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Abdulmahdi A. Hasan*
*Ph,D, pediatric & psychiatric Mental Health Nursing
Neonatal and Infant Nutrition
Introduction
What does ‘nutrition’ mean to you?
The OED definition
Nutrition (noun)
1. the process of taking in and assimilating nutrients.
2. the branch of science concerned with this process.
DERIVATIVES nutritional adj. nutritionist noun.
ORIGIN Latin, from nutrire ‘nourish’.
• Textbook answer
• Nelson’s Textbook of Paediatrics
– achievement of satisfactory growth and avoidance of deficiency states.
– Aims
• To explore the knowledge base behind key competencies in nutrition for
paediatricians
• Reference: A Framework of Competences for Core Higher Specialist
Training in Paediatrics (RCPCH, 2005.)
• Objectives
• By the end of this morning, you will
– understand the effects of fetal growth restriction on short- and longterm health
– understand the principles and importance of nutrition in the neonatal
period including assessment of nutritional status
– be able to make appropriate recommendations to address feeding
problems and faltering growth
• ‘Normal’ Nutrition
• Fetal nutrition
• 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
– Adaptation to nutrition after birth
• Gut adaptation is regulated by
– Endocrine factors
– Intraluminal factors
– Breast milk hormones and growth factors
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– Bacteria
Breast is best
Feeding the term infant
Breast feeding achieves
– Nutrition
– Immunological and antimicrobial protection
– Passage of breast milk hormones and growth factors
– Provision of digestive enzymes
– Facilitation of mother-infant bonding
Supplementing breast milk
Should be unnecessary, but
– Vitamin K levels are low
– Vitamin D levels are low in areas of little sunlight
– Iron levels are low (but very well absorbed)
– Artificial Feeds
Term formulas are broadly similar
– May be whey or casein based
– International agreed standards for constituents
– Artificial feeding
Practical considerations for making up feeds
– Water softeners increase sodium content
– Repeated or prolonged boiling can increase sodium content of water
– Bottled water can contain high levels of carbon dioxide, sodium,
nitrate and fluoride.
Monitoring feeding
Maternal sensation of engorgement and emptying
Frequency of feeding
Wet nappies
Stools
Jaundice
Weight
Normal output
Support for breast feeding mothers
Midwife
Infant feeding specialist
Breast feeding support groups
National Childbirth Trust
Nutrition for the preterm or sick baby
From little acorns…
The obstetric team ask you to talk to a mother who is being induced at 31
weeks gestation as she is ‘small for dates’.
What further information would you like?
Mrs Oak
28 year old primigravida
5’2, 80kg
Smokes 5 cigarettes daily
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Concerns about growth from 20 weeks
Latest ‘dopplers’ show absent EDF
Proteinuria and hypertension
In groups, plan your chat
How will you counsel the family?
Consider particularly:
– Risks of preterm delivery vs risk of continuing pregnancy
– Short term risks
– Approach to feeding
– Long term outcome
Short term risks of IUGR
Obstetric
– Intrauterine death
– Intrapartum asphyxia
– Short term risks of IUGR
Paediatric
– Hypoglycaemia
– Necrotising enterocolitis
– Increased risk of problems of prematurity
– (hypothermia)
– (polycythaemia)
NEC and IUGR
Case-control study (n=74)
– at 30-36 weeks GA, birth weight <10th centile is a significant risk
factor
– OR 6 (1.3-26)1
Observational study (n= 69)
– At 30-36 weeks 71% of cases were <10th centile2
• 1 Beeby and Jeffrey. 1991, ADC:67:432-5
• 2 McDonnell and Wilkinson. Sem Neonatol 1997
NEC and IUGR: Why?
Pathogenesis of NEC requires
– enteral feeding
– gut ischaemia
– bacterial infection
Abnormal gut blood flow recognised in IUGR
Ischaemic damage or reperfusion injury?
Normal doppler flow in umbilical artery
Absent end diastolic flow
Reversed end-diastolic flow
Abnormal dopplers and NEC
In 9 of 14 studies, AREDF led to an increased risk of NEC
OR 2.13 (95%CI 1.49 to 3.03)
• Dorling J, Kempley S, Leaf A. Feeding growth restricted preterm
infants with abnormal antenatal Doppler results. Arch. Dis.
Child. Fetal Neonatal Ed. 2005; 90: F359-F363
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So how to feed?
Delay start?
Use non-nutritive feeds?
Increase slowly?
Use friendly bacteria?
Cochrane review: early vs late feeding
72 babies in 2 studies
Early feeders had
– Fewer days parenteral nutrition
– Fewer investigations for sepsis
No difference in
– NEC
– Weight gain
– Cochrane review: rapid vs slow increase
369 babies in 3 studies
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
Cochrane review: minimal enteral nutrition
380 babies in 8 studies
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
Probiotics for preventing NEC
Systematic review of 1393 VLBW infants treated with a variety of organisms
Reduced risk of
– NEC (RR 0·36, 95% CI 0·20–0·65)
– Death (RR 0·47, 0·30–0·73)
Achieved full feeds faster
No difference in rates of sepsis
– Deschpande et al, Lancet 2007
– Preventing NEC: what works?
