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Title: Nutrition in Premature Infants

Nutrition in Premature Infants3/17/10
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  • Generally, the more premature the baby, the more
    serious and long lasting are the health problems.

  • Preterm Infant Infants born lt37 weeks of
  • Low Birth Weight (LBW) Birth weight lt 2500 grams
    (5½ lbs)
  • Very Low Birth Weight (VLBW) Birth weight lt 1500
    grams (31/3 lbs)
  • Extremely Low Birth Weight (ELBW) Birth weight
    lt1000 grams (2¼ lbs)
  • Small for Gestational Age (SGA) Infants born
    with growth parameters below the 10th percentile.
  • Intrauterine Growth Retardation (IUGR) Failure
    to sustain intrauterine growth at expected rates
    can be caused by placental insufficiency,
    infection, malnutrition, etc. may or may not be
    born prematurely.

Infants at highest risk post discharge
  • VLBW and ELBW
  • Small for gestational age (SGA) and
    Intrauterine Growth Retardation (IUGR)
  • Primarily breastfeeding with no fortification
  • Infants on special formulas
  • Infants who require tube feedings at home
  • Infants on total parenteral nutrition (TPN) gt 4
    weeks during hospitalization or on parenteral
    nutrition after hospital discharge
  • Infants with gastrostomies or tracheotomies
  • Infants with slow weight gain prior to hospital
    discharge (gaining less than 15 gm/kg/day)
  • Infants with any of the following complications
    of prematurity
  • o Bronchopulmonary dysplasia/chronic lung
  • o Chronic renal insufficiency
  • o Congenital alimentary track anomalies
  • o Short bowel syndrome
  • o Cyanotic congenital heart disease
  • o Osteopenia of prematurity
  • o Anemia of prematurity
  • o Severe neurological impairments
  • o Drug and/or alcohol exposure in utero

Problems for premature infants
  • temperature instability
  • respiratory problems
  • cardiovascular
  • PDA, hypo/hypertension, low HR
  • blood and metabolic
  • gastrointestinal - NEC
  • neurologic
  • infections decreased immunity

Care of premature babies may include
  • temperature-controlled beds
  • monitoring - temperature, blood pressure, heart
    and breathing rates, and oxygen levels
  • extra oxygen by a hood or by a ventilator
  • mechanical ventilators
  • intravenous (IV) fluids - IV placed in a hand,
    foot, or scalp
  • umbilical catheter
  • Peripherally inserted central catheter (PICC)
  • x-rays
  • medications
  • Kangaroo care

Oxygen Tent/Hood
PICC line - Peripherally inserted central
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Nasogastric Feeding Tube
Tracheostomy and Ventilator
Kangaroo care
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Infant Mortality
  • Infant mortality is defined as death that occurs
    within the first year
  • Major cause is low birthweight
  • (lt 2500 g)
  • Other leading causes inlcude
  • 1) congenital malformations
  • 2) preterm births
  • 3) SIDS- sudden infant death syndrome

Combating Infant Mortality
  • Factors associated with mortality
  • Social and economic status
  • Access to health care
  • Medical interventions
  • Teenage pregnancy
  • Availability of abortion services
  • Failure to prevent preterm LBW births

Premies have higher nutritional needs
  • Due to
  • 1) inadequate nutrient stores
  • 2) immature physiological systems
  • 3)  rapid growth rate
  • 4) medical complications/illnesses

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Table 8-3, p. 227
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Estimating Energy Needs in Pediatrics
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  • RDAs for Energy and Protein Category
  • Age Energy (Kcal/kg) Protein (gm/kg)
  • Infant 0-6 mos 108 2.2
  • Infant 6-12 mos 98 1.6
  • Child 1-3 yrs 102 1.2
  • Child 4-6 yrs 90 1.1

Estimating Nutritional Needs in Premature Infants
Energy Needs
  • Ideally 40 CHO, 50 fat, 10-12 protein
  • Healthy full term infants need 100 kcals/kg/d
  • Preterm infants need 110-180 kcals/kg/d to
    sustain a normal growth rate
  • Most premature infants experience a period of
    slow growth after birth, followed by a period of
    catch-up growth. Their catch-up growth can be
    achieved by providing calories in excess of the
    RDA. Potentially as much as 20-30 more energy
    may be required.

