Enteral Feeding LBW

Enteral Feeding in LBW NeonatesEnteral Feeding in LBW Neonates

CHAIRPERSONCHAIRPERSON

Dr. A.G. ShingwekarDr. A.G. Shingwekar, , MD,DCHMD,DCH

Professor & HeadProfessor & Head

Department of Paediatrics, G.R.M.C. & J.A. Group of Hospitals, Gwalior

Presented by

Dr. KISHORE CHANDKI

Guided by :Dr. Ajay Gaur MD, PhD

Dr. G. Das MD

Dr. Y.S. Verma MD

Dr.(Mrs) Neetu MD

Dr. (Mrs) Sunita MD


IntroductionIndications & Contraindications Goals of Feeding Routes of Enteral Feeding Choice of Milk for Feeding Amount & Schedule of Feeding Minimal Enteral Nutrition Converting Gavage to Oral Feeds Feeding Term LBW neonate


Judging the adequacy of nutrition Kangaroo Mother Care Micronutrient Supplementation Immunonutrition MCT Oil Post discharge feeding & advice Summary

Enteral FeedingEnteral Feeding

Defined as the “administration of nutrients directly into the gastrointestinal tract.”

If the patient is unable to meet his/her nutritional requirements with oral diet/ nutritional supplements, then enteral feeding is indicated.

Once the gastrointestinal tract is functional, enteral feeding is the optimal method of nutritional support.

Advantages w.r.t. ParenteralAdvantages w.r.t. Parenteral

More Physiologic More safe More nutritionally complete Less expensive

But decision for mode of nutrition is based on :WeightGestational AgeClinical Condition

Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

IndicationsIndications

Absent / impaired swallow

Inadequate oral intake

Neonates <1800 gm or < 34 weeks gestation, unable to breast feed

Necessity :

Functioning & accessible gastrointestinal tract

ContraindicationsContraindications

Complete bowel obstruction, Ileus

Intestinal ischemia

Necrotizing Enterocolitis

Complications of Enteral NutritionComplications of Enteral Nutrition

GI : Perforation, stricture, esophagitis, gastritis, nausea, vomiting, bleeding, GER

Mechanical : Dislodgement, tube migration, blockade, inflammation, granulation of skin site, aspiration, nasopharyngeal trauma, sinusitis, otitis media, laryngeal ulceration

Metabolic : Fluid overload, dehydration, hyper- & hypo-glycemia, electrolyte imbalance, azotemia, hypercapnea, hyperphosphatemia, vit. & mineral deficiency

Misc. : Aspiration pneumonia, Feed contamination & resulting infection, Abnormal LFT

Elizabeth K E, ‘Nutrition & Child Development’, 3rd Ed., 2004

Goals Of FeedingGoals Of Feeding

Achieve well-defined short-term growth & nutrient retention Mimic intrauterine growth rates Mimic reference fetal composition

Prevent Neonatal morbidities Improve feeding tolerance Reduce NEC Minimize nosocomial infection

Optimize long-term outcome Optimize neurodevelopmental outcome Reduce rates of allergy & atopic diseases

Ghai O.P., Essential Paediatrics, 2004

What is the Optimal Diet for LBW neonate ?What is the Optimal Diet for LBW neonate ?

“ “ Optimal diet should support a rate of growth Optimal diet should support a rate of growth approximating that of the third trimester approximating that of the third trimester intrauterine life without imposing stress on the intrauterine life without imposing stress on the developing & excretory functions!”developing & excretory functions!”

…the statement encourages mimicking the intrauterine environment by stimulating fetal accretion rates of nutrients & intrauterine growth rates!

Is it possible to extrapolate the extrauterine growth?Is it possible to extrapolate the extrauterine growth?

Thermal Thermal ProtectionProtection

Preferential Preferential nutrient nutrient deliverydelivery

Excretion Excretion handled by handled by placentaplacenta

Oxygen via Oxygen via placentaplacenta

Thermal Thermal instabilityinstability

Exogenous Exogenous nutrientsnutrients

Immature Immature kidneykidney

Birth asphyxiaBirth asphyxia

Is it possible to extrapolate the extrauterine growth?Is it possible to extrapolate the extrauterine growth?

UDPG UDPG prolonged prolonged jaundicejaundice

IVH, cerebral IVH, cerebral anoxiaanoxia

Low glycogen Low glycogen stores/brown fatstores/brown fat

Poor lactate Poor lactate metabolism metabolism acidosisacidosis

Poor immunity Poor immunity sepsis sepsis

Congenital Congenital anomaliesanomalies

Contd…Contd…

Poor Feeding Poor Feeding reflexesreflexes

Low gastric Low gastric acidity, low acidity, low enzyme levels, enzyme levels, low bile secretionlow bile secretion

NECNEC surfactant surfactant

HMDHMD Immature respi. Immature respi.