Feeding small or preterm infants: Choices
Human milk
– Mother’s own
– Banked donor milk
– Fortified
Artificial
– Term formula
– Preterm formula
Parenteral Nutrition
Parenteral Nutrition
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Parenteral Nutrition
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
– Energy
• Requirements
– Basal metabolic rate
– Physical activity
– Specific dynamic action of food
– Thermoregulation
– Growth
• Energy
• Requirements
kcal/kg/day
– Basal metabolic rate
40
– Physical activity
4+
– Specific dynamic action of food
(10%)
– Thermoregulation
variable
– Growth
70
(To match in-utero growth of 15g/kg/day)
• Protein
• With glucose infusion alone, infants lose 1-2% of endogenous protein stores
daily
• 1g/kg/day gives protein balance
• 2.5 to 3.5g/kg/day allows accretion
– nb energy requirement
• Safe to start soon after birth
• Fat
• Energy source
• Essential fatty acid source (intralipid)
• Cell uptake and utilisation of free fatty acids is deficient in preterm infants
• Start at max 1g/kg/day, increasing gradually to 3g/kg/day (less if septic)
• Benefits of PN
• Earlier, faster weight gain
• Avoidance of problems associated with enteral feeds
• Risks of PN
• Line associated sepsis
• Line related complications (eg thrombosis)
• Hyperammonaemia
• Hyperchloraemic acidosis
• Cholestatic jaundice
• Trace element deficiency
• Milk Feeds
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Human milk advantages
Protection from NEC
Improved host defences
Protection from allergy and eczema
Faster tolerance of full enteral feeds
Better developmental and intellectual outcome
Human milk shortcomings if preterm
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)
• Breast milk fortifiers
• Improved
– short term growth
– nutrient retention
– bone mineralisation
• Concerns
– trend towards increased NEC
• Term vs preterm formulas
• 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
• Feeding preterm infants: aim
“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”
American Academy of Pediatrics Committee on Nutrition
• Evidence Based Nutrition
• RA Ehrenkranz, Seminars in Perinatology 2007 (31): 48-55
• Post-Discharge Nutrition
• Post discharge nutrition
• Preterm infants tend to be small at discharge, and remain small into
adolescence
• Limited evidence for what rate of growth is optimal
• The evidence
• Comparison of ‘post-discharge’ formula with standard term formula
– No consistent difference in growth parameters or body composition
– Z-score reduces in both groups
– Term formula needs supplementing with vitamins and iron to achieve
targets
• The evidence
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Comparison of breast milk with term formula
– Calcium and phosphate deficiency in breast milk fed infants in first
year resolves by age two
– Little difference in growth (although small numbers)
Outcomes
Catch-up Growth
Enhanced nutritional intake sufficient to allow ‘catch-up’ growth improves
long term neurodevelopmental outcome
Body composition differences
Compared to term infants, ex-preterm infants fed at 120 kcal/kg/day
– Have more body fat
– Have a different fat distribution
The long range forecast with IUGR
Does the in-utero environment or early feeding permanently change organ
structure, function and metabolism?
Developmental Origins theory
Humans demonstrate ‘developmental plasticity’ in response to their
environment
Part of cardiovascular risk may be explained by in-utero and postnatal
growth
Developmental Origins theory
Geographically, coronary heart disease correlates with past neonatal
mortality
In epidemiological studies, adult cardiovascular disease is associated with:
– low birthweight
– rapid early postnatal growth
Is rapid catch-up growth bad?
Postnatal weight gain is associated with BMI and waist circumference at 19
years
IUGR infants are at increased risk of the metabolic syndrome
Preterm infants fed breast milk rather than preterm formula
– had lower BP at 13-16yrs
– were less insulin resistant
– had a better LDL:HDL ratio
Nutrition Assessment
How best to assess growth and nutrition?
Weight
– Reflects mass of lean 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
– Laboratory assessment
TPN requires regular monitoring of acid base status, liver function, bone
profile and electrolytes
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In enterally fed infants, monitoring albumin, transferrin, total protein, urea,
alkaline phosphatase and phosphate may be useful
Infant Feeding
Task
Read the GP referral letter
In pairs:
– Pick out the important aspects of the referral
– Decide what further questions you’d like to ask the family
– What sort of investigations (if any) might you consider?
Faltering Growth
‘Failure to Thrive’
Term first used to describe delayed growth and development,
– also called maternal deprivation syndrome.
“A failure of expected growth and well being”
Only growth can be objectively measured
Crossing centiles?
5% of normal infants cross 2 intercentile spaces from birth to 6 weeks.
