11/4/10 SUPPORTING PREMATURE INFANT NUTRITION WORKSHOP SAM: PREVENT MALNUTRITION 200. Workshop: Preventing extrauterine growth failure

Transcription

1 Jae H Kim MD PhD Lisa Stellwagen MD Division of Neonatology UC San Diego, Medical Center SUPPORTING PREMATURE INFANT NUTRITION WORKSHOP Workshop: Preventing extrauterine growth failure Jae H. Kim, MD, PhD, FAAP Neonatologist and Pediatric Gastroenterologist University of California, San Diego SAM: PREVENT MALNUTRITION 200 The Growth Pattern of a Premie 3.5 Sam was a 550 gm 23 5/7 weeker parent cals/kg total cals/kg Weight Kg 3 Parenteral support for first 5 weeks PDA medical and surgical treatment Cal/Kg/Day Weight (kg) Jejunal obstruction, surgery with ostomy Enteral feeding advancement Reanastomosis surgery DOL Better care through standard care Why should we standardize? reduce variability generate a steadier average obtain interpretable results What should we standardize? nutrient delivery energy targets nutrient targets growth goals Strategies Standardized early parenteral nutrition Standardized feeding protocol with programmed Early and exclusive human milk exposure Human milk analysis research Standardized response to growth 1

2 Nutritional Survey 775 surveyed, with 176 (23% response rate) most started PN day 1 with protein 2g/k/day 91% increased protein daily more than half use stock solutions intravenous lipids started day 1 80% used bolus enteral feeding MCT was the most common additive for supplementation but single additive use decreasing Carnitine added to PN 65% of time Standardized stock solutions provide the earliest delivery of parenteral protein Immediately 2.5% amino acid solution in glucose D5W or D10W Delivers 2 gm/kg/day of AA with TFI of 80 ml/kg/ day As soon as possible TPN with 3 gm/kg/day of AA Other elements that could help are calcium Avoid early electrolytes Hans et al (2009) Pediatrics 123(1): AGGRESSIVE ENTERIC FEEDS Priming feeds started with human milk Standardized feeding protocols Feeding intolerance defined Mimimize stops and starts Early/standardized Process driven by RN IMPLEMENTING FEEDING GUIDELINES FOR NICU PATIENTS <2000 G RESULTS IN LESS VARIABILITY IN NUTRITION OUTCOMES Infants BW < 2000 gms in Utah 58 infants in early 2005 (standard feeding progression) 68 infants in early 2006 (protocol driven feeding progression) Feedings were started on average dol 1 91% received some MBM in % received some MBM in 2006 Standardized feeding guideline led to: Less TPN days Fewer NPO days Less variability in day of first feeding Quicker advancement to 80 mls/kg/day feeds Decreased staff time in order writing process No increase in NEC, SIP, mortality or LOS Street JL et al. JPEN 2006:30: KEEPING GROWTH FRONT AND CENTER STANDARDIZED MEASUREMENT Review weight and measuring technique Adopt up to date growth chart Chart is reviewed by medical team Weekly SPIN rounds to discuss nutritiongrowth-milk production-oral feeding progression Ongoing feeding volume calculated daily by RN Dietician drives growth/nutritional assessment Lactation monitors/supports mother OT and LC guide and assist in oral feeding progression How to best measure and weigh the premature infant? 2

3 11/4/10 Growth Chart Comparisons Lubchenco Usher and McLean Benda and Babson Kramer n , 145M, 155F, single center n=300 (25-44w) n=4000 (T-1y) n=150 (1-10y) singletons, 347,570M 329,035F Gestation weeks: W weeks: HC, L weeks 25w-10y weeks Period Ethnicity medical indigent, 30% Hispanic, Colorado infants, Caucasian, Canadian (Montreal) Caucasian Canadian (minus Ontario), racial mix not known LMP, gestation age +/3 days Dates US, completed weeks Latest data 42 weeks 44 weeks Type of data Foot length, body circumferences, skin thickness also recorded not separated for sex Combined Usher and McLean and Child Health Developmental Studies (Oakland), and Child Research Council Comments included twins, racial exclusion of Black, Asian, Indian not separated for sex 10 years 43 weeks weights only, excluded Ontario Fenton Growth curve: VARIABILITY OF HUMAN MILK COMPOSITION Mother s milk is not all 20 cals/ oz (average=19.5 kcals/oz) Fat drives calories Lactose and protein are inversely correlated Near infrared milk analyzer Assessment of: protein, fat, lactose, and calories Small volume of milk Milk content varies greatly, from cals/ounce Potential for individual Growth Failure in Preterm Infants Cumulative losses by hospital discharge reduced body stores of nutrients increased zinc, iron, copper needs reduced bone density increased Ca, P needs an accumulated energy deficit Variability of human milk calories 51.2% fell either below 18 kcal/oz or above 22 kcal/oz 31% of the samples below 18 kcal/oz 14% were below 16 kcal/oz Standardize response to growth failure Reactive Poor growth x 4-7 days increase nutrients 3-4 such increments would represent days of poor growth on top of the deficit already incurred Preemptive Attempt to approximate caloric and nutrient needs and prescribe before wt loss occurs 3

4 Loss of nutrients with transfer of milk Syringe pumps and feeding tubing are the most important source of nutrient loss Minimize transfer from containers Continuous syringe pumps with inverted delivery Give maximum fluid volume tolerated Factors in nutrient loss in human milk oxidation refrigeration freezing heating photo-degradation adherence to the tubing system Tacken et al (2009) Arch Dis Child Fetal Neonatal Ed 94(6): F Human milk protein declines with time Is 20 kcal/oz the real target? 227 term milk samples from mothers aged 27.8±4.7 years Measurement by bomb calorimetry Calculation (prot:fat:carb = 4.22:9.16:3.87 kcal/g) Measured energy was significantly lower than that of the calculated energy (58.1±8.1 vs. 64.5±10.6 kcal/100 g,p< 0.05). Saarela et al (2005) Acta Paediatrica 94:1176 Hosoi et al (2005) Pediatr Int 47(1): 7-9. Nonprotein nitrogen accounts for about 20% of the total nitrogen Assumption on protein Infant formula Human milk Nutritional Protein Non-protein Nitrogen Bioactive Proteins Nutritional Protein Atkinson et al (1980) Am J Clin Nutr 33(4):

5 Human milk alone is insufficient to meet the growth of the preterm infant Growth of Human Milk-Fed Infants after Discharge Greater percent growth restricted at hospital discharge compared to at birth Growth lags behind that of formula-fed LBW infants Bone Mineralization Infants fed exclusively HM after discharge show signs of mineral deficiency compared to formulafed infants decrease in bone mineral content of radius lower serum phosphorus higher alkaline phosphatase Abrams et al (1988) J Pediatr 112: Abrams et al (1989) J Pediatr 114: Chan (1994) Am J Clin Nutr 60: Hall et al (1993) J Perinatol 13: Wauben et al (1998) Acta Paediatr 87: