Enteral Feeding in LBW Neonates

Enteral Feeding in LBW Neonates
CHAIRPERSON Dr. A.G. Shingwekar, MD,DCH Professor & Head
Presented by Dr. KISHORE CHANDKI
Guided by : Dr. Ajay Gaur MD, PhD Dr. G. Das MD Dr. Y.S. Verma MD Dr.(Mrs) Neetu MD Dr. (Mrs) Sunita MD
Department of Paediatrics, G.R.M.C. & J.A. Group of Hospitals, Gwalior

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

Judging the adequacy of nutrition Kangaroo Mother Care Micronutrient Supplementation Immunonutrition MCT Oil Post discharge feeding & advice Summary
Enteral Feeding
Defined as the administration of nutrients directly into the gastrointestinal tract. If the patient is unable to meet his/her nutritional requirements with oral diet/ nutritional supplements, then enteral feeding is indicated. Once the gastrointestinal tract is functional, enteral feeding is the optimal method of nutritional support.
Advantages w.r.t. Parenteral

More Physiologic More safe More nutritionally complete Less expensive But decision for mode of nutrition is based on : Weight Gestational Age Clinical Condition
Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Indications
Absent / impaired swallow Inadequate oral intake Neonates <1800 gm or < 34 weeks gestation, unable to breast feed Necessity : Functioning & accessible gastrointestinal tract
Contraindications
Complete bowel obstruction, Ileus Intestinal ischemia Necrotizing Enterocolitis
Complications of Enteral Nutrition

GI : Perforation, stricture, esophagitis, gastritis, nausea, vomiting, bleeding, GER Mechanical : Dislodgement, tube migration, blockade, inflammation, granulation of skin site, aspiration, nasopharyngeal trauma, sinusitis, otitis media, laryngeal ulceration Metabolic : Fluid overload, dehydration, hyper- & hypo-glycemia, electrolyte imbalance, azotemia, hypercapnea, hyperphosphatemia, vit. & mineral deficiency Misc. : Aspiration pneumonia, Feed contamination & resulting infection, Abnormal LFT
Elizabeth K E, Nutrition & Child Development, 3rd Ed., 2004
Goals Of Feeding

Achieve well-defined short-term growth & nutrient retention Mimic intrauterine growth rates Mimic reference fetal composition Prevent Neonatal morbidities Improve feeding tolerance Reduce NEC Minimize nosocomial infection Optimize long-term outcome Optimize neurodevelopmental outcome Reduce rates of allergy & atopic diseases
Ghai O.P., Essential Paediatrics, 2004
What is the Optimal Diet for LBW neonate ?

Optimal diet should support a rate of growth approximating that of the third trimester intrauterine life without imposing stress on the developing & excretory functions!
the statement encourages mimicking the intrauterine environment by stimulating fetal accretion rates of nutrients & intrauterine growth rates!
Is it possible to extrapolate the extrauterine growth?

Thermal Protection Preferential nutrient delivery Excretion handled by placenta Oxygen via placenta Thermal instability Exogenous nutrients Immature kidney Birth asphyxia

Poor Feeding reflexes Low gastric acidity, low enzyme levels, low bile secretion NEC qsurfactant HMD Immature respi. Center apnea, aspiration, pulmonary hemorrhage q UDPG prolonged jaundice IVH, cerebral anoxia Low glycogen stores/brown fat Poor lactate metabolism acidosis Poor immunity sepsis Congenital anomalies
Contd
Contd

Fetal Energy & Protein Accretion Weight gain 18 gm/kg/d (24-28 (24wks) 16 gm/kg/d (32-36 (32wks) ~ 2 gm/kg/d 1.4-1.9 gm/kg/d 1.4~30 kCal/kg/d (>28 wks) Postnatal Energy & Protein Accretion 15 gm/kg/d (During acute phase : Avoid catabolism) 3 gm/kg/d ~1.5 gm/kg/d ~50 kCal/kg/d
Protein Accretion Fat Accretion Calorie Accretion
So, the answer is probably NO

Fluid Requirements For Neonates

Fluid (mL/kg/d)
Day 1 2 3 4 5 6 7+
Birth weight <1000 gm 100 115 130 145 160 175 190 BirthWeight 10011001-1500 gm 80 95 110 125 140 155 170 Birth Weight >1500 gm 60 75 90 105 120 135 150
Additional Allowances : Phototherapy : 20-40 ml/kg/d, Radiant Warmer : 40-80 ml/kg/d 2040IAP Textbook of Pediatrics, 2nd Ed. 2002
Guidelines for Fluids & Feeding to LBW Babies

