Prematurity: Optimizing Growth in the NICU for Later Metabolic Outcomes

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1 Prematurity: Optimizing Growth in the NICU for Later Metabolic Outcomes Malki Miller MS, RD, CNSC Neonatal Dietitian, Maimonides Infants and Children s Hospital Adjunct Lecturer of Human and Pediatric, Brooklyn College/CUNY NYC Education Network January 29, 2016 Disclosures There are no financial relationships to disclose. 1

2 NICU : Goal To achieve postnatal growth velocity that mimics intrauterine growth rates (AAP) Prematurity/Catch-up growth Embleton et al

3 Postnatal Growth Neurocognitive Outcomes Better NICU weight gain in preterm infants Higher MDI/PDI developmental scores at 18M Lower rates of CP Lower rates of neurodevelopmental impairment Higher developmental scores at 5yr SGA Metabolic Outcomes: Barker s Hypothesis LBW Higher rates of obesity Insulin resistance/dm2 HTN High TG/low HDL 3

4 SGA Metabolic Outcomes: Barker s Hypothesis Rapid catch-up growth increased adiposity; linked with adult obesity Prematurity Metabolic Outcomes Prematurity Higher visceral adiposity Decreased insulin sensitivity Higher blood pressure?? related to rapid catch-up growth 4

5 Prematurity/SGA Metabolic Outcomes: Summary SGA early signs of metabolic syndrome SGA/rapid catch-up growth early signs of metabolic syndrome Prematurity early signs of metabolic syndrome,?? related to catch-up growth Prematurity = nutrient-restricted fetus Preterm babies:??high IUGR rates NICU nutrition inadequate? [fetal/nicu environmental stressors] Catch-Up Growth: Neurocognitive Development vs. Metabolic Syndrome?? 5

6 I m a NICU ist. What s the Bottom Line? al Management in NICU NICU : Crash Course al strategies: Then vs. Now Optimizing Kcal vs. Protein; protein-energy ratios Our NICU research 6

7 NICU Crash Course: Timeline Parenteral Transitional Period Enteral BIRTH Start TPN Trophic feeds EN, PN TF ml/k/d TPN d/c ed; human milk fortifier added to breastmilk Advancing EN ml/k/d Goal EN ml/k/d DISCHARGE Enteral Feeds: breastmilk/donor breastmilk (with HMF), preterm infant formula NICU Crash Course: Timeline Parenteral Transitional Period Enteral BIRTH Start TPN Trophic feeds EN, PN TF ml/k/d TPN d/c ed; human milk fortifier added to breastmilk Advancing EN ml/k/d Goal EN ml/k/d DISCHARGE 7

8 GOAL: Optimize at each step to: (1) MAINTAIN TARGETED NUTRIENT INTAKES MAINTAIN TARGETED GROWTH RATES (2) AVOID NEED FOR CATCH-UP GROWTH NICU Timeline: Old vs. New Trends Parenteral Transitional Period Enteral BIRTH DISCHARGE Old Guidelines: New Guidelines: Metabolic immaturity Slow dextrose, IL advancement Lower protein renal function?? more aggressive nutrient provision Starter TPN higher protein, promotes anabolism 8

9 NICU Timeline: Old vs. New Trends Parenteral Transitional Period Enteral BIRTH DISCHARGE Old Guidelines: New Guidelines: Breastmilk with HMF High kcal formulas Fat/CHO modulars Replacing EBM with higher kcal formulas Breastmilk encourage High protein HMF added to EBM Protein modulars added to EBM Higher-protein formulas Protein-energy ratios Linear growth, HC growth BMI curves NICU Timeline: Old vs. New Trends Parenteral Transitional Period Enteral BIRTH Poor growth decreased kcal/protein provision decreased BUN Growth failure at discharge: 4x more likely DISCHARGE JPEN J Parenter Enter Nutr;

10 NICU Timeline: Old vs. New Trends Old Guidelines How to write PN order? What to do if feeds held? TF 140 as if infant NPO; run PN at lower rate to maintain TF 140 Return TPN to NPO rate (TF140) Preferred feeds? Unfortified EBM; HMF added at EN ml/kg al Guidelines during Transition How to write PN order? What to do if feeds held? Preferred feeds? Old Guidelines TF 140 as if infant NPO; run PN at lower rate to maintain TF 140 Return TPN to NPO rate (TF140) Unfortified EBM; HMF added at EN ml/kg Revised Guidelines Concentrate PN kcal/aa in 100ml/kg; run at adjusted rate to maintain TF 140 Run TPN at 100ml/kg; piggyback additional D5% to maintain TF140 until new PN compounded. Unfortified EBM; HMF added at EN ml/kg 10