5% of normal infants cross 2 intercentile spaces from 6 weeks to 1 year.
Infants regress to the mean
Hence development of ‘thrive lines’
Causes and correlates
Organic disease
Abuse and Neglect
Deprivation
Undernutrition
Causes and correlates
Organic disease
– <5%, usually suggestive symptoms and signs
Abuse and Neglect
– increased risk, but a small proportion
Deprivation
– may influence referral
Undernutrition
The Energy Balance Equation
Undernutrition
Most are underweight for height
Fastest decline in weight gain when energy needs are highest
Poor appetite
Delayed progression to solid foods
Limited range of foods
Faltering Growth over time
Consequences
Lasting deficit in growth
Lasting effects on appetite and feeding
Low maternal self esteem
Developmental delay at 1 year
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– 7-10 DQ points
Small (not statistically significant) IQ difference at 8-9 years
Management
Few trials of intervention
One RCT found health visitor led intervention useful
One non randomised trial found dietary advice useful
Management is therefore based on ‘accepted best practice’
– Screening or Case Finding?
Up to 50% of children with FTT are never identified
Recommendations for frequency of weighing suggest paying more attention
to fewer weights.
Growth Monitoring
Primary or Secondary care?
Common problem, often resolves with simple interventions
Ill children or those losing weight need referral
Home visitor assessment
– Dietary history
– Simple explanation and advice
Second port of call should be dietician
Strategies
The Role of the Paediatrician
Investigations (if necessary) should be completed promptly
FBC, ferritin, U+Es, TFTs, TT glutaminase, MSU
Chromosome analysis in girls
CXR and sweat test in young infants or history of respiratory infections.
Pathway of care
If not improving?
Nursery nurse involvement or nursery placement
Help with other behavioural problems
Treat illness in mother
Social work input
Almost never need food supplements or hospital admission
Task
One volunteer to play the part of Neil’s parent
A second volunteer to be the registrar in clinic
Others to observe and be prepared to give feedback at the end
Question
What are the agendas of the health professionals and the parent?
How will you address the different priorities?
Where will you take things from here?
Feeding difficulties in ex-prems
Feeding issues are common, especially in those born before 28 weeks
Risk of
– Disordered oral-motor functioning
– Significant gastro-oesophageal reflux
– Oral hypersensitivity
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– Neurological impairment affecting feeding
Colic
What is Colic?
“excessive bursts of crying in an otherwise healthy infant not relieved by
routine comfort”
‘Colic’ crying is said to be of higher amplitude, greater intensity, more
frequent, and of longer duration
Problems in Evaluation
Poor case definition
Few controlled studies
Little evidence base for management or investigation
The Classic Definition
“crying lasting 3 or more hours per day, on more than 3 days a week, for at
least 3 weeks and resolving around 3 months”.
– Wassell, Pediatrics 1954
Study Results
Quantifying colic
– scoring scales
– acoustic cry assessments
No effect of sex, birth order, social class, ethnic origin.
Vagal tone and cortisol levels are the same as in non-colicky babies
The impact on parents
Resistance to soothing causes anxiety
Learned helplessness, causing anxiety and depression
Stress can cause parental coping crises
10% of mothers experience a depressive disorder postnatally
Temperament
Some reports link excessive crying to later difficult behaviours
– few studies only
– based on maternal recall
– possible that quality of care in later childhood is influenced by early
patterns of behaviour
Colic and difficulties with feeding
19 with colic v 24 without
Assessment:
– colic symptom checklist
– neonatal oral assessment score
– clinical feeding evaluation
Outcomes
Colic group showed:
– more disorganised feeding behaviours,
– less rhythmic nutritive and non-nutritive sucking,
– more discomfort during feeds,
– lower responsiveness during feeding interactions.
• Miller-Loncar, Arch Dis Child 2004; 89 908-12
Organic causes of a ‘colicky’ baby
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congenital heart disease
CNS abnormalities
NAI
fever eg UTIs
maternal drug ingestion
gastro-oesophageal reflux
cows milk protein intolerance
malabsorption
gut dysmotility
Gut hormones
Motilin initiates migrating motor complexes
Vagus stimulation increases number and force of contractions
Raised motilin in 2 small studies of infantile colic
Smokers have higher motilin levels
Systematic review of treatment
Lucassen et al, BMJ, 1998
50 complete studies, 27 controlled
reviewed.
Treatments for colic
Results as effect size
– Behavioural: (reducing stimulation) 0.48
– Dicycloverine: 0.46, but serious side effects
– Hydrolysate milks: 0.22
– Herbal tea: 0.32 (single small study)
– Low lactose and soya milks: no effect
– Simethicone: no effect
Treatments for colic
Any Questions?
Summary
Optimal growth for neonates and infants requires careful thought about
nutrition
Interventions (or lack of them) may have long term consequences
There is a limited evidence base to guide current practice
Colic is common
Feeding difficulties post SCBU are common