Age
Category of Neonates
< 1200 gm <30 weeks IVF. Try gavage if not sick 12001200-1800 gm 3030-34 weeks Gavage >1800 gm >34 weeks Breast feeding. If unsatisfactory, give katori-spoon katorifeeds. Breast feeding Breast feeding Breast feeding
Initial
Gavage After 1-3 1days KatoriKatori-spoon Later (2- 4 weeks) (2Breast feeding After sometime (4- 6 weeks) (4-
Katori-spoon KatoriBreast feeding Breast feeding
Ref. Teaching Aids : NNF
Routes of Administration of Enteral Nutrition

Least preferred TPN TPN + MEN PPN Alternative Feeding Exclusive Breast Feeding Most preferred
Routes of Administration of Enteral Nutrition
Oral- Spoon & katori, etc. Nasogastric/Orogastric Nasoduodenal / Nasojujenal Surgical or Percutaneous Endoscopic gastrostomy Surgical or Percutaneous Endoscopic jejunostomy
Indian J Pediatr 2002; 69 (5) : 411-415
Inserting a Nasogastric (NG) Tube
Normal anatomical Path
Inserting a Gastric Tube
Insert through nostril
Principles of Newborn Baby Care, WHO/UNICEF, 2003
Confirming Proper Placement of Tube

Air insufflation & auscultation method : with 1 to 2 ml of air - If a whistling sound is heard through the stethoscope as the air is injected, the end of the tube is correctly positioned in the stomach. You should also be able to withdraw the air you pushed in. Acidity of the aspirate: [Only suitable for babies more than 24 hours old or preterm LBW babies who are more than 48 hours old] If the blue litmus paper turns pink, the fluid is acidic and the tip of the tube is correctly positioned in the stomach.
Inserting a Gastric Tube

Signs that the tube may not be placed correctly are: X Coughing X Apnea X Cyanosis
Nasogastric Tube
Advantages
Easy to place Easy to secure Lasts longer, Cheaper No need to pass every time
Disadvantages
Risk of nasopharyngeal trauma Space occupying effect GER, aspiration (Gag reflex should be intact)
Agrawal K.N., Pediatrics & Neonatology, 1st Ed., 2000
Nasoenteric Tubes
Properties :
Has a small diameter available for patient comfort Is long enough for nasoenteric feeding Is flexible for easy insertion and removal Is radioopaque for X-Ray confirmation of Placement XHas several feed outlets at the distal end to prevent clogging Has a smooth rounded tip to prevent insertion trauma If a guide wire is used, the guide wire will not dislodge during insertion; it is easy to remove. Is preferably made of premium material, resistant to gut secretions
http://www.nutriciame-clinicalnutrition.com
Nasoenteric Tubes
Polyurethane tubes (PUR): Soft, flexible and do not (PUR):
react to gastric juices. Can stay for 6-8 weeks. Some juices. weeks. contain a guide wire for easy insertion. insertion. Polyvinylchloride (PVC): Contain a plasticizer to (PVC): keep the tube flexible, because the compound is sensitive to the low pH, becomes rigid after 7-10 days which can lead to irritation of the pharynx and to the esophagus. esophagus. If not replaced after 7 days of usage a digestion happen to the tube it self which make the content of toxic products to be leached and may cause nectorizing entercolitis in premature infants. After 7 infants. days as the tube become rigid and stiff it may cause perforation and intussusception. http://www.nutriciame-clinicalnutrition.com intussusception.
Inserting an Orogastric (OG) Tube
Orogastric Tube
Advantages
No space occupying effect Larger bore tube can be passed easily
Disadvantages
Difficult to secure, dislodgement Lasts shorter Need to pass with every feed
Routes of Enteral Feeding
Nasoduodenal feeding
Nasojejunal feeding
Nasoduodenal or Nasojejunal Tubes

