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Nutrition

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.

III. Parenteral Nutrition


A. Nutrient Goals. Historically, teh initiation of nutrition support was withheld for
the firtd weeks of life. This practice has changed as research suggests the earlier
nutrition intervention is desirable. Our initial goal for PN is to provide sufficient
calories and amino acids to prevent negative energy and nitrogen balance. Goals
there after include the promotion of appropiate weight gain, and growth, while the
awaiting the attainment of adequate enteral intake.
B. Indicate for initiating PN
1. Infant with a birth weight 1500 g. For those infants weighing > 1000 g, this is
often done in conjunction with slowly advancing entereal nutrition.
2. infants with a birth weight 1501 g to 1800 g for whom significant enteral intake
is not expected for > 3 days.
3. infants with a birth weight > 1800 g for whom significant enteral intake is not
expeceted for > 5 days
C. Peripheal versus Central PN
1. Parental solutions may be infused via peripheral veins pr central vein, usually
the superior or inferior vena cava. The AAP recommends teh peripheral solutions
maintain an osmolarity between 300 and 900 mOsm/L. Because of this limitation,
peripheral solutions often cannot adequately support growth in extremely low birth
weight infants. Central PN allows for the use of morehypertonic sollutions but also
incurs greater risks, particularly eatheter related sepsis.
2. We consider central PN to be warranted under the following conditions :
a. Nutritional needs exceed the capabilities of pheriperal PN
b. An extended period (e.g., >7 days) of inability to take enteral feedings, such as
in infants with necrotizing enterocolitis and in some postoperative infants.
c. Imminents lack of pheriperal venous access
d. carbohydrate. Dextrose (D-glucose) is the carbohydrate source in intra venous
solutions

1. the caloric value of dextrose is 3,4 kcal/g


2. because dextrose contibutes to the osmolarity of a solution, it is generally
recommeded that the concentration administered via perpheral veins be limited to
12,5% dextrose. We also limit concentration delivered via umbilical arterial
catheters to 12,5% dextrose but will use up to 25% dextrose for central venous
infusions. In unsual circumstances, higher concentrations have been used, if the
fluid volume must be severely restricted.
3. dextrose infusions are typically referred to in terms of the milligram of glucose
per kilogram per minute (mg/kg/min) delivered, which expresses the total glucose
load and accounts for infusion rate, dextrose concentration and patient weight
4. the initioal glucose requirement for term infants id defined as the amount that is
neccesary to avoid hypoglicemia. In general, this may be achieved with initial
infusion rates of approximately 4mg/kg/min
5. preterm infants usually require higher rates of glucose, as they have a higher
brain to body weight ratio and higher total energy needs. Initial infusion rates of 4
to 8 mg/kg/min are generally required to maintain euglycemia.
6. initial rates may be advanced, as tolerated, by 1 to 2 mg/kg/min daily to a
maximum of 11 to 14 mg/kg/min. This may be accomplished by increasing
dextrose concentration, by increasing infusion rate, or by a combination of both.
Infusion rates above 11 to 14 mg/kg/min may exceed the infants oxidative
capacity and are generally not recommended, as this may cause the excess glucose
to be converted to fat, particularly in the liver. This conversion may also increase
oxygen consumption, energy expenditure, and CO2 production.
7. the quantity of dextrose that an infant can tolerate will vary with gestational and
postnatal age. Signs of glucose intolerance include hyperglycemia and secondary
glucosuria with osmotic diuresis.

E. protein. Crystalline amino acid solutions provide the nitrogen source in PN.
1. the caloric value of amino acids is 4kcal/g.

2. at present, two pediatric amino acid formulations are commercially available in


