Importance of nutrition in preterm babies

Importance Of Nutrition For Optimal Short And Long Term Outcome In Preterm Infants
In this webinar we shall learn about : Recommended Nutritional Goal For Preterm Babies What is extra uterine growth restriction and its long term adverse effects Issues In VLBW Feeding including choice of Milk, How early to start feeds How much to start with, how to scale up feeds for ELBW & sick babies , how to administer the feeds. How to maintain mother’s milk output Nutritional concerns of VLBW babies and their management.
In this webinar we shall learn about : Recommended Nutritional Goal For Preterm Babies What is extra uterine growth restriction and its long term adverse effects Issues In VLBW Feeding including choice of Milk, How early to start feeds How much to start with, how to scale up feeds for ELBW & sick babies , how to administer the feeds. How to maintain mother’s milk output Nutritional concerns of VLBW babies and their management.
Premature infants have greater nutritional needs to achieve optimal growth in the neonatal period than at any other time in life. The AAP recommends that extra uterine growth of a preterm baby should parallel the intrauterine growth trajectory of a fetus of comparable GA without stressing the developing metabolic or excretory system.
However there are certain inherent limitations of the VLBW baby precluding optimal nutritional intake and optimal growth. These include: Limited nutrient stores, High metabolic needs Catabolic effects of illness due to associated problems like RDS, sepsis apnea Immature metabolic pathways & osmolar limitations Immature GI tract, Incoordination of suck swallow breathe cycle. Requirement for increased nutrient intake for rapid growth.
Hence the preterm baby is very likely to develop cumulative deficits in protein & energy resulting in slower growth. Large proportion of ELBW & VLBW babies develop Extra Uterine Growth Restriction EUGR defined as weight < 10th centile at 36 weeks PMA or at discharge.
Problems Associated Extra Uterine Growth Restriction Extra Uterine Growth Restriction is associated with several problems including Long term adverse neuro-developmental sequelae Increased risk of ROP Poor bone health Lower final weight & height at 20 years of age. Increased Post Natal Growth: Adult metabolic syndrome. Lets us understand the risks involved in a little more detail.
EUGR & ROP Coming to the association of EUGR & ROP: An Increased risk of type 1 ( Severe type) of ROP in extremely low gestational age newborns was observed when intake of total calories, lipids, and carbohydrates as well as the growth velocity in the first month were in the lowest quartile . Improving the early nutrition in ELGAN babies may help prevent development of sight-threatening ROP.
EUGR & Lower Final Weight & Height. Prematurity & LBW also increase the risk of underweight, stunting and wasting . One study showed that at 6 months of age, 28% of the study cohort of VLBW babies showed underweight and stunting and 22% had wasting. In a study by Hack, VLBW infants were twice as likely to have final height less than the third percentile at 20 years of age, than normal birth weight controls (10 versus 5 %).
Though rapid catch up growth is associated with better neuro developmental outcomes, studies have shown that babies with low weight in neonatal period, showing rapid catch up growth in infancy, show a high incidence of coronary heart disease, Type II diabetes mellitus, Hypercholesterolemia,Hypertension & stroke in adulthood also known as the metabolic symdrome.
Common Issues that need to be addressed In VLBW feeding include: Which Milk? How early to start feeds ? How much to start with ? How to maintain mother’s milk output. Adequacy of pre-term mother’s milk to sustain adequate growth.
Choice Of milk for preterm babies is definitely mothers own milk (MOM). Mothers own milk (MOM) is best suited to specific nutritional needs of the preterm baby , especially for initial few weeks as it has higher protein, sodium, chloride & magnesium levels, adequate taurine and cysteine for growth & neuronal & retinal maturation, enzymes, including lipases that enhance lipolysis and fat absorption, LCPUFA for cerebral and retinal functions & oligosaccharides for neuronal development, somatic growth, and development of intestinal immunity
Preterm milk also has numerous antimicrobial factors, nucleotides, growth factors and hormones resulting in lower incidence of sepsis, feed intolerance, necrotizing enterocolitis, bronchopulmonary dysplasia, retinopathy of prematurity, lower mortality rates, fewer hospital readmissions for illness in infancy, Lower neurodevelopmental disabilities & better MDI, PDI Human milk fed VLBW babies also show better intellectual performance scores at 7.5 to 8.0 compared to preterm formula fed babies .
  • Introduction...
  • 1. Importance of n...
  • 2. Learning object...
  • 3. Recommended nut...
  • 4. Inherent limita...
  • 5. The result.......
  • 6. Problems associ...
  • 7. Increased risk ...
  • 8. Increased risk ...
  • 9. Osteopenia of P...
  • 10. Neuro-developm...
  • 11. EUGR & lower f...
  • 12. Long term adve...
  • 13. In conclusion...
 

