Nutrition in the NICU ANDI MARKELL RD, LD

Transcription

1 Nutrition in the NICU ANDI MARKELL RD, LD PORTLAND, OREGON ANDI MARKELL NUTRITION CONSULTANT

2 Conflict of Interest I had no conflict of interest until 2015 when I was asked to join the Nutrition Advisory Committee with Prolacta Bioscience. As of 2018, I am employed at Prolacta Bioscience as the Sales Training Manager. I received no support from Prolacta, financial or otherwise, at the time of my study. ANDI MARKELL NUTRITION CONSULTANT

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5 Protocol Data Data Protocol ANDI MARKELL NUTRITION CONSULTANT

6 Nutritional Needs of Sick Infants > 37 weeks May not be too different than term baby Most issues around wound healing Supported on TPN Difficulty eating Wound healing

7 Nutritional Needs of Late Premature Infants weeks May not be too different than term baby Most issues around feeding are physical / endurance Unsynchronized suck/swallow/breathe Decrease stamina Inadequate intake

8 Nutritional Needs of Premature Infants weeks Much different than term baby Most issues around increased nutritional needs Third trimester Fetus / Placenta

9 Nutritional Needs of Premature Infants Incomplete Stores Rapid Development Sub-optimal Digestion and Absorption Related Diseases of Prematurity Early Discharge

10 Nutritional needs as gestational age Goal: Postnatal growth that approximates the in-utero growth of a normal fetus American Academy of Pediatrics

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14 z-scores (standard deviation score) Anthropometric value as a number of standard deviations (z-scores) below or above the reference mean z-score = Observed value-man value of reference population / standard deviation value of reference population Example of z-scores: 0 represents the score as identical to the mean + or scores represents the number of standard deviations the score is above or below the mean ANDI MARKELL NUTRITION CONSULTANT

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16 Neonatal Malnutrition (Goldberg DL et al, J Acad Nutr Diet, 2018)

17 Accretion Rates for the Reference Fetus (ZIEGLER ET AL. GROWTH 1978;40: )

18 Protein Accretion 2.5 Protein Ziegler, Protein 0.5 g/kg/day

19 Calculating Protein Requirements (Factorial Method, weeks) Accretion g/kg/day Dermal Loss g/kg/day Urinary Loss g/kg/day Required IV Intake g/kg/day Required PO Intake g/kg/day 90% GI absorption Breast Milk Intake g/kg/day 1 g 160 ml/kg/d

20 Calcium and Phosphorus Accretion Mineral Retention Ziegler, Calcium Phosphorus 40 mg/kg/day

21 Calculating Calcium Requirements (Factorial Method, weeks) Accretion mg/kg/day Dermal Loss mg/kg/day Urinary Loss mg/kg/day Required IV Intake mg/kg/day Required PO Intake mg/kg/day 65% GI absorption Breast Milk Intake mg/kg/day 28 mg Ca/dL at 160 ml/kg/d

22 Calculating Phosphorus Requirements (Factorial Method, weeks) Accretion mg/kg/day Dermal Loss mg/kg/day Urinary Loss mg/kg/day Required IV Intake mg/kg/day Required PO Intake mg/kg/day 85% GI absorption Breast Milk Intake mg/kg/day 15 mg Phos/dL at 160 ml/kg/d

23 Feeding the very low birth weight preterm infant is not a natural physiological process. Alan Lucas

24 Nutritional Needs Nutrient Preterm Term Max Difference Calories Kcal/kg Protein g/kg Calcium Mg/kg Phosphorus Mg/kg % % % %

25 Fortification In the NICU Birth Weight Nutrition Management < 1250 g MOM/BBM + Prolact+ 6 + > 145 ml/kg/d MOM/BBM + Prolact+ 8 + < 145 ml/kg/d 1251g 1500 g MOM/BBM + HMF 160 ml/kg/d 1501 g 2000 g MOM + HMF 22 Transitional formula > 2000 g MOM Term formula

26 Comparing Fortification Fortification MM+HMF 24 MM+Enfamil 24 MM 160 ml/kg 160 ml/kg 160 ml/kg % more calories with HMF 24, 20 % MM+E % more protein with HMF % MM+E % more calcium with HMF % MM+E 24

27 Growth Goals Groh-Wargo, Sharon, Melody Thompson, and Janice Hovasi Cox. ADA pocket guide to neonatal nutrition. American Dietetic Associati, Weight g/kg/d Length > 0.9 cm/wk OFC > 0.9 cm/wk Nutrient Goals Agostoni, Carlo, et al. "Enteral nutrient supply for preterm infants: commentary from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition." Journal of pediatric gastroenterology and nutrition 50.1 (2010): Calories kcal/kg Protein <1000g: g/kg > 1000g: g/kg ANDI MARKELL NUTRITION CONSULTANT

