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Neonatal nutrition

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					Neonatal nutrition

Mohammad khassawneh
                 Goals


• Ensure continuation of growth by giving
  enough calories
• Provide balance in fluid homeostasis
• keep electrolytes normal range
• Avoid imbalance in macro-nutrients
• Provide micro-nutrients and vitamins
       Feeding development
• Swallowing first detected at 11 weeks
• Sucking reflex at 24 weeks
• Coordinated suck-swallowing not
  present till 32-34 weeks
• Swallowing to coordinate with respiration
  – Respiration>60-80 NG feeding
  – Respiration>80 high risk for aspiration (NPO)
         Methods of feeding
• Oral feeding
  – >32 weeks
  – Respiration<60-80
  – Try 20 minutes
• Naso-gastric (NG) feeding bolus
• NG feeding continuous
• trans-pyloric
• Gastrostomy feeding
Trophic Feeding

• Keeping infant fasting (NPO)
  – Decrease in intestinal mass
  – Decrease in mucosal enzyme
  – Increase in gut permeability
• Trophic feeding:
  – small amount of feeding to prepare the
    intestine
  – release enteric hormones, better
    tolerance to feeds
    Enteral feeding

• 40-45% of calories are coming from
  carbohydrates (Lactose or glucose
  polymer)
• Protein requirement of infant is 2.2-
  4.0 gm/kg/d
• Protein is whey : casein 60:40
              Breast feeding
• Term baby has metabolic reserves
     • Hepatic glycogen
     • Brown fat
     • Extracellular and extravascular water
• milk production is stimulated
• Try to get baby onto the breast within first
  1-2 hours of life
• Colestrum ; high in protein and
  immunoglobuline
              breastfeeding


• DOL# 1:
    • Colostrum and transitional milk average volume 35
      mL (7-125mL)
• DOL# 3-5:
    • Increasing milk production
                 Breast feeding
• Q2-3 hours = 8-12 feeds per day
  – Quicker gastric emptying
  – frequent breast stimulation and emptying increase milk supply
  – Watch for feeding cues
• Duration
  – 10 minutes or longer
  – As long as swallowing continues
• Cluster feeds is normal
• Growth spurts
  – Baby may feeds more frequently for 1-2 days
  – Many growth spurts at 2wks, 6, wks, 2-3 months, and 5-6
    months they feed more during them
      Breast feeding

• Ineffective if baby sucks from nipple only
• Nipple and areola must be drawn deeply
  into baby’s mouth
• Listen for infant swallowing
  – DOL#1: intermittent swallows
  – DOL#2 on: 1 swallow : 1-3 jaw excursions
        Maternal factor
       causing low milk
• Gestational diabetes
• Hypothyroid
• Retained placental fragments
• Dehydration, hemorrhage, hypertension, infection
• Previous breast surgery
• Psychosocial
   –   Previous unsatisfactory experience
   –   Lack of partner support
   –   Post-partum depression
   –   Separation from infant
        Milk is what you eat
• Mom’s need extra 500kcal/day if breast
  feeding
• Caffeine
  – Limit to 1-2 cups/day
  – Babies may become overstimulated, fussy


• Spicy and gassy foods reflects
     Infant illness that affect breast
                  feeding
• Prematurity
    – Co-ordinated suck-swallow-breathing reflexes at 32-34 weeks
• SGA, IUGR
• Twins
• Cleft lip and Palate, Micrognathia, Ankyloglossia, Macroglossia
•   Jaundice
•   Neuromotor problems
•   Birth asphyxia
•   Cardiac lesions
•   Infection
•   Surgical problems
   Do I have to wake my baby to
               feed?
• Should wake baby during first 2-3 weeks
  while milk supply is being established
• Once milk supply good and baby back to
  birth weight can allow baby to go 5 hours
  during a 24 hour period without a feed
• If milk supply decreasing should reinstitute
  night time feed
         Is my milk enough???
• 8-12 feeds per day to 6-8 weeks of age
• Frequent swallowing
• Adequate urine output (2-6 times/day)
• Adequate stooling
•   Yellow stools by DOL#4
•   Weight loss no greater than 8% of BWT
•   Weight gain 15-30 grams/day
•   Good skin turgor, moist mucous membranes
•   Contentment 1.5-2 hours after feeds
              Enough milk
• Breasts feel full before and softer after
  feeds
• Milk leaks from contra-lateral breast during
  suckling
• Sensation of milk ejection  pins and
  needles
• Absent nipple trauma and pain
• Profound state of relaxation in mom during
  suckling
              Human milk
• Human milk is Ideal food for full term infant
• Inadequate components for premature
  infant <1500gm (human milk fortifier
  needed to be added)
  – Protein
  – Vitamin D
  – Calcium
  – Phosphorous
  – Sodium
Breast feeding

