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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.

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neonatal nutrition

Neonatal nutrition

Mohammad khassawneh

goals
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
general facts about neonatal fluid and nutrition
General facts about neonatal fluid and nutrition
  • Last trimester of pregnancy
    • Fat and glycogen storing
    • Iron reserves
    • Calcium and phosphoruos deposits
  • Premature babies more fluid (85%-95%), 10% protein, 0.1% fat. No glycogen stores
  • Insufficient protein and calories is life threatening to the sick
guidelines fluid management
Guidelines fluid management
  • 80 cc/kg/day, increase to 100-120cc/kg/d with increase 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
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
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
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
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
others
  • Minerals
    • Zinc, copper, molybdenum, chromium, selenium
    • Calcium, phosphorous, Magnesium
    • Na, K
  • Vitamins
    • Fat soluble
    • Water soluble
biochemical testing for patient on tpn
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
Complication of TPN
  • Infiltration under skin
  • Infection
  • Liver dysfunction
  • Renal overload
feeding development
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
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
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
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 predominant 60:40
breast feeding
Breast feeding
  • after delivery 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 a nd immunoglobuline
breastfeeding
breastfeeding
  • DOL# 1:
      • Colostrum and transitional milk average volume 35 mL (7-125mL)
  • DOL# 3-5:
      • Increasing milk production
breast feeding1
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 feeding2
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 of low milk
Maternal factor of low milk
  • Gestational diabetes
  • Hypothyroid
  • Retained placental fragments
  • Dehydration, hemorrhage, hypertension, infection
  • Previous breast surgery
  • Lack of prenatal engorgement
  • Psychosocial
    • Previous unsatisfactory experience
    • Lack of partner support
    • Post-partum depression
    • Separation from infant
milk is what you eat
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
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
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
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 turger, moist mucous membranes
  • Contentment 1.5-2 hours after feeds
enough milk
Enough milk
  • Breasts feel full before and softer after feeds
  • Milk leaks from contralateral 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
  • 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 feeding3
Breast feeding
  • Foremilk
  • Hind milk
nonnutritive sucking
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
premature formulas
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
standard infant formula
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
soy formulas
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.
case 1
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
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
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