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GROW, BABY GROW GROWING THE PRETERM INFANT IN AND OUT OF THE NICU

Kirsten Frank RD, CSP, LDN, IBCLC

No financial disclosures

Financial Disclosures

Objectives

¨  Review the unique nutritional needs of the preterm infant and some strategies to optimize growth and weight gain

¨  Discuss feeding options for the preterm infant ¤ Optimizing human milk feedings

¨  Examine the recommendations for outpatient care to optimize the growth, weight gain, and development of the preterm infant

Classification

•  Low Birth Weight (LBW) – Less than 2500g

•  Very Low Birth Weight (VLBW) – Less than 1500g •  Extremely Low Birth Weight (ELBW) – Less than

1000g •  Preterm- <37 weeks

•  Late Preterm- 34 through 36 6/7 weeks

•  Early Term – 37 through 38 6/7 weeks

Centers for Disease Control and Prevention: Preterm Birth, Dec 2014

Prevalence of Prematurity

q  Approximately 1 in 9 infants born in the US are preterm ( <37 wks) – 11.4% §  35% of all infant deaths in 2010 were related to

prematurity, it remains the #1 reason for newborn death

•  Leading cause of long-term neurological disabilities in children

Preterm Birth in the USA

¨  Birth rate has tapered after being on a steady rise ¨  Higher than that of most developed nations

Marchofdimes.org, The Serious Problem of Premature Birth

Nutrition Impacts Mortality and Morbidity

¨  Mortality has gone down with more morbidities present with younger babies surviving

¨  Optimal nutritional therapy can help with the severity of morbidities ¤ Feeding human milk, specifically mothers own, during

the NICU stay reduces the risk of short and long term morbidities

¨  The earlier the infant is born prior to their due date the greater their risk for morbidity and malnutrition and the likelihood that not all nutrient deficits will be resolved prior to hospital discharge

Meier, P. Improving the Use of Human Milk During and After the NICU Stay. Clin Perinatol. 2010 March; 37(1):217-245

Nutritional Goals in NICU

¨  Provide nutrients so that postnatal growth match intrauterine accretion rates

¨  Optimize neurodevelopment and long term health ¤ Feed early and aggressively

n Start PN/IL within hours of birth n  Optimize Enteral Nutrition

¨  Prevent Postnatal growth failure ¤ Associated with altered brain function, impaired long term

neurodevelopment and reduced IQ

Postnatal Growth Failure

¨  Common issue despite advances in care with attention to early aggressive nutrition

¨  Many infants experience growth failure at discharge ¨  Weight for Gestational Age <10%

¤ Weight gains <15g/kg/d

¨  Contributing Factors ¤ Conservative or interrupted feedings ¤  Feeding intolerance ¤  Transitional Feeding regimens – TPN, Line access, weaning ¤ Human Milk feedings

Updated Fenton Growth Curves

Grow, Baby Grow

¨  Monitor Growth

¨  Standardize growth measurements ¤ Same scale (bed scale) ¤ Stadiometers ¤ Head Circumference tapes

< 2000 gm

Weight Gain (over 5-7 days) 15-20 gm/kg/day

Length 0.8-1 cm/week

Head Circumference 0.8-1 cm/week

Kleinman RE. ed. Ped Nutrition Handbook 6th ed. AAP 2009

Optimizing weight gain and growth

¨  What is causing decreased rates of growth? ¤  Energy needs exceed energy intake?

n  Transition to enteral or nipple feedings n  Fluid restriction (PDA, BPD, GERD…) n  Malabsorption, Intolerance – feeds held

¤  Decreased protein intake/content of fortified mom’s milk or donor milk

¨  Potential interventions: ¤  Consult the Dietitian ¤  Maximize and optimize parenteral macronutrients ¤  Feed Early – start minimal enteral nutrition (colostrum) ¤  If Mom is breastfeeding, Consult Lactation & Use Hindmilk ¤  Increase volume (160-180ml/kg) ¤  Correct acid-base imbalance ¤  Optimize fortification and Add modulars (protein, MCT oil)

