Approach to enteral nutrition in premature infant new.pptx

Enteral nutrition

1. Approach to enteral nutrition in premature infant .

2. INTRODUCTION Premature infant have greater nutritional need in neonatal period to match the high rate of nutrition deposition achieved by infant in utero . In addition they have medical condition that increases their metabolic energy requirement including hypotension , hypoxia,acidosis,infection and surgery . Early and adequate nutritional support is needed to achieve appropriate rate of weight gain ,which are almost twice that of term infant ,to avoid postnatal growth failure.

3. Energy requirement. The energy requirement to achieve optimal growth are calculated from the estimated resting energy expenditure ( REE) plus the energy requirement for daily activities including feeding ,thermoregulation ,fecal loss,growth and chronic medical condition . For enterally fed premature infant ,the average daily energy requirement are 110-130 kcal /kg/day . For parenterally fed premature infant is 90-100 kcal/kg/day because of less fecal energy loss ,fewer episodes of cold stress and less activity .

4. Estimated daily energy requirement for growing premature infant Factor Kcal/kg Resting energy expenditure 50 Activity 15 Thermoregulation 10 Synthetic effect of feeding 8 Fecal loss 12 Growth 25 Total calorie requirement 120

5. Route of enteral feeding A- Infant requiring tube feeding Infant weight < 1800 gram birth weight usually less than 32 weeks gestation typically require tube feeding until they are sufficient mature to feed directly from oral route ( palladai /breastfeed ). Moderately preterm infant ( 32-34 wks ) often require a brief period of iv fluid and tube feeding before transition to oral feed . Whenever possible ,human milk should be used rather than formula . When EBM not available , pasteurizd human donor milk should be used for VLBW infant .In this case continue donor milk feeds until infant reaches approximately 34 weeks PMA ,weighs 2000 gram and or ready for hospital discharge . Evidence suggest that EBM is associated with fewer rate of NEC and feed intolerance compared with preterm formula .

6. TROPHIC FEEDS For all infant ,small volume trophic feed are started within the first day of life and ideally within 6 hours of life . Trophic feed was not associated with NEC and may reduce the risk of invasive infection . The rationale for early introduction of feed is that it promotes intestinal maturity ,prevent atrophy of mucosa ,promotes maturation of intestinal enzyme and motility and increased production of hormone gastrin ,which is required for intestinal growth . Start feed 15- 20 ml/kg/day devided and give every three hourly .

7. Feeding is begun with mother own milk OR pasteurized donor milk for preterm infant 1500 gram. For premature infant with weight > 1500 gram preterm formula may be used if EBM is not available . Trophic feed may be given to infant who have UAC, UVC and undergoing medical treatment for PDA .

8. Early enteral feeding benefits- The structural and functional integrity of GI tract depend upon provision of early enteral nutrition . MEN may describesd as non nutritive use of very small volume of human milk or formula for intended purpose of preservation of gut maturation rather than nutrient delivery . 1.less feeding intolerance 2 fewer days on PN 3.improved level of gut hormone 4 increased calcium and phosphorus retention . 5. improved weight gain .

9. RATE OF VOLUME INCREASE Birth weight (gram ) Initiation rate ml/kg/day When to advance Advancement rate ( ml/kg/d <1000 20 Maintain initial trophic feed for 3 days ,if feed tolerated may advance feeds every 24 hours thereafter . 20 to 30 1001 to 1500 20 Maintain initial trophic feed for 3 days for infant 1001to 1250 g and for 1 day for infant 1251 to 1500 g. If fed tolerated may advance feed 24 hourly thereafter. 30 1501 to 2000 20 If feed tolerated ,may advance every 24 hours. 30-40 2001 to 2500 25-30 Advance daily . 30-40 > 2500 and stable 50 or ad-lib (Infant with symptomatic or CCHD -20ml/kg/day) Advance daily 30-40

10. FEEDING SCHDULE More frequent feeding schedule improves feeding tolerance and reduces the time to attain full feeding . Infant receiving feeding every 2 hourly had a shorter time to reach full feed , attain greater weight gain , fewer days of receiving TPN.

11. FORTIFICATION OF FEED Human milk for preterm infant is routinely supplemented with HMF ( human milk fortifier). The use of HMF is recommended for VLBW infant 1500 g and may also be considered for infant with birth weight upto 2000 g and < 34 weeks gestation . Bovine milk based HMF as well as liquid donor human milk –based HMF are available. Studies showed that BMDF had increase risk of NEC,ROP, PDA,BPD as compared with HMDF. HMdF added when enteral feed reaches 60ml/kg/day designed to make 24-30 kcal /oz milk ( 1 oz= 30 ml milk ) because early introduction of HMF lead to greater length gain velocity and lesser decline in head circumference at 36 weeks PMA .

12. If donor human milk based HMF is not available,then continue on unfortified EBM until feeding volume reaches 100ml/kg/ day,then begin to fortify feed with Bovine HMF . These bovine HMF add 4 kcal/oz milk .

13. Targets - The target volume for feed is approximately 160 ml/kg/day of fortified human milk . This volume support a weight gain of 15 to 20 g/kg/day . Target energy of 110-130 kcal/kg day Target protein of 4-4.5 g/kg for infant < 1000 g and 3.5 -4g/kg for 1000-1500 g weight infant .