Example of Energy Needs in Premie
  • a growing enterally fed premature infant without
    any acute illness are listed as follows
  • Resting expenditure 50 cal/kg/d
  • Minimal activity 4-5 cal/kg/d
  • Occasional cold stress 10 cal/kg/d
  • Fecal loss (10-15 of intake) 15 cal/kg/d
  • Growth (4.5 cal/g of growth) 45 cal/kg/d
  • Total required to produce a 10 g/d weight gain
    125 cal/kg/d

Energy Reserves
  • Premies weighing 1000g have 1 body fat and 120
    kcals/kg in reserve.
  • Term infant has 16 body fat and 1500 1800
    kcals/kg in reserve.
  • Inadequate energy allotment will result in poor
    protein retention.

  • Should provide 40-50 of total calories
  • Too much can cause osmotic diuresis (loose
  • Too little CHO can cause hypoglycemia.
  • Human milk and standard infant formulas contain
    lactose as CHO source.
  • Preterm formulas contain lactose, glucose
    polymers, sucrose
  • Sucrose is well tolerated, sucrase activity is at
    70 in early 3rd trimester.

  • Premies born before 28-32 weeks often have low
    levels of lactase enzyme resulting in an impaired
    ability to digest lactose.
  • However, lactose enhances calcium absorption,
    which is important for bone mineralization in
  • Glucose polymers, have low osmolarity and are
    easily digestible.

Protein Needs
  • Term infants 1.8-2.2 g/kg/d to sustain normal
  • Preterm infants as much protein as tolerated
    3.5-4 g/kg/d in an infant weighing lt1800 gms to
    support normal growth rate
  • Protein requirements depend on age and clinical

  • Premature infant formulas contain more protein
    than term formulas.
  • Inadequate protein intake is growth limiting
  • Excessive protein intake can cause elevated
    plasma amino acid levels, azotemia or acidosis.

Preterm human milk
  • Preterm HM contains 3g protein per 100 kcals for
    the first 4 weeks.
  • Term human milk contains 1.5 g protein per 100
  • Preterm infants have immature hepatic enzymatic
  • Human milk or whey predominant premie formulas
    should be the feeding of choice.
  • Whey protein forms small curds and is higher in
    conditionally essential amino acids

  • 50 of total kcals
  • Linoleic acid (LA) should comprise
  • 3-5 of total kcals
  • Alpha Linolenic acid (ALA) should comprise 1 of
    total kcals
  • Arachadonic and docosahexanoic acids are added to
  • Human milk contains long chain fatty acids (LCFA)
    (including arachidonic acid AA and DHA) and
    two lipases to aid absorption.

  • ARA and DHA can be synthesized from linoleic acid
    (LA) and alpha linolenic acid (ALA). ARA and DHA
    become conditionally essential if there are
    inadequate amounts of LA and ALA provided.
  • Term formulas contain LCFAs.
  • LCFAs delay gastric emptying time.
  • Preterm infants have low levels of lipases and
    bile salts needed for fat digestion and
  • Preterm formulas contain LCFAs and MCT oil.

  • -Triacylglycerols with fatty acids of between 6
    and 12 carbons in length that are short enough to
    be water soluble and are absorbed directly into
    the portal vein.
  • -These synthetic fats are hydrolyzed rapidly and
    can rely on the small amount of intestinal lipase
    and bile salts for solubilization.
  • -They are transported as free fatty acids, bound
    to albumin through the portal system. 7.7
    cals/mL and 8.3 cals /gm

  • improves fat absorption, enhances calcium
    absorption, improves nitrogen retention and
    weight gain
  • Provides a vehicle for fat soluble vitamins and
  • does not require micelle formation for absorption
    and utilization.
  • bypasses the portal vein and is directly absorbed
    into the lymphatics system
  • enters the mitochondria independent of carnitine.

