Strategy For Reaching Optimal Growth and Development of Preterm Infants Dr. dr. Rinawati Rohsiswatmo, Sp.A(K)
Premature Birth before reaching 37 weeks ' gestation. Incidence in Indonesia was 15.5% 2/3 of premature birth, were Small for Gestasional Age Riskesdas, 2013
Low Birth Weight (LBW) Birthweight < 2,500 grams. Incidence in Indonesia: 10.2% 6-30 % LBW were categorized as IUGR (Helen Kay, 2000)
IUGR IUGR is a baby who has a birth weight below the 10th percentile of normal weight curve adjusted for gestational age. This is a condition in which the fetus is not able to develop in accordance with the normal size due to a disturbance of nutrition and oxygenation. According to WHO, in Indonesia, 2003, a precentation of IUGR was 19,8%,
Appropriate For Gestasional Age IUGR Small For Gestasional Age Catch Up Growth
EUGR EUGR occurs when a premature infant's growth falls below the 10th percentile in comparison to a normal fetus of the same gestational age. Extrauterine growth restriction (EUGR) is commonly seen in small premature infants due to a lack of early aggressive nutrition that results in energy and protein deficits during the first few days of life. These deficits lead to early postnatal growth failure that continues at discharge resulting in growth parameters being below the 10th percentile, which is associated with poor neurodevelopmental outcomes.
IMPACT OF UNDERNUTRITION DURING PREGNANCY AND EARLY CHILDHOOD Increased risk of dying from infectious diseases (one-third of child deaths) Stunting is associated with reduced school performance equivalent to 2-3 yrs of schooling Stunting associated with reduced income earning capacity (22% average; up to 45% has been reported!) Increased risk of non-communicable diseases in adult life Stunted girl is more likely to give birth to undernourished baby Reduced GMP by 2-3% About 20 million children suffer from severe acute malnutrition which greatly increases risk of death
FENTON CHART-GIRL FENTON CHART-BOY
INTRA UTERINE GROWTH IN THE LAST TRIMESTER BW 3500 g 375 g Brain Weight Body calcium 28000 mg 800 g 30 cm BL 50 cm 75 g 5600 mg Gestational age (weeks) (Klein CJ. J Nutr 2002)
The highest ratio of weight gain in fetus are at week 26 to 36 Optimal growth for the premature is the growth curve intra uterine, this requires the nutrients to be digestable and absorbable. 6th World Congress Perinatal Medicine In Developing Countries, Jakarta, March 9th, 2010
How to reach optimal growth and development of preterm infants? Enteral or oral ASAP Parenteral nutrition (if there are some contraindication)
Contraindication for oral-enteral feeding Shock Gastro intestinal bleeding Severe illness (not stable yet) Gastro intestinal Obstruction
NUTRITIONAL REQUIREMENTS OF SGA INFANTS Compared with AGA infants, oxygen consumption and energy expenditure of SGA infants are high (due to a large brain: body ratio and need for catch-up growth), while fat and protein absorption in SGA infants is lower. J Pediatr. 2013 Mar; 162(3 Suppl):S81-9.
EARLY VS DELAY FEEDING OF SGA INFANTS 600 babies in 2 studies Early feeders had Fewer days parenteral nutrition Fewer investigations for sepsis No difference in NEC Weight gain Cochrane Database Syst Rev. 2011;(3):CD001970.
RAPID VS SLOW INCREASED FEEDING 369 babies in 3 studies Rapid 20 to 35 ml/kg/day Slow 10 to 20 ml/kg/day Rapid group: reached full enteral feeds and regained birthweight faster No difference in NEC rate or length of stay Cochrane Database Syst Rev. 2008;(2):CD001241.
Minimal Enteral Feeding(MEF) For SGA Infants 380 babies in 8 studies 12 to 24 ml/kg/day for 5 to 10 days MEF group Faster to full enteral feeds Shorter length of stay No difference in NEC Cochrane Database Syst Rev 2000;(2):CD000504.
FEEDING INTOLERANCE The gastric residual volume (GRV) is the element of feeding that can be measured and compared most easily. Mihatsch et al. tolerated GRV up to 2 ml in newborns 750 grams and up to 3 ml in newborns from 750 to 1000 grams in their protocol, but concluded that additional research is required to evaluate if GRV threshold could be increased up to 5 ml/kg body weight. (Pediatrics 2002, 109:457 459) Cobb et al. found that GRV > 3.5 ml or 33% of a single meal may be associated with a higher risk for NEC while a GRV <1.5 ml or 25% of a meal is probably normal. (Pediatrics 2004, 113:50 53)
The goal of Early Parenteral Nutrition (EPN) To provide an intravenous substrate that promotes protein deposition and increased lean body mass that approximates fetal growth rate and accretion. Amitha R. Aroor et al. Early versus Late Parenteral Nutrition in Very Low Birthweight Neonates. SQU Med J, February 2012, Vol. 12.