Center Center apnea, apnea, aspiration, aspiration, pulmonary pulmonary hemorrhagehemorrhage

Is it possible to extrapolate the extrauterine growth?Is it possible to extrapolate the extrauterine growth?Contd…Contd…

So, the answer is probably ‘NO’So, the answer is probably ‘NO’Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Fetal Energy & Fetal Energy & Protein AccretionProtein Accretion

Postnatal Energy & Postnatal Energy & Protein AccretionProtein Accretion

Weight gainWeight gain

18 gm/kg/d (24-28 18 gm/kg/d (24-28 wks)wks)

16 gm/kg/d (32-36 16 gm/kg/d (32-36 wks)wks)

15 gm/kg/d15 gm/kg/d

(During acute phase (During acute phase : Avoid catabolism): Avoid catabolism)

Protein AccretionProtein Accretion ~ 2 gm/kg/d~ 2 gm/kg/d 3 gm/kg/d3 gm/kg/d

Fat AccretionFat Accretion 1.4-1.9 gm/kg/d1.4-1.9 gm/kg/d ~1.5 gm/kg/d~1.5 gm/kg/d

Calorie AccretionCalorie Accretion ~30 kCal/kg/d ~30 kCal/kg/d (>28 wks)(>28 wks)

~50 kCal/kg/d~50 kCal/kg/d

Fluid Requirements For NeonatesFluid Requirements For Neonates

DayDay

Fluid (mL/kg/d)Fluid (mL/kg/d)Birth weight Birth weight

<1000 gm<1000 gmBirthWeight BirthWeight

1001-1500 gm1001-1500 gmBirth Weight Birth Weight

>1500 gm>1500 gm

11 100100 8080 6060

22 115115 9595 7575

33 130130 110110 9090

44 145145 125125 105105

55 160160 140140 120120

66 175175 155155 135135

7+7+ 190190 170170 150150

IAP Textbook of Pediatrics, 2nd Ed. 2002Additional Allowances : Additional Allowances : PPhototherapy : 20-40 ml/kg/d, Radiant Warmer : 40-80 ml/kg/dhototherapy : 20-40 ml/kg/d, Radiant Warmer : 40-80 ml/kg/d

Guidelines for Fluids & Feeding to LBW BabiesGuidelines for Fluids & Feeding to LBW Babies

AgeAge

Category of NeonatesCategory of Neonates< 1200 gm< 1200 gm

<30 weeks<30 weeks1200-1800 gm1200-1800 gm

30-34 weeks30-34 weeks>1800 gm>1800 gm

>34 weeks>34 weeks

InitialInitial

IVF. Try gavage if IVF. Try gavage if not sicknot sick

GavageGavage Breast feeding. If Breast feeding. If unsatisfactory, unsatisfactory, give katori-spoon give katori-spoon feeds.feeds.

After 1-3 After 1-3 days days

GavageGavage Katori-spoonKatori-spoon Breast feedingBreast feeding

Later Later

(2- 4 weeks)(2- 4 weeks)

Katori-spoonKatori-spoon Breast feedingBreast feeding Breast feedingBreast feeding

After After sometime sometime

(4- 6 weeks)(4- 6 weeks)

Breast feedingBreast feeding Breast feedingBreast feeding Breast feedingBreast feeding

Ref. Teaching Aids : NNF

Routes of Administration of Enteral NutritionRoutes of Administration of Enteral Nutrition

TPN

TPN + MENTPN + MEN

PPNPPN

Alternative Feeding

Exclusive Breast Feeding

Least preferredLeast preferred

Most preferredMost preferred

Routes of Administration of Enteral NutritionRoutes of Administration of Enteral Nutrition

Oral- Spoon & katori, etc.

Nasogastric/Orogastric

Nasoduodenal / Nasojujenal

Surgical or Percutaneous Endoscopic gastrostomy

Surgical or Percutaneous Endoscopic jejunostomy

Indian J Pediatr 2002; 69 (5) : 411-415

Inserting a Nasogastric (NG) TubeInserting a Nasogastric (NG) Tube

Normal anatomical Normal anatomical PathPath

Inserting a Gastric TubeInserting a Gastric Tube

Principles of Newborn Baby Care, WHO/UNICEF, 2003

Insert through nostril

Confirming Proper Placement of TubeConfirming Proper Placement of Tube

Air insufflation & auscultation method : with 1 to 2 ml of air - If a whistling sound is heard through the stethoscope as the air is injected, the end of the tube is correctly positioned in the stomach. You should also be able to withdraw the air you pushed in.

Acidity of the aspirate: [Only suitable for babies more than 24 hours old or preterm LBW babies who are more than 48 hours old] If the blue litmus paper turns pink, the fluid is acidic and the tip of the tube is correctly positioned in the stomach.

Inserting a Gastric TubeInserting a Gastric Tube

Signs that the tube may not be placed correctly are:

X Coughing

X Apnea

X Cyanosis

Nasogastric TubeNasogastric Tube

Easy to place

Easy to secure

Lasts longer, Cheaper

No need to pass every time

Risk of nasopharyngeal trauma

Space occupying effect GER, aspiration (Gag reflex should be intact)

Advantages Disadvantages

Agrawal K.N., ‘Pediatrics & Neonatology, 1st Ed., 2000

Nasoenteric TubesNasoenteric Tubes

http://www.nutriciame-clinicalnutrition.com

Properties :Properties :

Has a small diameter available for patient comfortHas a small diameter available for patient comfort Is long enough for nasoenteric feeding Is long enough for nasoenteric feeding Is flexible for easy insertion and removal Is flexible for easy insertion and removal Is radioopaque for X-Ray confirmation of Placement Is radioopaque for X-Ray confirmation of Placement Has several feed outlets at the distal end to prevent clogging Has several feed outlets at the distal end to prevent clogging Has a smooth rounded tip to prevent insertion trauma Has a smooth rounded tip to prevent insertion trauma If a guide wire is used, the guide wire will not dislodge during If a guide wire is used, the guide wire will not dislodge during insertion; it is easy to remove. insertion; it is easy to remove. Is preferably made of premium material, resistant to gut Is preferably made of premium material, resistant to gut secretionssecretions