Grow, Baby Grow

¨  Provide and strive to maintain adequate energy and protein intakes

26-30 weeks 30-36 weeks 36-40 weeks

Energy Intake (kcal/kg/day) 126-140 120-130 115-121

Protein Intake (gm/kg/d) 3.8-4.4 3.6-4 3-3.4

Protein:Energy Ratio 3-3.3 2.8-3 2.6-2.8

Rigo J, Senterre, J. Pediatrics 2006;149:S80-S88

Protein:Energy Ratio

¨  Protein (g) divided by 100 calories ¤ Ex. Feeding provide 2.8g/100kcals : PE Ratio=2.8

¨  If energy intake restricted ¤ Protein is utilized for energy ¤  Increased calories may spare protein and improve

nitrogen retention

¨  If protein intake restricted ¤ Energy excess may be used for fat deposition

Standardize Feeding Practices

¨  Suggested TPN goals ¨  Feeding Protocols

¤ Helps minimize variation in practice. n Perception of the severity of illness influence feeds

¤ Facilitates the achievement of nutritional goals ¤ Can help reduce the incidence of NEC

¨  Standardize a plan to manage intolerance ¤  Intolerance Algorithm

n Example

•  Abdominal distention, discoloration, or tenderness •  Dark green or bloody residual (light green is

tolerated) •  Increased Apnea/Bradycardia •  Clinical instability/temp instability •  Bloody stool •  Frequent emesis

Refeed residual and continue normal feeding volume

Not present on exam

2nd consecutive occurrence of large residual

Notify MD/NNP

Present on exam

Notify MD/NNP

No residuals will be checked during the trophic feed period

(≤ 20ml/kg/day)

Normal Abnormal

NPO •  NEC •  Sepsis Evaluation •  Ileus Evalutation

•  Return residual and give full feed •  Return residual and subtract from feeding

volume •  Return residual and hold current feed •  Consider continuous feeding •  Consider reduction of volume by 20%

Feeding Intolerance Algorithm

Large gastric residual is considered >50% of the previous feeding

X-ray

Hansen et al

What to Feed?

•  In order of preference •  All preterm infants should receive Human milk •  Mothers own Milk ideal

•  Pasteurized Donor Human milk should be used if Mothers own milk is not available or it’s use contraindicated •  All human milk should be fortified with protein, minerals and

vitamins to ensure optimal nutrient intake for infants weighing <1500g

•  Infant formula •  Specific to the preterm infant

Breastfeeding and the Use of Human Milk, Pediatrics Vol. 129 No. 3 March 1, 2012

“All preterm infants should receive Human milk”

¨  Lower rates of necrotizing enterocolitis (NEC) ¤ Associated with 58% reduction in the incidence of NEC ¤  Exclusive human milk diet associated with 77% reduction in

NEC ¨  Protects from infection

¤  Lower rates of sepsis

¤ Helps develop immature infant gut (immune system) ¤  During 1st 10 days of human milk more white cells per mL than

there are in blood ¤  Lactoferrin, Secretory IgA, Lysozymes, neutrophils,

interferon, macrophages, neutrophils…


¨  Improved neurodevelopemental outcomes ¤ Higher scores for mental, motor, and behavior

ratings at 18 and 30 months ¤ Longterm studies at 8 years of age indicate that

intelligence test results, white matter, and total brain volume are greater for those who received human milk in NICU

Human Milk


Human Milk

¨  Reduces hospital readmissions in the year after NICU discharge

¨  Improved feeding tolerance : Get to full feeds faster! ¤ Contains its own lipase – improved fat digestion

¨  Associated with lower rates of severe retinopathy of prematurity

¨  Reduces costs associated with prematurity-related morbidities

Breastfeeding and the Use of Human Milk, Pediatrics Vol. 129 No. 3 March 1, 2012. Meier et al. Improving the Use of Human Milk During and After the NICU Hospitalization Clin Perinatol. 2010 Mar; 37(1): 217–245

