Dr Shipa Shah, Lorraine Bell Dietician

Transcription

1 CLINICAL GUIDELINES ID TAG Title: Author: Speciality / Division: Directorate: Enteral feeding and use of fortification and supplements in the preterm infant Dr Shipa Shah, Lorraine Bell Dietician Neonatalogy CYP Date Uploaded: 7 th January 2015 Review Date 16 th June 2017 Clinical Guideline ID: CG0092

2 1.0 INTRODUCTION: 1.1 Purpose of the Guideline To ensure appropriate nutritional management of preterm infants and guidance on use of nutritional products, introduction of iron supplementation and the use of vitamins 2.0 GENERAL INFORMATION AND CLASSIFICATIONS: 2.1 Classification Infants born less than 37 weeks are termed premature. World Health Organisation (WHO) classification of birth weight:- Low birth weight (LBW) <2500g Very low birth weight (VLBW) <1500g Extremely low birth weight (ELBW) <1000g 2.2 Expected weight gain of Neonates: A neonate s weight gain should be 15-18g per kg per day up to 2 kg bodyweight, changing to 30g per day thereafter until term age. The weight gain balance: Weight gain is important for brain development, however excessive weight gain may give rise to increased risk of type 2 diabetes and heart disease in adulthood. Rapid gain greater than 18g/kg/day is permitted, as long as baby is growing fast enough in length and head size. 2.3 Monitoring Growth Plot weights weekly for growth assessment. Length and head circumference are checked once per week and plotted on appropriate growth chart for the infant (entered into Badgernet). (Tuesday and Friday are weighing days, head circumferences are measured on Wednesday on the neonatal unit). 3.0 NUTRITIONAL REQUIREMENTS: ESPGHAN 2010 provides guidance on enteral requirements for preterm infants. Randomised control trials now indicate that suboptimal energy and other micronutrients may lead to lower cognitive achievements. All requirements are calculated using birth weight until birth weight has been regained 3.1 Energy Requirements kcal/kg/day is required (assumes a weight gain of 16-20g/kg/day). Increasing energy intake beyond 135kcal/kg may not be appropriate for infants whose growth appears inadequate (without evidence of fat malabsorption) because it is more likely that other nutrients are rate limiting i.e. protein. Increasing calories alone can lead to a higher percentage of body fat.

3 3.2 Protein Requirements 4-4.5g protein/kg or g protein per 100kcal is required for an infant <1000g 3.5-4g protein/kg or g protein per 100kcal is required for an infant >1000g Foetal protein accretion rate of 2g/kg/day can be achieved by having 3-4g/kg assuming a minimum energy intake of 110 kcal/kg. Protein intake can be reduced towards discharge if the infant s growth pattern allows for this. Note: if serum urea falls <2mmol/L additional protein may be considered (low levels may be secondary to immaturity of the urea synthetic pathway in those aged less than 31 weeks and this can continue up to day 21. If a steady decline is seen then supplementation should be considered). 3.3 Fluid Requirements Range from 135 to 200 ml per kg per day Lower fluid volumes i.e. 135mls/kg are likely to minimise risk of long-term morbiditiy such as patent ductus arteriosis, bronchopulmonary dysplasia. 3.4 Micronutrients and Electrolytes: These should be referred to when assessing the options of nutritional products and also to assess the need for supplementation. - ESPGHAN TYPE OF FEED OPTIONS: 4.1 Breast Milk and Expression (EBM = Expressed Breast Milk) Breast milk is the feed of choice for preterm infants. The benefits of human milk in preterm infants are well documented (Agostoni et al 2010). IgA benefits (antimicrobial activity through the gut) Epidermal growth factor (gut mucosal repair) Sepsis risk decreases with a minimum of 50mls/kg breast milk during the first 4 weeks of life. All woman should be on vitamin D throughout pregnancy and whilst breastfeeding (maternal and pre-school nutrition guidelines ( PHA 2012) Breast feeding mothers who are vegan should be encouraged to take Vitamin B12 supplement (Agostoni et al 2010)

