Nutritional support in nicu/picu

1. Lecturer: Hengame Shariati Rad Registered Dietitian September 2016 Nutritional support in nicu/picu

2. To achieve a postnatal growth at a rate that approximates the same post-conceptional age • Provide balance in fluid homeostasis and electrolytes • Avoid imbalance in macro-nutrients • Provide micro-nutrients and vitamins Goals of nutrition

3. Parenteral (mostly) • Stores are laid late in gestation • At 28 weeks, a fetus has: 20% of term calcium and phosphorus stores 20% of term fat stores About a quarter of term glycogen stores Fetal nutrition

4. Gut adaptation is regulated by Endocrine factors Intraluminal factors Breast milk hormones and growth factors Bacteria Adaptation to nutrition after birth

5. Normal output

6. Nutrition for the preterm or sick baby

7. Early feeders had: Fewer days parenteral nutrition fewer investigations for sepsis • No difference in: NEC Weight gain Early vs late feeding

8. Rapid: 20 to 35 ml/kg/day • Slow: 10 to 20 ml/kg/day • Rapid group: Reached full enteral feeds and regained birthweight faster • No difference in NEC rate or length of stay Rapid vs slow increase

9. 12 to 24 ml/kg/day for 5 to 10 days MEN group: Faster to full enteral feeds Shorter length of stay No difference in NEC Minimal enteral nutrition

10. Reduced risk of: NEC Death • Achieved full feeds faster • No difference in rates of sepsis Probiotics for preventing nec

11. Human milk Mother’s own Banked donor milk Fortified • Artificial Term formula Preterm formula • Parenteral Nutrition Feeding small or preterm infants:choices

12. Parenteral nutrition

13. If an infant can’t, won’t or shouldn’t be fed enterally What’s in the bag? Fluid Carbohydrate Protein Fat Minerals and Trace elements Parenteral nutrition

14. Requirements: kcal/kg/day Basal metabolic rate 40 Physical activity 4+ specific dynamic action of food 10% Thermoregulation variable Growth 70 energy

15. With glucose infusion alone, infants lose 1-2% of endogenous protein stores daily 1g/kg/day gives protein balance 2.5 to 3.5 g/kg/day allows accretion nb energy requirement Safe to start soon after birth protein

16. Energy source Essential fatty acids source( intralipid) Cell uptake and utilization of free fatty acids is deficient in preterm infants Start at max 1g/kg/day, increasing gradually to 3g/kg/day (less if septic) fat

17. risks of pnBenefits of pn • Earlier and faster weight gain • Avoidance of problems associated with enteral feeds • Line associated sepsis • Line associated complication( eg thrombosis) • Hyperammonaemia • Hyperchloraemic acidosis • Cholestaticjaundice (Liver dysfunction and renal overload)

18. Milk feeds

19. Protection from NEC Improved host defences Protection from allergy and aczema Faster tolerance of full enteral feeds Better developmental and intellectual outcome Human milk advantages

20. Human milk may not provide enough Protein Energy Sodium Calcium, Phosphorus and Magnesium Trace elements( Fe, Cu, Zn) Vitamins( B2, B6, Folic acid, C, D, E, K) Human milk shortcomings if preterm

21. Improved Short term growth Nutrition Retention Bone mineralization • Concerns: Trend towards increased NEC Breast milk fortifiers

22. Term formulas do not provide for preterm protein, calcium, sodium and phosphate requirements, even at high volumes Term formula( vs preterm formula) fed infants . grow more slowly . have lower developmental score and IQ at follow up Term vs preterm formulas

23. To provide nutrient intakes that permit the rate of postnatal growth and the composition of weight gain to approximate that of a normal fetus of the same gestational age, without producing metabolic stress Feeding preterm infants: aim

24. Enhanced nutritional intake sufficient to allow “catch-up” growth improves long term neurodevelopmental outcome Compared to term infants, ex-preterm infants fed at 120 kcal/kg/day Have more body fat Have a different fat distribution Catch-up growth

25. Nutritional assessment

26. Weight Reflects mass of lean body tissue, fat, intra- and extra- cellular fluid compartments Length More accurately reflects lean tissue mass Head circumference Correlates well with overall growth and developmental achievement How best to assess growth & nutrition ?

27. TPN requires regular monitoring of acid base status, liver function, bone profile and electrolytes In enterally fed infants, monitoring albumin, transferrin, total protein, urea, alkaline phosphatase and phosohate may be useful Laboratory assessment

28. Oral feeding >32 weeks respiration<60-80 try 20 minutes Naso-gastric (NG) feeding bolus NG feeding continuous Trans-pyloric Gastrostomy feeding Methods of feeding

29. 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 feed Trophic feeding

30. Weight: 20-30 g/day Length: ~1 cm/week HC: 0.5 cm/week Growth goals

31. Preterm goal: ~120 kcal/kg/day Term goal: ~110 kcal/kg/day Total fluid of enteral feeds required to deliver adequate calories for growth is ~150 cc/kg/day Caloric requirements for growth

32. Determine fluid requirement for first day: full term: 60-80 ml/kg/day late preterm & preterm infants(30-37 weeks): 80 ml/kg/day very-preterm infants: 100-120 ml/kg/day Determine gluose infusion rate(GIR); GIR: (%dextrose. IV rate) / (6. wt in kg) calculated GIR from known dextrose concentration(%) tpn

33. Protein and amino acids goal for premature infants: 4g/kg/day goal for term infants: 3 g/kg/day source: trophamine • Other added nutrients: lipids cystein phosphorous magnesium trace minerals heparin MVI tpn

34. Breast milk is best The American Academy of Pediatrics recommends breastfeeding for the first year of life Started when an infant is clinically stable Breast milk and standard infant formula have 20kcal/30cc Trophic tube feeds may be continuous or bolus and advanced gradually (10-20 ml/kg/day) Transition to bolus from continuous typically begins after achieving full feeds PO feeds typically attempted around 32-34 weeks, when develop suck and swallow coordination Premies are often supplements with TPN as they work up on feeds ENTERAL NUTRITION

35. 20% decreasing in Mg 25% increasing in TG 30% increasing in urea 52% decreasing in Albumin ↑ uremia→↓ SD scores for weight & arm circumferance between admission and discharge ↑ TG→>ventilator dependence days & length of stay Biochemestric in picu

36. Higher rate of protein synthesis & turnover Greater oxygen consumption during growth Higher energy cost due to transepidermal water loss Higher rate of fat deposition Prone to hyperglycemia Higher total body water content Unique nutritional aspects of the vlbw infants

37. Skin to skin contact may strengthen the mother-infant dyad and lead to longer breastfeeding periods over the first two years of life Non-nutritive breastfeeding can stimulate milk volume and imprive breastfeeding success rates Early attachment

38. Infants should be transitioned from gavage to oral feedings when physiologically capable, not based on arbitrary weight or gestational age criteria. Best practice