the united states: aminosyn PF, abbott laboratories, and trophamine, Bbraun. In
theory, these products are better adapted to the needs of newborns than are
standard adult formulations, as they have been modified for improved tolerance
and contain conditionally essential amino acids. However, the optimal amino acid
composition for neonatal PN has not yet been defined, and there are no products
currently available that are specifically designed for preterm infants.
3. it has been demonstrated that VLBW infants who do not receive amino acids in
the first days of life catabolize body protein at a rate of at least 1g/kg per day.
Studies investigating the use of early amino acids have consistently shown a
reversal of this catabolism without adverse metabolic consequences. Current data
therefore support the infusion of amino acids in a dose of at least 1g/kg per day
beginning in the first 24 hours of life.
4. we provide all infants with a birth weight <1250g with 1,5g/kg per day
beginning immerdiately after birth. Infants with a birth weight between 1250 and
1500 g are initiated on 1.5g/kg per day within the first 24 to 48 hours of life.
Infants >1500g are only initiated on 1,5g.kg per day if indicated; depending on
their size, clinical condition and estimated time to achieve significant enteral
volumes.
5. infusion rates are generally advanced by approximately 1g/kg per day to a target
of 3,5g/kg per day for all infants weighing 1500 gr at birth and 3.0 g/kg per day
for neonates weighing > 1500 g at birth
F. Lipid. Soybean oil, or a combination of soybean and safflower oil, provides the
fat source for intravenous fat emulsions
1. the caloric value of 20% lipid emulsions is 2kcal/mL (approximately 10 kcal/g).
the use of 20% emulsions is preferred over 10% because the higher ratio of
phospholipids to triglyceride in the 10% emulsions interferes with plasma
triglyceride clearance. Twenty percent emulsions also provide a more concentrated
source of calories. For these reasons, we only use 20% lipid emulsions
2. current data suggest that preterm infants are at risk of essential fatty acid (EFA)
deficiency within 72 hours of life, if an exogenous fat source is not delivered. This

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).

5. Vitamin A is important for normal growth and differentiation of epithelial tissue,


particularly the development ang maintenance of pulmonary epithelial tissue.
Extremely-low-birth-weight (ELB) infants are known to have low vitamin A stores
at birth, minimal enteral intake for the first several weeks after birth, poor enteral
absorption of vitamin A, and unreliable parenteral delivery. Studies have suggested
that vitamin A supplementation can reduce the risk of chronic lung disease. At
present, we supplement infants weighing < 1000 g at birth with 5000 IU vitamin A
intramusculary three times per week for the first 4 weeks of life, beginning in the
first 72 hours of life (see Chap.24)
IV. Enteral Nutrition
A. Early enteral feeding
1. The structural and functional integrity of the gastrointestinal (GI) tract is
dependent upon the provision of enteral nutrition. Withholding enteral
feeding after birth places the infant at risk for all the complications
associated with luminal starvation, including mucosal thinning, flattening
of the villi, and bacterial translocation. Trophic feedings (also referred to
as gut priming or minimal enteral feedings) may be described as
feedings that are delivered in very small volumes ( 10 mL/kg per day)
for the purpose of induction of gut maturation rather than nutrient
delivery.
2. Benefits associated with trophic feedings include:
a. Improved levels of gut hormones.
b. Less feeding intolerance.
c. Earlier progression to full enteral feedings.
d. Improved weight gain
e. Improved calcium and phosphorus retention
f. Fewer days on parenteral nutrition
3. We adhere to the following guidelines for the use of thropic feedings:
a. Begin as soon after birth as possible, ideally by day of life 2 to 3.
b. Use full-strength human milk or full-strength 20 kcal/oz preterm
formula at a volume of 10 mL/kg per day. We administer trophic
feedings every 4, 6, or 8 hours.
c. We do not use trophic feedings in infants with severe hemodynamic
instability, suspected or confirmed NEC, evidence of ileus, or clinical

signs of intestinal pathology. We also do not feed infants who are


undergoing treatment with indomethacin for patent ductus arteriosus.
d. Controlled trials of feeding with umbilical arterial catheter (UACs) in
place have not shown an increased incidence of NEC. We do not
consider the presence of a UAC to be a contraindication to trophic
feeding. However, the clinical condition accompanying the prolonged
use a UAC may serve as a contraindication.
B. Preterm infants
1. Fortified human milk. Human milk provides the gold standard for
feeding term infans, we consider the use of fortified human milk to be the
most
nutritionally
optimal
diet
for
preterm
infants.
a. preterm human milk contain higher amounts of protein, sodium,
chloride, and magnesium than term milk (see table 10.1). However, the
levels of these nutrients remain below preterm recommendations, the
differences only persist for the first 21 days of lactation, and composition
is known to vary.
b. for these reasons, we routinely supplement human milk for preterm
infants with human milk fortifier (HMF). The addition of HMF to human
milk (table 10.1) increases energy, protein, vitamin, and mineral contents
to levels more appropriate for preterm infants.
c. infants born weighing < 1500 g are supplemented with HMF once they
are tolerating 100 mL/kg of human milk. Infants > 1500 g are
supplemented once they achieve full volume feedings.
d. because the addition of HMF has resulted in hypercalcemia in the past,
we may monitor calcium and phosphorus levels. Hypercalcemia has been
less of a problem with the newer HMF formulations.
e. When human milk is fed via continous infusion, incomplete delivery of
nutrients may occur, in particular, the nonhomogenized fat and nutrients
in the HMF may cling to the tubing. Small, frequent bolus feedings may
result in improved nutrient delivery and absorption compared with
continous feedings.
f. our protocols for the collection and storage of human milk are outlined
in chap.11.
2. Preterm formula (see table 10.1 and 10.6) are designed to meet the
nutritional and physiologic needs of preterm infants and have some
common features:

a. Whey-predominant, taurine-supplemented protein source, which is


better tolerated and produces a more normal plasma amino acid
profile than casein-predominant protein.
b. Carbohydrate mixture of 40 to 50% lactose and 50 to 60% glucose
polymers to compensate for preterm infants relative lactase
deficiency.
c. Fat mixture containing approximately 50% medium-chain
triglyserides, to compensate for limited pancreatic lipase secretion and
small bile acid pools, as well as 50% long-chain triglycerides to
provide a source of EFAs.
d. Higher concentrations of protein, vitamins, minerals, and electrolytes
to meet the increases needs associated with rapid growth, decreased
intestinal absorption, and limited fluid tolerance.
3. Feeding advancement. When attempting to determine how best to
advance a preterm infant to full enteral nutrition, there is very limited
data to upport any one method as optimal. The following guidelines
reflect our current practice:
a. We use full strength, 20 kcal/oz human milk or preterm formula and
advance feeding volume according to the guidelines in Table 10.5 for
any infant being fed by tube feedings.
b. For those infants with a birth weight < 1500 g, caloric density is
advance from 20 to 24 kcal/oz at 100mL/kg of volume. As previously
discaused in the case of human milk-fed infants, this is accomplished
through the addition of HMF. This volume is then maintained for
approximately 24 hours before the advancement schedule is resumed.
For those > 1500g, caloric density is advanced after achieving full
volume feedings.
c. As enteral volumes are increased, the rate of any IV fluid is reduced
accordingly so that the total daily fluid volume remains the same.
Enteral nutrients are taken into account when administering any
supplemental PN
C. Term infants
1. Human milk is considered the preferred feeding choice for term infants.
2. Term formulas. The AAP provides specific guidelines for the
composition of infant formulas so that term infant formulas approximate

human milk in general composition. Table 10.6 describes the composition


of commonly available formulas, many of which derived from modified
cows milk.
D. Specialized formulas have been design for a variety of congenital and
neonatal disorders, including milk protein allergy, n=malabsorption
syndromers, and several inborn errors of metabolism. Indications for the
most commonly used of these specialized formulas are briefly reviewed in
Table 10.7, while composition is outlined in Table 10.6. However, it is
important to note that these formulas were not designed to meet the special
nutritional needs of preterm infants. Preterm infants fed these formulas
require vigilant nutritional assessment and monitoring for protein, mineral,
and multivitamin supplementation
E. Caloric-enhanced feedings. Many ill and preterm infants require increased
energy/nutrient intakes in order to achieve optimal rates of growth.
1. In general, we first increase caloric density by concentrating feedings to
24kcal/oz; if needed, MCT oil and/or Polycose are added in increments
of 2kcal/oz.
2. We also supplement protein intake with Promod for all VLBW infants in
order to increase the protein content to approximately 4.0g/kg per day.
3. These supplements are further described in Table 10.8
4. Growth patterns of infants receiving these supplements are monitored
closely and the nutritional care plan is adjusted accordingly.
F. Feeding method. These should be individualized based on gestational age,
clinical condition, and feeding tolerance.
1. Nasogastric/orogastric feedings. We utilize nasogastric tube feedings
more frequently, as orogastric tubes tend to be more difficult to secure.
a. Candidates
1. Infants < 34weeks gestation, as most do not yet have the ability to
coordinate suck-swallow-breathe patterns.
2. Infants with impaired suck/swallow coordination due to conditions
such as encephalophathy, hypotonia and maxillofacial
abnormalities
b. Bolus versus continuous. Studies may be found in support of either
method and, in practice, both are utilized. We tend to initiate with
bolus feedings every 3 to 4 hours. If difficulties with feeding tolerance
occur, we will lengthen the amount of time over which a feeding is

