Symposium 3

“Fl id d N t iti S t f th“Fluid and Nutrition Support of the Pre-term Infant in the First Week

of Life”

Enteral nutritional support in the t i f t d i th fi tpreterm infant during the first

weeks of lifeweeks of life

Caroline KingPaediatric DietitianPaediatric Dietitian

Hammersmith Hospital

Areas to cover

• Type of enteral feed (milk)• When to start enteral feeding• Minimal enteral feeding• Minimal enteral feeding• Rate of feed increase• Continuous vs bolus

To begin: what is overall aim

• Obviously aiming for growth and development through optimal nutrition

Development of the cortex 24 k t t24 weeks to term

Courtesy of Mary Rutherford MRI Unit Hammersmith Hospital

To begin: what is overall aim

• But and overriding influence is to avoid nectrotising enerocolitis (NEC)

Necrotising enterocolitisNecrotising enterocolitisImmature gut

-mucosal

-motility

H iHypoxia

Substrate (milk)

Overgrowth of abnormal gutabnormal gut flora

genetics

Type of milk ?

First choice for enteral feed

• Human milk• Preferably mothers own • If not donor milk from a milk bank• If not donor milk from a milk bank

Human milk decreases riskHuman milk decreases risk necrotising enterocolitisnecrotising enterocolitis

• Lucas & Cole Lancet 1990

• Beeby & Jeffrey Arch Dis Child 1992

• Schanler et al Pediatr 1999

• McGuire Arch Dis Childh 2003 vs

i h• McGuire Cochrane review

Human milk decreases risk ofHuman milk decreases risk of infectioninfection

• Schanler et al Peds 1999Schanler et al Peds 1999

• Hylander et al Peds 1998y

• El-Mohandes et al Ped Res 1995

• El-Mohandes et al J.Perinatol 1997

• See also de Silva et al Arch Dis Childh 2004

©

Human milk; other effects

• Balanced LCPsced C s• Optimal amino acid profile• Increases lactase activity• Increases lactase activity• Metabolic adaptation enhanced• Promotes maturation of gut motor

functionfunction• Faster gastrointestinal transit

Human milk and days to full enteralHuman milk and days to full enteral feeds

50

354045

202530

5101520

05

Donor Human Milk Preterm Formula Term Formula

Quoted by Lucas in Rennie & Roberton 1999©

Human milk and long termHuman milk and long term effectseffects

• Lower blood pressure– Singhal et al Lancet 2001

• Improved lipid profileSinghal et al Lancet 2004– Singhal et al Lancet 2004

• Ameliorates detrimental effects of poor h d l lgrowth on neurodevelopmental outcome

– Lucas et al Arch Dis Childh 1994Lucas et al Arch Dis Childh 1994

Other milks

• Protein hydrolysates• Have been used in belief that reduce risk

NEC – no evidence• Belief that easier to digest- but no

advantage over human milkadvantage over human milk – prot digestion ok

lactase induced with feeding– lactase induced with feeding– Lipid most problematic – human milk BSSL

When to start ?

When to start?

• GI motor development lags behind t t lstructural

• Leads to high amount of anti peristalsisg p• Therefore high risk of poor tolerance of

enteral feedsenteral feeds– aspirates (can be bile stained-but not indication

of obstruction)of obstruction)

– poor GI motility ( abdo dist)

When to start?

• However giving enteral feeds appears to accelerate GI motor development compared to nil by mouthy

• Berseth et al

Enteral Feeds Normalise ImmuneEnteral Feeds Normalise ImmuneEnteral Feeds Normalise Immune Enteral Feeds Normalise Immune Function on TPNFunction on TPN

• Okada et al, J Pediatr Surg (1998)

10 infants on PN 10 infants on PN Pl t lPl t lPlus enteral Plus enteral trophic feedtrophic feed

10 infants on 10 infants on PN PN

No enteralNo enteral

9 controls9 controls

No enteralNo enteral

Blood sample Blood sample takentaken

Innoculated with Coagulase Innoculated with Coagulase Negative StaphNegative Staph

Tested for TNF

Tested for Tested for Bacteriocidal Bacteriocidal

activityactivityNegative StaphNegative Staphalfa activityactivity

Enteral Feeds Normalise ImmuneEnteral Feeds Normalise ImmuneEnteral Feeds Normalise Immune Enteral Feeds Normalise Immune Function on TPNFunction on TPN

Results:

• TPN alone poorest immune function– poorest immune function

– Lowest bactericidal activity and TNF α

• Immune function significantly improved with trophic feeding

Minimal enteral feedingg

Also known as:

Trophic feedingp gGut priming

l i f diHypocaloric feeding

Clinical outcomes

T hi f d f ll f d• Trophic feeds for parenterally fed preterm infantspreterm infants

Cochrane Review Tyson & Kennedy 2005• Diamond to the left favours trophic feeding

Days to full enteral feedingCochrane Review Tyson & Kennedy 2005

Days hospital stayCochrane Review Tyson & Kennedy 2005

Days phototherapyC h R i & d 200Cochrane Review Tyson & Kennedy 2005

Incidence of NECC h R i & d 200Cochrane Review Tyson & Kennedy 2005

Rate of increase ?

Rate of increase contentious

• Some suggest up to 35ml/kg/day

• Others that should stay at trophic levels• Others that should stay at trophic levels (~20ml/kg) for first 10 days– otherwise risk NEC

Rate of increase contentious

• Why differences?• Different populations

Rate of IUGR– Rate of IUGR– Socioeconomic

• Different rates of maternal breast milk• Different rates of skin to skin of mum andDifferent rates of skin to skin of mum and

baby – enteromamary pathway

Rate of increase contentious

• Common for nursing staff to be consulted• They are in close contact with baby and

sensitive to changes in condition and feed gtolerance

• IndicatorsIndicators – Stooling pattern

Abdominal girth– Abdominal girth– Gastric aspirates

How is feed tolerance measured?

• Gastric aspirates – what defines intolerancep– “small” (up to 10% of feed volume)

>20%– >20%– >50%– >2 ml– >3 ml– “excess”

• No niform consens s• No uniform consensus• NB Rate of secretion in term neonate 7 ml /h

P t l t l f d i t dP t l t l f d i t dPoor tolerance enteral feeds- associated with

Poor tolerance enteral feeds- associated with

L t ti• Low gestation

• Morphine• Morphine

• Birth asphyxiap y• Berseth & McCoy, Pediatr (1992)

Poor tolerance enteral feedsPoor tolerance enteral feeds• Cisapride – no longer in use in UK

Poor tolerance enteral feedsPoor tolerance enteral feedsp g

helps - not RCT Melis & Janssens, Acta Gast Bel (1990)

hi d RCT Cl l A h i Child (1999)hinders RCT McClure et al, Arch Dis Child (1999)

• Erythromycinhelps - not RCT Ng et al J Paed Chil H (1997) &helps - not RCT Ng et al, J.Paed Chil H (1997) &

Kubota et al, Acta Paed Jap (1994)

no help RCT Stenson et al Arch Dis Child (1998)no help RCT Stenson et al, Arch Dis Child (1998)

Glycerine chips ?Glycerine chips ?

New study

• Attempt to answer question

• In high risk infants is it safer to withhold• In high risk infants is it safer to withhold enteral feeds or to start – cautiously?

• ADEPT multi centred RCT in the UK• ADEPT multi centred RCT in the UK

Bolus vs continuous ?

Clinical outcomes.

C i i ilk f di• Continuous nasogastric milk feeding versus intermittent bolus milkversus intermittent bolus milk

feeding for premature infants less than 1500 grams

Cochrane Review Premji & Chessell 2003Cochrane Review. Premji & Chessell 2003

B l i f diBolus vs continuous feedingPremji & Chessell 2003

• Days to full enteral feeds• Days to full oral feeds• Days feed stopped due to intolerance• Days feed stopped due to intolerance• Hours NBM per day• Days of parenteral nutrition

Di d t i ht f b l• Diamond to right favours bolus

Bolus vs continuous feedingPremji & ChessellPremji & Chessell

Bolus vs continuous feedingBolus vs continuous feeding

• In UK most common practice is bolus

• Some evidence for promotion of cyclic gut• Some evidence for promotion of cyclic gut hormone surges which may be of benefit?

Continuous Feeds- draw backs

• Risk contamination from lengthy hang time- Lemons et

al, Am J.Perinatol, (1983)

• Fat Loss - Narayanan et al, Arch Dis Child, (1984)

• Sedimentation of any additivesy

• Takes more nursing timeTakes more nursing time

Slide Courtesy of N. Wight MD, IBCLC, Neonatologist Sharp Mary Birch Hospital for Women and Children California