“Pasteurized Donor Human milk should be used if Mothers own milk is not available”

¨  Contraindications to OMM: HIV, substance abuse (controversial) –certain medications (defer to infant risk center and pediatricians), metabolic syndromes (ie. galactosemia, PKU)

¨  Donor Milk Protocol ¤ Here we provide Donor Milk (after consent):

n <1500gm to 34wks n First 28 days if <1500gm and >34wks

Concerns with Donor Milk

¨  Slow Growth from inadequate nutrient content ¤ Constant composition- Pooled from mostly term mothers ¤ Average protein 0.85 ± 0.08 g/dL ¤ Meta-analysis showed an average daily weight gain of

2.7-3.8 g/kg less for infants fed DHM compared to preterm formula fed infants n Despite standard methods of human milk fortification

¨  Expensive ¤ $5.00/oz

¨  Pasteurization Process – may alter protein structure and impair nitrogen balance

Wagner, J. Donor Human Milk for Premature Infants. ICAN 2013 Vol5 No2

Pasteurization on Human Milk

¨  Holder Pasteurization Method ¤ Held for 30mins at 62.5°C (144.5°F) once center

container reaches temperature, preserves as many of the properties of milk as possible and eliminates viral and bacterial pathogens

Core Curriculum for Lactation Consultant Practice . 3rd ed 2013 Pictures courtesy of www.hmbana.org

Effects of Pasteurization on HM

¨  It eliminates the activity of bioactive compounds by: ¤  22-60% of Secretory IgA and IgG ¤  44-78% Lactoferrin – binds iron, retards bacterial growth ¤  33-69% Lysosyme – attacks bacterial cell walls ¤  100% of Lipoprotein lipase and bile salt activated lipase

¨  Other key nutrients are preserved ¤  oligosaccharides, Vit A, D, E, lactose, and LCPUFA ¤  Epidermal growth factor (EGF) – important for intestinal

maturation


¨  Bioactive Proteins in donormilk, albeit reduced, are still greater than those in infant formula

¨  Pasteurized Human milk has been found to inhibit the adherence of E. Coli to human epithelial cells despite reduction in IgA levels

Effects of Pasteurization on HM


Give it Anyway!

¨  It’s especially crucial for the sick and smallest of preemies ¤  Immune-modulation ¤ Reduction in the incidence of NEC

¨  Close attention to fortification methods and nutrient provision is needed when trying to meet the nutrition needs of preterm infants fed DHM n  Consult the Dietitian and the Lactation consultant

Ziegler, et al, J. Perinatal Med. 38 (2010) Wagner, J. Donor Human Milk for Premature Infants. ICAN 2013 Vol5 No2

Is Breastmilk Enough?

¨  Not by itself: <34-36 weeks ¤  Preterm infants have limited energy stores, high energy

needs, deficient fat stores, high protein needs ¨  Protein, sodium, zinc content decreases slowly over time

¤  Preterm need for these nutrients remains high

¨  Calcium and Phosphorous concentration remain consistent through out lactation but are inadequate to meet the high needs of the preterm infant

¨  Human milk requires fortification to provide nutritional needs of preterm infants

Koletzko et al. Nutritional Care of Preterm Infants. World Review of Nutrition and Dietetics. 2014; Vol 110

Nutrient Needs & Human Milk

Protein (g/kg)

Calcium (mg/kg)

Phosphorous (mg/kg)

Sodium (mEq/kg)

Vitamin D (IU/d)

Iron (mg/kg)

Estimated Needs

3.5-4 120-220 60-140 2-4 400 2-4

PTHM (150ml/kg)

2.1 38 20 1.7 3 0.2

Donor HM (150ml/kg)