given (e.g., feed over a 2 hour period based on a 4 hours feeding


interval).
2. Transpyloric feedings
a. Candidates. There are only a few indications for transpyloric feedings.
1. Infants intolerant to nasogastric/orogastric feedings
2. Infants at increased risk for aspiration
3. Severe gastric retention or regurgitation
4. Anatomic abnormalities of the GI tract such as microgastria.
b. Other considerations
1. Transpyloric feedings should be delivered continuously, as the
small intestine does not have the same capacity for expansion as
does the stomach
2. There is an increased risk for fat malabsorption, as lingual and
gastric lipase secretions are bypassed
3. These tubes are routinely placed under guided fluoroscopy
3. Transition to breast/bottle feedings is a gradual process. Infants who are
approximately 34 gestation who have coordinated suck-swallow-breathe
patterns and respiratory rates <60 per minute are appropriate candidates
for introducing breast/bottle feedings.
4. Gastrostomy feedings
a. Candidates
1. Infants whose transition to breast/bottle feedings is expected to be
prolonged (e.g.,>2 months)
2. Infants wih neurological impairment and/ or those who are unable
to take sufficient volumes via breast/bottle feeding to maintain
adequate growth/hydration status.
G. Iron. The AAP recommends that preterm infants receive a source of iron,
provided at 2 to 4 mg/kg per day, by the time they are 2 months of age or
have doubled their birth weight. We administer iron supplementation
according to the guidelines outlined in Table 10.9. Iron supplementation is
recommended until the infant is 2 years of age.
1. Vitamin E is an important antioxidant that acts to prevent fatty acid
peroxidation in the cell membrane. The recommendation for preterm
infants is 6 to 12 IU vitamin E/kg per day, with the upper limit being
desirable. Preterm infants are not initiated on iron supplements until they
are tolerating full enteral volumes of 24 kcal/oz feedings, which provides

vitamin E supplement would be required to meet the upper end of the


recommendation.
H. Current controversles
1. Glutamine. As with parenteral glutamine supplementation, there are
presently no recommendation for enteral glutamine supplementation in
preterm infants.
2. Long-chain polyunsaturated fatty acids (LCPUFAs). The inclusion of
LCPUFAs, specificially docosahexaenoic acid (DHA) and arachidonic
acid (ARA), in infant formulas has been the subject of much debate in
recent years. These LCPUFAs are derivatives of the essential fatty acids,
linoleic acid and -linoleic acid, and they are important in cognitive
development and visual acuity. Human milk contains these LCPUFAs
but, until recently, standard infant formula did not. Controlled trials
investigating the effects of LCPUFAs-supplemented formula on cognitive
development in preterm infants have been inconclusive. The effects on
visual acuity have more consistently suggested an advantage.
Furthermore, no adverse effects were noted.
V. Special Considerations
A. Gastro-esophageal reflux (GER). Episodes of gastroesophageal reflux, as
monitored by esophageal pH probes, are common in both preterm and full term
infants. The majority of infants, however, do not exhibit clinical compromise from
GER.
1. introduction of enteral feeds. Emesis can be associated during the introduction
and advancement of enteral feeds in preterm infants. These epidodes are most
commonly related to intestinal dysmotility secondary to prematurity, and will
respond to modifications of the feeding regimen.
a. temporary reductions in the feeding volume, removal of nutritional additives,
lengthening the duration of the feeding (sometimes to the point of using continous
feeding), and temporary cessation of enteral feeds are all possible strategies
depending upon the clinical course of the infant.