Length : From tip of nose to knee joint Advantages
Less aspiration Less expensive & safer than TPN Less chances of reflex bradycardia Less risk of dislodgement
Disadvantages
Requires fluoroscopic or endoscopic control for insertion Expensive tubes wrt NG/NJ Risk of gut perforation Frequent supervision
Transpyloric Feeding
Candidates : Intolerance to naso/orogastric feeding owing to gastric retention or regurgitation Neonates at increased risk for aspiration Anatomic abnormalities of GI tract e.g. microgastria Problems : Must be delivered continuously Fluoroscopic control required for placemnent Increased risk for fat malabsorption because of by passing of lipases
Cloherty, Eichenwald, Stark, Manual of Neonatal Care; 5th Ed, 2004
Transpyloric Feeding
No difference in short/long term growth, rather increase in GI disturbance & increased mortality Hence, avoided as far as possible
Indian J Pediatr 2002; 69 (5) : 401-404
Routes of Enteral Feeding
Gastrostomy (GT) feeding
Jejunostomy (JT) feeding
Enterostomy Tubes
Advantages
Less aspiration (qq with jejunostomy) Less chances of reflex bradycardia, trauma to air passages Less risk of dislodgement No interference with breathing
Disadvantages
Requires endoscopic control/anesthesia for insertion Expensive tubes wrt NG/NJ Peristomal infection, peritonitis, tube blockage, inadvertent removal, tube fracture and leakage
Postgraduate Medical Journal 2002;78:198-204
Enterostomy Tubes
Indications :
Congenital anomalies of the mouth, jaw, pharynx, gastrointestinal tract, and/or airway (ie, esophageal fistula, tracheoesophageal fistula, cleft lip and palate, intestinal atresia, and abdominal wall defects) Prolonged enteral nutrition (>6 weeks)
Contraindications :
Abdominal wall infection Coagulopathy Massive ascites
http://www.naspghan.org/sub/ENTERAL_AND_PARENTERAL_NUTRITION.htm
Choice of Milk for Feeding

Human milk alone (Term/Preterm) Human Milk + Calcium Phosphate & Vit. Supplements Human Milk (EBM) + Preterm formula Human milk + Fortifier (HMF) Top milk with or without Fortifier
Contd
Contd
Human milk alone (Term/Preterm) : Expressed breast milk Besides usual advantages, has Immunological advantages Better neurodevelopmental and visual outcomes (possibly because of LC-PUFA) Reduced incideence of NEC
But it does have short comings : Does not have enough protein and calorie to ensure optimal EARLY growth at 20 kCal/Oz Does not have enough sodium to compensate for high sodium losses. Does not have enough calcium or phosphate
Contd
Human milk alone (Term/Preterm) : Expressed breast milk

-
Is deficient in vitamins and iron relative to the needs of a preterm infant who will have mixed out on the last trimester placental transfer. Composition varies Losses A/W collection, storage, feeding procedures, esp. fats & vitamins.
Because of this, many units routinely supplement EBM with HMF upto 24 kCal/Oz in babies <32 weeks or <1500 gm (when the baby is tolerating 150ml/kg/day)
Contd
Human Milk + Calcium Phosphate & Vit. Supplements Has : All the biological advantages of Breast Milk! But : Still will have LESS protein than the required
Contd
Preterm formula Has : Adequate calories, calcium, phosphate & vitamins fed at the rate of 150-180 mL/kg/d But : Does not have any of biologically active immune substances, or enzymes of growth factors May still require supplements of sodium, chloride, vitamin A & D and iodine More chances of contamination while preparation Hence: Not preferred in general If required, given until neonate reaches a weight of 2-2.5 kg or on full breast feeds!
Breast Milk Substitute : Formula Milk

Use when the mother cannot breastfeed or express breast milk. Use a breast-milk substitute designed for premature or small babies. Once the container is open, use within the recommended time according to the manufacturers instructions. Check the expiry date of the breast-milk substitute. Use aseptic technique to prepare the breast-milk substitute from liquid concentrates or powders, using high-level disinfected or sterile utensils and containers, and sterilized or boiled and cooled water.
Managing Newborn Problems, WHO/UNICEF, 2003
Breast Milk Substitute : Formula Milk

Wash hands with soap and water. Determine the required volume of milk for the feed. Measure the breast-milk substitute and water, mix them, and feed the baby using a cup, cup and spoon, or other device. Have the mother do this whenever possible. Store remaining milk in a labelled container in a refrigerator for a maximum of 24 hours. Breast-milk substitute is not available, have the mother use a breast-milk substitute that is based on animal milk and prepared at home.

