Transcript Transition of the Premature Infant from Hospital to Home

Nutrition and Growth in Primary Care
of the Premature Infant
Ma. Teresa C. Ambat, MD
Neonatology-TTUHSC
10/21/2008
Postnatal Growth of Premature Infants

Goal of nutrition support for VLBW from birth to term:
match the in utero growth rates of the normally growing
fetus

This goal is rarely achieved

Problem of chronic undernutrition and poor growth
– 99% of ELBW and 97% of VLBW had weights <10th percentile at
36 wks PMA
Postnatal Growth of Premature Infants

For each gestational age
category, the postnatal
study growth curve was
shifted to the right of the
reference curve
Postnatal Growth of Premature Infants

Extra-uterine growth retardation
– Caused by early growth delay, coupled with a lack of catch-up
growth
– Most frequent cause of morbidity seen in VLBW
– Have long term consequences on neurodevelopmental
outcomes
Postdischarge Nutrition of Premature Infants

Only recently that attention has been paid to nutritional
support of these infants after hospital discharge

Best practice should continue to evolve

Key questions
– Whether VLBW infants have special nutritional requirements in
the postdischarge period and
– Whether this period of nutrition is also critical for later health and
development
Infants at Highest Risk for Nutritional
Deficiencies after NICU Discharge
1.
2.
3.
4.
5.
6.
7.
8.
ELBW, VLBW
SGA, IUGR
Exclusively breastfed
Requiring special formulas
Requiring tube feedings at
home
Fail to gain at least 20g/day
before D/C
G Tube / tracheostomies
TPN >4 wks
9.
Diagnosis of any of the ffg:
BP
Chronic renal insufficiency
Congenital GI anomalies
Cyanotic CHD
IEM
Malabsorption
Osteopenia
Poverty/LSES
Severe neurologic impairment
SBS
Human Milk for Premature Infants

Preferred feeding for ELBW/VLBW
– Nutritional value
– Immunologic and antimicrobial components
– Contains hormones and enzymes

Once growth is established, nutritional needs of the
preterm infant exceed the content of human milk for
protein, Ca, P, Mg, Na, Co, Zn and vitamins
Human Milk for Premature Infants

Unsupplemented HM
– Associated with slower growth rate
– Nutritional deficiencies: hyponatremia, hypoproteinemia,
osteopenia, Zn deficiency

Infants discharged with subnormal weight for CA should
be supplemented

??? continued use of HMF
Human Milk for Premature Infants

Transition from supplemented EBM to exclusive
breastfeeding
– Favorable strategy???
– Optimal supplementary/complementary feeding?
– No best practice protocols
Human Milk for Premature Infants

Other practical points
–
–
–
–
Fresh milk may be fed immediately or refrigerated at ~40 C
Refrigerated milk should be fed within 48 hrs
Freezing: ~ -200 C
Frozen milk retains most of its immunologic properties and
vitamin content within 3 months
– Frozen milk should be thawed in cool or lukewarm running tap
water or in a basin of warm water
– Use of microwave not recommended

Reduces IgA levels and lyzozyme activity, produce hot spots
Postdischarge Nutrition of Premature Infants

Potential discharge strategies
– Provide calorically enhanced, EBM at the energy density
tolerated before D/C  gradual increase in exclusive
nursing sessions (-1 bottle feeding at a time) as the infant
outgrows the need for extra calories
– Nurse on demand but specify a required daily intake of
nutrient enriched post discharge formula (e.g. 2-3 feedings
of PDF per day)
– Strategy should be individualized
– Collaboration with dietitian/lactation consultant
Postdischarge Formula for Premature Infants

Nutrient-enriched formula for preterm infants after
hospital discharge - postdischarge formula (PDF)
– Enfacare 22 cal, Neosure 22 cal
– Intermediate in composition between preterm and term formulae

Compared to term formula, PDF contains
– Increased amount of protein with sufficient additional energy
– Contains extra Ca, P, Zn - necessary to promote linear growth
– Additional vitamins and trace elements
Postdischarge Formula for Premature Infants

Use of PDF after discharge in preterm infants 
improved growth, with differences in weight and length

AAP recommendations
1. Use of PDF vs term formulas to 9mos chronological age 
greater linear growth, weight gain and bone mineral content
2. Iron and vitamin fortified  no other supplements
3. If average intake 150ml/k/day  +Iron 1mg/k/day until 12 mos
Other Infant Formulas

AAP Recommendations
– No role for use of low iron formulas
– Hypoallergenic formulas
protein hydrolysates – may be useful in prophylaxis or
eradication of symptoms in sensitized infants
 No evidence to support the routine use for tx of colic,
sleeplessness or irritability
 HM,
– Soy formulas
 Carbohydrate,
protein and mineral absorption and utilization
not well documented in preterm
 Not recommended for: PT <1800g, prevention of colic or
allergy, cow-milk protein induced enterocolitis or enteropathy
Caloric Supplementation

Indications
1.
Flat or decelerating growth curve pattern
Volume restricted (severe BPD, cardiac disease)
Unable to take enough
2.
3.

