Académique Documents
Professionnel Documents
Culture Documents
Following birth, term infants rapidly adapt from a relatively constant intrauterine
supply of nutrients to intermittent feedings of milk. Preterm infants, however, are
at increased risk of potential nutritional compromise. These infants are born with
limited nutrients reserves, immature pathways for absorption and metabolisme, and
increased nutrient demands. In addition, medical and surgical contions commonly
associated with prematurity frequently alter nutrition requirements and complicate
adequate nutrient delivery. As mortality rates for these high risk newborns continue
to improve, optimizing nutritional care, beginning in the immediate postnatal
period, has become an important topic of clinical research. Current investigations
suggest that earlier, more aggresive nutrition intervention is desirable.
I. Growth
a. fetal body composition changes throughout gestation, with accretion of most
nutrients occuring primarily in the late second and throughout the third trimester.
Term infants will normally have sufficient glycogen and fat stores to meet energy
requirements during the relative starvation of the first days of life. In contrast,
preterm infants, will rapidly deplete their limited nutrient reserves, becoming both
hypoglycemic and catabolic unless appropiate nutritional therapy is provided. In
practice, it is generally assumed that the severity of nutrient insufficiency is
inversely related to gestational age at birth and birth weight.
b. postnatal growth varies from intrauterine growth in that it begins with a period
of weight loss , primarily through the loss of extracellular fluid. The typical loss of
5 to 10% of birth weight for a full term infant may increase to as much as 15% of
birth weight in infants born preterm. The nadir in weight loss ussually occurs by 4
to 6 days of life, with birth weight being regained by 14 to 21 days of life in most
preterm infants. Currently, there is no widely accepted measure of neonatal growth
that captures both the weight loss and subsequent gain characteristic of this period.
Our goals are to limit the degree and duration of initial weight loss in preterm
infants and to facilitate regain of birth weight within 7 to 14 days of life.
c. after achieving birth weight, intrauterine growth and nutrient accretion rate data
are widely accepted as reference standards for assessing growth and nutrient
requirement. We use goals of: 10 to 20 g/kg pper day weight gain ( 15 to 20 g/kg
per day for infants 1500g), ~ 1 cm /week in length, and 0.5 to 1.0 cm/week in
head circumference. Although these goal are not initially attainable in most
preterm infants, replicating growth of the fetus at the same gestational age remains
an appropiate goal as reccomended by the americans academy of pediatrics.
d. along with monitoring rates of growth, serial measurements of weight, head
circumference, and length plotted on growth curves provide valuable information
in the nutritional assessment of the preterm infant. Available intrauterine growth
curves are criticized for limited sample sizes, lack of racial diversity, and being out
of date. However, until more contemporary curves are available, we use the
Lubchenco intrauterine growth curves (1996) (fig.10.1) because these are based on
reasonably sized sample, provide curves to monitor weight, lenght and head
circumference, and are easy to use and interpret.
A number of other growth curves are also available, but we do not recommend
their use in the neonatal intensive care unit (NICU). Postnatal growth curves
follow the same infants over time (i.e. longitudinal growth curves), and are
available from a number of single-NICU studies and more recently from the
National Institute for Child Health and Human Development ( NICHD) multi
centre study (2000). The problem with these curves, however, is that they show
actual, not ideal growth. Althought these curves provide interesting information by
allowing comparison of the growth of infants in one NICU to those in another, they
do not indicate if either group of infants is growing adequately. Intrauterine growth
remains the gold standard for comparison.
e. when an infant is full term corrected gestational age, the monitorng of growth
should take place on the 2000 Centers for Disease Control (CDC) United States
Growth Charts (fomerly, the National Center for Health Statistic, NCHS, growth
curves). Alternative growths curves, based on a sample of low-birth- weight infants
(1501 t0 2500 g at birth) and very-low-birth-weight infants (<1500 g at birth), are
also available for this age group. However, these curves are subject to the same
criticisms as the postnatal growth curves. We do not recommend their use in
former preterm infants, because these infants should still be striving to grow at the
rate of their averange peer.
