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Nutrition in premature infants

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					Nutrition in premature infants

         David Hilmers
       December 10, 2007
                 Objectives
   Discuss the goals for growth in premature
    children
   Describe the special nutritional
    requirements in premature children
   Outline options for formulas and caloric
    density that can be used
   Strategies to advance diets and meet
    nutritional goals in premature children
                         Case
   Patient is a 4 mo former 28 week premature girl
    recently sent home from the BT NICU. She is at
    MLK today for her first followup visit. Her
    weight is 2.5 kg Her problem list is a long one
    but includes:
       BPH s/p trachesotomy takedown
       CHF
       Renal insufficiency
       GERD
   She has experienced poor weight gain and is
    well below the 3%ile for both height and weight
   What is your nutritional plan for this child?
    Conditions leading to poor feeding

   Preterm birth
   Prolonged and complicated nursery course
   Neurodevelopmental deficits leading to suck-
    swallow problems
   BPD, CHF, GERD
   Lack of parental skills, misconceptions
   Poor parental bonding
   Child abuse and neglect
    Catch up Growth and Nutrition
   Catchup growth usually occurs after discharge
    and by 12-18 mos differences are minimal from
    full term infants
   Breast milk is optimum for babies; however,
    requires fortification and supplementation in
    high-risk babies
   Premature formulas have extra calories, protein,
    Fe, Ca, P, Mg, Cu, Zn, vits B2, B6, D, E, and K
    that may be lacking in breastmilk
   Recommend 137-165 kcal/kg in preterm infants
    and higher if chronic lung disease and growth
    failure
               Weight gain goals
   Daily weight gain normally lower than age-
    matched infants
       20-30 gms per day
   Excessive weight gain post-discharge has been
    associated with increased risk of diabetes,
    hypertension, and obesity later in life for both
    premature babies and babies who are IUGR
             Nutritient requirements
   Daily vitamin requirements in premies weighing
    1800-2000 gms are similar to term infants,
    except for Vits D and E
       Vit E rqmt can be met with standard formulas
       Vit D, Ca, and P are NOT met with BM or standard
        formulas
            1 cc of multivitamin solution recommended until body weight
             is 3.5 – 4.0 kg or 750 ml/D of formula consumed per day
            Folic acid should also be supplemented (50-65 mcg per day)
             until wgt is 2 – 2.5 kg
            Fe in amount of 2-4 mg/kg/day of elemental Fe if >2 mos
             and exclusively breast feeding
              Guidelines for feeding
   BW <1000 gms, discharge wgt <2000 gms,
    <3%ile, BPD or osteopenia
       Breastfed
            Use fortifier to add protein and minerals
            Iron 2-4 mg/kg/day
            Continue until 5 kg weight
       Formula fed
            24 kcal/oz premature formula with iron until 1850 gms
            22 kcal/oz until catch up achieved or 9-12 mos
            Then 20 kcal/oz
            May need 4 mg/kg/day of iron
   May need to continue higher density formula if
    fluid restriction (CHF or BPD)
         Guidelines for feeding (2)
   BW > 1 kg, discharge wgt > 2 kg, growth %ile
    > 5%ile
       Breast fed
            Supplement with enriched or standard formula
            Multivitamins and 2 – 4 mg/kg/day of Fe until 5 kg
       Formula fed
            22 kcal/oz formula with iron until catch up complete
            Then, 20 kcal/oz formula until 1 yr corrected age
            If following normal growth pattern, 20 kcal/oz formula until 1
             year
            If standard formula used 1 cc of multivits/day + 2-4 mg/kg/d
             Fe used until intake > 32 oz/day
    Recommendations for advancing
               diet
   Similar to term infants
   No cow’s milk until 1 year (not sufficient iron,
    B6, C and EFA’s)
   If not gaining weight adequately, increase
    volume or density of formula
   If lactose intolerant, try soy (also for
    galactosemia)
   If documented protein-induced enteropathy, use
    elemental formulas
    Suggested Feeding Schedules
   Birth – 4 months
       Fe fortified formula (FeFF) (premature or std) 18 – 32 oz per day
       BM (+/- fortifier) 8 – 12 times per day (may weigh pre/post)
   4 – 6 mos
       FeFF or BM 27 – 45 oz/day
       May add infant cereal with iron 1 – 6 Tbls/day
   6 – 8 mos
       FeFF or BM 24 – 32 oz/d, offer cup
       Infant cereal 4 – 6 tbls/day
       Add vegetables, meat, fruits, etc one per week
   9 – 12 mos
       FeFF or BM 24 – 32 oz/d decreasing to 20 – 24 oz/d as near 12
        mos
       Increase solid foods consistently
                     Special formulas
   24 kcal formulas (greater concentration of vitamins and
    minerals)
       Similac Special Care 24
       Enfamil Premature 24
       Nestle Good Start
       Use when need calorie dense foods because of limited po
        intake or fluid restricted
   22 kcal formulas (higher protein content and higher in
    some vitamins and minerals)
       Neosure
       Enfamil 22
   Other formulas can be mixed to 22 or 24 kcal but will
    not have a similar higher density of minerals and
    protein as premature formulas
                       Case 1

   4 mo old former 28 week premie, has
    BPD, CHF, weighs 2.5 kg
       She will need 22 kcal formula or BM with
        fortifier (because she is < 3%ile) until she
        catches up or reaches 9 – 12 mos
       Because of CHF and BPD may need to
        continue to restrict volume and may need to
        keep on denser formula until 1 yr
       Should add 2 mg/kg/day Fe (+/-) 1 cc
        vitamins
                        Case 2
   Former 1.7 kg 33 week premie discharged
    at 3 weeks of life at 2.1 kg with
    uncomplicated nursery course
       BM with enriched or standard formula,
        multivits and 2 – 4 kg/kg/d of iron until 5 kg
       Or,
       22 kcal/oz until catch up complete then 20
        kcal/oz until 1 yr + multivits and Fe until
        intake >32 oz/day
                         Pearls
   Premature infants require special care and attention and
    these children are at very high risk for parental neglect
   Premature infants are at risk for nutritional problems
    such as bone disease, iron deficiency, delayed growth,
    and complications of other vitamin/mineral deficiencies
   There is evidence that premature infants who have too
    rapid catch up growth are at greater risk for obesity,
    diabetes and other metabolic complications later in life
   Selection of formula and feeding schedules will depend
    upon a number of factors including discharge weight, co-
    morbid conditions, and rate of growth
   Will need to see these children for weight checks and
    parental education every week or two initially and more
    often than the normal well-child schedule
                References

   Verma, Sridhar, Spitzer, “Continuing Care
    of NICU Graduates”, Clinical Pediatrics,
    May, 2003
   La Hood and Bryant, “Outpatient Care of
    the Premature Infant”, American Family
    Physician, October 15, 2007

				
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