1.2 38 20 1.7 3 0.2

Texas Children's Hospital. Pediatric Nutrition Reference Guide 10th Ed. 2013

Dose-Response Relationship

4 Critical Exposure periods ¨  Colostrum

¤  Stimulate rapid growth in intestinal mucosal surface area ¤  Especially for the extreme preemie who was not exposed to

the growth factors in amniotic fluid in the last trimester ¤ Oral swabbing as immune therapy even as NPO

¨  1st 14-28 days post birth ¤  Facilitate closure of paracellular pathways by forming tight

junctions. Tight junctions inhibit the translocation of bacteria

Meier et al. Improving the Use of Human Milk During and After the NICU Hospitalization Clin Perinatol. 2010 Mar; 37(1): 217–245

Dose-Response Relationship

¨  Through NICU Stay ¨  Human Milk after discharge

¤ Associated with advantageous health outcomes during the first 18 and 30 months of age corrected.

¤ Exclusive or high doses of human milk in the NICU associated with lower incidence and severity of morbidities and shorter NICU stay


Hindmilk/Foremilk

¨  Way to increase calories but still needs fortification ¨  The Breast only makes one kind of milk

¤ Dynamic fat content – rich energy source ¨  Lipid concentration varies

¤  stage of lactation ¤  frequency of milk expression ¤  time of day ¤  completeness of breast emptying

¨  Moms pump until first forceful letdown/spray. ¤ Change containers-collect hindmilk

¨  LC can visually asses and tailor pumping methods to optimize output

Bonyata, K. Foremilk and hindmilk – what does this mean? 2011 www.kellymom.com

Human Milk Fortification Options

¨  Acidified Liquid HMF ¨  Hydrolyzed Protein concentrated Liquid HMF ¨  100% Human Milk Fortifier ¨  Hindmilk ¨  30 kcal preterm formula ¨  Preterm and Transitional formula ¨  Macronutrient Modulars

¤ MCT oil ¤ Hydrolyzed liquid protein modular ¤ CHO/FAT modular

Human Milk Analysis

¨  Analysis helps bring clarity to assumptions ¤  Blindly fortify based off

of an assumed nutritional baseline. n  20kcal/oz n  0.9-1gm protein/dL

¨  Milk sample from an “advanced lactation” Mama.

LactoEngineering

¨  May Improve Growth ¤  Recent studies have shown that 58% of VLBW infants fed with

fortified breastmilk have postnatal growth failure ¨  Human Milk Analyzers

¤  Crematocrit –measures lipid/energy content ¤  Spectrophotometry-measures protein, fat, energy, and

carbohydrates ¨  Target Fortification

¤ Variable amounts of fortifier and/or modulars added to provide targeted amounts of nutrients

¨  Adjustable Fortification ¤  Fortifiers/modulars added and adjusted based on lab

indices n  For example: Incremental increases in protein based off of the

BUN Fusch, G. Target Fortification of Breast Milk. J Pediatr 2013;163:1001-7

Lactoengineering Example

(150ml/kg/d) Donor Milk Preterm Human Milk

Protein Content g/kg 1.7 2.1

Addition of HMF (1 vial: 25mL)

3.2 3.6

Addition of liquid protein 4.3 (goal target met with 6mL Liquid protein)

4.3 (goal target met with 4mL Liquid protein)

Acidified Liquid HMF

¨  Promotes enhanced symmetrical growth ¨  Commercially Sterile

¤ Citric Acid ¤ pH ~ 4.7 when mixed with human milk

¨  Concentrated to reduce displacement ¨  Added DHA and ARA ¨  Protein:Energy Ratio – 4 gm/100kcal

Moya et al. Pediatrics. 2012:130

Hydrolyzed Protein Concentrated Liquid HMF

¨  Extensively hydrolyzed protein ¨  Non-acidified, commercially sterile ¨  Lutein and DHA/ARA added ¨  Protein:Energy ratio – 3.6 gm/100kcal ¨  Improved weight gain and protein intake ¨  Low Iron content