• Foremilk
  – Less fat and less
    calories
• Hind milk
  – More fat and calories
         Nonnutritive sucking
• Pacifier
  – In premature
     • ?/ no effect (wt gain, hospitalization, improved
       oxygenation, faster oral feeding)
• May give infant comfort and calm more
  quickly
• In term infant nipple confusion with bottle
  and pacifier against breast feeding
      Standard infant formula
• 100% lactose
• Fat is all long chain triglyceride
• Protein is whey 60%, casein 40%
• Iron fortified 12mg/liter and low iron versus
  low 1.5mg/liter (should not give it)
• Ready to feed or prepare from powder
         Premature formulas
• lack natural standard
• 50% lactose and rest glucose polymer
• Protein
  – 150% in amount of term formula
  – Whey predominant
• Fat 50% LCT 50%MCT.
• Higher Ca, P, higher Ca : P ratio of 2:1
• Long chain polyunsaturated fatty acids
             Soy formulas
• Lactose free
  – Primary and secondary lactase defeciency
  – Galactosemia
• Carbohydrate is sucrose or corn syrup
• Fat is vegetable oil such as coconut oil
• Not recommended in very low birth weight
  infant related to weight gain and
  osteopenia.
      Indication for
     Parenteral intake

•   Respiratory distress
•   Severely ill patient
•   Abdominal pathology
•   Prematurity
•   advancement of feeding
  Guidelines fluid management
• 80 cc/kg/day, increase to 100-120cc/kg/d with
  increase insencible water loss (IWL)
• Increase to 100cc/kg/d 2nd day
  – add sodium 2-4 mEq/kg/d and K= 2 mEq/kg/d.
  – Calcium may be added
• after 2nd day adjust according to
  –   urine output 2-3cc/kg/hour with 110-140cc/kg/d
  –   Specific gravidity 1.008-1.012,
  –   watch weight change,
  –   total in/out
 Nutritional pathway for premature
                infant
• Day1, parenteral glucose 5-7mg/kg/minute
  – Watch blood sugar
  – Electrolytes check at 24 hours
  – Consider trophic feeding
• Day2, TPN if not feeding
• Day 3 or more: enteral feeding slowly increased
  20cc/kg/day
   – 1.5kg= 30cc/day =2.5cc every 2 hours
• Day10-20, full nutrition
           Energy use in body
•   Resting energy use 45 kcal/kg/d
•   Minimal activity       4 kcal/kg/d
•   Occasional cold stress 10 kcal/kg/d
•   Fecal loss of energy 15 kcal/kg/d
•   Growth 4.5kcal/gm      40-45 kcal/kg/d

• Total                   110-120 kcal/kg/d
Distribution of energy sources

•   Glucose   16.3gm = 55 kcal/kg/d…. 50%
•   Protein    3.1gm =12.5 kcal/kg/d…12%
•   Fat         4gm = 40 kcal/kg/d…38%
•   Total               108 kcal/kg/d
Total parenteral nutrition (TPN)
• This began 1968 first use
• growth of 10-15gm/kg/day weight
  gain
  – 3gm/kg/d protein (amino acid)
  – 3gm/kg/d fat (Fatty acid)
  – 16gm/kg/d Dextrose 10-25% (carbohydrate)
• this will give100-120 k.calories/kg/day
                    others

• Minerals
  – Zinc, copper, molybdenum, chromium,
    selenium
  – Calcium, phosphorous, Magnesium
  – Na, K
• Vitamins
  – Fat soluble
  – Water soluble
Biochemical testing
for patient on TPN

•   Urine glucose
•   Triglyceride
•   BUN, Albumin
•   Ca, P, Mg, creatinine, Na, Cl, CO2
•   direct (conjugated) bilirubin, ALT
•   Trace element level
Complication of
    TPN

•   Infiltration under skin
•   Infection
•   Liver dysfunction
•   Renal overload
                   Case 1
• 4 kg baby boy d in delivered by C/S and
  mother interested in bottle feeding.
  – Type of milk advised
    • Sihha, NAN1, similac, S26
  – Amount
  – frequency
                 Case two
• 3.5 Kg mother wants to breast feed her
  infant. She is primi-gravida
  – Is small amount of milk in first 3ds enough
  – How to encourage her to continue breast
    feeding
  – Signs of successful breast feeding
  – For how long breast feeding to continue
  – Discuss AAP guideline
  – Baby jaundice at 2 weeks
                       Case 3
• 1.4 kg baby born at 30 week and has RDS
  – Discuss fluid management in first 3 days
  – How to feed him
    •   Amount
    •   Rate of increase
    •   Type of formula
    •   Risks of fast feeding

				
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posted:10/31/2011
language:English
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