Transcript Preventing Perinatal HIV Transmission

Nutritional Support of the
VLBW Infant
Toolkit Principle Authors:
Nancy
Wight, MD, IBCLC, FABM, FAAP, Sharp Mary Birch Hospital for Women
William Rhine, MD, FAAP, Lucile Packard Children’s Hospital at Stanford University
David Durand, MD, FAAP, Children’s Hospital Oakland
David Wirtschafter, MD, FAAP, Southern California Permanente Medical Group
Jae Kim, MD, PhD, FRCPC, FAAP, University of California, San Diego
Courtney Nisbet, RN, MS, CPQCC
Objectives
Following self-study of the slide presentation and reading of the Nutritional
Support of the Very Low Birth Weight (VLBW) Infant Toolkit, the participant
will have/be able to:
 Recognize that nutrition during critical periods in early life may
permanently affect the structure and/or function of the infant’s organs
and tissues;
 Identify three physiological goals of VLBW infant nutrition management;
 List suggested best practices for the major aspects of infant nutrition
promotion, including parenteral nutrition, establishing enteral nutrition,
human milk/breastfeeding, transition to oral feeding and discharge
planning;
 Recognize that new research has only reinforced prior best practices;
 Demonstrate knowledge and skills necessary to establish and support
breastfeeding.
Gold Standard of Growth for
VLBW Infants
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To approximate the in utero growth of a normal
fetus of the same post-conceptional age.
Body weight
Body composition
AAP Committee on Nutrition: Nutritional needs of low
birth weight infants. Pediatrics 1985;75:976
AAP Committee on Nutrition: Nutritional needs of the
preterm infant, in Kleinman RE (ed): Pediatric Nutrition
Handbook, ed 5, Elk Grove Village, IL, AAP, 2004, p 2354.
Unique Nutritional Aspects of
the VLBW Infant
Higher organ:muscle mass ratio
 Higher rate of protein synthesis and turnover
 Greater oxygen consumption during growth
 Higher energy cost due to transepidermal
water loss
 Higher rate of fat deposition
 Prone to hyperglycemia
 Higher total body water content
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Unique Nutritional Aspects of
VLBW infants - Brain Growth
Brain Growth over 8 weeks:
 At 28 wks
100% Increase
 At term
40% Increase
 At 3 mo
25% Increase
Preventing Feeding-Related
Morbidities in VLBW Infants
Necrotizing enterocolitis
 Osteoporosis
 Vitamin and mineral deficiencies
 Feeding intolerance
 Prolonged TPN and related cholestasis
 Prolonged hospitalization
 Lack of full physical and intellectual potential
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Optimizing Long Term
Outcome
Nutritional Programming:
Nutrition during critical periods in early
life may permanently affect the
structure and/or function of organs
or tissues.
Alan Lucas, 1990
Early Diet Influences Longterm Health and Disease
Breastfeeding leads to reduction in diastolic
blood pressure in later years of 3.2 mmHg,
a greater impact that seen by other public
health measures including:
Weight loss (-2.8 mmHg)
Alcohol reduction (-2.1 mmHg)
Salt restriction (-1.3)
Exercise (-0.2 mmHg)
Early Diet Influences Longterm Health and Disease
Adverse effects of growth acceleration in
humans include:
Obesity
Elevated blood pressure
Insulin resistance and diabetes
IGF-1 concentrations
Cardiovascular mortality
Nutritional Care/Outcomes in VLBW
Infants - Potential Improvements
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Human milk
“Early” TPN
Prevent protein deficit
Prevent EFA deficiency
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GI priming/MEN/Trophic feeds
Prevent GI atrophy effects
Faster realization of full enteral feeds
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Fortification/Supplementation
Starting earlier
Continuing longer
Benefits of Human Milk Reduced Infections
Otitis media – with a reduction in the frequency
and duration of ear infections in breastmilk
versus formula fed newborns
 Respiratory tract illnesses including respiratory
synctial virus infection
 Gastrointestinal illness
 Urinary tract infections
 Infant botulism
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Benefits of Human Milk Reductions in Chronic Diseases
Obesity
 Allergies/atopy
 Type 1 juvenile onset diabetes
 Crohn’s disease
 Lymphoma
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Benefits of Human Milk
for Preterm Infants
Host Defense
 Gastrointestinal Development
 Special Nutrition
 Neurodevelopmental Outcome
 Physically & Psychologically Healthier
Mother
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Immunoglobulins : 90% IgA and sIgA
More IgA in preterm milk