Nasoenteric TubesNasoenteric Tubes Polyurethane tubes (PUR):Polyurethane tubes (PUR): Soft, flexible and do not Soft, flexible and do not react to gastric juices. Can stay for 6-8 weeks. Some react to gastric juices. Can stay for 6-8 weeks. Some contain a guide wire for easy insertion. contain a guide wire for easy insertion. Polyvinylchloride (PVC):Polyvinylchloride (PVC): Contain a plasticizer to Contain a plasticizer to keep the tube flexible, because the compound is keep the tube flexible, because the compound is sensitive to the low pH, becomes rigid after 7-10 days sensitive to the low pH, becomes rigid after 7-10 days which can lead to irritation of the pharynx and to the which can lead to irritation of the pharynx and to the esophagus. If not replaced after 7 days of usage a esophagus. If not replaced after 7 days of usage a digestion happen to the tube it self which make the digestion happen to the tube it self which make the content of toxic products to be leached and may cause content of toxic products to be leached and may cause nectorizing entercolitis in premature infants. After 7 nectorizing entercolitis in premature infants. After 7 days as the tube become rigid and stiff it may cause days as the tube become rigid and stiff it may cause perforation and intussusception.perforation and intussusception.

http://www.nutriciame-clinicalnutrition.com

Inserting an Orogastric (OG) TubeInserting an Orogastric (OG) Tube

Orogastric TubeOrogastric Tube

No space occupying effect

Larger bore tube can be passed easily

Difficult to secure, dislodgement

Lasts shorter

Need to pass with every feed



Routes of Enteral FeedingRoutes of Enteral Feeding

Nasoduodenal feeding Nasojejunal feeding

Nasoduodenal or Nasojejunal TubesNasoduodenal or Nasojejunal Tubes

Length : From tip of nose to knee joint

Less aspiration

Less expensive & safer than TPN

Less chances of reflex bradycardia

Less risk of dislodgement

Requires fluoroscopic or endoscopic control for insertion

Expensive tubes wrt NG/NJ

Risk of gut perforation

Frequent supervision



Transpyloric FeedingTranspyloric Feeding

Candidates :

Intolerance to naso/orogastric feeding owing to gastric retention or regurgitation

Neonates at increased risk for aspiration

Anatomic abnormalities of GI tract e.g. microgastria

Problems :

Must be delivered continuously

Fluoroscopic control required for placemnent

Increased risk for fat malabsorption because of by passing of lipases

Cloherty, Eichenwald, Stark, ‘Manual of Neonatal Care’; 5 th Ed, 2004

Transpyloric FeedingTranspyloric Feeding

No difference in short/long term growth, rather increase in GI disturbance & increased mortality

Hence, avoided as far as possible

Indian J Pediatr 2002; 69 (5) : 401-404

Routes of Enteral FeedingRoutes of Enteral Feeding

Gastrostomy (GT) feeding Jejunostomy (JT) feeding

Enterostomy TubesEnterostomy Tubes

Less aspiration ( with jejunostomy)

Less chances of reflex bradycardia, trauma to air passages

Less risk of dislodgement

No interference with breathing

Requires endoscopic control/anesthesia for insertion

Expensive tubes wrt NG/NJ

Peristomal infection, peritonitis, tube blockage, inadvertent removal, tube fracture and leakage


Postgraduate Medical Journal 2002;78:198-204

Enterostomy TubesEnterostomy Tubes

Indications : Congenital anomalies of the mouth, jaw, pharynx,

gastrointestinal tract, and/or airway (ie, esophageal fistula, tracheoesophageal fistula, cleft lip and palate, intestinal atresia, and abdominal wall defects)

Prolonged enteral nutrition (>6 weeks)

http://www.naspghan.org/sub/ENTERAL_AND_PARENTERAL_NUTRITION.htm

Contraindications :

Abdominal wall infection

Coagulopathy

Massive ascites

Choice of Milk for FeedingChoice of Milk for Feeding

Human milk alone (Term/Preterm) Human Milk + Calcium Phosphate & Vit.

Supplements Human Milk (EBM) + Preterm formula Human milk + Fortifier (HMF) Top milk with or without Fortifier

Contd…



Human milk alone (Term/Preterm) : Expressed breast milk

Contd…

Besides usual advantages, has Immunological advantages Better neurodevelopmental and visual outcomes (possibly

because of LC-PUFA) Reduced incideence of NEC

But it does have short comings :- Does not have enough protein and calorie to ensure optimal

EARLY growth at 20 kCal/Oz- Does not have enough sodium to compensate for high sodium

losses. - Does not have enough calcium or phosphate



Human milk alone (Term/Preterm) : Expressed breast milk

Contd…

- Is deficient in vitamins and iron relative to the needs of a preterm infant who will have mixed out on the last trimester placental transfer.

- Composition varies- Losses A/W collection, storage,

feeding procedures, esp. fats & vitamins.

Because of this, many units routinely supplement EBM with HMF upto 24 kCal/Oz in babies <32 weeks or <1500 gm (when the baby is tolerating 150ml/kg/day)



Human Milk + Calcium Phosphate & Vit. Supplements

Contd…

Has : All the biological advantages of Breast Milk!

