ENTERAL FEEDING CHALLENGES IN PREMATURE NEONATES

BY: ELAHE RASTKAR MSC OF NEONATAL INTENSIVE CARE NURSING

Importance of Enteral FeedingFI and NECDecision making challenges

Benefits of Enteral Nutrition :

Prevention of complications: PN-associated liver disease

Osteopenia of prematurity Poor neurologic outcomes EUGR

Achievement of intrauterine growth rates

Risks Of Enteral FeedingNecrotizing Enterocolitis7-14% in VLBW20-40% mortalityComplication :Intestinal strictureShort bowel syndrome Neurodevelopmental delay

.

Feedinge IntoleranceDefinition

Increased GRs

Abdominal distention Emesis

Feeding intolerance may be a major factor affecting the duration of hospitalization

Factors that affect on feeding tolerance :Intestinal motilityGastric emptyingStool outputDigestive enzymesType of milkRapidity of feedingVolume of feedingConcentration of milkConcomitant medicationsMedical conditions

Stool outputSome clinicians do not begin

enteral feeding until the immature infant has passed a stool

Glycerine suppositoryRapid meconium evacuation

appears to improve the tolerance of feedings in ELBW infants during the first 14 days after birth

Feeding delay :Impaired intestinal growthMucosal atrophyDecreased enzymatic activity Increases in intestinal permeability

and bacterial translocationDelays in the maturation of intestinal

motor activity and intestinal motilityLack of hormonal response such as

gastrin secretion (trophic hormone for intestinal growth)

Minimal Enteral Feeding (MEF)12 to 24 ml/kg/day0.5-1 ml/kg/hourUnfortified human milk or 20

kcal/oz preterm formula Non-nutritional nutritionDiluted milk and water?!

MEF …Shortens time to regain birth weightImproves feeding toleranceReduces duration of PNEnhances enzyme maturationReduces intestinal permeabilityImproves gastrointestinal motilityMatures hormone responsesImproves mineral absorption and

mineralizationReduces duration of phototherapyLowers incidence of cholestasis

Time to start MEF2 to 4 days after birth versus 5 to

7 daysUnanswered questions:Optimal dosage and durationHuman milk exclusivelyRisks versus benefits in unstable infantsMEF earlier than 48 hours after birth

Advancement of Enteral Feeds15- 20 ml/kg/day versus 30

ml/kg/dayBenefits of faster advancementQuestions:Diet, initiation, and duration of

MEFELBW infants ??

Methods of Enteral FeedingOrogastric tubeNasogastric tubeTranspyloric feeding tubeBottle or cup feedingBreast feedingGastrostomy

Nasogastric/Orogastric Tube Placement

OGT or NGTSize:5 or 6 Fr for 1000 gr6 or 8 Fr for 1000 grMeasurement the length of tubeWeight(gr) insertion length(cm)750 13750-999 151000-1249 161250-1500 17

Consider Esophageal perforation if:Difficult insertionBlood aspirateIncreased oral secretionRespiratory distressPneumothorax

Verify tube placement with X-RAY

Transpyloric tube feeding

Indications :Severe GERD with risk of

aspirationSuspected gastroesophagial

reflux-associated apneaGastric distention with CPAPIntolerance to gastric feeds

Transpyloric tube feeding

Continuous feeding only!Verify with X-RAY only!Complications:Aspiration Difficulty with tube placement Perforation of the gut Malabsorption

Gastric feeding should be resumed as soon as possible

Delivery of Enteral NutritionContinuous or intermittentBenefits of bolus feedingsNo difference in time to full

feedings ?!Continuous feedings: Risk and

benefitExtend time of bolus feeding

Gastric ResidualsIndicator of FI , delayed GE ,early

symptom of NECAspiration of GR and mucosal

damage Discarding GR ???!

Only 4% of nurses replaced GR after aspiration!!!

FI has defined as :GRV 2 mL in 750gr and 3ml in 750gr

GRV ≥ 2 mL/kgGRV 50% of the previous volumeGRV and NEC ?!Color of GR and NECSize and location of OG or NGPosition and GE

Oral feedingReadiness Physiologic Developmental Synchrony of suck-swallow reflex :32-34wComplete coordination: 36-37w Some techniques for facilitation of

feeding:NNS and milk odorFirm nipple with slow flowSwaddlingDevelopmental burping

Feeding During Blood TransfusionsTANECTheories of TANECOld blood and TANEC ?!Withholding feeding during

transfusion decreases the risk of TANEC ?

Duration of NPO statusType of diet and TANEC

Special condition and feedingPDA and COX inhibitors and NEC

UAC and feedingApnea and feedingPositive occult blood

SUMMARY AND RECOMMENDATIONS Enteral feedings are initiated in the

first two to five days after birth Feeding is begun with unfortified

human milk or 20 kcal/oz preterm formula

Feeding is started at 20 mL/kg per dayMilk volume is advanced when the

infant is clinically stable and minimal feedings are tolerated

Feeding is advanced at a rate of 15 to 30 mL/kg per day.

…continueWhen the infant tolerates at least

100 mL/kg per day or has fed unfortified human milk for at least one week, the caloric density of milk is increased by either changing the formula from 20 to 24 kcal/oz preterm formula or adding human milk fortifier to unfortified human milk.

…The final goal is achieving to

weight gain of more than 15 g/kg per day

This goal is achieved by providing 150 to 160 mL/kg per day of a 24 kcal/oz preterm formula or 160 to 180 mL/kg per day of fortified human milk

Thanks for attention…