4 Preterm infants <1500grms and <34 weeks (Table 1) Fortification of breast milk is considered for all neonates weighing <1500g not be started until day 14 and on (150mls/kg) serum urea <4mmols/l and falling Breast milk fortifier (BMF) is used for this purpose. This should be considered as sodium, calcium, phosphorous, vitamin A, vitamin D and water soluble vitamin levels in breast milk are insufficient to match the requirements of the preterm infant. If not fortified then these will need replaced individually but this can raise osmolality, increase risk of error and risk of milk contamination. *Aim to stop fortification at 2kgs or 1.8kgs if discharge pending * Preterm infants >1500grams(Table 2) Aim should be feeding volumes 180mls/kg/day expressed breast milk (EBM) to adequate intake of all nutrients. If it is not possible to feed these volumes then consider use of breast milk fortifiers. In infants >2kgs fortifier is unlikely to be required 4.2 Donor Breast Milk Donor breast milk is an alternative form of milk when the mother s own supply is not available or in short supply and should be considered for all neonates weighing <1500grms- ( Table 3 ) Used in babies recovering from necrotising entercolitis Had consistently Absent or Reversed End Diastolic Flow Intrauterine growth restricted with birthweight <1800grms Verbal consent from parents should be obtained and documented in the notes Serum sodium and weight gain should be monitored at least once a weekly Breast milk fortifier should be introduced once the baby is on a 150mls/kg/day but not earlier than day 14 The most frequently encountered problems with prolonged donor milk use are hyponatraemia and poor weight gain. 4.3 Oral/Enteral Feeding of Neonates Recommended Infant Milk Options in Order of Preference:- EBM (fresh) Refrigerated EBM (keeps up to 48 hours inside main fridge) Frozen EBM (keeps up to 3 months) Donor EBM Preterm formula (Nutriprem 1: until weight = g) (Nutriprem 2: > g until 6 months corrected age if required.

5 4.3.2 Formula Choice for Neonates Nutriprem (1) is the preferred choice of formula for infants <1800grams if breast feeding is not an option, it contains nucleotides and prebiotics, higher in protein (13% protein energy ratio), sodium 70mgs/100mls and Ca:PO4 1.5:1ratio. Nutriprem 1 is the preterm formula that currently best meets ESPGHAN 2010 recommendations. Infants born weighing <1800g and not receiving breast milk should be given Nutriprem 1 and change to Nutriprem 2 at 1.8-2kgs. Infants born weighing g who are breast feeding but require supplementary feeds should receive Nutriprem 1 as top-ups rather than donor milk Alternatively BMF could be used to fortify EBM if supply allows. Nutrient enriched term formulas (SMA High Energy, Nutricia Infatrini, Abbott Similac) have a role when volume is an issue e.g. cardiac anomalies, Chronic Lung Disease (CLD) or fluid restriction. However, these formulas are designed for term infants so consider using supplements such as protifar, maxijul, duocal etc to increase the protein and calories of preterm formula particularly if the infant is <1500g and <34 weeks. Introduce products slowly eg 1% commencement. Calculate the phosphorous, sodium, iron and vitamin D intake from the nutrient enriched term formula as these levels are lower in nutrient enriched term formula compared to preterm formula Supplementation with vitamins and minerals No vitamin supplements are required for preterm infants who are having 150mls/kg/day of preterm formula since these feeds will meet nutrient requirements. Table (see below):vitamin and mineral supplements for preterm babies on unfortified breast milk Vitamin and Requirements Dose/day Preparation comment mineral ESPGHAN Vitamin A 400IU IU/kg 2500IU Dalivit 0.3mls Discontinue Vitamin D IU/day 5mcg/200IU Dalivit 0.3mls Discontinue Thiamine mcg/kg 500mcg Dalivit 0.3mls Discontinue Riboflavin mcgs/kg 200mcg Dalivit 0.3mls Discontinue Niacin mg/kg 2.5mg Dalivit 0.3mls Discontinue Vitamin c 11-46mg/kg 25mg Dalivit 0.3mls Discontinue