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

feeding volume or nutrition density may result in problems with malabsorption,


dumping syndrome, and poor growth.
a. Re-feeding. Output from the proximal intestinal enterostomy can be re-fed into
the distal portion(s) of the intestine through the mucous fistula(s). This may
improve the absorption of both fluid ant nutrients.
b. PN support. If growth targets cannot be achieve using enteral feeds, continued
use of supplemental PN may be indicated depending on the patients overall status
and liver function. Enteral feeding should be continued at the highest rate and
nutritional density tolerated, and supplemental PN should be given to achieve the
nutritional goals outlines in section III.
C. Chronic Lung Disease. Preterm infants who have chronic lung disease (CLD)
have increased caloric required due to their increased metabolic expenditure, and at
the same time have a lower tolerance for excess fluid intake.
1. fluid restriction. Total fluid intake is typically restricted from the usual 150 ml/
kg per day to 140 mL/kg per day. In cases of severe CLD, further restriction to 130
and, rarely, 120 mL/kg per day may be required. Careful monitoring is required
when fluid restrictions are implemented to ensure adequate caloric and
micronutrient intake. Growth parameters must also monitored so that continued
growth is not compromised.
2. caloric density. Infants with CLD will commonly required up to 30 kcal/oz feeds
in order to achieve the desired growth targets. In fluid-restricted infants with severe
CLD, the maximum density of 32 kcal/oz is used on an infrequent basis.
VI. Nutritional Considerations in Discharge Planning. Recent data describing postnatal growth in the United States suggest that a significant number of VLBW and
ELBW infants continue to have catch-up growth requirements at the time of
discharge from the hospital.
a. Human milk. The use of human milk and efforts to transition to full breastfeeding in former preterm infants who continue to require enhanced caloric
density feedings poses a unique challenge. We plan individualized care in
order to support the transition to full breastfeeding while continuing to allow
for optimal rates of growth. Usually this is accomplished by a combination

of a specified numbers of nursing sessions per day, supplemented by


feedings of calorically enhanced breast milk. Growth rate data obtained in
the hospital are forwaded to infant follow-up clinics and the private
pediatrician for all VLBW and ELBW infants
b. Formula choices
1. Transitional formulas. Preterm infants fed nutrient-enriched
postdischarge formulas grow better than infants fed standard term
formulas. The AAP suggest these nutrient enriched formulas may be used
to a postnatal age of 9 months. We consider all preterm infants to be
appropriate candidates for the use of transitional formulas, either as an
additive to human milk or as a sole formula choice, once they are 2000
g and 35 weeks corrected
2. Term formulas may also be utilized; however; careful attention must be
paid to ensure adequate caloric and micronutrient intake.
c. Vitamin supplementation. We presently adhere to the following vitamin
supplementation guidelines:
1. Preterm infants who are > 2000 g and 35 weeks corrected gestational age,
and human milk-fed, are supplemented with 1 mL of pediatric MVI and
0.6 mg/kg zinc daily for their remaining period of hospitalization.
2. Human milk fed are discharged on 1 mL QD of pediatric MUI in
accordance with the AAP recommendation for 200 IU per day vitamin D
until they are weaned to at least 500 mL per day of vitamin D fortified
formula or milk
3. Iron supplementation is provided as previously described

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.

II. physiology of lactation. Hormonal influences during pregnancy prepare the


breast for lactation. Colostrum is secreted as early as the second trimester due
placental lactogen. After delivery, the release of prolactin stimulates milk
production. Breastfeeding is the most effective stimulant for continued prolactin
production. Tactile stimulation of the nerve endings in the areola and nipple
result in oxytocin release from pituitary gland that causes myoepithelial breast
cells to contract and eject milk. Milk ejection, or the letdown reflex, is
neuroendocrine reflec that is negatively affected by maternal stress or pain.
Environmental influences including pain, stress, separation from the infant, and
maternal illness can all negatively affect lactogenesis and result in delayed or
decreased milk production.
A. Benefits of breastfeeding
1. Decreased incidence and severity of infection due to the presence in
milk of secretory antibodies, leukocytes, and carbohydrates active
against viruses, bacteria, and parasites.
2. Improved function of immune system ang effectiveness of response to
immunizations.
3. Improved nutrition and growth due to properties that make human
milk more easily digestible. The pattern of growth is different for
breastfed than formula-fed infants. Breast-fed infants are less likely to
developobesity as adult.
4. Decreased incidence of chronic deseases, including type 1 and 2
diabetes, celiac disease, inflammatory bowel disease, childhood
cancer, and allergic disease, including asthma.
5. Potential effects on cognitive development. Long-chain
polyunsaturated fatty acids present in human milk are important for
brain growth and development.
6. Maternal health and psychosocial benefits include assistance in
expulsion of the placenta, minimazing maternal blood loss, and
facilitating more rapid uterine involution. Health benefits appear to be
cumulative opver a mothers lifetime, and may reduce the risk of
breast and ovarian cancer. Breastfeeding increases maternal selfconfidence and may enhance maternal-infant bonding.
7. Socioeconomic benefits include the cost saving of not buying formula
and of reduce illness in the breastfed infant.