II Nutrient recommendations
a. sources for nutrient recommendation for preterm infants include the American
Academy of Pediatrics Committee on Nutrition (AAP-CON), the Europen Society
of Pediatrics gastroenterology and nutrition Committee on Nutrition (ESPGANCON), and the consensus recommendation published by Tsang and colleagues
(table 10.1). these recommendations are basen on: (1) intrauterine accretion rate
data, (2) the nutrient content of human milk,(3) the assumed decreased nutrient
stores and higher nutritional needs in preterm infants, and (4) the available data on
biochemical measures reflecting adequate intake. However, due to the limitations
of the currently available data, the goals for nutrient intake for preterm infants are
considered to be recommendations only.
b. Fluid (see chap.9, Fluid and Electroyte management). The initial step in
nutritional support is to determine an infants fluid requirements, which is
dependent on gestational age, postnatal age, and environmental conditions.
Generally, baseline fluid needs are inversely related to gestational age at birth and
birth weight. During the first week of life, very-low-birth-weight (VLBW) infants
are known to experience increased water loss because of the immaturity of their
skin, which has a higher water content and increased permeability, and the
immaturity of their renal function with a decreased ability to concentrate urine.
Environmental factors, such as radiant warmers, phototherapy, and low
humidity,also increase insesable losses and raise fluid requirements. Conversely,
restriction of fluid intake may be neccessary to assits with the prevention and/or
treatment of patente ductus arteriosus, renal insufficiency, and chronic lung
disease. Fluid requirements in the first weeks of life are, therefore, continually
reassessed, as the transition is made frpm fetal to neonatal life, and at least daily
afterward.
c. Energy. Estimates suggest the preterm infants in a thermoneutral environment,
require approximately 40 to 60 kcal/kg per day for maintenance of body weight,
assuming adequate protein is provided. Additional calories are needed for growth,
wirh the smallest neonates tending to demonstrate the greatest need, as their rate of
growth is highest ( table 10.2 ). In practice, we generally strive for energy intakes
of 120 to 160 kcal/kg per day. Lesser intakes ( 90 to 120 kcal/kg per day ) may
sustain intrauterine growth rates, if energy expenditure is minimal or if parenteral
nutrition is used.
E. protein. Crystalline amino acid solutions provide the nitrogen source in PN.
1. the caloric value of amino acids is 4kcal/g.
deficiency state can be avoided by the administration of 0,5 to 1,0 g/kg per day of
lipid emulsion. Therefore, in our institution all infants weighing <1000 g at birth
are intiated on 0,5 to 1,0 g/kg per-day within the first 24 to 48 hours of life. This
rate is advanced by approximately 0,5 g/kg per day, as tolerated, to a target of 3,0
g/kg per day. All infants weighing > 1000 g at birth are initiated on 1,0 g/kg per
day within ated to a target of 3,0 g/kg perday
3. tolerance also correlates with hourly infusion rate, and no benefit to a rest period
has been identified. We, therefore infuse lipid emulsions over 24 hours for optimal
clearance. However, due to sepsis risk factors, syringes are changed every 12 hours
G. Electrolytes
1. sodium and potassium concentrations are adjusted daily based on individual
requirements (see chap 9)
maintenance requirements are estimated at
approximants 2 to 4 mEq/kg
2. increasing the proportion of anions provided as acetate aids in the treatment of
metabolic acidosis in vlbw infants
H. vitamins. The current vitamin formulation (MVI pediatric, neosan
pharmaceuticals) does not maintain blood levels of all vitamins within an
acceptable range for preterm infants. However, there are no products currently
available that are specifically designed for preterm infants. Table 10.3 provides
guidelines for thee use of the available formulations for term and preterm infants,
we typically add 1,5 mL MVI pediatric/ 100 mL PN administered at a rate of 150
mL/kg. for those infants receiving <150 mL/kg, the american society of clinical
nutrition and AAP guidelines of 40% of the currently available single dose vial per
kg (not to exceed 5 mL per day) may need to be considered. Vitamin A is the most
difficult to provide in adequate amounts to the VLBW infant without providing
excess amounts of the other vitamins, as it is subject to losses via photodegradation
and absorption to plastic tubing and solution-containing bags. B vitamins may also
be affected by photodegradation. This is of particular concern with long-term PN
use and for this reason PN-containing plastic bags and tubing should be shielded
from light
I. mineral. The amount of calcium and phosphorus that can be administered via IV
is limited by the precipitation of calcium phosphate. Unfortunately, the variables
that determine calcium and phosphate compatibility in PN are complex and what
constitutes maximal safe concentrations is controversial. We adhere to the
following guidelines:
1. calcium. Our standard, peripheral PN solution contains 30 mg/dL (1,5 mEq/dL)
of elemental calcium
2. phosphorus. 1,0 mEq/dL of potassium phosphate is also routinely added to our
standard, peripheral PN. This provides approximately 21 mg/dL of phosphate (0,68
mM/dL of phosphate)
3.these standard mineral concentrations provide only about one-third of daily
intrauterine accretion rates for calcium and phosphorus. Therefore,preterm infants
receiving prolonged PN are at increased risk for metabolic bone disease (see Chap
29)
4. increasing the mineral content of these solutions may diminish metabolic bone
complications. However, this also increases the risk of precipitations and
administration requires central venous access. Our standard, central PN solution
contain 50 mg/dl of elemental calcium and 2.0 mEq/dL potassium phosphate with
a goal calcium to phosphorus ratio of approximately 1.3:1 to 1.7:1 by weight (1.1:1
to 1.3:1 molar)
5. we do not use 3-in-1 PN solution (dextrose,amino acid, and lipid moxed in
single bag) for the following reasons.