Human Milk
  • Human milk is limited nutritionally for the small
    premature infant
  • has unique nonnutritive qualities that make it a
    superior choice
  • contains hormones, growth factors, antiviral and
    anti-inflammatory agents that help decrease the
    probability of sepsis and help to establish a
    healthy gastrointestinal flora.
  • Contains 21 kcals/oz or 0.7 kcals/mL

Benefits of Human Milk for the Preterm Infant
  • Whey-predominant protein
  • Improved nutrient absorption, especially of fat,
    zinc, and iron
  • Low renal solute load
  • Increased omega-3 fatty acids (DHA EPA)
  • Presence of anti-infective factors
  • Possible protection against necrotizing
    enterocolitis (NEC) and late-onset sepsis
  • Promotion of maternal-infant attachment

Human Milk Fortifier
  • Milk based
  • Increases levels of protein,
  • energy, calcium, phosphorus,
  • and many other vitamins and minerals
  • Used to boost nutrients in breast milk
  • Essential in feeding the preterm or sick infant
    consuming breast milk

Benefits of Fortification of Human Milk for
Preterm Infants
  • Improved weight gain
  • Increased linear growth
  • Normalization of serum calcium, phosphorus, and
    alkaline phosphatase
  • Improved protein status
  • Increased bone mineralization

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Human Milk Fortifier
  • 3.5 kcals/packet
  • To increase 2 calories per ounce add 1 packet to
    50 mL of breast milk
  • To increase 4 calories per ounce add 1 packet to
    25 mL of breast milk

  • glucose polymers from hydrolysis of cornstarch.
  • To be used as a caloric supplement.
  • mixes easily, has minimal flavor, and a low renal
    solute load.
  • Comes in powder (23 kcals/6g Tbsp) or liquid (2

Vegetable oil
  • 1 mL of canola oil has 8.3 kcals per mL and 9
    kcals per g of weight.
  • Add 1 mL of oil to 3 ounces of milk and increase
    calories from 20 kcals/oz to 22.75 kcals/oz

Preterm Infant Formulas
  • RTF at 24 kcals/oz and 27 kcals/oz for hospital
    use only.
  • At discharge, formula prescribed is 22 kcals/oz
  • Preterm formulas are all hypo-osmolar (260
    mOsm/L) to prevent osmotic diarrhea

  • measurement of osmotic concentration/dissociation
    of particles in a solution.
  • Serum osmolarity is 300 mOsm/kg water
  • Amniotic fluid is 275 mOsm/L and infant begins
    swallowing this at 16 weeks gestation.
  • Preterm breast milk is 290 mOsm/L.
  • Preterm Infant formulas are 260 Mosm/L.

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  • Soy-based formulas are not recommended for
    preterm infants.
  • Preterm infants receiving soy formula have
    suboptimal carbohydrate and mineral absorption
    and utilization than cows milk-based formula.
  • The American Academy of Pediatrics (AAP) doesnt
    recommend soy formula for infants born lt 1800 g
    since preterm infants showed significantly less
    weight gain, less linear growth, and lower serum
    albumin levels than those infants receiving cows
    milk-based formula.
  • Studies also have shown lower levels of bone
    marker formation in the premature population
    which can lead to osteopenia.

  • Goats milk is not recommended for preterm
  • Goats milk is deficient in folic acid and
    vitamin B6.
  • It is also higher in protein than human milk and
    infant formula which puts the premature infant at
    risk for dehydration due to the higher renal
    solute load.

Breastfeeding preterm babies
  • Feeding human milk to preterm infants provides
    nutritional, gastrointestinal, immunological,
    developmental, and psychological benefits that
    may impact their long term health and
    development. Human milk is advocated as the
    nutrition for preterm infants because it provides
    substances not supplied in formula.
  • From the AAP American Academy of Pediatrics

  • Trophic feeding within the first 24 hours
  • small, sustained amounts of enteral feedings soon
    after birth to sick or stabilizing premature
    infants, has become a standard of medical, as
    well as nutritional care in many neonatal
  • This practice is best considered as an induction
    of gut maturation and function rather than as a
    source of nutrition for the purpose of sustaining

Early enteral feedings (trophic)
  • defined as 5-25 mL/kg/d in the early days of life
  • stimulates GI enzymatic development and activity
  • promotes bile flow
  • increases villous growth in the small intestine
  • decreases the incidence of cholestatic jaundice
    (occurs with TPN use and no use of the GI tract)
  • can improve overall tolerance of feeds
  • gradual advancement of feeds will minimize the
    risk of feeding related complications such as
    Necrotizing Enterocolitis (NEC).