14. FEEDING INTOLERANCE * Difficulty tolerating enteral feedings is a major problem for premature infants, especially in those with gestational age below 28 weeks, those who require positive pressure support, or those who have positive blood cultures . *Factors that affect feeding tolerance include intestinal motility, gastric emptying, stool output, digestive enzymes, type of feeds (formula or human milk), rapidity of feeding, volume of feeding, concentration of milk, concomitant medications, and medical conditions. * An infant's intolerance of enteral feeding is a primary factor for clinical decision-making to initiate, advance, and discontinue feedings. Thus, feeding intolerance may be a major determinant of the duration of hospitalization.

15. CLINICAL ASSESMENT Symptoms and signs suggesting feeding intolerance – Symptoms of feeding intolerance are nonspecific and vary between patients. Most clinicians use a composite of the following clinical symptoms to determine feeding intolerance [68]: •Emesis • Abdominal examination – Distention or tenderness, bowel sounds decreased or absent •Gastric residual fluid – Change in quantity of fluid (usually increased volume) or change in color to green (bilious) or red (blood) •Stool output – Any change in the frequency of stool output and presence of blood in stools •Other – Increased episodes of apnea and bradycardia, diminished oxygen saturation (desaturation events), and lethargy Any of these symptoms should prompt the clinician to reassess the infant and evaluate the possibility of feeding intolerance and/or underlying pathology.

16. 1.GRV= The GRV is the amount of milk left in the stomach several hours after a feeding and is typically measured just prior to scheduled feeding . It is indirect measure of gastric emptying and intestinal function /pathology but is nonspecific because it may affected by position of infant or position of feeding tube . Omission of GRV in stable and asymptomatic infant increased delivery of enteral nutrition ,improved weight gain and earlier hospital discharge . However measuring GRV may still be useful marker with signs of feeding intolerance especially abdominal distention and vomiting .

17. 2. Blooody or bilious gastric aspirates . GRV that is green usually indicates overdistention of stomach and retrograde flow of bile into stomach but occasionally indicates intestinal obstrucrion . Blood stained GRV is usually due to slight mucosal irritation from indwelling gastric tube or sometimes due to inflammatory process.

18. 3.Stool output Stool output provides an index of intestinal motility . Use of glycerine suppository to stimulate stool output for evacuation of meconium during the 1 st week of life is associated with improvd feeding tolerance . 4. blood in stool = The presence of gross blood in stool is usually a sign of feeding intolerance and should raise concern for NEC if combined with abdominal distention , temperature instability and apnea. Measurement of occult blood is no more recommended . D/D- 1. swallowed blood from delivery ,suctioning ,gastric tube, breastmilk from mother with nipple trauma. 2.colitis due to infection or milk protein sensitivity. 3. Coagulopathy or thrombocytopenia.

19. Management of feed intolerance Adjustment of feeding- minor or isolated feding intoleranvce can be corrected by reducing the volume of feed or postponing advancement of feed volume or withholding feed for short period of time and asses for hemodynamics before giving next feed .it is important to avioid withholding feed for prolonged period of time to prevent the complication of parenteral nutrition and intestinal atrophy . Acid suppressant- like histamnine type 2 receptor antagonist and PPI not used to treat feeding intolerance as they appear to be associated with higher rate of NEC . Erythromycin –used for the treatment for feeding intolerance ,has prokinetic property.early use of erythromycin during 1 st week of life increases the risk for CHPS during infancy .

20. 2. Bolus vs continuous feeding Feeding are usually initiated as bolus , devided every 3 to 4 hours . If difficulty with feeding tolerance occur ,the amount of time over which a feeding is given may be lengthened by delivery via a syringe pump for 30-120 min . When human milk is fed through continuous infusion ,incomplete delivery of nutrient particularly fat and nutrient from HMF may cling to the tubings . Small frequent bolus feeding may result in improved nutrition delivery and absorption compared with continuous infusion Continuous feeding may usful for infant who fed via transpyloric route to avoid DUMPING syndrome and those who had intestinal surgery .

21. 3.Transpyloric feeding This mode also risk for fat malabsorption because it bypasses gastric lipase secretion . Indication – 1.evidence of severe regurgitation and aspiration . 2. specific surgical condition like post –op duodenal atresia with placed post anastomatic feeding tube These tube placed under guided fluoroscopy Feed should be give as continuous infusion because the small intestine cannot expand like stomach . .

22. Transition to breast/bottle feeding 1.Nonnutritive sucking (NNS) attempt at the breast should be encouraged before 33-34 weeks if tolerated . Early NNS facilitate milk production and increases the likelihood the infant is breastfeed at the time of discharge . 2.Infant who are approximately 33-34 weeker who have co-ordinated suck-swallow –breathe pattern and respiratory rate < 60/min are candidate to introduce breast/bottle feeding . 3.Nutritive oral feeding attempt at the breast should precede oral feeding with bottle/ paladai .

23. Nutritional assessment of infant <1500gram birth weight Lab test Frequency Hemoglobin After the infant receiving iron supplementation ,measure every 2 week until results are stable .Recheck prior to hospital discharge . Calcium ,phosphorous ,alkaline phosphatase Measure starting at 5-6 weeks of age .measure weekly until ALPo4 is < 600 IU/L and serum phosphorus is > 4.5 mg/dl . BUN Measure in infant with poor growth .BUN < 10 mg/dl suggest the need for more protein intake . Serum electrolyte Measure in infant receiving dieuretics ,feed of unfortified human milk ,limited intak or slow growth .