Feeding of low birth weight babies

1. FEEDING OF LOW BIRTH WEIGHT BABIES Dr Pradeep

2. LBW--<2500gm Prev. 15.5%, 96.5% are born in developing world Can be d/t preterm birth or small for gestational age SGA- Wt. for gestation <10 th centile LBW babies are more prone to: Malnutrition Recurrent infections Neurodevelopmental delay LBW contributes 60-80% of neonatal deaths definition

3. classification group Wt - 2000- 2500gm Term LBW 1500-2000gm Preterm (32-36 wks) 1000-1500gms Preterm <32 wks <1000gms Preterm <28 wks Classification of LBW(birth wt)

4. Birth asphyxia Hypothermia Feeding difficulties Infections Hyperbilirubinemia LBW (Preterm) : Problems Respiratory distress Apneic spells Intraventricular hemorrhage Hypoglycemia Metabolic acidosis

5. Feeding lbw babies- how is it diferrent Inadequate feeding skills Prone to illness-prematurity Higher fluid requirements--- higher feed volumes Gut immaturity Low body stores of micronutrients

6. Mothers own milk best for all LBW infants/Expressed breast milk Donor breast milk Infant formula Animal milk What to feed Standard infant formula Preterm formula < 1500 gms & up to 2000 gms achieved

7. Behavior at breast Range of gestation Response when offered expressed breast milk Occasional suckling effort 28-31 wks Opening mouth, tongue out of mouth, licking milk. Not able to co ordinate breathing n swallowing Root n attach to breast . Weak suckling attempts 32- 33 wks Opening mouth, tongue forwar d, licking milk, i.e -co-ordinate Root n attach to breast 34-36 wks Able to suck at milk from cup Assessment of feeding readiness

8. Is stable? Fast breathing (RR>60/min) Severe chest in-drawing Apnea Requirement for oxygen Convulsions Abnormal state of consciousness Abdominal distension Shock If unstable, start intravenous (IV) fluids Presence of any one of these signs = UNSTABLE Deciding the initial feeding method

9. Initial feeding method in stable babies Clinically stable no Start i.v fluid yes Birth wt > 1250 gms Manage as sick babies guidelines Able to breast feed effectively Rot, attach and suckle effectively no yes Initiate BF YES NO Able to accept feed by alternate methods- When offerd cup swallows without coughing/spluttering Adequate quantity to satisffy needs Give oral feeds by cup / spoon/ paladay INTRAGASTRIC FEED yes NO

10. Steps in progression feeding How to decide the initial feeding method

11. Progression of feeding low birth wt

12. On exclusive breast feeding – iron has to be given 2mg /kg/day from 2- 23 months of age Breast feed infants < 1500 gms =: when tolerating the feed - Supplementation calcium 80mg /kg /day Until 40 wks post menstrual age phosphorous 15mg/kg/day do Vitamin D 400 IU/Day do

13. How much to feed

14. Rec. fluid requirements & feed volumes Day of life Fluid ml/kg/d Feed every 3 hrly ( vol ) Fluid ml/kg/d Feed every 3 hrly Fluid ml/kg/d Feed every 2 hrly Day 1 60 17 60 12 60 6 Day 2 80 22 75 16 70 7 Day 3 100 27 90 20 80 8 Day 4 120 32 115 24 90 9 2000-2500gms 1500-2000gms 1000-1500gms

15. Rec. fluid requirements & feed volumes 2000 - 2500 1500-2000 1000-1500gms Day of life Fluid ml/kg/d Feed every 3 hrly ( vol Fluid ml/kg/d Feed every 3 hrly Fluid ml/kg/d Feed every 2 hrly Day 5 140 37 130 28 110 11 Day 6 150 40 145 32 130 13 Day 7 onwards 160+ 42 160 35 150 16

16. Breast milk should be given as trophic feed 5-10 ml / day if clinically stable Special consideration

17. For breast feeding Assessment of feeding adequacy Observe attachment/suckling/tiredness of infants Look for sore nipple/engorgement Ask mother How many times in 24 hours feeds Any problems experienced by her

18. Assessment of feeding adequacy of alternating methods Ask Volume/freq in 24 hrs/spills/splutters of milk Or Baby take too long time to feed Observe Spluttering/spitting the milk Or Tiring of infants to take required amount

19. Sign of inadequate feeding Breast feeding <8 times in 24 hrs Poor attachment/ineffective suckling Baby tired/take him off before completion of feeds Mother having engorged /sore nipple By alternative methods Feed vol less than indicated Less freq/excessive spilling Take long time top finish

20. Wt loss not more than 10% of birth wt Start wt gaining after 2 wks Average daily wt gain of LBW in initial 3 -4 mnths Identification of poor wt gain Birth wt -<1500gms: 13.5 to 16 gm/kg/d If > 1500gms – 10- 13 gm /kg/d