But : Still will have LESS protein than the required



Preterm formula

Contd…

Has : Adequate calories, calcium, phosphate & vitamins

fed at the rate of 150-180 mL/kg/d

But : Does not have any of biologically active immune

substances, or enzymes of growth factors May still require supplements of sodium, chloride, vitamin A &

D and iodine More chances of contamination while preparation

Hence: Not preferred in general If required, given until neonate reaches a weight of 2-2.5 kg or

on full breast feeds!Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Breast Milk Substitute : Formula MilkBreast Milk Substitute : Formula Milk

Managing Newborn Problems, WHO/UNICEF, 2003

• Use when the mother cannot breastfeed or express breast milk.

• Use a breast-milk substitute designed for premature or small babies.

• Once the container is open, use within the recommended time according to the manufacturer’s instructions.

• Check the expiry date of the breast-milk substitute.

• Use aseptic technique to prepare the breast-milk substitute from liquid concentrates or powders, using high-level disinfected or sterile utensils and containers, and sterilized or boiled and cooled water.

Breast Milk Substitute : Formula MilkBreast Milk Substitute : Formula Milk


• Wash hands with soap and water.

• Determine the required volume of milk for the feed.

• Measure the breast-milk substitute and water, mix them, and feed the baby using a cup, cup and spoon, or other device. Have the mother do this whenever possible.

• Store remaining milk in a labelled container in a refrigerator for a maximum of 24 hours.

• Breast-milk substitute is not available, have the mother use a breast-milk substitute that is based on animal milk and prepared at home.


Ref. : Deptt. of Agriculture, United States

• Top Milk :Term Term

Breast MilkBreast MilkCow’s Cow’s MilkMilk

Buffalo’s Buffalo’s MilkMilk

Goat’s Goat’s MilkMilk

Calories (Kcal/dl)Calories (Kcal/dl) 6767 6767 117117 7272

Protein (gm/dl)Protein (gm/dl) 1.11.1 3.23.2 4.34.3 3.33.3

Fat (gm/dl)Fat (gm/dl) 4.54.5 4.14.1 6.56.5 4.54.5

Carbohydrate (gm/dl)Carbohydrate (gm/dl) 7.17.1 4.44.4 5.15.1 4.44.4

Calcium (mg/dl)Calcium (mg/dl) 3333 120120 169169 134134

Phosphorus (mg/dl)Phosphorus (mg/dl) 1515 9090 117117 111111

Iron (mg/dl)Iron (mg/dl) 0.030.03 0.20.2 0.120.12 0.050.05

Vitamin A (IU/dl)Vitamin A (IU/dl) 250250 70-22070-220 178178 185185

Sodium (mEq/dl)Sodium (mEq/dl) 0.80.8 0.760.76 0.520.52 0.500.50

Folic Acid (mcg/dl)Folic Acid (mcg/dl) 55 55 66 11


• Top Milk :

Animal milk and term formula milk are unsuitable for feeding preterm as composition does not meet recommended nutrient intake and it predisposes to late hypocalcemia as phosphate contains high.

Animal milk with human milk fortifier is not yet studied.


Human Milk Fortifier (HMF) Human Milk Fortifier (HMF)

Is the nutritional supplement product that may be added to breast milk to supplement its nutrient content


Cochrane review

Short term benefitsGreater weight gainGreater length gainGreater HC gainIncreased N2 balanceIncreased bone mineral content

Long term benefit (at 18 mo)No benefit in terms of :-xWeightxLengthxHCxNeurodevelopmental x outcome

Adverse effectsNo increase in NECFeed intolerance

Currently available HMF have low protein, low sodium, high soluble calcium & phosphate, high osmolality and difficulty in mixing leading to separation of fat and disruption of fat globules with addition of calcium

Composition of various feedsComposition of various feeds

Mineral & Mineral & Vitamin per Vitamin per 100 Kcal100 Kcal

Preterm-Preterm-RNI RNI (AAPCON (AAPCON 1998)1998)

Preterm-Preterm-EBM (per EBM (per 100 ml)100 ml)

Preterm Preterm EBM + HMF EBM + HMF (Per 100 ml)(Per 100 ml)

Preterm Preterm Formula (Per Formula (Per 100 ml)100 ml)

Calories Calories (Kcal/kg/d)(Kcal/kg/d)

105-130105-130 6767 8181 8080

Protein Protein (gm/kg/d)(gm/kg/d)

3.5-43.5-4 1.61.6 22 22

Carbohydrate Carbohydrate (gm/kg/day)(gm/kg/day)

11-15.511-15.5 7.37.3 9.79.7 9.19.1

Calcium Calcium (mg)(mg)

175175 2525 125125 128128

Phosphorus Phosphorus (mg)(mg)

9191 1414 6464 6464

Iron (mg)Iron (mg) 1.7-2.51.7-2.5 0.090.09 0.090.09 0.80.8

Contd…

Composition of various feedsComposition of various feeds

Mineral & Mineral & Vitamin per Vitamin per

100 Kcal100 Kcal

Preterm-Preterm-RNI RNI

(AAPCON (AAPCON 1998)1998)

Preterm-Preterm-EBM (per EBM (per

100 ml)100 ml)

Preterm Preterm EBM + HMF EBM + HMF (Per 100 ml)*(Per 100 ml)*

Preterm Preterm Formula (Per Formula (Per

100 ml)100 ml)

Vitamin A Vitamin A (IU)(IU)

75-22575-225 4848 15081508 241241

Vitamin D Vitamin D (IU)(IU)

270270 88 508508 7272

Sodium Sodium (mEq)(mEq)

2.1-2.92.1-2.9 1.261.26 1.561.56 2.22.2

Vitamin E Vitamin E (IU)(IU)

>1.1>1.1 11 33 44


* 1 Sachet (2 gm) of HMF is added to 50 ml of expressed breast milk.