100% Human Milk HMF

¨  Fortified with essential minerals ¨  Protein delivery up to 3.7g/100mL of fortified milk ¨  Protein:Energy ratio – 2.8-3.6 gm/100kcal

¨  24-30 kcal/oz ¨  Reduces the odds of developing NEC by 77% in VLBW

infants ¨  Pooled donor human milk, pasteurized and extensively

screened for viruses and bacteria. ¨  Very Expensive: ~ $6/mL

Sullivan S, et al. An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk based products. J Pediatr. 2009:156(4):562-567

30 Calorie Preterm Formula

¨  Approved as a Breastmilk fortifier ¤  Extender-large displacement factor ¤ Could be beneficial with low milk supply ¤  Increases calcium and phosphorus content of human milk to

support growing bones ¨  Does not add to osmolality

¤ Nearly isotonic when mixed 1:1 – 25 kcals/oz ¨  Mixing

¤  2:1 – 23kcals/oz ¤  1:2 – 27kcal/oz

¨  Lower protein:Energy ratio ¤  2.5-2.8 gm/100kcal

Macronutrient Modular

¨  Liquid Protein Fortifier ¤ Extensively hydrolyzed

n Casein Hydrolysate

¤ Sterile ¤ 1 gm protein in 6mL ¤ When 6mL added to 100mL adds 40-50 mOsm/kg

H2O

¨  Can be used with or without fortifiers and can be used in both breastmilk and formula

Macronutrient Modular

¨  MCT Oil ¤ Does not require bile salt or pancreatic lipase for

absorption ¤ Not a source of essential fatty acids ¤  1ml = 7.7kcal & 0.95gm fat

¨  Carbohydrate & Fat ¤ Powdered – Not sterile ¤ Lactose, sucrose, and fructose free ¤ Fat Blend: 35% MCT/65% LCT ¤ 13.9kcals/tsp and 0.62g fat/tsp

NICU Breastfeeding Support

¨  Lactation Technologies to manage Human Milk Feeding issues ¤ Effective, efficient and comfortable breast pump ¤ Creamtocrit/analysis technology – quick, inexpensive,

lipids/calories only ¤ Nipple shield- helps transition to feeding at breast,

allows milk to be removed from breast with immature suction pressures

¤ ac/pc weights- pre and post feeding weights help accurately measure milk intake n 1ml=1gm


NICU Breastfeeding Support

¨  Kangaroo care ¤  Skin to Skin – help increase maternal milk supply

¨  Expert Lactation Support for family and staff ¨  Encouragement from the medical staff

¤  MD vs other care team members ¨  Prevention, identification and management of common human

milk feeding problems should be a priority for NICU care providers and the LC’s of the unit.

¨  Nursing education and Support groups in and out of the NICU ¨  Supportive environments: private rooms – Mom can pump in

privacy with infant present


Infant Formula

¨  Preterm Infant Formula ¤  Liquid-mix systems: 20-30 kcals/oz

¨  Transitional Infant Formula ¤  “Discharge formula”

¨  Standard Infant formula ¨  Treatment Formulas

¤  Semi-elemental: Hydrolyzed proteins ¤  Elemental: Free amino Acids

¨  Specialty & Metabolic Formulas ¤  Inborn Errors of metabolism ¤ Diabetes insipidus, chyle leaks, Renal injury, etc

What makes Preterm Formula Unique?