Top Milk :
Term Breast Milk Cows Milk 67 3.2 4.1 4.4 120 90 0.2 70-220 700.76 5 Buffalos Milk 117 4.3 6.5 5.1 169 117 0.12 178 0.52 6 Goats Milk 72 3.3 4.5 4.4 134 111 0.05 185 0.50 1
Calories (Kcal/dl) Protein (gm/dl) Fat (gm/dl) Carbohydrate (gm/dl) Calcium (mg/dl) Phosphorus (mg/dl) Iron (mg/dl) Vitamin A (IU/dl) Sodium (mEq/dl) Folic Acid (mcg/dl)
67 1.1 4.5 7.1 33 15 0.03 250 0.8 5
Ref. : Deptt. of Agriculture, United States

Top Milk : Animal milk and term formula milk are unsuitable for feeding preterm as composition does not meet recommended nutrient intake and it predisposes to late hypocalcemia as phosphate contains high. Animal milk with human milk fortifier is not yet studied.
Human Milk Fortifier (HMF)

Is the nutritional supplement product that may be added to breast milk to supplement its nutrient content
Cochrane review
Short term benefits Greater weight gain Greater length gain Greater HC gain Increased N2 balance Increased bone mineral content Long term benefit (at 18 mo) No benefit in terms of :xWeight xLength xHC xNeurodevelopmental x outcome Adverse effects No increase in NEC Feed intolerance
Currently available HMF have low protein, low sodium, high soluble calcium & phosphate, high osmolality and difficulty in mixing leading to separation of fat and disruption of fat globules with addition of calcium Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Composition of various feeds

Mineral & Vitamin per 100 Kcal Calories (Kcal/kg/d) Protein (gm/kg/d) Carbohydrate (gm/kg/day) Calcium (mg) Phosphorus (mg) Iron (mg) PretermPretermRNI (AAPCON 1998) 105105-130 3.53.5-4 11-15.5 11175 91 1.7-2.5 1.7Preterm PretermPretermEBM (per 100 EBM + HMF (Per 100 ml) ml) 67 1.6 7.3 25 14 0.09 81 2 9.7 125 64 0.09 Preterm Formula (Per 100 ml) 80 2 9.1 128 64 0.8
Contd
Contd
Composition of various feeds

PretermPretermRNI (AAPCON 1998) 75-225 75270 2.12.1-2.9 >1.1 PretermPretermPreterm EBM (per 100 EBM + HMF ml) (Per 100 ml)* 48 8 1.26 1 1508 508 1.56 3 Preterm Formula (Per 100 ml) 241 72 2.2 4
Mineral & Vitamin per 100 Kcal Vitamin A (IU) Vitamin D (IU) Sodium (mEq) Vitamin E (IU)
* 1 Sachet (2 gm) of HMF is added to 50 ml of expressed breast milk.

Human Milk provides the Gold Standard for feeding LBW neonates!
Gut Starvation : Need for early feeding ?

Morphological Changes mass q Cell production q Villus height o Permeability q Amino acid absorption q Sucrase q Lactase q Number of lymphocytes q IgA secretion o Bacterial translocation
Zeigler,Lucas,Moro Nutrition of the VLBW Infant, 1999
qMucosal
Functional Changes Enzymes Immunity
Minimal Enteral Nutrition (MEN)

Syn. Trophic feeding, Gut priming feeding, minimal feeds, gut stimulation, early feeding, or hypocaloric feedings
Def. : Feedings that are delivered in very small amounts (e 10 mL/kg/d) for the purpose of induction of gut maturation rather than nutrient delivery! Advantages : Improved levels of gut hormones Trophic effects on mucosa Improved peristalsis Improved calcium & phosphorus retention
Cloherty, Eichenwald, Stark, Manual of Neonatal Care, 5th Ed, 2004
Contd
Less feeding intolerance Earlier progression to full enteral feedings, Fewer days on parenteral nutrition Improved weight gain Reducation in episodes of culture positive sepsis Low serum bilirubin levels No increased risk of NEC
Cochrane review, Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Contd
No consensus guideline as when to start, how to progress, how long to continue MEN & when to advance to full nutritive feeding Recommended for all babies
Sick babies with significant respiratory distress
& hemodynamic instability remain NPO till they are stable, ideally by 1st 2nd day of life Donot use in suspected or confirmed NEC or evidence of ileus. ileus.
Can be started with EBM at a volume of e10
mL/kg/d @ 3-8 hourly intervals

Rapid (Vs Slow) Advancements

Better gain in weight, length & HC Shorter hospital stay Risk of GER, aspiration Risk of NEC with very fast advancements
Recommendation You can make rapid enhancements upto 30 ml/kg/d in stable LBW infants without increased risk of NEC, esp. after day 4/5 of life!
Indian J Pediatr 2002; 69 (5) : 401-404
Guidelines for Tube Feeding

Birth weight (gm) < 800 800800-1000 10011001-1250 12511251-1500 15001500-1800 18011801-2500 >2500 Initial rate (mL/kg/day) 10 10-20 1020 30 30-40 3040 50 Volume Increase (mL/kg/day) 10-20 1010-20 1020-30 2030 30-40 3040-50 4050
Feeding MUST always be individualized depending on neonates condition!

Cloherty, Eichenwald, Stark, Manual of Neonatal Care; 5th Ed, 2004
Intermittent Bolus Vs Continuous

Advantages
More physiological
Disadvantages
Risk of GER Risk of aspiration
Preferred in general!
May be used for : GER Bolus feeding Intolerance

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

Teach the mother how to express breast milk herself. The mother should: - obtain a clean (washed, boiled or rinsed with boiling water, and air-dried) cup or container to collect and store the milk; - wash her hands thoroughly; - sit or stand comfortably and hold the container underneath her breast; - express the milk - support the breast with four fingers and place the thumb above the areola; - squeeze the areola between the thumb and fingers while pressing backwards against the chest;
Principles of Newborn Baby Care, WHO/UNICEF, 2003

- express each breast for at least four minutes, alternating breasts until the flow of milk stops (both breasts are completely expressed). If the milk does not flow well: - ensure that the mother is using the correct technique; - have the mother apply warm compresses to her breasts
While feeding, babys lips should cover areola in addition to nipple!

www.breastfeeding.org
Recommendations for storage of Breast Milk

Duration of Storage with respect to temperature Room Temperature Refrigerator (<4C; 39F) (<4 Freezer Compartment, or Deep Freezer ( <-20 C; <-4 F) <<6-8 hours 24 hours 6 months
Store in hard plastic or glass containers with well-fitting tops. Warm frozen or refrigerated milk in a warm water bath (~40 C). C). Use the rewarmed milk promptly. Discard the remaining once promptly. warmed. warmed.
Feeding by Alternative Methods

Ensure that the mother can properly express breast milk Feed the baby using a cup, a cup and spoon, or other suitable device (e.g. paladai) Use clean (washed, boiled or rinsed with boiled water, and air-dried) utensils and feeding devices for each feed. Feed the baby immediately after the milk is expressed, if possible. If the baby does not consume all of the milk, store the remaining milk
Feeding by Alternative Methods

Have the mother feed the baby unless she is not available. The mother should: - measure the volume of breast milk in the cup - hold the baby sitting semi-upright on her lap; - rest the cup (or paladai or spoon) lightly on the babys lower lip and touch the outer part of the upper lip with the edge of the cup; - tip the cup (or paladai or spoon) so the milk just reaches the babys lips; - allow the baby to take the milk; do not pour - end the feeding when the baby closes her/his mouth and is no longer interested in feeding.
Feeding by Gastric Tube

Ensure that the mother properly express breast milk can
Insert a gastric tube, if one is not already in place. Confirm that the tube is properly positioned before EACH feeding. Encourage the mother to hold the baby and participate in feedings. Determine the required volume of milk for the feed according to the babys age

Remove the plunger of a high-level disinfected or sterile syringe or a clean (washed, boiled or rinsed with boiled water, and air-dried) syringe and connect the barrel of the syringe to the end of the gastric tube: Pour the required volume of milk into the syringe with tip of the syringe pointed downward. Have the mother hold the syringe 5 to 10 cm above the baby or suspend the tube above the baby and allow the milk to run down the tube by gravity. Do not force by plunger.

o You may apply slight pressure with the plunger initially (just to start the feeding) o When the feeding is completed, clear the tube with some of water. Try not to put extra air into the stomach. o There is no need to burn the baby after feeding o Place the baby on his or her right side or hold upright after feeding
RightRight-side lying position after feeding

Whaley & Wongs Essentials of Pediatric Nursing, 5th Ed, Mosby, 1997

Using this method, each feeding should take 10 to 15 minutes. When the feeding is finished, remove, wash, and high-level disinfect or sterilize the syringe, and cap the tube until the next feeding. Progress to feeding by cup/spoon when the baby can swallow without coughing or spitting milk. Replace the gastric tube with another clean gastric tube after 2-3 days, or earlier if it is pulled out or becomes blocked.