Contd…

Human Milk provides the ‘Gold Standard’ for feeding LBW neonates!

Gut Starvation : Need for early feeding ?Gut Starvation : Need for early feeding ?

Morphological ChangesMorphological Changes

Mucosal massMucosal mass Cell productionCell production Villus heightVillus height

Functional ChangesFunctional Changes

PermeabilityPermeability Amino acid absorption Amino acid absorption

EnzymesEnzymes

Sucrase Sucrase LactaseLactase

ImmunityImmunity

Number of lymphocytesNumber of lymphocytes IgA secretionIgA secretion

Bacterial translocationBacterial translocation

Zeigler,Lucas,Moro ‘Nutrition of the VLBW Infant’, 1999

Cloherty, Eichenwald, Stark, ‘Manual of Neonatal Care’, 5 th Ed, 2004

Minimal Enteral Nutrition (MEN)Minimal Enteral Nutrition (MEN)

Syn. Trophic feeding, Gut priming feeding, minimal feeds, gut Syn. Trophic feeding, Gut priming feeding, minimal feeds, gut stimulation, early feeding, or hypocaloricstimulation, early feeding, or hypocaloric feedingsfeedings

Def. :

Feedings that are delivered in very small amounts ( 10 mL/kg/d) for the purpose of induction of gut maturation rather than nutrient delivery!

Advantages :

Improved levels of gut hormones Trophic effects on mucosa

Improved peristalsis

Improved calcium & phosphorus retention


Less feeding intolerance

Earlier progression to full enteral feedings, Fewer days on parenteral nutrition

Improved weight gain

Reducation in episodes of culture positive sepsis

Low serum bilirubin levels

No increased risk of NEC

Cochrane review, Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

Contd…


……No consensus guideline as when to start, how to progress, No consensus guideline as when to start, how to progress, how long to continue MEN & when to advance to full how long to continue MEN & when to advance to full

nutritive feedingnutritive feeding

Recommended for all babies Sick babies with significant respiratory distress & Sick babies with significant respiratory distress &

hemodynamic instability remain NPO till they are hemodynamic instability remain NPO till they are stable, ideally by 1stable, ideally by 1stst – 2 – 2ndnd day of life day of life

Donot use in suspected or confirmed NEC or evidence Donot use in suspected or confirmed NEC or evidence of ileus.of ileus.

Can be started with EBM at a volume of Can be started with EBM at a volume of 10 mL/kg/d 10 mL/kg/d @ 3-8 hourly intervals@ 3-8 hourly intervals


Contd…

Rapid (Vs Slow) AdvancementsRapid (Vs Slow) Advancements

Better gain in weight, length & HC

Shorter hospital stay

Risk of GER, aspiration

Risk of NEC with very fast advancements

Indian J Pediatr 2002; 69 (5) : 401-404

Recommendation

You can make rapid enhancements upto 30 ml/kg/d in stable LBW infants without increased risk of NEC, esp. after day 4/5 of life!

Cloherty, Eichenwald, Stark, ‘Manual of Neonatal Care’; 5 th Ed, 2004

Guidelines for Tube FeedingGuidelines for Tube FeedingBirth weight (gm)Birth weight (gm) Initial rate Initial rate

(mL/kg/day)(mL/kg/day)Volume Increase Volume Increase

(mL/kg/day)(mL/kg/day)

< 800< 800 1010 10-2010-20

800-1000800-1000 10-2010-20 10-2010-20

1001-12501001-1250 2020 20-3020-30

1251-15001251-1500 3030 3030

1500-18001500-1800 30-4030-40 30-4030-40

1801-25001801-2500 4040 40-5040-50

>2500>2500 5050 5050

Feeding MUST always be individualized depending on neonate’s condition!

Intermittent Bolus Vs ContinuousIntermittent Bolus Vs Continuous

More physiological Risk of GER

Risk of aspiration


Preferred in general! May be used for :

GER

Bolus feeding Intolerance

Indian J Pediatr 2002; 69 (5) : 401-404

Expressing Breast MilkExpressing Breast Milk

Principles of Newborn Baby Care, WHO/UNICEF, 2003

• Teach the mother how to express breast milk herself. The mother should:

- obtain a clean (washed, boiled or rinsed with boiling water, and air-dried) cup or container to collect and store the milk;

- wash her hands thoroughly;- sit or stand comfortably and hold the container

underneath her breast;- express the milk- support the breast with four fingers and place the

thumb above the areola;- squeeze the areola between the thumb and fingers

while pressing backwards against the chest;


- express each breast for at least four minutes, alternating breasts until the flow of milk stops (both breasts are completely expressed).