¨  Higher calorie ¤ Liquid mix Systems

¨  Higher Vitamin and Mineral content ¨  Higher Protein ¨  Higher content of MCT

Standard vs Preterm Formula Standard Infant Formula

(Per 100mL) Preterm Infant Formula

(Per 100mL)

Calories 67 67-100

CHO (gm) 7.4 7-7.8

CHO Source Lactose, Galacto-oligosaccharides Lactose, Corn Syrup Solids

Fat (gm) 3.6 3.7-6.7

Fat Source Palm Oil, Soy, Coconut, High oleic Oil, DHA/ARA

50% MCT, 30% Soy, 18% Coconut oil

Protein (gm) 1.4 2-3

Protein Source Milk protein isolate, whey protein concentrate

Nonfat milk, whey protein concentrate

Calcium (mg) 53 122-183

Phosphorous (mg) 29 68-101

Vitamin D (IU) 41 101-152

Sodium (mEq) 0.8 1.3-1.9

Potassium (mEq) 1.9 2.2-3.4

Iron (mg) 1.2 1.2-1.8


Vitamins/Minerals Supplementation

Preterm Infant Receiving

Weight/issue MVI/Iron (suggested)

Iron Goal (mg/kg/d)

Vit D Goal (IU/day)

Fortified HM (Bovine) or preterm formula

None 2-4 400

Fortified BM (Bovine) or preterm formula

Osteopenia Alk Phos >800

1 ml Vit D (400iu) 2-4 800

Non Fortified HM <2500g 2 mg/kg Fe 1mL MVI

2-4 400

Non Fortified HM >2500g 1 mL MVI w/ Fe 2-4 400

Transitional Formula <5kg 0.5 mL MVI with or without Fe

2-4 400

Transitional Formula >5kg or >6 months

none 2 400

Term Formula < 3kg 0.5mL MVI w/ Fe 2-4 400


¨  At 150ml/kg of transitional formula an infant would receive approximately 2mg/kg of iron

Potentially Better Practices in our unit to help grow babies ¨  Minimal Enteral Nutrition on DOL #1 for stable infants

¤ Within 4 days on all infants ¤ MEN during Indocin/ibuprofen treatment for PDA

¨  Feeding protocols and intolerance algorithm ¨  Donor milk ¨  Interdisciplinary rounding

¤  RD provides macronutrient provision, growth, and interventions

¤  Focus infants <1500g and <10% ¨  Hindmilk-fortification process

¤ Avoid powders

Get them Growing in the NICU

¨  Feed early and aggressive ¨  Standardize Feeding practice and how to handle

intolerances ¨  Increase the dose and exposure to human milk

¤  Encourage Mom to provide breastmilk ¤  Provide expert lactation care and human milk feeding support to

family and staff ¤  Prioritize the initiation, establishment, and maintenance of

maternal milk volume ¤  Utilize lactation technologies to manage issues

¨  Fortification of human milk is necessary and analysis crucial ¨  Affordable Analyzer needed for target fortification ¨  Close outpatient followup


Discharge

¨  Most infants are around 1800-2000gm and generally >35 weeks CGA at discharge though there is no universal standard for specific gestational age or weight at discharge ¤ Depends on physiologic maturity and parental/

caretaker readiness ¨  Work with discharge coordinator to provide special

recipes, instructions and/or counseling regarding infant’s individual nutritional needs

¨  Need close follow up at discharge

Discharge

¨  Parameters of physiological maturity related to nutrition include: ¤ Ability to maintain adequate body temperature in an

open bed ¤  Adequate lab indices

n  For example: hemoglobin and hematocrit levels (or evidence of adequate retic activity)

¤ Appropriate growth and weight gain from nutrition regimen (hopefully by po feeding)

Nutrition Goals at Discharge

¨  Provide nutrients to optimize growth and bone mineralization and promote a pattern of weight gain and growth that supports appropriate catch up growth