Continuous Feeding :
Set up feeding pump and give the feeding Flush the feeding tube with water every 4 hours. Change the feeding bag every 24 hours
Feeding the Term LBW neonates

Constitute 2/3rd of LBW neonates in India Growth retarded Have inadequate transplacental transfer of nutrients like Calcium, phosphate & multivitamins
No guidelines available yet about how to provide them optimum nutrition.

But, if inadequate weight gain on full breast feeds, may be supplemented with extra calories or proteins with fortifiers or preterm formulas!
Feeding the baby : Standards of Care

Encourage & teach the mother to express breast milk at least eight times in 24 hours Assess the feeding ability TWICE DAILY, and encourage & support the mother to begin breast feeding as soon as the baby shows signs of readiness to suckle Record the following EACH TIME the baby is fed : Time of feeding Amount & kind of milk given Any feeding difficulty Assess the babys growth frequently.
Monitoring
Monitor : Abdominal girth >2 cm is significant Pre feed gastric aspirate Compare with amount of previous feed
<30% of pre feed volume
30-50% of pre feed volume/vomiting / abd. distension.
>50% of pre feed volume, or u3 mL/kg (whichever greater)
Stop feeding, IVF for 12 hrs.

Improving Not improving
Continue with same
Restart at same rate as last feed & observe
Continue IVF for another 12 hrs & reassess

Indian Pediatrics, Vol. 41, May, 2004: 436
Contd...
Monitoring
>50% of pre feed volume, or u3 mL/kg (whichever greater) Discontinue feeding for next 24 hours, then reassess Investigate for Sepsis & NEC
Negative
Positive
Restart feeding at half the volume at the time of discontinuation
Continue with management of the condition
Indian Pediatrics, Vol. 41, May, 2004: 436 2003
Monitoring
Assess hydration daily: - If there are signs of dehydration (e.g. sunken eyes or fontanelle, loss of skin elasticity, or dry tongue and mucous membranes), increase the volume of fluid by 10% of the babys body weight on the first day; - If there are signs of over hydration (e.g. excessive weight gain, puffy eyes, or increasing oedema over lower parts of the body), reduce the volume of fluid by half for 24 hours. Weigh the baby daily. If the daily weight loss is more than 5%, increase the total volume of fluid by 10 ml/kg body weight for one day to compensate for inadequate fluid administration. Monitor Hb/PCV, Serum sodium weekly till 4-6 weeks Monitor serum calcium, phosphate and alkaline phosphatase fortnightly till discharge, and at term corrected age before stopping calcium supplements.
Judging the adequacy of Nutrition

Weight Pattern :

Not >10-15% cumulative weight loss during first week of life 10-15% Birth weight regained between 10-14th day of life 10Starts gaining weight by second week of life at 15-20 gm/day. 15- gm/day. (SFD neonates may start without any appreciable weight loss at all) unless sick. sick. For this weigh the baby : o Daily when in the hospital o At 2 weeks, 4 weeks & then monthly after discharge!
Baby should gain 0.75 cm of HC per week till 40 weeks of gestation Baby should gain 1.1 cm of length per week between 28-40 28weeks of gestation
Weight Gain & Feeding

If the baby still requires feeding using an alternative feeding method but is on full milk feeds: - Increase the volume of milk in increments of 20 ml/kg body weight per day until the baby reaches 180 ml/kg body weight of breast milk per day; - Continue to increase the volume of milk as the babys weight increases to maintain a volume of 180 ml/kg body weight of breast milk per day.
Weight Gain & Feeding

If weight gain is inadequate (less than 15 g/kg body weight per day over three days): - Increase the volume of milk to 200 ml/kg body weight per day; - You can have the mother express breast milk into two different cups. Have her give the contents of the second cup, which contains more of the fat-rich hind milk, to the baby first, and then supplement with whatever is required from the first cup. - If weight gain is inadequate for more than one week and the baby has been taking 200 ml/kg body weight breast milk per day, treat for inadequate weight gain
Inadequate weight gain / Excessive Weight Loss

Inadequate calorie provided/consumed Cold stress Anemia Underlying systemic illness, e.g. sepsis. Urinary tract infection Late hyponatremia Late metabolic acidosis
Recording & Monitoring Weight
Converting Gavage to Oral Feeds

