean wide-mouthed container with tight lid At room temperature 8-10 hrs Refrigerator – 24 hours, Freezer - 20° C – for 3 months
  60. 60. Ten steps to successful breastfeedingEvery facility providing maternity services and care for newborn infants should Have a written breastfeeding policy that is routinely communicated to all health care staff Train all health care staff in skills necessary to implement this policy Inform all pregnant women about the benefits and management of breastfeeding
  61. 61. Ten steps to successful breastfeeding (contd….) Help mothers initiate breastfeeding within half hour of birth Show mothers how to breastfeed, and how to maintain lactation even if they are separated from their infants Give no food or drink, unless medically indicated Practice rooming-in : allow mothers and infants to remain together 24 hrs a day
  62. 62. Ten steps to successful breastfeeding (contd….) Encourage breastfeeding on demand Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital.
  63. 63. Bottle FeedingParents can share caring for newbornHigher incidence of allergic reaction(cow)Problem with powder concentrationCow milk not acceptable for infant feeding.Too much protein,calcium,phosphate, sodium,potassium
  64. 64. Parenteral Nutrition (PN) Infused via peripheral or central veinIndication: When extended period >7days of inability to take enteral feedings