 Concentration decreases over time
 IgA found in stool of breastfed infants
unchanged: lines intestine to protect
 Increased urinary excretion of IgA with
breastmilk
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Incidence of Necrotizing Enterocolitis
by Type of Feed
Type of feed
Proportion
EBM
EBM + PTF
PTF
Necrotizing Enterocolitis
Incidence
1.2 %
3/253
2.5 %
11/437
7.2 %
17/236
Statistical Comparison:
PTF v. PTF + EBM p < .005
PTF v. EBM
p < .001
Lucas & Cole, Lancet 1990;336:1519
GI Benefits of Human Milk for the
Preterm Infant
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Gastrointestinal development
Reduces intestinal permeability faster
Induces lactase activity
Multiple factors to stimulate growth, motility
and maturation of the intestine
Human milk empties from the stomach faster
than artificial milks
Less residuals and faster realization of full
enteral feedings
Factors in Breastmilk That May
Promote GI Maturation
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Epidermal growth
factors
Nerve growth
factors
Somatomedin-C
Insulin-like growth
factors
Insulin
Cortisol
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Thyroxine
Nucleotides
Taurine
Glutamine
Lactose
Amino sugars
Cytokines
Groer & Walker. Advances in
Pediatrics 1996; 43:335-358
Time Needed to Attain Full Enteral
Feeds in 95% of VLBW Infants
Type of feed
Expressed breastmilk
Standard formula
Preterm formula
Number of days
20
45
48
Lucas & Cole. Lancet 1990;336:1519
Benefits of Human Milk
for the VLBW Infant
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Special nutritional needs
Different quantity and quality of proteins
Fats: Cholesterol, DHA, ARA
Carbohydrates designed for human infants
Lower osmolality/renal solute load
Other factors: e.g. erythropoietin, EGF
Human Milk and Retinopathy of
Prematurity in VLBW Infants
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145 VLBW (<1500gm) Jan 1992-Feb 1993
Incidence of ROP
Human Milk
Formula
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p<0.005
Incidence of ROP at discharge
Human Milk
Formula
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37.3%
63.8%
22.3%
p<0.0007
53.4%
Multiple Regression Analysis:
feeding correlated with ROP incidence and severity
dose response relationship
even small vol. (<20%) of human milk protective
Hylander et al. J Perinatol 2001; 21:356-362
General Principles
Poor growth during antenatal or postnatal life is
associated with increased risk to long-term health.
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Significant growth restriction occurs during the inhospital phase of post-natal growth among VLBW
infants.
Maximizing volume of feeding and nutrient
fortification has been shown to improve overall
growth.
Due to high relative growth rate standardizing the
response to poor or suboptimal growth should
improve overall growth.
Best Practice #1.1
Establish consistent, comprehensive,
multidisciplinary nutritional monitoring
as an integral component of improving
nutrition outcomes in the neonatal
population.
Best Practice #1.2
Establish standards of nutritional practice
based on best evidence or expert opinion
if evidence is lacking. Track nutritional
continuous quality improvement (CQI)
data and use it to modify and improve
current practices and outcome.
Implementation Strategies
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Daily rounds and progress notes should include a
specific place for weight and feeding adjustment
and should address progress toward daily growth
targets.
Weekly measurement and plotting of weight,
length and head circumference should be done.
Standardize response to poor or suboptimal
growth.
Mother’s milk expression and collection should be
encouraged, supported and monitored routinely.
Parenteral Nutrition for
VLBW Infants
Sophisticated techniques for providing short and
long-term parenteral nutrition to critically ill
infants have been developed.
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In-utero protein and energy gain is more than 4
gm/kg/day.
Administration of 3 gm/kg/day of protein
immediately after birth is safe and can reduce the
early protein deficit cumulated within the first
week of life.
Early administration of at least 1 gm/kg/day pf
intravenous lipids will prevent essential fatty acid
deficiency.
Best Practice #2.1
Parenteral nutrition, including protein and
lipids, should be started within the first 24
hours of life.
 Parenteral nutrition should be increased
rapidly so infants receive adequate amino
acids (3.0-4.0 gm/kg/day) and non-protein
calories (80-100 kcal/kg/day) as quickly as
possible.
