Hospital re-admission Brain development Chronic diseases Behavioural and psychomoto Respiratory function GOALS OF NUTRITION

Transcription

1 ENTERAL NUTRIO ON IN PRETERM NEONA ATES

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3 ONG OUTCOME IN PR RETERM Hospital re-admission Brain development Chronic diseases Behavioural and psychomoto or problems Respiratory function GOALS OF NUTRITION

4 Introd dution Proper nutrition is essential for Normal growth Immunity to infection Optimal neurologic and cogn nitive development Providing adequate nutrition n to preterm infants is challenging because of seve eral problems Immaturity of bowel function n Inability to suck and swallow w High risk of necrotizing enter rocolitis (NEC) Illnesses that may interfere with adequate enteral feeding e.g. RDS, PDA..)

5 Main qu uestions When to initiate enteral feeding Progessi ion from minimal enteral feeding to nutritive feedings Bolus ver rsus continuous feeding Choice of enteral formulation

6 When to initiate enteral feeding Progession from minimal enteral feeding to nutritive feedings

7 rophic feeding defined as dilute or full strength feedings providing <= 25ml/kg/d for >= 5d (5 days) ropic feeding vs. no feeding (9 trials, N = 754) ): NO SIGNIFICIANT DIFFERENCE Days to full enteral feedings The incidence of NEC Mortality Days of regain birth weight Invasive infection Days of phototherapy Hospital stay Tropic feeding vs. advancing feeding ( one trial): in nfants given tropic feedings reqired more days of full enteral feeding and longer hospital stay. Tropic fee eding were associated with a significiant reduction in NEC.

8 he effect of delayed (more than 4 days after birth) versus earlier troduction progressive enteral feeds (N = 1106): NO IGNIFICIANT DIFFERENCE The incidence of NEC Mortality No intolerance The incidence of infection

9 arly (1-2 days) versus delaye ed (5-6 days) enteral feeding = 404, 54 United Kingdom and Ireland hospitals) Shorter duration of parental nu utrition and high-dependency care Lower incidence of cholestatic c jaudice Improved SD score for weight at discharge Alison Leaf et al

10 trials, N = 949, slow (15-24 ml/kg/day) versus rapid rate 0 ml/kg/day) advancement of feedings: Incidence of NEC Mortality Feeds intolerance ( causing in nterruption of enteral feeding) Incidence of invasive infection n

11 NEC NO SIGNIFICIAN DIFFERENCE

12 MORTALITY Faster rates of fe advancement: decrease mortality ELBW

13 NO INTOLERANCE NO SIGNIFICIANT DIFFERENCE

14 INVASIVE DECREASE INFECTION

15 Bolus or continuous tube feeding

16 ontinuous nasogastric milk feeding versus termittent bolus milk for premature infant less an 1500gram, 2008 Coch hrane collaboration 7 trials, N= 511, found no diffe erences in time to achieve full enteral. No significiant difference in so omatic growth and incidence of NEC uthors' conclusions: mall sample sizes, methodologi ic limitations, inconsistencies in ontrolling variables that may affe ect outcomes, and conflicting sults of the studies to date mak ke it difficult to make universal commendations regarding the best tube feeding method for remature infants less than grams. The clinical benefits and sks of continuous versus interm mittent nasogastric tubemilk eding cannot be reliably discern ned from the limited information vailable from randomised trials to date.

17 ompare probiotics versus place ebo: 24 trials Reduced the incidence of sever re NEC(stage II - III): RR 0,43 (95% CI , 20 trials, N = ) Reduced mortality: RR 0.65 (95 5% CI , 17 trials, N = 5112) Nosocomial sepsis : no differen nce RR 0.91 (95% CI , 19 trials, N = 5338) Lactobacillus alone or in combin nation with Bifidobacterium:

18 NTERAL FEEDING ptodate (2016) he final goal: 160 ml/kg/days( PN 00ml/kg/day) 1000g: Day 1-3: 15 ml/kg/day Day 4: increase 15 ml/kg/day g: Day 1-2: 20 ml/kg/day Day 3: increase 20 ml/kg/day g: Day 1: 25 ml/kg/day Increase 25 ml/kg/day stop when enteral feeds

19 NTERAL FEEDING ohn Hunter Children s Hospital (2013) BW Initial feeding (ml/kg g/day) Increasing (ml/kg per 12 hours) < 1000 g g g g 30 15

20 ime to full feeding ( ml/kg/day) < 1kg: 2 weeks 1kg: 1 week itial and increasing feeding < 1kg: ml/kg and incre ease ml/kg/day 1kg: 30 ml/kg and increase he frequency of feeding: < 1250g: every 2 hours 1250g: every 3 hours 30 ml/kg/day

21 SSESSMENT OF FEE ED TOLERANCE Nause, vomiting Abdomen : distension, pain, visible bowel loops Gastric residuals: GRV, gree en, yellow, brown Stool: diarrhea, bloody Symptoms : apnea, bradycar rdia, temperature instability

22 ormula milk versus maternal breast milk for eeding preterm or low birth weight infants 008 Cochrane Collabo oration There are no data from rand domised trials of formula milk versus maternal breast milk for feeding preterm or low birth weight infants. Maternal breast milk remain ns choice of enteral nutrition because observational studie es, and meta-analyses of trials comparing feeding with form mula milk versus donor breast milk, suggest that feeding wi ith breast milk has major non- nutrient advantages for prete erm or low birth weight infants.

23 onor breast milk vers sus infant formula for reterm infants: system matic review and meta- nalysis. Cochrane col llaboration trials, N 471 Lower risk of NEC in infants receiving donor breast milk (RR 0.1, 95% CI ) Donor breast milk: slower gr rowth in the early postnatal period, but its long-term effe ect is unclear

24 ulti-nutrition fortificat tion of breast milk for reterm infants, Cochra ane trials, N 1071 Increase growth rates preter rm infants during their initial hospital admission ( low- qua ality evidence)

25 reastfeeding uman milk: Reduce rates of sepsis, NEC Fewer hospital readmissions Vitamins or minerals: vit A, vit D, Vit K, iron, zinc, calcium and phosphorus HMF product

26 ONCLUSION Early initiation of enteral nutr rtion Advancement of feeds depen nd on gestational age and birth weight Use of approriate enteral pro oducts Monitoring of growth and nut trition

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