III. Potential contraindications to breastfeeding. There are few


contraindications to breastfeeding or the use of expressed breastmilk.
A. Mothers with the following conditions should be advised not to be
breastfeed.
1. HIV infection is a contraindication to breastfeeding in develop
countries, due to the risk of transmission via the milk. In
developing countries, the mortality risk associated with not
breastfeeding must be weighed against the risk of transmission of
HIV.
2. Cytomegalovirus (CMV) may be shed intermittently in human
milk. Infants born to CMV-seronegative women who seroconvert
during lactation and premature infants with low concentrations of
transplacentally acquired maternal antibodies to CMV can develop
symptomatic disease and should not be breastfed or receive
expressed milk. Pasteurization of milk appears to inactivate CMW;
freezing milk at 20 o C (- 4oF) decreases viral titers but does not
reliably eliminate CMV. Disease transmission is uncommon in
term infants, most likely because of passively transferred maternal
antibodies.
3. Human T-cell lymphotropic virus type I, a retrovirus associated
with development of malignant neoplasms and neurologic
disorders in adults, appears to be transmitted through
breastfeeding. Women who are HTLV-I seropositive should not
breastfeed.
4. Human T-cell lymphotropic virus type II, a retrovirus, may also be
transmitted through breastfeeding, although the rate and timing are
uncertain. Seropositive women should not breastfeed.
5. Herpersimplex virus type I has been isolated from human milk in
the absence of vesicular lesions or drainage from the breast, or
concurrent positive cultures from the maternal cervix, vagina, or
throat. Women with herpetic lesions on their breasfeed should
refrain from breastfeeding; active lesions elsewhere should be
covered.
6. Infants with galactosemia cannot breastfeed because they cannot
metabolize lactose, a sugar present in human milk.

7. Drug of abuse such as amphetamines, cocaine, heroin, marijuana,


and phencyclidine are hazardous to the nursing infant.
B. Conditions in which breastfeeding may considered.
1. Hepatitis B surface antigen (HbsAg) has been detected in milk
from HbsAg-positive women. Infants born to know HbsAgpositive women should receive Hepatitis B Immune Globulin
(HBIG) and hepatitis B virus vaccine to eliminate the risk of
transmission through breastfeeding.
2. Hepatitis C transmission through human milk has not been shown,
thus, the risk of infection is no greater for breastfeed than bottlefed infant. Transmission may occur if the mother has cracked or
bleeding nipples.
3. Rubella virus has been isolated from human milk, but the presence
of the virus in milk has not been associated with significant disease
in infants. Women with rubella or who have just been immunized
with rubella live-attenuated virus vaccine may breastfeed.
4. Varicella vaccine may be considered for a susceptible
breastfeeding mother if the risk of exposure to natural varicellazoster virus is high. It is not known whether varicella vaccine virus
is secreted in human milk or whether the virus would infect a
breasfeeding infant.
5. Infants with phenylketonuria can breastfeed with special clinical
management.
6. Tobacco and alcohol are not absolutely contraindicated in
breastfeeding. Alcohol is present in breastmilk , and intake should
be limited, or the milk discarded. Nicotine appears in milk of
mothers who smoke and may decrease their milk supply. However,
the benefits of human milk outweigh the risks of nicotine
exposure.
IV. Prenatal education. Breastfeeding support and education should
begin during the prenatal period. This should include a history of
previous breastfeeding experience and any breast surgery or disease. A
nipple assessment should be made to identify anatomic deviations that
may interfere with breastfeeding success. Women should be
encouraged to attend prenatal breastfeeding classes and informed of

community resources available to assist with breastfeeding.


Breastfeeding promotion should be viewed as health education, as
important as discussions of infant car seat safety and immunizations.
V. breastfeeding the healthy term infant.
a. guidelines for the initial postpartum period
1. infants should nurse as soon as possible after delivery, preferably
during the initial alert phase, and subsequently should nurse on
demand (on average 8 to 12 times per 24 hours) in response to early
feeding cues (i.e., rooting, hands to face and mouth). Rooming-in
facilitates demand feeding.
2. infants should nurse on the first breast until satisfied and come off
spontaneously before offering the second side. This ensure they
receive the high fat hindmilk component of the feeding.
3. pacifiers and supplemental feedings should be avoided during the
first 2 weeks unless medically indicated while the milk supply is
being established.
4. A deep latch is essential to milk transfer at the breast. The infants
gums should be as far back on the areola as possible (0.5 to 1.0 cm)
for efficient and comfortable nursing.
5. signs of adequate milk transfer include a minimum of 15 to 20
minutes of rhythmic sucking with audible swallowing, breast
softening, milk in the infants mouth, satiation, and six to eight wet
diapers and at least two soft yellow stools per day. If milk transfer is
inadequate, supplementation (usually by bottle) may be required. This
should ideally be done with expressed breastmilk.
6. follow-up is recommended 1 to 2 days following discharge.
B. Common problems in the postpartum period
1. sore nipples are almost always due to shallow latch (the infant sucking on the tip
of the nipple rather than farther back on the areola). Correct positioning should be

