Nutrition in the NICU ANDI MARKELL RD, LD PORTLAND, OREGON ANDI MARKELL NUTRITION CONSULTANT
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
ANDI MARKELL CONSULTANT
Protocol Data Data Protocol ANDI MARKELL NUTRITION CONSULTANT
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
Nutritional Needs of Late Premature Infants 34-37 weeks May not be too different than term baby Most issues around feeding are physical / endurance Unsynchronized suck/swallow/breathe Decrease stamina Inadequate intake
Nutritional Needs of Premature Infants 24-33 weeks Much different than term baby Most issues around increased nutritional needs Third trimester Fetus / Placenta
Nutritional Needs of Premature Infants Incomplete Stores Rapid Development Sub-optimal Digestion and Absorption Related Diseases of Prematurity Early Discharge
Nutritional needs as gestational age Goal: Postnatal growth that approximates the in-utero growth of a normal fetus American Academy of Pediatrics
ANDI MARKELL NUTRITION CONSULTANT
ANDI MARKELL NUTRITION CONSULTANT
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
ANDI MARKELL NUTRITION CONSULTANT
Neonatal Malnutrition (Goldberg DL et al, J Acad Nutr Diet, 2018)
Accretion Rates for the Reference Fetus (ZIEGLER ET AL. GROWTH 1978;40:329-341)
Protein Accretion 2.5 Protein Ziegler, 1976 2 1.5 1 Protein 0.5 g/kg/day 0 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Calculating Protein Requirements (Factorial Method, 26-37 weeks) Accretion ---------------------- 1.9 g/kg/day Dermal Loss------------------- 0.2 g/kg/day Urinary Loss------------------- 1.5 g/kg/day Required IV Intake---------- 3.6 g/kg/day Required PO Intake--------- 4.0 g/kg/day 90% GI absorption Breast Milk Intake------------ 1.6 g/kg/day 1 g protein/dl @ 160 ml/kg/d
Calcium and Phosphorus Accretion 140 120 100 Mineral Retention Ziegler, 1976 80 60 Calcium Phosphorus 40 mg/kg/day 20 0 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39
Calculating Calcium Requirements (Factorial Method, 26-37 weeks) Accretion ----------------- 105 mg/kg/day Dermal Loss----------------- 2 mg/kg/day Urinary Loss----------------- 5 mg/kg/day Required IV Intake----- 112 mg/kg/day Required PO Intake---- 172 mg/kg/day 65% GI absorption Breast Milk Intake----------45 mg/kg/day 28 mg Ca/dL at 160 ml/kg/d
Calculating Phosphorus Requirements (Factorial Method, 26-37 weeks) Accretion ------------------- 68 mg/kg/day Dermal Loss------------------ 2 mg/kg/day Urinary Loss----------------- 20 mg/kg/day Required IV Intake-------- 90 mg/kg/day Required PO Intake------ 106 mg/kg/day 85% GI absorption Breast Milk Intake----------- 22 mg/kg/day 15 mg Phos/dL at 160 ml/kg/d
Feeding the very low birth weight preterm infant is not a natural physiological process. Alan Lucas
Nutritional Needs Nutrient Preterm Term Max Difference Calories Kcal/kg Protein g/kg Calcium Mg/kg Phosphorus Mg/kg 110-130 108 1-20 % 3.5-4.5 1.6 220-280 % 120-200 60 200-330 % 60-140 30 200-460 %
Fortification In the NICU Birth Weight Nutrition Management < 1250 g MOM/BBM + Prolact+ 6 + CR @ > 145 ml/kg/d MOM/BBM + Prolact+ 8 + CR @ < 145 ml/kg/d 1251g 1500 g MOM/BBM + HMF 24 @ 160 ml/kg/d 1501 g 2000 g MOM + HMF 22 Transitional formula > 2000 g MOM Term formula
Comparing Fortification Fortification MM+HMF 24 MM+Enfamil 24 MM Calories @ 160 ml/kg Protein @ 160 ml/kg Calcium @ 160 ml/kg 130 130 108 4.1 2.1 1.6 179 62 45 20 % more calories with HMF 24, 20 % MM+E 24 150 % more protein with HMF 24 30 % MM+E 24 300 % more calcium with HMF 24 38 % MM+E 24
