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
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