¨  Optimize and promote human milk feedings ¤  Infants will still have a degree of immaturity and may

have difficulty with latch, suck, and swallow

¨  Minimize nutrient deficits ¨  Avoid Overfeeding

Discharge Planning

¨  Ideally home nutrition plan in place approx 5 days before discharge ¤ Transition to home orderset ¤ Adjust/Modify regimen as needed while remaining

under close inpatient supervision if growth falters ¤ Allows time to evaluate intake, tolerance and growth on

d/c regimen ¨  Documented growth at least 48hr prior to d/c ¨  For infants being d/c’ed with postnatal growth

failure a more individualized nutrition intervention may be warranted

Growth after Discharge

¨  Carefully Monitor weight gain velocity and linear growth

¨  Growth charts ¤  Fenton charts trough 50 wks CGA ¤  Transition to the WHO growth standards and correct for

prematurity through 24months ¤ Don’t use the CDC growth charts

¨  Preterm infants may show rapid weight gains (30-35gm/d) from 38-48wks corrected gestational age (their term counterparts usually see this type of rapid intrauterine growth from 32-36 weeks)

Growth Rate Recommendations

Age Weight (g) Length (cm/wk) Head Circ (cm/wk)

Preemie < 2 kg 15-20 g/kg/d 0.8-1.1 0.8-1

Preemie > 2kg 20-30 g/day 0.8-1.1 0.8-1

0-4 months 23-34 g/day 0.8-0.93 0.38-0.48

4-8 months 10-16 g/day 0.37-0.47 0.16-0.2

8-12 months 6-11 g/day 0.28-0.37 0.08-0.11


Nutritional Needs for the Growing Preterm Infant

Nutrient/kg/day Units Enteral

Energy Kcal 105-130

Protein Gm 3.5-4

Calcium Mg 100-220

Phosphorus Mg 60-140

Iron Mg 2-4

Vitamin D IU/day 150-400

¨  Average daily energy and protein needs to support catch up growth will generally exceed that of normal term newborn

¨  Not all infants will require those large amounts of calories and protein for catch up growth

¨  Closely monitor growth and transition to DRI’s if needed Texas Children's Hospital. Pediatric Nutrition Reference Guide 10th Ed. 2013

Growth & Weight Gain

¨  Feeding volumes should be given to achieve recommended growth (at least 20g/day) ¤ Min intake 120ml/kg (hydration and some nutrition)

¨  High caloric density feedings may be warranted for infants whom were born very premature and/or cannot tolerate larger volumes due to pulmonary, cardiac, hepatic, renal, GI or neurological dysfunction ¤ Fortified Human Milk ¤ Transitional “Discharge” premature formula

Breastfeeding at Discharge

¨  Morbidity risk factor for re-hospitalization ¨  Pre-discharge planning and education is key to

breastfeeding success ¨  Progression of breastfeeding while admitted

depends on the infants feeding ability and mothers availability ¤ Utilize the LC’s to help individualize feeding plan/

strategies


¨  Factors to consider for discharge: ¤ What is Mom’s breastfeeding plan? ¤  Infants nutrients needs and growth trends

n  HMF is not recommended after discharge n  Discontinue HMF for infants weighing >2kg and >34wks CGA

¤  Encourage at the breast feedings n  2-3 feedings/day of fortified 22-24kcal/oz milk or preterm

formula ¤ Oral feeding ability

n  Nipple shield needed? ¤ Need for test weighing procedures (AC/PC weights) ¤ Need for on-going pumping at home to protect milk supply



¨  Provide realistic timeframe ¨  Many mothers of preterm infants incorrectly think they

will be discharged exclusively breastfeeding ¤  Education important to stress importance of ongoing

fortification – Most, but not all, require it ¤  Breastfed infants may be more likely to transition exclusively

to the breast ¨  Should continue to pump at least 1 month after

discharge to protect/maintain milk supply as baby may not be a good po feeder

¨  Better developmental outcomes have been seen for infants who were breastfed in the NICU and for 2 months post discharge

Formula Feeding at Discharge

¨  Premature transitional formula is recommended: ¤  Birth weight <1800gm ¤  Poor growth ¤  Fluid restriction ¤ Abnormal labs

¨  Transitional formula is 22kcal/oz at standard dilution with P:E ratio of 2.8gm/100kcal ¤  Increased Iron, Vit D, Calcium, Phosphorus, sodium and

potassium

¨  May be provided through 6-9months corrected age.