• If the milk does not flow well:

- ensure that the mother is using the correct technique;

- have the mother apply warm compresses to her breasts


While feeding, baby’s lips should cover areola in addition to nipple!

www.breastfeeding.orgwww.breastfeeding.org

Recommendations for storage of Breast MilkRecommendations for storage of Breast Milk

Duration of Storage with respect to temperatureDuration of Storage with respect to temperature

Room TemperatureRoom Temperature 6-8 hours6-8 hours

Refrigerator (<4Refrigerator (<4°C; 39ºF)°C; 39ºF) 24 hours24 hours

Freezer Compartment, or Deep Freezer Compartment, or Deep Freezer ( <-20 Freezer ( <-20 °C; <-4 °F)°C; <-4 °F)

6 months6 months

Store in hard plastic or glass containers with well-fitting tops. Warm frozen or refrigerated milk in a warm water bath (~40 °C).°C). Use the rewarmed milk promptly. Discard the remaining once Use the rewarmed milk promptly. Discard the remaining once

warmed.warmed.

Feeding by Alternative MethodsFeeding by Alternative Methods

• Ensure that the mother can properly express breast milk

• Feed the baby using a cup, a cup and spoon, or other suitable device (e.g. paladai)

• Use clean (washed, boiled or rinsed with boiled water, and air-dried) utensils and feeding devices for each feed.

• Feed the baby immediately after the milk is expressed, if possible. If the baby does not consume all of the milk, store the remaining milk

Feeding by Alternative MethodsFeeding by Alternative Methods• Have the mother feed the baby unless she is not

available. The mother should:

- measure the volume of breast milk in the cup

- hold the baby sitting semi-upright on her lap;

- rest the cup (or paladai or spoon) lightly on the baby’s lower lip and touch the outer part of the upper lip with the edge of the cup;

- tip the cup (or paladai or spoon) so the milk just reaches the baby’s lips;

- allow the baby to take the milk; do not pour

- end the feeding when the baby closes her/his mouth and is no longer interested in feeding.

Feeding by Gastric TubeFeeding by Gastric Tube

• Ensure that the mother can properly express breast milk

• Insert a gastric tube, if one is not already in place.

• Confirm that the tube is properly positioned before EACH feeding.

• Encourage the mother to hold the baby and participate in feedings.

• Determine the required volume of milk for the feed according to the baby’s age

Feeding by Gastric TubeFeeding by Gastric Tube• Remove the plunger of a high-level

disinfected or sterile syringe or a clean (washed, boiled or rinsed with boiled water, and air-dried) syringe and connect the barrel of the syringe to the end of the gastric tube:

• Pour the required volume of milk into the syringe with “tip” of the syringe pointed downward.

• Have the mother hold the syringe 5 to 10 cm above the baby or suspend the tube above the baby and allow the milk to run down the tube by gravity. Do not force by plunger.


o You may apply slight pressure with the plunger initially (just to start the feeding)

o When the feeding is completed, clear the tube with some of water. Try not to put extra air into the stomach.

o There is no need to burn the baby after feeding

o Place the baby on his or her right side or hold upright after feeding


Right-side lying position after feedingWhaley & Wong’s Essentials of Pediatric Nursing, 5th Ed, Mosby, 1997

Feeding by Gastric TubeFeeding by Gastric Tube• Using this method, each feeding should

take 10 to 15 minutes.

• When the feeding is finished, remove, wash, and high-level disinfect or sterilize the syringe, and cap the tube until the next feeding.

• Progress to feeding by cup/spoon when the baby can swallow without coughing or spitting milk.

• Replace the gastric tube with another clean gastric tube after 2-3 days, or earlier if it is pulled out or becomes blocked.


Continuous Feeding :

Set up feeding pump and give the feeding

Flush the feeding tube with water every 4 hours.

Change the feeding bag every 24 hours

Feeding the Term LBW neonatesFeeding the Term LBW neonates

Constitute 2/3rd of LBW neonates in India Growth retarded Have inadequate transplacental transfer of nutrients like

Calcium, phosphate & multivitamins

“No guidelines available yet about how to provide them optimum nutrition”.

But, if inadequate weight gain on full breast feeds, may be supplemented with extra calories or proteins with fortifiers or preterm formulas!


Feeding the baby : Standards of CareFeeding the baby : Standards of Care

Encourage & teach the mother to express breast milk at least eight times in 24 hours

Assess the feeding ability TWICE DAILY, and encourage & support the mother to begin breast feeding as soon as the baby shows signs of readiness to suckle

Record the following EACH TIME the baby is fed : Time of feeding Amount & kind of milk given Any feeding difficulty

Assess the baby’s growth frequently.

MonitoringMonitoring

Indian Pediatrics, Vol. 41, May, 2004: 436

Monitor :

Abdominal girth >2 cm is significant

Pre feed gastric aspirate Compare with amount of previous feed

<30% of pre feed volume

30-50% of pre feed volume/vomiting / abd. distension.

>50% of pre feed volume, or 3 mL/kg (whichever greater)

Continue

with same

Stop feeding, IVF for 12 hrs.

Continue IVF for another 12 hrs & reassess

Restart at same rate as last feed & observe

Not improvingNot improvingImprovingImproving


Indian Pediatrics, Vol. 41, May, 2004: 436 2003

>50% of pre feed volume, or 3 mL/kg (whichever greater)

Discontinue feeding for next 24 hours, then reassess

Investigate for Sepsis & NEC

Continue with management of the condition

Restart feeding at half the volume at the time of discontinuation

PositiveNegative

Contd...Contd...



