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
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
• 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
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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
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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
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Glucose
Protein
Fat
Total
16.3gm = 55 kcal/kg/d…. 50%
3.1gm =12.5 kcal/kg/d…12%
4gm = 40 kcal/kg/d…38%
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
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Urine glucose
Triglyceride
BUN, Albumin
Ca, P, Mg, creatinine, Na, Cl, CO2
direct (conjugated) bilirubin, ALT
Trace element level
Complication of TPN
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Infiltration under skin
Infection
Liver dysfunction
Renal overload
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 predominant 60:40
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
• 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 of low milk
• Gestational diabetes
• Hypothyroid
• Retained placental fragments
• Dehydration, hemorrhage, hypertension, infection
• Previous breast surgery
• Lack of prenatal engorgement
• Psychosocial
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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
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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
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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
• 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 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
• Hind milk
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
• 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
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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
• 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
• 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
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Amount
Rate of increase
Type of formula
Risks of fast feeding