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Best Practice #2.2
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Start parenteral lipids within the first 24
hours of life. Lipids can be started at
doses as high as 2 g/kg/d. Lipids can
be increased to doses as high as 3.0-3.5
g/kg/day over the first few days of life.
Best Practice #2.3
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Discontinue parenteral nutrition, with
removal of central catheters, as soon as
adequate enteral nutrition is established.
Implementation Strategies
Standardized policies, order sets and TPN
solutions should be used to provide
balanced, maintenance parenteral nutrition.
 Amino acids (of at least 2 gm/kg/day) and
intravenous lipid administration should be
started within the first 24 hours of life
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Available pre-mixed TPN /TNA (Total
Nutrition Admixture) may simply
administration and mixing issues.
Establishing Enteral Feedings
Current research confirms that human milk (with
appropriate fortification for the VLBW infant) is the
standard of care for preterm as well as term infants.
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The objective of feeding during the early days of
life is to stimulate gut maturation, hormone release
and motility.
Early introduction of feedings shortens the time to
full feeds and discharge and does not increase the
incidence of NEC.
Benefits of human milk include: key digestive
enzymes, immunologic protective factors,
immunomodulators, anti-inflammatory factors,
anti-oxidants, growth factors, hormones and other
bio-active factors.
Best Practice #3.1
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Human milk should be used whenever
possible as the enteral feeding of choice
for VLBW infants.
Best Practice #3.2
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Enteral feeds, in the form of trophic or
minimal enteral feeds (also called GI
priming), should be initiated within 1-2
days after birth, except when there are
clear contraindications such as a
congenital anomaly precluding feeding
(e.g. omphalocele or gastroschisis), or
evidence of GI dysfunction associated
with hypoxic-ischemic compromise.
Implementation Strategies
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Create a supportive environment to maximize milk
production in the early post-partum period.
Teach mothers hand expression and collection techniques
to maximize colostrum availability.
Establish a relationship with a human milk bank and
procedures for obtaining heat-treated donor milk quickly.
Specific standardized feeding policies should be available in
each NICU.
Reasons for withholding feedings should be documented
and discussed in rounds.
Best Practice #7: Every mother of an infant admitted to the
NICU should be provided with an appropriate breast pump
and the support to use it effectively.
Guidelines for advancing feeds have been shown to
be associated with more consistent orders and
responses to residuals between physicians, faster
rates of advancement and lower rates of necrotizing
enterocolitis.
Best Practice #3.3
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NICU’s should standardize feeding
management based on best available
evidence.
NICUs should standardize their definition of
feeding intolerance, with specific reference to
acceptable residual volumes, changes in
abdominal girth and the presence of heme-positive
stools.
Enteral feeds should usually be given by
intermittent bolus, rather than continuously, and
by gastric, rather than transpyloric administration.
Best Practice # 3.3 continued
Pumps delivering breastmilk should be
oriented so that the syringe is vertically
upright, and the tubing (smallest caliber
and shortest possible) should be positioned
and cleared to prevent sequestration of fat.
Enteral feeds should be advanced until they
are providing adequate nutrition to sustain
optimal growth (2% of body weight/day).
For infants fed human milk this could
mean as much as 170 - 200+ mL/kg/day.
Best Practice # 3.4
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VLBW infants fed human milk should be
supplemented with protein, calcium, phosphorus
and micronutrients. Multinutrient fortifiers may
be the most efficient way to do this when feeding
human milk. Formula fed infants may also
require specific caloric and micronutrient
supplementation.
Implementation Strategies
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Each NICU should discuss and agree on a
definition of feeding intolerance.
Staff should be educated on policies, plans and
practice changes.
NICU feeding policy should specify modes and
methods of feeding as well as fortification
Reason for variance should be discussed and
documentation.
Human Milk and Breastfeeding
Maximal human milk exposure for the
vulnerable preterm infants during
hospitalization is essential.
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A concerted effort of a multidisciplinary team is an
excellent strategy to improve human milk
exposure along with the development of a strong
unit culture in support of human milk.
Early milk production is correlated with later
maintenance milk volume and lactation success.
Human milk is a body substance and therefore
carries risks of transmission of infectious agents.
Safe handling should minimize the risk to the
VLBW infant.
Best Practice # 4.1
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Educate & advocate for human milk for
NICU infants.