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.

5. topical or intraductal candidiasis can occur. Symptom include itching, burning,


and shooting pain in the breast that is not associated with feeding. A fine, pinpointraised red shiny rash may occur on the nipple and areola. Susceptibility is
increased in mothers with cracked nipples and those who receive antibiotic during
pregnancy or after delivery. Prevention includes keeping the nipples as dry as
possible between feeds, and changing pads the absorb leaking milk frequently.
Treatment includes a topical antifungal agent. Infection that do not respond to
topical therapy are considered intraductal and require systemic treatment. The
infant of an effected mother should be treated with an oral antifungal agent, even if
there are no symptomps. Breastfeeding can continue if both mother is infected
should be discarded.
VI. Special situations
a. Hyperbilirubinemia is not a contraindication to breastfeeding. Frequent
breastfeeding should be encourage to enhance gut motility and bilirubin
excretion (see chap. 18, neonatal hyperbilirubunemia)
b. Hypoglikemia can usually be prevented in term infants with early, frequent
breastfeeding.
c. Near-term infants (35 to 37 weeks) may not be developmentally able to
breastfeed consistently like term infants. They may require supplementation
for 2 to 3 weeks until their feeding abilities mature. Weighing the infant
before and after feeding may help determine appropriate volumes and
frequency of supplementation. Mothers should pump after feedings to help
initiate and maintain an adequate supply; this milk can be used for
supplementation while the baby matures.
d. Cesarean delivery and anesthesia should not cause a delay in breastfeeding
once the mother is alert enough to hold the infant safely. However, maternal
anesthesia may reduce the infants level of alertness and ability to feed. Also,
maternal intravenous fluid may lead to edema of breast tissue and make it
more difficult for the infant to latch on. Because pain may inhibit the let
down reflex, analgesic should not be discouraged.
e. Multiple births. These infants are able to breastfeed because the supply of
milk increases to meet the demand.
f. Birth defects. Infant with birth defects can often benefit from breastfeeding
but may need special management.

1. Ankyloglossia (tongue tie). Severe ankyloglosia may interfere with


nursing, although indications for and timing of frenectomy are
controversial.
2. Craniofacial anomalies. Infant with cleft lip / palate may have difficulty
latching on the breast. Assistance with positioning and devices may help
achieve a complete seal.
3. Cardiac defects. Infant with cardiac defects who become stressed or
fatiqued during nursing may require more frequent feedings for shorter
durations. An upright position may improve comfort with feeding.
4. Developmental and neurogical problems. Poor muscle tone, weak
suckling, and sleepiness may interfere with nursing. These infants often
require supplementation.
VII Premature and hospitalized infants. Mother of premature infant should be
encouraged to provide breast milk for their infants because of the nutritional and
other health advantages over formula feedings. (see chap. 10, nutrition)
a. Initiating and maintaining lactation. Mother must pump in order to establish
and maintain an adequate supply of milk. An adequate milk volume is
defined as 18 to 20 oz of milk over a 24-hour period at 2 weeks postpartum.
1. Pumping should begin as soon after delivery as possible, preferably
within 6 hours.
2. Mother should pump frequently, at least 8 to 12 times per 24 hours.
Simultaneous pumping of both breasts is most efficient. Pumping should
last 10 to 15 minutes during the first few days. Once the breasts fill with
milk, pumping should continue for 1 to 2 minutes after milk flow stops to
empty the breasts and remove the high fat hindmilk.
3. Mother should use the best available pump, preferably a hospital-grade
electric breastpump 9e.g., medela classic) with a double collection kit.
Vacuum should be sufficient to just draw the nipple into the tunel and to
make milk flow. Increased vacuum will not yield more milk, but may
lead to nipple damage.
b. Delay or decrease in milk production. Onset of lactation may be delayed for
up to a week in women with complications of pregnancy such as
hemorrhage, hypertension, infection, preterm labor, and cesarean delivery.
Stress and fatique can also cause the milk supply to fluctuate.