Candidates
Neonate of ~34 wk gestation with coordinated suck-swallow-breathe pattern & respiratory rate e60/min Transition should be slow At first, give a supervised spoon feed & if the baby accepts well I.e. can finish the measured amount within 20-30 min without any sign of fatigue (apnea, vomiting, color changes, poor weight gain & slow to finish the full volume), then, number of spoon feeds can be increased over next few days like : o One spoon feed every 6 feeds o One spoon feed per 2 gavage feeds o Alternate spoon & gavage feed o 2 spoon feeds per gavage feed o And finally to full spoon feeds Always try NNS while on gavage from 30-32 weeks gestation
Non Nutritive Sucking (NNS)

Used In transition from gavage to breast feeding During gavage feeding Rationale Facilitates the development of sucking behaviour Improves digestion of enteral feeding Benefits Early transition from gavage to breast feeding Decrease length of hospital stay Method Done with empty breast or with a pacifier Burping is a MUST because aerophagia is likely
Combining IV Fluid & Feeding

If the baby tolerates the feed and there are no problems, continue to increase the volume of feeds while decreasing the volume of IV fluid to maintain the total daily fluid volume according to the babys daily requirement Feed the baby every three hours, or more frequently if necessary, adjusting the volume at each feeding accordingly. Add the total volume of feeds and fluid given each day. Compare this volume with the required daily volume, and adjust the volume that the baby receives accordingly. Discontinue the infusion of IV fluid when the baby is receiving more than two-thirds of the daily fluid volume by mouth and has no abdominal distension or vomiting. Encourage the mother to breastfeed exclusively as soon as the baby is receiving 100% of the daily fluid volume by mouth.
Kangaroo Mother Care (KMC)

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

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

Ensure that the mother is fully recovered from any childbirth complications before she begins KMC. Ensure that the mother has support from her family to stay at the hospital or return when the baby is ready for KMC and to deal with responsibilities at home. Explain to the mother that KMC may be the best way for her to care for her baby once the babys condition permits: - the baby will be warm; - the baby will feed more easily; - episodes of apnea will be less frequent.

Take the baby away from the mother only to change napkins (diapers), bathe, and assess for clinical findings. Babies can be cared for using KMC until they are about 2.5 kg or 40 weeks post-menstrual age.
Sodium Supplementation

Preterms especially <34 weeks are often hyponatremic due to excessive sodium loss in urine. Hence monitor serum sodium weekly till post conceptional age of 34 weeks. If serum sodium <130 mEq/L, extra sodium supplementation given.
o o
3% NaCl (1ml = 0.5 mEq), or 0.9% NaCl (1ml = 0.15 mEq).
Supplement should be orally diluted with feeds to maintain serum sodium between 135-140 mEq/L. 135Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Iron Supplementation

Although iron stores are low in preterms & term-SFDs, termrequirements are minimum in first few weeks of life!
Birth weight e1000 gm
Birth weight >1000 gm
Iron @ 3-4 mg/kg/d 3-
Iron @ 2-3 mg/kg/d 2-
Start at 4-6 weeks of life when active erythropoesis starts 4 Start earlier at 4 weeks of life if baby had frequent phlebotomies Recent evidence is in favor of starting as early as 2 weeks of postnatal age, if full enteral feed are established!
How long to continue supplements ?

Stop the HMF or Preterm formula when the baby reaches 2 kg or starts accepting full breast feeds, and start calciumcalcium-phosphate and vitamin supplements. If the baby was only on breast milk continue calciumcalciumphosphate till baby reaches corrected age of term (wt. ~3(wt. ~33.5 kg) check serum calcium, phosphate and alkaline kg) phosphatase before stopping especially in ELBW babies to rule out any osteopenia or prematurity. Stop multivitamins when the baby reaches 6 months or multivitamins 4.5 kg. kg. Continue iron for at least 1 year, and if weaning is not year, adequate continue till 2-3 year of age. [23 months: WHO] 2Journal of Neonatology, NNF-India, Vol. 18, No.1, Jan-Mar 2004
Immunonutrition
Diets that are specifically designed to enhance immune function. Glutamine L-arginine N-acetyl Cysteine Glutathione MCT & LCT n3 fatty acid Vitamin A, E, C, Zinc, Selenium
Immunonutrition
Use of specific nutrients supplements singly or in combination, stimulate the immune response and should result in fewer infections, particularly in LBW infants. Maximum benefit of immune enhancement has been shown to occur in postoperative adult patients. Whether overall mortality is actually improved still remains to the established. Present Status : More studies are needed for their use in low birth babies.
MCT Oil
Primarily has caprylic & capric fatty acids and is a yellow, odorless, and translucent liquid. Human milk contains 3-7% of fat as MCT. Cows milk has 1% and formula milk has ~10% Rapidly absorbed into blood stream from lacteals without biliary binding Exhibit rapid mitochondrial uptake Rapidly cleared from blood stream
Indian J Pediatr 2001; 68 (4) : 333-337
MCT Oil
When added to enteral feeds, significantly increases the caloric density without increasing much osmolar load Does not contain any EFA. Excessive use of MCT i.e. >60% of total fat intake decreases the uptake of EFA. Growth is not improve. Expensive, however coconut oil can be used in place Can be added as 2 kCal/Oz to the milk (has 7.8 kCal/ml) Present status : Routine use is not recommended.
Advice on Discharge

Explain the mother that

Her milk is best for the baby Breast feeding is especially important for a small baby It may take longer for a small baby to establish breast feeding It is usually normal if the baby : Tires easily & suckles weakly at first Suckles for shorter periods of time before resting Falls asleep during feeding Pauses for long periods between suckling
Contd
Contd
Advice on Discharge
Breast feeding will become easier once the baby becomes bigger
Assure the mother that

Ensure that the baby is fed frequently

If the baby weighs 1250 to 2500 gm, feed the baby at least eight times in twenty four hours (I.e. every 3 hours). If the baby weighs less than 1250 gm, feed the baby at least twelve times in twenty four hours (i.e. every 2 hours).
Contd
Advice on Discharge
Lethargy, refusal to feed. Hypothermia Tachypnoea, Grunting, Gasping Seizures, Vacant Stare. Abdominal distension Bleeding, icterus over palms / soles.
Danger signals (Early detection & referral) :

Ref. : Teaching Aids, NNF-India.
Summary
Appropriate & adequate nutrition to LBW Babies. Babies. Early nutrition for long term growth and neurodevelopment. neurodevelopment. Breast milk provides the gold standard for feeding. feeding. Role of non nutritive sucking, KMC and micronutrient supplementation. supplementation.
Thanks

Enteral Feeding in LBW Neonates

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Enteral Feeding in LBW Neonates

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Enteral Feeding in LBW Neonates

CHAIRPERSON Dr. A.G. Shingwekar, MD,DCH Professor & Head

Presented by Dr. KISHORE CHANDKI

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

Enteral Feeding in LBW Neonates

Enteral Feeding in LBW Neonates

Advantages w.r.t. Parenteral

Complications of Enteral Nutrition

Ghai O.P., Essential Paediatrics, 2004

What is the Optimal Diet for LBW neonate ?

Is it possible to extrapolate the extrauterine growth?

Is it possible to extrapolate the extrauterine growth?

Is it possible to extrapolate the extrauterine growth?

Protein Accretion Fat Accretion Calorie Accretion

So, the answer is probably NO

Fluid Requirements For Neonates

Guidelines for Fluids & Feeding to LBW Babies

Katori-spoon KatoriBreast feeding Breast feeding

Ref. Teaching Aids : NNF

Routes of Administration of Enteral Nutrition

Routes of Administration of Enteral Nutrition

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

Inserting a Nasogastric (NG) Tube

Normal anatomical Path

Inserting a Gastric Tube

Insert through nostril

Principles of Newborn Baby Care, WHO/UNICEF, 2003

Confirming Proper Placement of Tube

Inserting a Gastric Tube

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

Inserting an Orogastric (OG) Tube

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

Routes of Enteral Feeding

Nasoduodenal or Nasojejunal Tubes

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

Routes of Enteral Feeding

Gastrostomy (GT) feeding

Jejunostomy (JT) feeding

Choice of Milk for Feeding

Choice of Milk for Feeding

Choice of Milk for Feeding

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

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

Choice of Milk for Feeding

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

Choice of Milk for Feeding

Breast Milk Substitute : Formula Milk

Managing Newborn Problems, WHO/UNICEF, 2003

Breast Milk Substitute : Formula Milk

Managing Newborn Problems, WHO/UNICEF, 2003

Choice of Milk for Feeding

67 1.1 4.5 7.1 33 15 0.03 250 0.8 5

Ref. : Deptt. of Agriculture, United States

Choice of Milk for Feeding

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

Human Milk Fortifier (HMF)

Composition of various feeds

Composition of various feeds

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

Gut Starvation : Need for early feeding ?

Functional Changes Enzymes Immunity

Minimal Enteral Nutrition (MEN)

Minimal Enteral Nutrition (MEN)

Minimal Enteral Nutrition (MEN)

Assure the mother that

Ensure that the baby is fed frequently