• Assess hydration daily:

- If there are signs of dehydration (e.g. sunken eyes or fontanelle, loss of skin elasticity, or dry tongue and mucous membranes), increase the volume of fluid by 10% of the baby’s body weight on the first day;

- If there are signs of over hydration (e.g. excessive weight gain, puffy eyes, or increasing oedema over lower parts of the body), reduce the volume of fluid by half for 24 hours.

• Weigh the baby daily. If the daily weight loss is more than 5%, increase the total volume of fluid by 10 ml/kg body weight for one day to compensate for inadequate fluid administration.

• Monitor Hb/PCV, Serum sodium weekly till 4-6 weeks

• Monitor serum calcium, phosphate and alkaline phosphatase fortnightly till discharge, and at term corrected age before stopping calcium supplements.


Judging the adequacy of NutritionJudging the adequacy of Nutrition

Weight Pattern :Weight Pattern : Not >10-15% cumulative weight loss during first week of lifeNot >10-15% cumulative weight loss during first week of life Birth weight regained between 10-14Birth weight regained between 10-14thth day of life day of life Starts gaining weight by second week of life at Starts gaining weight by second week of life at 15-20 gm/day15-20 gm/day. .

(SFD neonates may start without any appreciable weight loss (SFD neonates may start without any appreciable weight loss at all) unless sick. at all) unless sick.

For this weigh the baby :For this weigh the baby :o Daily when in the hospitalDaily when in the hospitalo At 2 weeks, 4 weeks & then monthly after discharge!At 2 weeks, 4 weeks & then monthly after discharge!

Baby should gain Baby should gain 0.75 cm0.75 cm of HC per week till 40 weeks of of HC per week till 40 weeks of gestationgestation

Baby should gain Baby should gain 1.1 cm1.1 cm of length per week between 28-40 of length per week between 28-40 weeks of gestationweeks of gestation


Weight Gain & FeedingWeight Gain & Feeding


• If the baby still requires feeding using an alternative feeding method but is on full milk feeds:

- Increase the volume of milk in increments of 20 ml/kg body weight per day until the baby reaches 180 ml/kg body weight of breast milk per day;

- Continue to increase the volume of milk as the baby’s weight increases to maintain a volume of 180 ml/kg body weight of breast milk per day.

Weight Gain & FeedingWeight Gain & Feeding


• If weight gain is inadequate (less than 15 g/kg body weight per day over three days):

- Increase the volume of milk to 200 ml/kg body weight per day;

- You can have the mother express breast milk into two different cups. Have her give the contents of the second cup, which contains more of the fat-rich hind milk, to the baby first, and then supplement with whatever is required from the first cup.

- If weight gain is inadequate for more than one week and the baby has been taking 200 ml/kg body weight breast milk per day, treat for inadequate weight gain

Inadequate weight gain / Excessive Inadequate weight gain / Excessive Weight LossWeight Loss

Inadequate calorie provided/consumed Cold stress Anemia Underlying systemic illness, e.g. sepsis. Urinary tract infection Late hyponatremia Late metabolic acidosis


Recording & Monitoring WeightRecording & Monitoring Weight

Converting Gavage to Oral FeedsConverting Gavage to Oral Feeds

Candidates Neonate of ~34 wk gestation with coordinated suck-swallow-breathe pattern & respiratory rate 60/min

Transition should be slow At first, give a supervised spoon feed & if the baby accepts well

I.e. can finish the measured amount within 20-30 min without any sign of fatigue (apnea, vomiting, color changes, poor weight gain & slow to finish the full volume), then, number of spoon feeds can be increased over next few days like :

o One spoon feed every 6 feedso One spoon feed per 2 gavage feedso Alternate spoon & gavage feedo 2 spoon feeds per gavage feedo And finally to full spoon feeds

Always try NNS while on gavage from 30-32 weeks gestation


Non Nutritive Sucking (NNS)Non Nutritive Sucking (NNS)

Used In transition from gavage to breast feeding During gavage feeding

Rationale Facilitates the development of sucking behaviour Improves digestion of enteral feeding

Benefits Early transition from gavage to breast feeding Decrease length of hospital stay

Method Done with empty breast or with a pacifier Burping is a MUST because aerophagia is likely

Combining IV Fluid & FeedingCombining IV Fluid & Feeding


• If the baby tolerates the feed and there are no problems, continue to increase the volume of feeds while decreasing the volume of IV fluid to maintain the total daily fluid volume according to the baby’s daily requirement

• Feed the baby every three hours, or more frequently if necessary, adjusting the volume at each feeding accordingly.

• Add the total volume of feeds and fluid given each day. Compare this volume with the required daily volume, and adjust the volume that the baby receives accordingly.

• Discontinue the infusion of IV fluid when the baby is receiving more than two-thirds of the daily fluid volume by mouth and has no abdominal distension or vomiting.

• Encourage the mother to breastfeed exclusively as soon as the baby is receiving 100% of the daily fluid volume by mouth.

Kangaroo Mother Care (KMC)Kangaroo Mother Care (KMC)

Kangaroo mother care (KMC) is care of a baby who is continuously carried in skin-to-skin contact by the mother and exclusively breastfed (ideally). It is the best way to keep a small baby warm and it also helps establish breastfeeding.

