Feeding and fluid electrolyte management of LBW

Feeding and fluid electrolyte management of LBW

1. Feeding and fluid electrolyte management of newborn Dr Jyoti Prajapati Assistant Professor Paediatrics

2. WHO recommends that all LBW infants, irrespective of their gestation be fed breast milk. Breast milk is the ideal feed for all infants, including LBW infants The best milk for LBW infants is mother’s milk. All else is inferior.

3. LBW infants need optimal nutrition during the neonatal period for proper growth and development. Appropriate feeding of LBW and VLBW infants improves their chances of survival normal birth wt 2800-3000gm LBW ( Low birth weight) <2500gm VLBW ( very low birth weight) <1500gm ELBW ( extremely low birth wt) < 1000gm

4. LBW: Significance 75% neonatal deaths and 50% infant deaths occur among LBW infants LBW babies are more prone to: Malnutrition respriatory distress apnea episodes gastrointestinal problems Recurrent infections Neuro developmental delay LBW babies have higher mortality and morbidity

5. Types of LBW Preterm < 37 completed weeks of gestation Account for 1/3 rd of LBW Small-for-date (SFD) / intra uterine growth retardation (IUGR) < 10 th centile for gestational age Account for 2/3 rd of LBW neonates 2 types based on the origin

6. The goal is to enable every LBW infant to receive feeding directly and exclusively from her/his mother’s breast at the earliest. preterm infants have feeding difficulties initially  -Inability to coordinate suck, swallow and breathing (<34wk)  -Immature and sluggish gut  -Systemic illness( hypothermia, sepsis, hyopglycemia, respiratory problems etc.)

7. Full term SGA infants may also experience.  Poor attachment and sucking effort on the breast  Poor swallowing  Easy tiredness (and hence poor intake)  Vomiting, regurgitation or abdominal distension Lower the birth weight, greater is the likelihood of feeding difficulties.

8. Initiation of successful breast feeding Every effort should be made to provide breast milk to LBW infants. This would require: 1. stable infants a. Placing infant in skin to skin contact with the mother immediately after delivery b. Initiating breastfeeding within one hour c. Initiating and providing Kangaroo Mother Care (KMC) d. Offering breastfeeding frequently every two hours, and on demand e. Ensuring continued frequent feeding at night f. Ensuring proper positioning and attachment g. Managing breast/nipple problems such as retracted or cracked nipple, and breast engorgement

9. 2. For unstable infants (with cardio-respiratory problems, temperature instability, abdominal distension or acute serious illness such as asphyxia or sepsis; on life support) a. Offering expressed breast milk by alternate methods b. As the infant improves, putting her on the breast to stimulate lactation c. Initiating Kangaroo Mother Care (KMC) once the infant stabilizes

10. LBW: Feeding schedule Begin at 60 to 80ml/kg/day Increase by 15ml/kg/day Maximum of 180-200ml/kg/day early initiation and then every 2 hourly

11. Weight >1800 g; Gestation > 34 wks* Breast feeding Katori-spoon feeding, if sucking not satisfactory on breast Shift to breast feeds as soon as possible LBW: Fluids and feeding

12. Weight 1200-1800 g; Gestation 30-34 wks* Start initial gavage feeds Katori-spoon feeding after 1-3 days Shift to breast feeds as soon as baby is able to suck * May need intravenous fluids, if sick LBW: Fluids and feeding

13. LBW: Fluids and feeding Weight <1200 g; Gestation <30 wks* Start initial intravenous fluids Introduce gavage feeds once stable Shift to katori-spoon feeds over next few days. Later on breast feeds * May try gavage feeds, if not sick

14. SPECIAL CONSIDERATIONS FOR INFANTS BELOW 1200 GRAMS have many problems - breathing difficulty, hypothermia, and hypoglycaemia. -Maintenance of temperature, -Prevention of infections (asepsis and hand washing) -Require constant monitoring . -Strict aseptic precautions should be observed while giving iv fluids -Monitoring for fluid overload

15. Even while on intravenous fluids, they can be administered small amounts of milk feeds called minimal enteral nutrition (MEN) or trophic feeds. It helps in the growth and maturation of the gastrointestinal tract. started as 12 - 24 ml/kg/day divided into 4 - 6 feeds given via the intragastric route. As the infant stabilises, breast milk feeding is gradually advanced to full requirements

16. Assisted feeding

17. LBW: Feeding Gavage feeding/ OG feeding

18. Paladi feeding LBW: Feeding

19. KMC

20. LBW: Adequacy of nutrition expected changes in Weight pattern* Loses 1 to 2% weight every day initially Cumulative weight loss 10%; more in preterm (10-15%) Regains birth weight by 10-14 days adequacy of feeding frequency of urine (8-12 times for day) weight gain (15-20 grams per day)

21. Excessive loss or inadequate weight —check the amount of intake, frequency, night feeds —assess attachment (breastfeeding), —spillage (if on paladai / cup / spoon feeds). —Nipple and breast problems —cold stress, sepsis, oral thrush, anaemia and late metabolic acidosis

22. LBW: Supplements Vitamins : IM Vit K 1.0 mg at birth Vit A 1000 I.U. per day Vit D 400 I.U. per day Iron : Oral 2 mg/kg per day from 8 weeks of age

23. FLUID AND ELECROLYTE MANAGEMENT Newborns are born with an excess of total body water (TBW) fetus 90% at birth 75- 80% adult 60% this excess TBW is normally lost by diuresis during 1st week of life

24. WATER LOSS SENSIBLE— kidney and GIT( kidneys have limited capacity to dilute urine initially owing to low GFR) INSENSIBLE - skin 70% and respiratory system 30% IWL PRETERM > TERM fever , tachypnea, radiant warmer ,phototherapy increases IWL

25. Guidelines for fluid requirements First day 60-80 ml/kg/day Daily increment 15 ml/kg till day 7 Add extra 20-30 ml/kg for infants under radiant warmer and 15 ml/kg for phototherapy

26. Fluid requirements (ml/kg)

27. initial 2 days , iv fluids consist of D10% only. After that, sodium (2-4 mEq/kg/day) and potassium (2-3 mEq/kg/day) is added to dextrose. Maintenance fluid since 3rd day if baby is passing urine = N/5 saline ( four parts of D10% + one part of NS)

28. monitoring in iv fluid therapy small volume infusion set should be used. Too rapid an infusion may result in ccf and even death in a small baby. Adequacy of fluid therapy is indicated by weight pattern in the expected range

29. THANKS