Introduction

DR. JAYASHREE MONDKAR
MD, DM (Neonatology)

Professor & Head
Department of Neonatology
LTMMC and Sion Hospital
Mumbai

1. Importance of nutrition in preterm babies

â–º Preterm infants are at risk for poor growth while in
    NICU and after discharge from the NICU



â–º Hence special attention should be provided to feeding
    of preterm babies soon after birth

2. Learning objectives

â–º Recommended nutritional goal for preterm babies



â–º “ Extra Uterine Growth Restriction (EUGR) ”



â–º Short and long term adverse effects of EUGR

3. Recommended nutritional goal for preterm babies

â–º Premature infants have greater nutritional needs to achieve
    optimal growth in the neonatal period than at any other time
    in life

â–º Extra uterine growth of a preterm baby should parallel the
    intrauterine growth trajectory of a fetus of comparable
    gestational age




* American Academy of Pediatrics Committee on Nutrition Pediatrics 1985; 75(5): 976 -986

4. Inherent limitations of the preterm baby

â–º Immaturity
      ♦ Limited nutrient stores
      ♦ Immature metabolic pathways & osmolar limitations
      ♦ Immature GI tract,
      ♦ Incoordination of suck swallow breathe cycle

â–º Catabolic effects of illness
      ♦ Due to associated problems like RDS, sepsis, apnea

â–º High metabolic needs
      ♦ Requirement for increased nutrient intake for growth

5. The result....

â–º Cumulative deficits in protein & energy resulting in slower
    growth

â–º Large proportion of VLBW babies have postnatal growth failure
    also called extrauterine growth restriction (EUGR)

â–º EUGR can be defined as weight <10th centile at 36 weeks
    PMA or at discharge

6. Problems associated extra uterine growth restriction

â–º Short term
   ♦ Increased risk of retinopathy of prematurity
   ♦ Chronic lung disease
   ♦ Poor bone health (osteopenia of prematurity)

â–º Long term
   ♦ Blindness due to ROP
   ♦ Adverse neuro-developmental sequelae
   ♦ Lower final weight & height at 20 years of age
   ♦ Adult metabolic syndrome

7. Increased risk of retinopathy of prematurity (ROP)

â–º Increased risk of type 1 ROP (Severe Type) In extremely low
    gestational age newborns if

      ♦ Intake of total calories, lipids, and carbohydrates in the
        first month was in the lowest quartile and gowth velocity
        was in the lowest quartile

      ♦ Improving the early nutrition in very preterm babies may
        help prevent development of sight-threatening ROP and
        blindness



* Vander Veen DK et al. PLoS One. 2013; 8(5): e64325

8. Increased risk of chronic lung disease

â–º Chronic lung disease is a common morbidity in smaller preterm
    babies, related to ventilation, oxygen toxicity and infection

â–º Babies with poor nutritional status, especially those with intra
    uterine growth restriction are at greater risk for chronic
    lung disease

â–º Chronic lung disease further increases the risk of poor
    nutritional status and post natal growth



* Ehrenkranz RA. Pediatr Res 2011

9. Osteopenia of Prematurity

â–º Suboptimal supplementation of milk with phosphorus, calcium
    and vitamin D results in osteopenia of prematurity also called
    metabolic bone disease

â–º This can result in
      ♦ Increased risk of fractures of long bones and ribs
      ♦ Poor linear growth and
      ♦ Failure to wean from the ventilator

10. Neuro-developmental sequelae

â–º Preterm brain is very vulnerable to undernutrition which
    may permanently affect later cognitive attainment

â–º Lower weight gain is associated withpoor mental development
    index, poor psychomotor development index, higher risk
    of neurodevelopmental impairment and cerebral palsy

11. EUGR & lower final weight and height

â–º Long term
      ♦ VLBW infants are twice as likely to have a height less
         than the third percentile at 20 years of age

* Flannery DJ, Schluchter M, et al. Outcomes in young
adulthood for very-low-birth-weight infants.
N Engl J Med 2002; 346:149

12. Long term adverse effects of EUGR

â–º As adults, EUGR babies are at increased risk for
      ♦ Coronary heart disease
      ♦ Type II diabetes mellitus
      ♦ Hypercholesterolemia
      ♦ Hypertension
      ♦ Stroke

*(Barker Br J Obstet Gynaecol 1992; 99: 275-276)

13. In conclusion

â–º Early enteral nutrition is important for optimal growth of
    preterm babies

â–º Poor nutrition is associated with EUGR

â–º EUGR causes increased risk of ROP, BPD, Osteopenia

â–º EUGR also increases the risk of poor ND outcomes