11 Demographic/Clinical Factors Group 1 Study Group (n=63) Group 2 - Controls (n=153) n (%) n (%) p-value Ethnicity Males 43 (68) 79 (52) NS Gestational age (week + SD) BW (grams + SD) Postnatal steroids 2 (3.2) 4 (2.6) 0.82 IVH > Stage 3 0 (0) 8 (5.2) BPD 5 (7.9) 11 (7.2) Sepsis 4 (6.3) 29 (18.9) NEC > stage 2 2 (3.2) 10 (6.5) Respiratory support on DOL 1: mechanical ventilation 14 (22.2) 42 (27.5) CPAP 45 (71.4) 100 (65.3) room Air 5 (8.1) 11 (7.2) z-score at birth + SD z-score at DOL 7 + SD z-score at start of transition + SD z-score at end of transition + SD z-score at CGA 35 wk + SD Demographic/Clinical Factors Group 1 Study Group (n=63) Group 2 - Controls (n=153) n (%) n (%) p-value Ethnicity Males 43 (68) 79 (52) NS Gestational age (week + SD) BW (grams + SD) Postnatal steroids 2 (3.2) 4 (2.6) 0.82 IVH > Stage 3 0 (0) 8 (5.2) BPD 5 (7.9) 11 (7.2) Sepsis 4 (6.3) 29 (18.9) NEC > stage 2 2 (3.2) 10 (6.5) Respiratory support on DOL 1: mechanical ventilation 14 (22.2) 42 (27.5) CPAP 45 (71.4) 100 (65.3) room Air 5 (8.1) 11 (7.2) z-score at birth + SD z-score at DOL 7 + SD z-score at start of transition + SD z-score at end of transition + SD z-score at CGA 35 wk + SD

12 Demographic/Clinical Factors Group 1 Study Group (n=63) Group 2 - Controls (n=153) n (%) n (%) p-value Ethnicity Males 43 (68) 79 (52) NS Gestational age (week + SD) BW (grams + SD) Postnatal steroids 2 (3.2) 4 (2.6) 0.82 IVH > Stage 3 0 (0) 8 (5.2) BPD 5 (7.9) 11 (7.2) Sepsis 4 (6.3) 29 (18.9) NEC > stage 2 2 (3.2) 10 (6.5) Respiratory support on DOL 1: mechanical ventilation 14 (22.2) 42 (27.5) CPAP 45 (71.4) 100 (65.3) room Air 5 (8.1) 11 (7.2) z-score at birth + SD z-score at DOL 7 + SD z-score at start of transition + SD z-score at end of transition + SD z-score at CGA 35 wk + SD Results: Trends in z-score weight gain: gm/kg/day * Study Group Controls weight gain: gm/kg/day *p<

13 Results: Total Energy Intake p <0.05 Results: Total Protein Intake 13

14 Protein-Energy Ratio (gm/100kcal) Results: Protein-Energy Ratio EN volume (ml/kg) Results: Protein-Energy Ratio 14

15 NICU : Summary of Newer Trends Parenteral Transitional Period Enteral BIRTH Start TPN Trophic feeds Aggressive TPN; protein from birth Avoid nutritional deficits/need for catch-up growth EN, PN TF ml/kg/d TPN d/c ed; human milk fortifier added to breastmilk Concentrated TPN Advancing EN ml/kg/d Goal EN ml/kg/d DISCHARGE High protein HMF Protein modulars; PER Breastmilk avoiding rapid wt gain NICU Growth Goals: Old vs. New Trends Old Guidelines: Get them to 10 th percentile!! New Guidelines: Maintain their growth curve Prevent nutrition lags at each step of nutrition timeline Avoid rapid catch-up growth 15

16 Case Study TPN: cautious advancement of AA, dextrose, IL Weaning TPN MCT oil/rice cereal Switch EBM to higher kcal formula Increase volumes of fortified EBM Goal: catch up to 10 th percentile Case Study Aggressive TPN; protein from birth Concentrated TPN to maintain kcal/pro High protein HMF Protein modulars; PER avoiding rapid wt gain 16

17 Questions? 17