a. the ph of lipid emultions is more basic and increases the pH of the total solution,
which decreases the solubility of calcium and phosphaterus and limits the amount
of these minerals in the solution
b. if the calcium and phosphorus in a 3-in 1 solution did precipitate would be
difficult to detect, as the solution is already cloudy
c. 3 in 1 solutions require either a larger-micron filter or no filter, which may pose
a greater sepsis
j. trace elements
1. we currently add 0,2 mL/dL of neotrace and 1,5 g/dL of selenium beginning in
the first days of PN. However, when PN is supplementing enteral nutrition or
limited to < 2 weeks, only zinc may be needed
2. as copper and manganese are excreted in bile, we routinely reduce or omit these
trace elements if impaired biliary excretion and/ or cholestatic liver disease is
present
K. general PN procedures
1. if possible, the continuity of a central line shoud not be broken for blood
drawing or blood transfusion because of the risk of infection.
2. most medications are not given in PN solutions. If necessary, the PN catheter
may be flushed with saline solution and medication then infused in a compatible
IV solution. Refer to the table in Appendix A for our guidelines for PN/IL and
medication compatibility.
3. Heparin is added to all central lines at a concentration of 0.5 unit/mL of solution.
L. metabolic monitoring for infants receiving PN. All infants receiving PN are
monitored according to the schedule indicated in table 10.4
M. Potential complications associated with PN
1. Cholestasis (see Chap .18) may be seen and is more often transient than
progressive. Experimentally, even short term PN can reduce bile flow and bile salt
formation.
a. risk factors include :
1) Prematurity
2) Duration of PN administration
3) Duration of fasting (lack of enteral feeding also produces bile inspissations
and cholestasis)
4) Infection
5) Narcotic administration
b. recommended management
1) Attempt enteral feeding. Even minimal enteral feedings may stimulate bile
secretion.
2) Avoid overfeeding
3) Provision of a mixed fuel source may be helpful
2. metabolic bone disease (see Chap.29). the use of earlier enteral feedings and
central PN, with higher calcium and phosphorus ratios, has reduced the incidence
of metabolic bone diseases. However, this continues to be seen with the prolonged
use of PN in place of enteral nutrition.
3. metabolic abnormalities. Azotemia, hyperammonemia, and hyperchloremic
metabolic acidosis have become uncommon since introduction of the current
crystalline amino acid solutions. These complications may occur, however, with
amino acid intakes exceeding 4 g/kg per day.
4. metabolic abnormalities related to lipid emultions
a. hiperlipidemia/hypertriglyseridemia. The incidence is inversely related to
gestational age at birth and postnatal age. A short-term decrease in the lipid
infusion rate usually is sufficient to normalize serum lipid levels. We typically aim
to maintain serum triglyceride levels below 200 mg/dL
b. indirect Hyperbilirubinemia. Since free fatty acids can theoretically displace
bilirubin from albumin-binding sites, the use of lipid emulsions during periods of
neonatal hyperbilirubinemia has been questioned. Recent research however suggest
that infusion of lipid at rates up to 3 g/kg per day is unlikely to displace bilirubin.
However, during periods of extreme hyperbilirubinemia (e.g., requiring exchange
transfusion) rates < 3 g/kg per day should be provided.
c. sepsis has been associated with decreased lipoprotein lipase activity and
impaired triglyceride clearance.therefore, during a sepsis episode, it may be
necessary to temporarily limit the lipid infusion to approximately 2.0g/kg per day
if the triglyceride level is > 150 mg/dL.
d. the potential adverse effects of lipid emulsions on pulmonary function, the risk
of chronic lung disease, and impaired immune function remain subjects of debate.
Because of the concern about toxic products of lipid peroxidation, lipid emulsions
should also be protected from both ambient and phototherapy light.
N. Current controversies
1. Carnitine facilitates the transport of lung-chain fatty acids into the mitochondria
for oxidation. However, this nutrient is not routinely added to PN solusions.
Preterm infants who receive prolonged, unsupplemented PN are at risk of carnitine
deficiency due to their limited reserves and inadequate rates of carnitine synthesis.
For those infants who are able to tolerate enteral nutrition, we assume their needs
are met by the use of human milk and/or carnitine-containing infant formula.
However, for infant requiring prolonged (e.g.,>4 weeks) PN, we will routinely
supplement carnitine at an initial dose of approximately 10 mg/kg per day until
enteral nutrition can be established.
2.Cysteine is not a component of current crystalline amino acid solusions, as it is
unstable over time and will form a precipitate. Cysteine is ordinarily synthesized
from methionine and provides a substrate for taurine. However, this may be
considered an essential amino acid for preterm infants due to low activity of the
enzyme hepatic cystathionase, which converts methionine to cysteine.
Supplementation with L-cysteine hydrochloride lowers the pH of the PN solution
and may necessitate the use of additional acetate to prevent acidosis. However, the
lower pH also enhances the solubility of calcium and phosphorus and allows for
improved mineral intake. We routinely supplement cysteine at a rate of
approximately 40 mg/g protein.
3. glutamine is an important fuel for intestinal epithelial cells and lymphocytes,
however, due to its instability, it is presently not a componentof crystalline amino
acid solutions. Its use as an additive to PN solutions is currently under review.
4. insulin is not routinely added to PN. Its use must be weighed against the risk of
wide swings in blood glucose levels, as well as the concerns surrounding the
overall effects of the indreased uptake of glucose. When hyperglycemia is severe
or persistent, an insulin infusion may be useful. We initiate an infusion of regular
insulin at a rate of 0.05 unit/kg per hour, with the dose titrated to maintain blood
glucose concentrations of 100 to 200 mg/dL. A convenient initial solution is 10
units of insulin per 100 mL of fluid (0.1 unit/mL). The IV tubing should first be
thoroughly flushed with thee solution (see Chap.29).
b. Rarely, specialized formulas are used when all other feeding modification have
been tried without improvement. In general, these formulas shoud only be used for
short periods of time with close nutrional monitoring.
c. infants who have repeated episodes of symptomatic emesis that prevent
achievement of full volume enteral feeds may require evaluation for anatomic
problems such as malrotation or Hirchprungs desease. In general, radiographic
studies are not undertaken unless feeding problems have persisted for 2 or more
weeks or unless bilious emesis occurs.
2. established feeds. Preterm infants on full-volume enteral feeds will have
occasional episodes of symptomatic emesis. If these episodes do not compromise
the respiratory status or growth of the infant , no intervention is required other than
continued close monitoring of the infant. If symptomatic emesis is associated with
respiratory compromise, repeated apnea, or growth restriction, theurapeutic
maneuvers are indicated.
a. positioning. Re-position the infant to elevate the head and upper body, in either a
prone or right side down position
b. feeding intervals. Shortening the interval between feed to give a smaller volume
during each feed may sometimes improve signs of GER. Infant feed by gavage
may have the duration of the feed increased
c. metoclopramide. Infants who remain clinically compromised from GER after
positioning and feeding interval change can have a therapeutic trial of
metoclopramide, at a dose of 0.03 to 0.1 mg/kg po/pg q8 hours. The
metoclopramide should be discontinued after 1 week if there is no improvement in
clinical status.
d. thickened feeds. Infants who are nipple feeding may benefit from feed thickened
with rice cereal, starting at teaspoon per ounce of feed, if clinically
compromised by GER
e. Fullterm infants may benefit from therapeutic trials of anti reflux positioning
and/or thickened feeds
3. Apnea. Studies using pH probes not shown an association between GER and
apnea episodes. Treatment with promotility agents should not be used for
uncomplicated apnea of prematurity.
B. Necrotizing enterocolitis (NEC). Nutritional support of the patient with NEC
focuses around providing complete perenteral nutrition during the acute phase of
the disease, followed by gradual introduction of feeds after the patient has
stabilized snd the gut has been allowed to heal.
1. Parenteral nutrition. For at least 2 weeks after the initial diagnosis of NEC, the
patient is kept NPO and receives total perenteral nutrition. The goals for PN were
delineated previously in section III
2. initiation of feeds. If the patient is clinically stable after a minimum 2 weeks of
bowel rest, feeds are introduce at approximately 10 mL/kg per day, preferably with
human milk, although a standard formula appropriate for the gestational age of the
patient may also be used (i.e., preterm formula for the typical NICU infant). More
specialized containing elemental proteins are rarely indicated.
3. feeding advancement. If tropic feedings (10 mL/kg per day) are tolerated for 24
to 48 hours, gradual advancement of feeding volume is continued at approximately
10ml/kg every 12 to 24 hours for the next 2 to 3 days. If this advancement is
tolerated, further advancement proceeds according to the guidelines in Table 10.5.
Supplemental PN is continued until enteral feeds are providing 75% of goal
volume.
4. Feeding Intolerance. Signs of feeding intolerance include large gastric residuals,
emesis, abdominal distension, and increased numbers of apnea episodes. Reduction
of feeding volume or cessation of feeding is usually indicated. If these clinical
signs prevent attainment of full-volume enteral feeds despite several attempts to
advance feeds, radiographic contrast studies may be indicated to rule out intestinal
strictures. This type to achieve full-volume enteral feeds.
5. enterostomles. If one or more enterostomies are created as a result of surgical
theraphy for NEC, it may be difficult to achieve full nutrition intake by enteral
feeds. Depending on the length and function of the upper intestinal tract, increasing
BREASTFEEDING
I. Introduction. Breastfeeding is a learned art that requires education and
support to be successful. Its health and socioeconomic benefits are well
documented. The American Academy of Pediatrics (AAP) encourages the
promotion of breastfeeding as the preferred source of nutrition for at least
the first year after birth. The health-care team is in a unique position to
promote and support breastfeeding, especially during the first 2 to 3 weeks
postpartum when most difficulties occur.
demonstrated for the mother. Interventions include nursing first on the least sore
side, bathing nipples in breastmilk and allowing them to air-dry after nursing or
pumping, and avoiding the use of drying agents such as soaps or lotions on the
nipples. Purified lanolin, applied sparingly 3 or 4 times per day with the mothers
milk, may hasten healing. It does not need to be washed off before feeding.
Hydrogel dressings or breast shells worn between feedings may be helpful. When
nipple damage is severe, the mother should uses a breastpump and the infant fed
expressed milk while the nipples heal. Nipple shields can be used to protect sore
nipples.
2. engorgement may present at 2 to 5 days postpartum as bilateral generalized
breast swelling. The breasts become hard and do not always often with feeding.
Infants often have difficulty latching on. The mother may have a low-grade fever
and ussualy experiences discomfort. If untreated, engorgement can lead to
decreasing milk supply and plugged ducts. Frequent breastfeeding is the best
prevention and treatment for engorgement. Full breasts should be emptied
frequently (every 2 to 3 hours). The use of head and massage may facilitate milk
removal. If breasts are engorged, it may be helpful to hand express or pump for a
few minutes to soften the areola and evert the nipple before nursing. Applying ice
packs to breasts for 5 to 10 minutes before and after feeding and / or pumping
decreases edema and promotes milk flow. Engorgement usually resolves within 24
hours with treatment.
3. plugged ducts present isolated, tender lumps in an otherwise well mother. Heat
and massage applied to the area before and during breastfeeding may facilitate
drainage. Positioning the infants jaw toward the plugged duct may help release the
plugged during feeding. Prevention includes frequent milk removal and avoiding
potential interference with removal, such as underwire bras or constrictive
clothing. If untreated, plugged ducts can lead mastitis.
4. mastitis usually present after the initial postpartum period as can erythematous,
painful, hardened area in the breast. Mother are usually febrile and have flulike
symptoms. Mother with mastitis should continue breastfeeding and contact their
physician who will prescribe the appropriate antibiotic. Most antibiotic are
compatible with breastfeeding.