Kangaroo In-Hospital AdaptationKMC can be started in the hospital

as soon as the baby’s condition permits (i.e. the baby does not require special treatment, such as oxygen or IV fluid). KMC, however, requires that the mother stay with the baby or spend most of the day at the hospital.


•Ensure that the mother is fully recovered from any childbirth complications before she begins KMC.

•Ensure that the mother has support from her family to stay at the hospital or return when the baby is ready for KMC and to deal with responsibilities at home.

• Explain to the mother that KMC may be the best way for her to care for her baby once the baby’s condition permits:- the baby will be warm;- the baby will feed more easily;- episodes of apnea will be less frequent.


• Take the baby away from the mother only to change napkins (diapers), bathe, and assess for clinical findings.

• Babies can be cared for using KMC until they are about 2.5 kg or 40 weeks post-menstrual age.

Sodium Supplementation Sodium Supplementation

Preterms especially <34 weeks are often hyponatremic due to excessive sodium loss in urine.

Hence monitor serum sodium weekly till post conceptional age of 34 weeks.

If serum sodium <130 mEq/L, extra sodium supplementation given.

o 3% NaCl (1ml = 0.5 mEq), or

o 0.9% NaCl (1ml = 0.15 mEq). Supplement should be orally diluted with feeds to maintain

serum sodium between 135-140 mEq/L.


Iron Supplementation Iron Supplementation

Although iron stores are low in preterms & term-SFDs, requirements are minimum in first few weeks of life!


Birth weight 1000 gm Birth weight >1000 gm

Iron @ 3-4 mg/kg/d Iron @ 2-3 mg/kg/d

Start at 4-6 weeks of life when active erythropoiesis starts

Start earlier at 4 weeks of life if baby had frequent phlebotomies

How long to continue How long to continue supplements ? supplements ?

Stop the HMF or Preterm formula when the baby reaches 2 kg or starts accepting full breast feeds, and start calcium-phosphate and vitamin supplements.

If the baby was only on breast milk continue calcium-phosphate till baby reaches corrected age of term (wt. ~3-3.5 kg) check serum calcium, phosphate and alkaline phosphatase before stopping especially in ELBW babies to rule out any osteopenia or prematurity.

Stop multivitamins when the baby reaches 6 months or 4.5 kg. Continue iron for atleast 1 year, and if weaning is not adequate

continue till 2-3 year of age.


ImmunonutritionImmunonutrition

Diets that are specifically designed to enhance immune function.

• Glutamine

• L-arginine

• N-acetyl Cysteine

• Glutathione

• MCT & LCT

• n3 fatty acid

• Vitamin A, E, C, Zinc, Selenium Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004

ImmunonutritionImmunonutrition

Use of specific nutrients supplements singly or in combination, stimulate the immune response and should result in fewer infections, particularly in LBW infants.

Maximum benefit of immune enhancement has been shown to occur in postoperative adult patients. Whether overall mortality is actually improved still remains to the established.

Present Status : More studies are needed for their use in low birth babies.


MCT OilMCT Oil

Indian J Pediatr 2001; 68 (4) : 333-337

Primarily has caprylic & capric fatty acids and is a yellow, odorless, and translucent liquid.

Human milk contains 3-7% of fat as MCT. Cow’s milk has 1% and formula milk has ~10%

Rapidly absorbed into blood stream from lacteals without biliary binding

Exhibit rapid mitochondrial uptake

Rapidly cleared from blood stream

MCT OilMCT Oil

When added to enteral feeds, significantly increases the caloric density without increasing much osmolar load

Does not contain any EFA. Excessive use of MCT i.e. >60% of total fat intake decreases the uptake of EFA.

Growth is not improve.

Expensive, however coconut oil can be used in place

Can be added as 2 kCal/Oz to the milk (has 7.8 kCal/ml)

Present status : Routine use is not recommended.


Advice on DischargeAdvice on Discharge

Explain the mother that Her milk is best for the baby Breast feeding is especially important for a small baby It may take longer for a small baby to establish breast

feeding It is usually normal if the baby :

Tires easily & suckles weakly at first Suckles for shorter periods of time before resting Falls asleep during feeding Pauses for long periods between suckling

Contd…


Assure the mother that

Breast feeding will become easier once the baby becomes bigger

Ensure that the baby is fed frequently

If the baby weighs 1250 to 2500 gm, feed the baby at least eight times in twenty four hours (I.e. every 3 hours).

If the baby weighs less than 1250 gm, feed the baby at least twelve times in twenty four hours (i.e. every 2 hours).

Contd…


Danger signals (Early detection & referral) :

Lethargy, refusal to feed.

Hypothermia

Tachypnoea, Grunting, Gasping

Seizures, Vacant Stare.

Abdominal distension

Bleeding, icterus over palms / soles.

Contd…

Ref. : Teaching Aids, NNF-India.

SummarySummary

Appropriate & adequate nutrition to Appropriate & adequate nutrition to LBW Babies. LBW Babies.

Early nutrition for long term growth Early nutrition for long term growth and neurodevelopment.and neurodevelopment.

Breast milk provides the gold Breast milk provides the gold standard for feeding. standard for feeding.

Role of non nutritive sucking, KMC Role of non nutritive sucking, KMC and micronutrient supplementation. and micronutrient supplementation.

ThanksThanks

Enteral Feeding LBW

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