6 Vitamin and iron supplements No additional supplements are required while using Nutriprem 1 or 2 at normal volumes ( 150mls/kg/day). Formula containing 1.3mg iron/100ml ensures an iron intake of 2mg/kg when fed 150mls/kg. In breast fed infants, vitamins and iron should be used even if Nutriprem is given as top-ups. Iron should not be given at the same time as calcium and phosphorous as insoluble compounds may be formed thus reducing each minerals bioavailability. They can be stopped if Nutriprem replaces breastfeeding/ebm. *Do not use breast milk fortifier and Dalivit together. Once fortifier stops then recommence dalivit if baby receiving breast milk* Iron has a high osmolality when given undiluted but when given in EBM it may disrupt breast milk anti-infective properties if given in the first four weeks postnatally. This can be avoided by commencing iron between 4-6 weeks post birth thus avoiding giving too early and giving too late >8 weeks post birth. In breast fed infants having EBM with BMF then only iron supplementation is needed. BMF can be stopped if formula makes up >50% of the feeds. If Nutriprem is stopped before 6 months of age and replaced by normal infant formula, iron and vitamins will be required and should be prescribed (1ml Sytron daily and 0.3ml Dalivit daily). Use of vitamins and iron should be regularly reviewed

7 5.0 OSMOLALITY 5.1 Osmolality of Feeds: Hyperosmolar feeds may be associated with necrotising enterocolitis (NEC), therefore consider this factor when selecting feeds. Osmolality of feeds should not be > 450 mosm/kg: (research into this is ongoing). Expressed Breast Milk (EBM) : 279 mosm/kg EBM + Full strength Nutriprem Breast Milk Fortifier (BMF): 450mOsm/kg Nutriprem 1: 375 mosm/kg Nutriprem 2: 310mOsm/kg (liquid), 340 mosm/kg (powder) SMA Gold Prem 1: 272 mosm/kg SMA Gold Prem 2: 312 mosm/kg liquid, 311mOsm/kg (powder) Infatrini = 360 mosm/kg- note for term babies SMA HE = 415 mosm/kg Pregestimil 280 mosm/kg Peptijunior 210m mosm/kg 5.2 Osmolality of Drugs Consider if refluxing/possetting/irritability or poor feed tolerance. Other Factors Affecting Osmolality to be Considered: Medicines added to breast milk or formula will increase osmolality if not given in adequate amount of milk: Drug Dose Breast Milk Required Sodium iron federate 1ml 12ml Folic Acid 500μg 11.5ml Dalivit 0.6ml 6ml Sodium Acid Phosphate 0.5mmol 8ml 1mmol 16ml NaCl 1mmol 7ml 2mmol 10ml Caffeine reduces osmolality Ranitidine isotonic Chloral Hydrate 30mg/kg 9ml

8 Table 1 Exclusive breast milk Baby weight <1500grms Day 28 Start prophylactic Sytron 1ml (5.5mgs) daily, irrespective of PCV (Exclusive breast milk (EBM)) Add Fortification day 14 and on 150mls/kg Stop Fortification 2kgs or 1.8kgs if discharge pending Stop at 6-12 months Dalivit 0.3mls to be commenced once fortifier stopped and to continue for 6-12months NB: If on TPN and lipids are completed commence Dalivit supplementation. Table 2 Baby weight >1500grms-2000grms Exclusive breast milk/ebm Optimise fluids to 180mls/kg/day To fortify only if weight gain inadequate Day 28 Prophylactic iron (Sytron) 1ml (5.5mgs) daily Dalivit 0.3mls daily when on 150mls/kg/day Discontinue 6-12 months Discontinue 6-12 months

9 Table 3 Donor Breast Milk (High Risk groups) <1500grms/IUGR/Risk of NEC No EBM available/or establishing EBM Donor Milk until feeds fully established (150mls/kg of enteral feeds and off TPN) Fortify Donor milk Day 14 Nb: do not commence dalivit until fortifier is stopped Introduce Alternate (EBM/Preterm Formula) Special situations Refer to Consultant Paediatrician Table 4 <1800grms or <34 weeks gestation EBM not available NP1/SMA Gold Prem 1 NP2/SMA Gold Prem2- change at 2kgs (or sooner at 1.8kgs if discharge pending) Continue until 6 months corrected age No vitamins/iron given routinely unless deficiency

10 References 1. ESPGHAN guidance Boyd C.A., Quigley M.A., Brocklehurst P. Donor Breast Milk versus infant formula for preterm infants; systematic review and meta analysis. Arch Disease Child and Fetal Neonatal Ed 2007; 92: F169-F175:doi: /adc NB:Guideline adapted from South Eastern Trust department Nutrition and Diet therapy and Neonataology