1. Mother should be reassured that milk volume will eventually increase if


they continue to pump diligently.
2. Kangaroo skin (skin to skin holding) may help increase milk supply.
3. Herbs (fenugreek, blessed thistle) and medication (metoclopromide,
domperidone) have been used as galactogogues with varying results.
These medications are not approved in the united states for this
indication.
c. Storage of breast milk. (see table 11.1)
1. Expressed breast milk should be stored in small sterile containers. Glass
or hard plastic is preferred to plastic bags for storage in the hospital. The
container should be labeled with the infants name, medical record
number, date and time pumped, and any maternal medication. A new
container should be used for each pumping session.
2. Fresh milk should be refrigerated after it is expressed until it is frozen or
used. Frozen milk should not be allowed to thaw during during transport.
3. Expressed breastmilk should be warmed or thawed in a warm water bath.
Microwave heating of breast milk is not recommended. Milk that has
been warmed and not used should be discarded.
d. Early feedings at the breast
1. Expectations. Premature infants can be put to breast as soon as they are
extubated and stable. These session should be regarded as getting
acquainted. Although nearly all nutrition will come gavage feedings,
these sessions allow the mother to become comfortable holding the baby
and provide the breast as the babys first oral experience. They also
motivate many mothers to continue pumping.
a. Expectations should be based on gestational and developmental
ability. In general, infant do not breastfeed consistently well until they
reach 38 to 40 weeks postmenstrual age.
b. An early feeding typically lasts only a few minutes. Following that, a
gavage feeding should be given.
c. If the baby can not coordinate oral feeding well, the mother can pump
before putting the baby to breast.
d. Mother should put their babies to breast with each visit as tolerated.
2. Nipple shields. Silicon nipple shields may help premature infants to
achieve and maintain latch and increase the volume of milk intake. The
need should be assessed on an individual basis. Nipple shields should be

considered only after infants have developed the ability to coordinate


sucking, swallowing, and breathing. Milk supply and infant growth
should be monitored closely.
3. Supplementation. Premature infants often require supplementation of
nursing and continued fortification of breast milk because of increased
nutritional requirements. Supplementation with nasogastric tube feeding
is preferred in the hospital. After discharge, supplementation is usually
provided by bottle (preferably slow flow), although other methods, such
as cupfeeding, fingerfeeding, spoonfeeding, and supplemental nutrition
system at the breast, are sometimes used.
4. Test weights. Weighing the infant before and after feeding may help to
plan the volume and frequency of supplementation required and validate
the mothers assessment of the sufficiency of nursing.
e. Discharge planning. Few premature infants are discharge from the NICU
exclusively breastfeeding because discharge often occurs before
breastfeeding behaviours are developmentally mature. The discharge feeding
plan should consider the infants gestational age at birth, postmenstrual age
at discharge, the mothers breastfeeding goals and milk supply , and
observation of the baby at breast during hospitalization. Parents should be
comfortable and confident in the plan.
1. The pediatrician should provide close follow-up until supplementation is
no longer needed. The pediatrician should see the infant within a day or
two of discharge to assess the weight and revise the breastfeeding and
check the weight.
2. The mother should continue to pump to maintain her milk supply until
the baby is breastfeeding well and no longer needs supplements.
VIII. Medications. Medications taken by a lactating mother often can appear
in her milk. In general, if medication is safe to administer to an infant, it is
safe to give to lactating women. (see Appendix B.)
a. The amount of drug transferred to the infant through breast milk depends
on a number of factors, including maternal dose, frequency and duration
of administration, absorption, and distribution characteristics of the drug.
The concentration of drug in the infant is usually less than a therapeutic
dose.

b. The potential effect on the infant of a medication taken by the mother is


influenced by the infants maturity, postnatal age, clinical issue, and
pattern of breastfeeding.
c. Physicians caring for breastfed infants should be aware of potential
interactions of drugs that the mother and infant are receiving.
d. When appropriate medications are prescribed for lactating woman, the
benefits of breastfeeding should be weighed against the infants risk of
exposure to the drug. In most cases, the benefits far exceed the risk.
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