21. Weeks of life 2000-2500gms 1500-2000gms 1000-1500gms Wks 3-4 100 100 - Wks 5-6 100 100 100 Wks 7-11 200 150 100-150 Wks 12-13 250 200 150 Expected wt gain of LBW INFANTS till 3 months of age Per week

22. Causes of inadequate weight gain

23. Management of inadequate weight gain Proper counselling of mothers and ensuring adequate support for breastfeeding their infants Assessment of positioning/attachment, managing sore/flat nipple Explaining the frequency and timing of breastfeeding and spoon/ paladai feeds Infrequent feeding is one of the commonest Mothers should be properly counselled regarding the frequency and the importance of night feed A time-table where mother can fill the timing and amount of feeding Giving EBM by spoon/ paladai feeds after breastfeeding also helps in preterm infants who tire out easily while sucking from the breast.

24. Proper demonstration of the correct method of expression of milk and paladai feeding: observe how the mother gives paladai feeds; the technique and amount of spillage followed by a practical demonstration of the proper procedure. Initiating fortification of breast milk when indicated Management of the underlying conditions such as anemia , feed intolerance,etc . If these measures are not successful- Energy (calorie) content of milk by adding MCT oil, corn starch Infants on formula feeds given concentrated feeds (by reconstituting 1 scoop in 25 mL of water) OR b. Feed volume – to 200 mL /kg/day.

25. Symptoms: 1. Vomiting (altered milk/bile or blood-stained)* 2. Systemic features: lethargy, apnoea Signs: 1. Abdominal distension (with or without visible bowel loops)* 2. Increased gastric residuals: >2mL/kg or any change from previous pattern 3. Abdominal tenderness 4. Reduced or absent bowel sounds 5. Systemic signs: cyanosis, bradycardia, etc. Indicators of feed intolerance

26. FEEDING IN HIV MTCT accounts for most cases of hiv in children… Without any intervention risk during breastfeeding is 5-20 % Major risk factors are -primary infection at time of breastfeeding( viraemia ) -severe disease -poor local health( mastitis, fissures, oral thrush*) -mixed feeding -prolonged feeding

27. Recommendations-WHO 2010 Exclusive breastfeeding for first 6 months of life unless replacement feeding is acceptable, feasible, affordable,sustainable and safe .. When replacement feeding is acceptable, feasible,affordable , sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended. All HIV-exposed infants should receive regular follow-up c are and periodic re-assessment of infant feeding choices, At 6 months, if adequate feeding from other sources cannot be ensured, continue to breastfeed their infants and give complementary foods in addition, . All breastfeeding should stop once an adequate diet without breast milk can be provided .

28. Replacement feeds Process of feeding a child who is not breastfeeding with a diet that provides all the nutrients the child needs, until the child is fully fed on family food. Could be formula based or heat treated breast milk.

29. Chronological age -from date of birth Post –conception/post menstrual age- gestation at birth in wks + chronological age Corrected age – chronological age in wks-no of wks the infant born early(40 wks) Growth monitoring for infants up to 40 wks done by UK CHARTS. After that by WHO CHARTS growth monitoring

30. Steps of Paladai Feeding Place the infant in up-right posture on mother’s laP Keep a cotton napkin around the neck to mop the spillage Take the required amount of expressed breast milk by using a clean syringe Fill the paladai with milk little short of the brim Hold the paladai from the sides; DO NOT put your finger Place it at the lips of the baby in the corner of the mouth Tip the paladai to pour a small amount of milk into the infant’s mouth

31. Feed the infant slowly; he/she will actively swallow the milk If the infant does not actively accept and swallow, try to arouse him/her with gentle stimulation While estimating the milk intake, deduct the amount of milk left in the cup and the amount of estimated spillage Wash the paladai with soap and water and then put in boiling water for 20 minutes to sterilize before next feed Steps of Paladai Feeding

32. Steps of Intra-gastric Tube Feeding 1. Before starting a feed, check the position of the tube 2. Remove the plunger the syringe (ideally a sterile syringe should be used) 3. Connect the barrel of the syringe to the end of the gastric tube 4. Pinch the tube and fill the barrel of the syringe with the required volume of milk 5. Hold the tube with one hand, release the pinch and elevate the syringe barrel 6. Let the milk run from the syringe through the gastric tube by gravity; DO NOT force milk through the gastric tube by using the plunger of the syringe 7. Control the flow by altering the height of the syringe. Lowering the syringe slows the milk flow, raising the syringe makes the milk flow faster

33. 8. It should take about 10-15 minutes for the milk to flow into the infant’s stomach 9. Observe the infant during the entire gastric tube feed. Do not leave the infant unattended. Stop the tube feed if the infant shows any of the following signs: breathing difficulty, change in colour/ looks blue, becomes floppy, and vomiting 10. Cap the end of the gastric tube between feeds; if the infant is on CPAP, the tube is preferably left open after about half an Hour 11. Avoid flushing the tube with water or saline after giving feeds. Steps of Intra-gastric Tube Feeding......