28 4/20/2018 RANDALL CHILDREN'S HOSPITAL 28

29 Contrary to popular opinion, in the NICU, one does not have to be Pro-breastfeeding to support a woman s lactation efforts any more than one is Pro-respirator or pro-blood transfusion. Paula Meier 4/20/2018 RANDALL CHILDREN'S HOSPITAL 29

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31 EHMD MOM/DM Exclusive Human Milk Diet Human Milk Based HMF Human Milk Based Modulars ANDI MARKELL NUTRITION CONSULTANT

32 Mixing Room Centralized location to mix all feeds ASEPTIC technique Goal: Reduce incidence of bacterial contamination Accuracy in technique Goal: Decrease in variability in calculations and method

33 Feeding Protocol 2010 Initiate Advance Fortify Goal ~10 ml/kg/d ml/kg/d 100 ml/kg/d MOM/DM + Prolact ml/kg/d MOM/DM + Prolact+4 ANDI MARKELL NUTRITION CONSULTANT

34 Data Collection Birth anthros Discharge anthros Wt. at DOL 29 DOL amino acids started DOL Lipids started DOL 90 kcal/kg ordered TPN DOL 3.5 g/kg ordered TPN Total days on TPN DOL first feed Milk used Protocol used DOL fortification started Fortification type / volume DOL 120 kcal/kg received feeds DOL 4 g/kg received feeds Received EBM / DHM / Prolacta / formula < 33 weeks / electrolytes NEC ANDI MARKELL NUTRITION CONSULTANT

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36 Study Criteria Groups PTF: infants who received PTF only or EBM plus bovine fortifier supplemented with PTF HMBF: those who received EBM or DHM with bovine fortifier EHM: those who received EBM or DHM with human milk based fortifier ANDI MARKELL CONSULTANT

37 Feeding Protocol Initiate ~10 ml/kg/d ~10 ml/kg/d Advance ml/kg/d ml/kg/d Fortify 100 ml/kg/d ml/kg/d ml/kg/d +6 EHMD High Risk NEC < 1500g 3-4 weeks and PRN <1250g 3-4 weeks and PRN Goal 160 ml/kg/d ml/kg/d +6 < 145 ml/kg/d +8 ANDI MARKELL NUTRITION CONSULTANT

38 Growth and Clinical Data for Exclusive Human Milk Groups EHM 1 EHM 2 p-value N PMA (weeks) NS Birth Weight (g) NS Weight Gain (g/kg/day) NS PMA at Discharge for Wt Length Gain (cm/week) a PMA at Discharge for Length and HC Head Circumference Gain (cm/week) b Days PN log(days PN) c DOL log(dol 24) d < NEC Stage 1 0/32 (0%) 3/94 (3.2%) NS NEC Stages 2 and 3 1/32 (3.1%) 2/94 (2.1%) NS NEC All Stages 1/32 (3.1%) 5/94 (5.3%) NS ANDI MARKELL NUTRITION CONSULTANT

39 Final Model for the Analysis of Covariance for Weight Gain Coefficient 95% CI p (Intercept) to < GROUP EHM to GROUP PTF to PMA to < Birth Weight to < PDA to NEC All Stages to < DOL to

40 Final Model for the Analysis of Covariance for Head Circumference Gain Coefficient 95% CI p (Intercept) to < GROUP PTF to PDA to < ERA to

41 Primary Outcome Growth Parameter Weight Gain (g/kg/day) Length Gain (cm/wk) PTF ( ml, no protocol) HMBF 2 (80-100ml) EHM 2 (40-50 ml) HC Gain (cm/wk)

42 Secondary Outcome NEC Group (N) NEC stage 1 NEC stage 2 and 3 NEC all stages PTF (54) 3 (5.6%) 6 (11.1%) 9 (16.7%) HBMF (111) 4 (3.6)%) 6 (5.4%) 10 (9%) EHM (94) 3 (3.2%) 2* (2.1%) 5 (5.3%) * EHM: 2 infants with NEC stage 2 or 3 were off EHM receiving bovine fortifier ANDI MARKELL NUTRITION CONSULTANT

43 Feeding Protocol Initiate ~10 ml/kg/d ~10 ml/kg/d ~10 ml/kg/d ~10 ml/kg/d Advance ml/kg/d ml/kg/d m/kg/d m/kg/d Fortify 100 ml/kg/d ml/kg/d ml/kg/d +6 EHMD High Risk NEC < 1500g 3-4 weeks and PRN <1250g 3-4 weeks and PRN Goal 160 ml/kg/d ml/kg/d +6 < 145 ml/kg/d ml/kg/d ml/kg/d +6 <1250g 3-4 weeks and PRN 160 ml/kg/d +6 < 145 ml/kg/d ml/kg/d ml/kg/d ml/kg/d +CR <1250g 3-4 weeks and PRN Till 34 weeks HR NEC 160 ml/kg/d +6+CR < 145 ml/kg/d +8+CR ANDI MARKELL NUTRITION CONSULTANT

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45 Protocol Data Data Protocol ANDI MARKELL NUTRITION CONSULTANT

46 Questions