Growth Goals Groh-Wargo, Sharon, Melody Thompson, and Janice Hovasi Cox. ADA pocket guide to neonatal nutrition. American Dietetic Associati, 2009. Weight 15-20 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): 85-91. Calories 110-135 kcal/kg Protein <1000g: 4-4.5 g/kg > 1000g: 3.5-4 g/kg ANDI MARKELL NUTRITION CONSULTANT
https://bionews-tx.com/news/2014/11/19/uthealth-receives-1-6-million-nih-grant-to-study-probiotic-effect-on-necrotizing-enterocolitis/ 4/20/2018 RANDALL CHILDREN'S HOSPITAL 28
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
EHMD MOM/DM Exclusive Human Milk Diet Human Milk Based HMF Human Milk Based Modulars ANDI MARKELL NUTRITION CONSULTANT
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
Feeding Protocol 2010 Initiate Advance Fortify Goal ~10 ml/kg/d 10-20 ml/kg/d 100 ml/kg/d MOM/DM + Prolact+4 160 ml/kg/d MOM/DM + Prolact+4 ANDI MARKELL NUTRITION CONSULTANT
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
ANDI MARKELL NUTRITION CONSULTANT
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
Feeding Protocol 2010 2014 Initiate ~10 ml/kg/d ~10 ml/kg/d Advance 10-20 ml/kg/d 20-30 ml/kg/d Fortify 100 ml/kg/d +4 60 ml/kg/d +4 130 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 +4 160 ml/kg/d +6 < 145 ml/kg/d +8 ANDI MARKELL NUTRITION CONSULTANT
Growth and Clinical Data for Exclusive Human Milk Groups EHM 1 EHM 2 p-value N 33 94 ----- PMA (weeks) 26.2+2.2 26.6+2.4 NS Birth Weight (g) 855+209 904+200 NS Weight Gain (g/kg/day) 13.2+1.9 13.6+1.6 NS PMA at Discharge for Wt 40.0+4.8 37.9+2.2 0.0014 Length Gain (cm/week) a 0.96+0.14 1.06+0.19 0.002 PMA at Discharge for Length and HC 40.0+4.8 37.3+2.3 0.0001 Head Circumference Gain (cm/week) b 0.71+0.12 0.81+0.15 0.0004 Days PN 32+30 18+13 ----- log(days PN) c 3.20+0.72 2.73+0.54 0.001 DOL 24 27+12 11+7 ----- log(dol 24) d 3.18+0.55 2.23+0.49 <0.0001 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
Final Model for the Analysis of Covariance for Weight Gain Coefficient 95% CI p (Intercept) 10.066 7.157 to 12.974 <0.0001 GROUP EHM -0.482-0.897 to -0.086 0.017 GROUP PTF 0.922 0.382 to 1.463 0.0009 PMA 0.361 0.246 to 0.475 <0.0001 Birth Weight -0.005-0.007 to -0.004 <0.0001 PDA -0.631-1.101 to -0.160 0.0087 NEC All Stages -1.999-2.691 to -1.308 <0.0001 DOL 24-0.032-0.057 to -0.006 0.0166
Final Model for the Analysis of Covariance for Head Circumference Gain Coefficient 95% CI p (Intercept) 0.758 0.727 to 0.789 <0.0001 GROUP PTF 0.097 0.046 to 0.148 0.0002 PDA -0.075-0.109 to -0.040 <0.0001 ERA 2 0.062 0.027 to 0.097 0.0006
Primary Outcome Growth Parameter Weight Gain (g/kg/day) Length Gain (cm/wk) PTF (80-100 ml, no protocol) HMBF 2 (80-100ml) 14.9+2.4 14.1+1.8 13.6+1.6 EHM 2 (40-50 ml) 1.07+0.23 1.03+0.23 1.06+0.19 HC Gain (cm/wk) 0.84+0.15 0.79+0.18 0.81+0.15
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
Feeding Protocol 2010 2014 2016 2018 Initiate ~10 ml/kg/d ~10 ml/kg/d ~10 ml/kg/d ~10 ml/kg/d Advance 10-20 ml/kg/d 20-30 ml/kg/d 20-30 m/kg/d 10-20 m/kg/d Fortify 100 ml/kg/d +4 60 ml/kg/d +4 130 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 +4 160 ml/kg/d +6 < 145 ml/kg/d +8 25 ml/kg/d +4 80-100 ml/kg/d +6 <1250g 3-4 weeks and PRN 160 ml/kg/d +6 < 145 ml/kg/d +8 25 ml/kg/d +4 60 ml/kg/d +6 130 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
Protocol Data Data Protocol ANDI MARKELL NUTRITION CONSULTANT
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