Monitor for dietary intolerance (GI symptoms, bloody
stools), hydration status

If increased caloric supplementation does not improve
growth  further evaluation by endo, GI, dietitian
Caloric Supplementation
Caloric amount
Breast Milk
24 cal
1 tsp formula powder to 90 ml EBM
26 cal
1 ½ tsp formula powder to 90ml EBM
Potential formulas: Enfacare, Neosure, Enfamil Lipil, Similac Advance
Other prep: 1 tsp Neosure advance + 75 ml water (24 cal )
Caloric amount
Enfacare Lipil
Neosure Advance
24 cal
2 scoops + 3.5 oz water  4
oz formula
3 scoops + 5.5 oz water
 6.5 oz formula
27 cal
2 scoops + 3 oz water  3.5
oz formula
5 scoops + 8 oz water 
9 oz formula
Caloric Supplementation

Weaning
1.
Gradual adjustments to caloric density followed by weight
checks
2.
Serial measurements of growth (adjusting for prematurity)
including length and HC
3.
4.
Breastfed: assessment of infant’s ability to transfer sufficient
quantities of milk as well as adequacy of mother’s milk
supply
Formula-fed: assessment of infant’s volume intake
Micronutrient Supplementation

No guidelines for supplementing premature infants with
water-soluble vitamins after discharge
– Supplementation until 1 yr chronological age is not unreasonable
– PDF supply more water-soluble vitamins > term formulas

Little info about supplementation of fat-soluble vitamins
– For HM fed, oral solutions of A,D,E available
– PDF supply adequate amounts of fat-soluble vitamins
– For healthy PT, probably not necessary to supplement after
attaining weight of 3 kg
Micronutrient Supplementation
Nutrient
Breastfed
Formula fed
Elemental iron1 2mg/k/d starting at 1 mo
12 mos
Only iron-fortified formulas
Intake of 150ml/k/d = 1.8mg/k/d
of iron. Infants may benefit from
additional 1mg/k/d.
Vitamin D2
Ingesting <500ml/day,
supplement with 200 IU/d
200 IU/d starting at 2 mos
 12mos3
1. If on EPO: give 6mg/k/day
2. Most standard MVI prep contains 400 IU per mL
3. If weaned to at least 500mL per day of Vit-D fortified formula, this may be
d/cd
Micronutrient Supplementation

Calcium and Phosphorus
– Continued use of nutrient enriched formulas in PT until 9 mos 
improved bone mineral content
– Greater challenge in breastfed former PT (2-3 feedings of PDF
per day may enhance mineral intake)
– Infant with hx of osteopenia (separate discussion)

Fluoride
– Supplementation should be based on total amount of fluoride
from all sources available
Micronutrient Supplementation

Trace minerals
1.
2.
3.
4.
Zinc: PTF, TF and HMF provide sufficient Zn
Copper: RDI can be met by HM or PTF
Iodine: all formula for PT will supply RDI
HM will not supply enough iodine by itself, though
supplementation has not been established
Selenium, chromium, molybdenum or manganese: deficiency
in PT has not been reported

Most optimal strategies for the postdischarge nutritional
management of ELBW/VLBW are unknown

Further research needed to determine best practice
guidelines

Serial measurements of growth and maintaining
postdischarge feedings may offer favorable strategy until
more specific, universally accepted protocols are
established
Complimentary Feeding
1.

2.



Introduce solid foods when the infant is
developmentally ready, generally between 4-6 months
No nutritional indication to add complimentary foods to
diet of the healthy term infant <4 months of age
Introduce new foods slowly enough so that any allergic
reaction or intolerance to food can be identified
AAP: no more than 3 foods be introduced/ week
No particular order
Meat has an advantage of providing iron and zinc
Complimentary Feeding
3. Juice should not be introduced into the diet of infants < 6
months (risk that juice will displace BM or formula 
reduced intake of protein, fat, vitamins and minerals)


Fruit juices should be limited to 4-6oz/day after 6 months
Neither breastfed nor formula-fed require extra water
4. Do not give cow’s milk before 12 months, because it may
adversely affect the infant’s iron status
5. Do not give reduced-fat cow’s milk to children < 2years
(children at this age should not have fat-restricted diet)
Complimentary Feeding
6. Offer fruits and vegetables to infants daily beginning at
6-8 months
7. Limit the amount of salt added to foods fed to infants
 When salt is used, use iodized salt
8. Limit consumption of low-nutrient foods
References
1.
2.
Pediatric Nutrition Handbook
Primary Care of the Premature Infant