  • Begin feeds at 2cc/kg per feeding with an
    absolute minimal volume of 2 cc.
  • Advance feeds every 7 days by 10-20 cc/kg/d

Early Exposure to Enteral Feedings
  • a decrease in the amount of time to reach full
  • a decrease in the number of days that feedings
    were held due to clinical signs of feeding
  • a reduction in total hospital length of stay
  • a minimized incidence of metabolic bone disease
  • faster growth due to better total caloric intake
    compared with those who received TPN without
    enteral feedings

Fewer Total Days of TPN
  • resulted in lower bilirubin levels
  • a decreased incidence of cholestasis
  • improved calcium and phosphorus retention
  • maintenance of lower alkaline phosphatase levels
    Alk Phos
  • All have been found in premature infants fed
    small amounts of enteral nutrition compared with
    similar babies who remained NPO on TPN alone.

Route of enteral feedings
  • The route for enteral feeding is determined by
    the infant's ability to coordinate sucking,
    swallowing, and breathing, which appear at
    approximately 32 to 34 weeks' gestation.
  • Infants who are alert and vigorous may be fed by
  • Infants who are less mature, weak, or critically
    ill require feeding by tube to avoid the risk of
    aspiration and to conserve energy

Feeding route
  • Nasogastric and orogastric feedings are the most
    commonly used tube feedings in the neonatal
    intensive care unit.
  • may be accomplished with intermittent bolus or
    continuous infusions of fortified human milk.
  • Intermittent feedings every 2 to 3 hours simulate
    the pattern of feeding the infant will have when
    advanced to bottle feeding or breast feeding.

When premies are ready to feed orally
  • eyes may be open or closed
  • responds to light touch
  • looks at your face
  • hands are near the mouth
  • rooting (searching for the nipple) or sucking
  • body movements are smooth, calm, and quiet

Contraindications to feeding the premie
  • Metabolic acidosis
  • Respiratory instability
  • Abdominal distension
  • Severe asphyxia in the past 72 hours
  • Sepsis
  • Hypotension
  • Hemodynamically significant PDA (Patent Ductus

When NOT to oral feed
  • stares or avoids looking at you
  • panic or worried look
  • cannot wake up, excessive yawning
  • shaking, startles easily
  • gagging, gasping
  • frantic activity back arched, arms extended,
    hands open, fingers separated
  • color changes in skin

  • gagging
  • grimacing, pushing away
  • milk drools out of the mouth
  • stops sucking often or for a long time
  • poor muscle tone, body and extremities are limp,
    jaw is open
  • behavior change such as asleep, fussing, crying,
    shut down
  • breathing faster than 60 times per minute
  • stops breathing, heart rate slows, hypoxia
  • seizures
  • nostrils open wide (nasal flaring)

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Necrotizing Enterocolitis
  • Necrotizing enterocolitis (NEC) is a serious
    intestinal illness in infants.
  • "necrotizing" means damage and death of cells
  • "entero" refers to the intestine
  • "colitis" means inflammation of the colon
  • Although NEC may develop in low-risk newborns,
    most cases occur in premature babies. NEC is more
    common in babies weighing less than 1,500 grams.

necrotizing enterocolitis
  • Premature infants with difficult blood and oxygen
    circulation, digestion, and fighting infection
  • High-risk infants with enteral feeds
  • difficult delivery or lowered oxygen levels, the
    body oxygenates and purfuses the most essential
    organs first, results in lowered oxygen in the
    gastrointestinal circulation.
  • Too many red blood cells in the blood can slow
    down the oxygen delivery rate.