Amino Acids Lipid Start amino acids within 2 hours of birth with 1.5-3 g/kg/day & increase by 1 g/kg daily to max 4.0 g/kg/day Start lipids within 24 hrs of birth at 1.0 g/kg/day & increase by 0.5-1 g/kg daily to max 3.0 g/kg/day Glucose Initiate GIR 4mg/kg/min & increased daily by 1-2 mg/kg/min TPN Don t stop TPN until enteral feeds are >90% of requirements
Feeding protocol in preterm Consensus between Neonatal working group and Nutrition metabolic working group of Indonesian Pediatric Society regarding nutrition support for preterm infants.
Feeding guidelines for preterm baby <28 weeks < 1000 g 28 weeks 1000-1800 g Stabilization Stabilization Enteral feeding begin after 24 hours Enteral feeding begin within 24 hours Breast milk/donor breast milk 10 ml/kg/day Breast milk/donor breastmilk 10 ml/kg/day Increase 20 ml/day until 180 ml/kg/day Increase 20-30 ml/day until 180 ml/kg/day
Feeding guidelines for preterm baby When to used preterm formula Breastmilk+ HMF nor enough Weight length and HC less than 25 IHDP Chart/fenton chart When to used post discharge formula Weight 1800/2000 gram. Weight, length and HC > p.25 When to used standar formula Z- score -2 s/d + 2 weight for age WHO chart Z- score -2 s/d + 2 weight for length WHO chart
PDF powder supplementation of mother breast milk PDF Powder Supplementation Of Mother Breast Milk
FENTON CHART
How to measure?
management of LBW with proper nutrition (1) (2) Breastmilk + HMF weight does not increase If HMF (-) weight does not increase Standard Formula IF BreastMilk (-) Premature Formula (5) Post Discharge Formula (4) Standard Formula (3)
Management of LBW with mild moderate Malnutrition (1) (2) Breastmilk IF BreastMilk (-) Standard Formula Post Discharge Formula Or Premature Formula weight does not increase Evaluations 2-4 weeks (5) (4) (3)
Management of LBW with Severe Malnutrition (1) (2) IF BreastMilk (-) Premature Formula Premature Formula Post Discharge Formula Post Discharge Formula
late preterm Infants Gestasional Age34 0/7 36 6/7 weeks Birth Weight 2000-3000 gr Standard Formula If nutritional status unchanged PDF Breast milk If Breastmilk (-) Premature Formula If nutritional status unchanged
Management of IUGR (Term-SGA) 1. Term baby 2.Organ Function mature enough Standard Formula If nutritional status unchanged 3. Able to receive appropriate nutrition with gastrointestinal osmolality Breastmilk PDF Premature Formula If nutritional status unchanged
Catch Up Growth 1. Pola catch up growth belum dipahami benar 2. Kehilangan pertumbuhan dipengaruhi oleh berat dan lama gangguan pertumbuhan serta usia sat timbul 3. Sulit terkoreksi bila gagal tumbuh berlangsung lebih dari 2 tahun 4. Defisit BB terkoreksi lebih dahulu kemudian PB 5. Anak yang wasted tetapi tidak stunted catch up lebih cepat
Kenaikan Berat Badan,Panjang Badan & Lingkar Kepala Bayi Baru Lahir 0-3 bulan usia koreksi : 20 g/hari 3-6 bulan usia koreksi : 15 g/hari 6-9 bulan usia koreksi : 10 g/hari 9-12 bulan usia koreksi : 6 g/hari Panjang badan : 1 cm/bulan Lingkar kepala : 0,5 cm/minggu
Koreksi parameter pertumbuhan Lingkar Kepala: 18 bulan Berat Badan: 24 bulan Panjang Badan: 42 bulan
How much Ideal Catch Up growth?
Ringkasan Dukungan nutrisi untuk BBLR meliputi dukungan nutrisi pada saat dan pasca rawat, yang dimulai dengan TPN, trophic feeding dan enteral feeding ASI merupakan nutrisi terbaik untuk BBLR, pada keadaan tertentu perlu disuplementasi HMF Bila ASI tidak tersedia formula pasca rawat (PDF) dan formula prematur standar dapat menjadi alternatif Pemberian nutrisi yang tidak adekuat (kurang/lebih) akan berdampak pada status kesehatan BBLR di masa dewasa Prematur Discharge Formula dapat digunakan untuk Bayi premature, Bayi IUGR dan Bayi EUGR