Formula Feeding at Discharge

¨  Transitional formula has been shown to promote better linear growth, weight gain, and bone mineral content than a standard term formula

¨  Monitor growth trends and intakes closely as well as biochemical indices as indicated

¨  Infants may demonstrate catch up growth quickly after discharge

¨  May be changed to a standard term formula between 48-52 weeks CGA if weight, length and weight-for-length are all at the 25%ile for age

Multivitamins at Discharge

¨  At full term size (approximately 4kg) the need for micronutrient supplementation decreases ¤  If premature issues like osteopenia have resolved

¨  Infants receiving breastmilk and fortified breastmilk should remain on Vitamin D and Iron ¤ 400IU/day of Vitamin D3 ¤ 2-4 mg/kg IronPts on BM need iron supp

Catch Up Growth

¨  Velocity of weight gain is higher than what is expected for age ¤ Around term corrected age velocities would

approximate the velocities of term infants

¨  Hard to achieve without excessive feeding and fat gain

¨  What are the long term consequences of catch up growth?

Fetal Origins of Adult Disease

¨  Excessive weight gain patterns may predispose the infant to adverse health consequences such as diabetes, cardiovascular disease and metabolic syndrome later in life

¨  However, Improved nutrient intake that leads to catch up growth is responsible for improvement in neurocognitive development/outcomes.

¨  Doubled edged sword: ¤  Grow poorly but avoid potential adult disease at the expense

of neurodevelopement ¤  Catch up in weight and growth, be heavier but smarter

Singhal A, Lucas A. Lancet. 2004;363:1642-5

Solid Food Introduction

¨  In the NICU: Meet the infant’s developmental milestones, not nutrient needs. Nutrient needs are met through breastmilk and/or formula intake.

¨  The AAP recommends that solid foods be introduced at 6 months of age. ¤  For preemies: 6 Months corrected gestational age

¨  Signs of readiness: ¤ Medically stable ¤ Not at risk for aspiration and has functional swallow ¤ Able to sit with support ¤ Good head and Neck control


Solid Food Introduction

¨  Solid Food Feeding Recommendations ¤  Introduce single ingredient baby appropriate foods one

at a time and continue 3-5 days before trying a new food

¤ May use single meat or iron fortified rice cereal ¤ Single ingredient vegetables or fruits

¨  May consider an occupational therapy consult to assess and assist with developmental appropriateness and solid food introduction


In Summary at Discharge

“It takes a village to raise a child…” ¨  Interdisciplinary approach

¤ Consult a Dietitian n  Ideally someone who is a Board Certified Specialist in

Pediatric Nutrition ¤ Consult a Lactation consultant (IBCLC)

¨  Keep home fortification strategies simple for family to utilize. ¨  Support the mother infant dyad/family ¨  Use corrected age for assessment and recs ¨  Utilize the appropriate growth chart ¨  Encourage Breastfeeding ¨  Monitor Micronutrient needs

Overall…

¨  Smaller and sicker infants are now surviving thanks to more sophisticated neonatal medicine and surgery (and nutrition)

¨  Better nutritional support is associated with improved growth which in turn is associated with improved neurodevelopmental outcomes

Additional References

¨ Thomas K. McInerny, MD, FAAP, ed. 2009. Textbook of Pediatric Care. Elk Grove Village, IL. American Academy of Pediatrics. ISBN 1-58110-268-2, ISBN 978-1-58110-268-0.

¨ Koletzko et al. Nutritional Care of Preterm Infants. World Review of Nutrition and Dietetics. 2014; Vol 110

¨ Texas Children's Hospital Pediatric Nutrition Reference Guide 10th ed. 2013

¨ ADA Pocket Guide to Neonatal Nutrition, Groh-Wargo et al. 2009

¨ Core Curriculum for Lactation Consultant Practice . 3rd ed 2013

THANK YOU!

[email protected]

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