Risk Factors That May Predispose Premature
Infants to Increased Incidence of Necrotizing
Enterocolitis by Drenkpohl et al in ICAN, vol 2
number 1, Feb 2010
  • 384 charts reviewed.
  • 78 infants dxd w/ NEC compared 246 w/o NEC
  • Mtrs of NEC infants had higher incidence of PROM
    premature rupture of membranes
  • More males developed NEC than females
  • African Americans had a higher incidence of
    developing NEC
  • NEC infants had a higher prior dx of sepsis, were
    prescribed H2 blockers more frequently.
  • Gut priming and early enteral feeds less
    incidence of NEC
  • True etiology remains unclear

Symptoms usually develop in first 2 wks
  • Abdominal distention
  • Increased gastric residuals
  • bile-colored (green) fluid in stomach
  • bloody bowel movements
  • signs of infection such as apnea, low heart rate,

  • An x-ray of the abdomen may show a bubbly
    appearance in the intestine and signs of air or
    gas in the large veins of the liver.
  • Air may also be outside the intestines in the
    abdomen. A needle may be inserted into the
    abdominal cavity. Withdrawing intestinal fluid
    from the abdomen is often a sign of a perforation
    in the intestines.

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Problems from NEC may include
  • perforation in the intestine, bacterial infection
  • scarring or strictures of the intestine
  • malabsorption if surgical resection is indicated
    and a large amount of intestine is removed.
  • severe, overwhelming infection

  • stop feedings, bowel rest
  • NG tube to suction stomach
  • IV fluids for nutrition and fluid replacement
  • antibiotics for infection
  • frequent x-rays to monitor the progress of the
  • oxygen or ventilator if the abdomen is so
    distended that it interferes with breathing
  • isolation procedures to prevent spread of infx
  • Severe cases of NEC may require Bowel resection
    of the intestine or bowel to an ostomy (opening
    on the abdomen).

  • Because the exact causes of NEC are unclear,
    prevention is often difficult.
  • Studies have found that breast milk (rather than
    formula) may reduce the incidence of NEC.
  • Starting feedings after an infant is stable and
    slowly increasing feeding amounts have been

Chronic Lung Disease/Bronchopulmonary dysplasia
  • long-term respiratory problem
  • caused by injury to the lung tissue, such as
    mechanical ventilation and oxygen therapy.
  • Oxygen can be toxic to the lungs especially when
    delivered into the lungs from a ventilator.
  • The lung tissue can repair over time with
    adequate nutrition and subsequent growth.

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hyaline membrane disease/respiratory distress
  • a condition in which the air sacs cannot stay
    open due to lack of surfactant production in the
  • Signs and symptoms include breathing difficulties
    at birth, cyanosis, flaring nostrils, grunting
    sounds with breathing, chest retractions.
  • Treatment is with surfactant replacement.

PDA is a normal fetal structure that is expected
to close within the first 24 hours. To prevent
damage to the heart, it must be closed with
either medications, a plug or with surgery.
Patent Ductus Arteriosus (PDA)
  • is a normal fetal structure, allowing blood to
    bypass circulation to the lungs since the fetus
    does not use her lungs (oxygen is provided
    through the mothers placenta).
  • Flow from the right ventricle needs an outlet and
    the ductus provides this, shunting flow from the
    left pulmonary artery to the aorta.
  • The high levels of oxygen which the PDA is
    exposed to after birth causes it to close in most
    cases within 24 hours.
  • When it doesnt close, it is termed a Patent
    Ductus Arteriosus.

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diaphragmatic hernia
  • Diaphragmatic hernia is a life threatening,
    multifactorial condition, "many factors," both
    genetic and environmental, are involved. It is
    thought that multiple genes from both parents are
  • In utero, the diaphragm forms between the 7th and
    10th week of pregnancy.
  • With the heart, lungs, and abdominal organs all
    taking up space in the chest cavity, the lungs do
    not have space to develop properly, called
    pulmonary hypoplasia.

Signs and Symptoms at birth
  • difficulty breathing
  • fast breathing
  • fast heart rate cyanosis (blue color of the skin)
  • abnormal chest development, with one side being
    larger than the other
  • abdomen that appears caved in (concave)
  • GI problems, reflux may develop
  • Developmental delays may occur