Obstetric, perinatal, neonatal and pediatric
professionals should have the knowledge, skills
and attitudes necessary to effectively support the
provision of breastmilk to the VLBW infant.
Mothers and families should be given accurate
information about human milk for VLBW infants,
and their decisions respected.
Breastfeeding Resources
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International
ABM (Academy of Breastfeeding Medicine)
WHO/UNICEF
ILCA (International Lactation Consultant Association)
IBLCE (International Board of Lactation Consultant Examiners)
Wellstart International
WABA (World Alliance for Breastfeeding Advocacy)
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National
AAP (American Academy of Pediatrics)
ACOG (American College of Obstetricians & Gynecologists)
AAFP (American Academy of Family Physicians)
DHHS: Office of Women’s Health/Maternal-Child Health Bureau)
March of Dimes
WIC (Women, Infant, Children Supplemental Nutrition Program)/USDA
NIH (National Institutes of Health)
CDC (Centers for Disease Control & Prevention)
Breastfeeding Resources
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State
DHHS (Dept. Health & Human Resources)
WIC
AAP/ACOG/AAFP Chapters
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Local/Regional
Breastfeeding Coalitions
Hospital Lactation Programs
Private Lactation Consultants
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Web Resources
www.breastfeeding.org
www.bfmed.org
Academy of Breastfeeding Medicine
Academy of Breastfeeding Medicine
www.bfmed.org
Best Practice #4.2
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Mothers’ milk supply should be
established and maintained.
Best Practice # 4.3
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Human milk should be handled to
ensure safety and maximal nutritional
benefit to the infant.
Best Practice # 4.4
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Obstetric, perinatal, and neonatal
professionals should counsel mothers
when breastfeeding may be of concern
or contraindicated.
Implementation Strategies
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Hold regular CME, CEU and other inservice activities
related to lactation issues.
Develop competencies regarding human milk handling and
usage.
Designate a Director of Lactation as a resource person.
Risk factors for insufficient lactation should be
communicated to perinatal and post-partum staff as well as
to perinatal staff of referring facilities.
Routine and standardized patient education should begin
during pre-pregnancy OB/GYN visits and continue
through pregnancy.
Remove formula company influences from the perinatal
area.
Breastfeeding-Supportive Infant
Environment?
Transition to Oral Feedings
Early attachment is beneficial for
milk production and mother-child
bonding.
Skin-to skin contact may strengthen the
mother-infant dyad and lead to longer
breastfeeding periods over the first two
years of life.
 Non-nutritive breastfeeding can stimulate
milk volume and improve breastfeeding
success rates.
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Best Practice #5.1
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Infants should be transitioned from
gavage to oral feedings when
physiologically capable, not based on
arbitrary weight or gestational age
criteria.
Best Practice # 5.2

A definitive protocol for transition to oral
feedings of human milk or formula does
not currently exist. NICU healthcare
providers should make use of safe
techniques for which some evidence
exists (skin-to-skin care, non-nutritive
breastfeeding, test-weighing, alternate
feeding methods) to effectively facilitate
transition to full oral feeding.
Implementation Strategies
Implement and encourage routine skin-toskin time.
 Measure lactation time
 Measure breastfeeding frequency and
breastfeeding status at the time of discharge.
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Discharge Planning and
Post-Discharge Nutrition
In the weeks prior to discharge from
the NICU an individualized
nutritional plan should be prepared.
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These plans should be coordinated between the
family, neonatology, lactation consultants,
dieticians, nursing staff and if possible the primary
care physician continuing to provide care
following discharge.
Post-discharge nutrition, including the need for
special diets, frequency of visits and monitoring of
growth and biochemical markers is required.
VLBW infants grow faster and have higher bone
mineral content up to 1 year of age if provided
with additional nutrients including protein, calcium
and phosphorus.
Best Practice #6.1
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Nutritional discharge planning should
be comprehensive, coordinated and
initiated early in the hospital course.
Planning should include appropriate
nutrient fortification and nutritional
follow-up.
Best Practice #6.2
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Mothers should be encouraged to
eventually achieve exclusive breastfeeding
after discharge while ensuring
appropriate growth for the infant.
The End
Questions?
Review the CPQCC
Toolkit: Nutritional
Support of the Very
Low Birth Weight
Infant.
Available at:
www.cpqcc.org