Chakradhar Maddela*
Department of Neonatology, ESIC Medical College, Sanath Nagar, Telangana, India
*Corresponding Author: Chakradhar Maddela, Department of Neonatology, ESIC Medical College, Sanath Nagar, Telangana, India.
Received: April 06, 2022; Published: April 28, 2022
Citation: Chakradhar Maddela. “Comprehensive Clinical Approach to Nutritional Management in Preterm Infants: Review Article”. Acta Scientific Paediatrics 5.5 (2022): 65-71.
Introduction: Nutrition is “the process of providing or obtaining the food necessary for the health and growth of cells or organisms” [1,2]. Preterm extremely low birth weight infants (ELBW) are born in mid trimester of pregnancy and experience sudden interruption of intrauterine nutrition at birth and delay in establishment of full enteral nutrition in postnatal life. Foetus multiplies in weight five times during last trimester and maximum accretion of nutrients occurs during same period of pregnancy [3] (Fenton 2013). These babies are prone to develop extra uterine growth restriction (EUGR) in early infancy, [4] Embleton 2001. Parenteral nutrition (PN) is a mandatory life saving and nutrition promoting intervention for preventing EUGR, tissue breakdown and achieving optimum nutrition, growth and development until full enteral feeds are established. Hence, assessment of nutritional needs, early aggressive parenteral nutrition and early trophic feeds within 24 of life [5], incremental increase in enteral feeds with extracted fresh human milk, full enteral feeds, breast milk fortification, preterm formula feeds and post discharge plan are crucial in the nutritional management of extremely low birth weight infants.
Methods: A Boolean literature search conducted in February 2022 through online databases - PubMed, Web of Science (WOS), Google Scholar, Cochrane library, Researchgate and manual search for scientific articles and texts with the title topic and keywords - preterm infants, nutrition, needs, requirements and management. The retrieved articles were screened with title and abstract for interested study research title. Retrieved 33 articles from PubMed, 10 from Cochrane library, 27 from WOS, 6 from Google scholar, 2 from researchgate and 12 from other sources. Articles were also searched through citations and references from collected study articles. Study restricted to articles written in English language. The following filters were used in retrieving study articles - free full text articles, Human, Newborn, Systematic reviews, meta-analysis, randomized control trials (RCTs), Clinical trials and Reviews. Animal studies were excluded. The retrieved articles were screened for the interested research title topic after going through the article title and abstract. A total of 32 study papers were analysed.
Results: The collected study papers were narrated with the subheadings - definition, nutritional needs of ELBW infant, TPN, enteral nutrition (minimal enteral nutrition, MEN and nutritional feeds), human milk fortifier, feeding intolerance, nutritional assessment, catch up growth and feeding advice at discharge.
Keywords: Preterm; Infant; Nutrition; Management; Requirements.
CNR: Calorie Nitrogen Ratio; DEBM: Donar Expressed Breast Milk; ELBW: Extremely Low Birth Weight; ECF: Extracellular Fluid; EMBM: Expressed Mother’s Breast Milk; GIR: Glucose Infusion Rate; GRV: Gastric Residual Volume; HMF: Human Milk Fortifier; HC: Head Circumference; MEN: Minimal Enteral Nutrition; NEC: Necrotizing Enterocolitis; NICU: Neonatal Intensive Care Unit; NEPDF: Nutrient Enriched Post Discharge Formula; PN: Parenteral Nutrition; PTI: Preterm Term Infant; PPHN: Persistent Pulmonary Hypertension of Neonate; PENALD: Parenteral Nutrition Associated Liver Dysfunction; PMA: Postmenstrual Age; RCT: Randomized Control Trial; TPN: Total Parenteral Nutrition; WOS: Web of Science
Table 1: Nutritional requirements of ELBW infants (ESPGHAN European Society for Paediatric Gastroenterology, Hepatology and Nutrition): [8].
Total parenteral nutrition (TPN): “is provision of nutrition for metabolic requirements and growth through the parenteral route”. TPN is an expensive, technically skilled procedure with associated merits and demerits. In preterm infants (PTI), it should be initiated early and continued until ¾ of nutritional needs are achieved by enteral feeds [9]. All TPN preparations should be carried in a sterile zone with utmost care. It needs well trained NICU nurses, appropriate laboratory back up and equipment like infusion pumps. Preterm infants lose 1% of body protein per day if they kept on only dextrose infusion after birth [10]. TPN is indicated in 1. PTI < 30 weeks GA 2. Birth weight < 1250 gm 3. No enteral feeds by day 5 irrespective of GA and weight and 4. Inability to tolerate enteral nutrition.
Sodium requirement is 2-3meq/kg/day and needs 4 to 6 ml of 3% saline.
Potassium requirement is 1-2meq/kg/day. Potassium chloride (KCL-15%) 1ml = 2meq.
Calcium requirement is 2meq/kg/day. Calcium gluconate (10%) 1ml = 0.45meq. Approximately 4ml/kg/day of 10% calcium gluconate is needed.
Magnesium 0.3meq/kg/day is required. Magnesium sulphate (50%) 1ml = 4meq.
Trace elements added in the form of Neotrace (not easily available in India). Injection Celecel (Chromium, Copper, Manganese and Selenium) should be added in a dose of 0.1 - 0.2 ml/kg.
Vitamins - injection paediatric MVI 1ml/kg as aqueous solution should be used.
Aqueous solution containing dextrose, amino acids, micronutrients and vitamins is delivered through a burette containing bacterial filter and connected to Y connector (triple lumen) of peripheral, umbilical or central vein to which the lipid infusion is attached. Restrict proteins to 12% and PN osmolality to 850mosm when peripheral vein is selected.
Calorie nitrogen ratio calculation: CNR is equal to the sum of carbohydrate calories (8gm × 3.4) plus lipid calories (gm×9) multiplied by 6.25 ÷ amino acids in gm. Normal range is 100 to 200 calories/gm. Approximately 25 non-protein kilocalories/Kg are required for every 1gm protein/kg promote protein utilization.
TPN Complications [12]:
Sepsis - is more common with central lines.
All ELBW infants are born in a nutritional emergency state with low micro and macro nutrient reserves and their high demand. Enteral feeds should be offered in hemodynamically stable preterm babies, initially with minimal enteral nutrition [14] (MEN). MEN is giving EBM of 12-24ml/kg/D as an alternative to enteral fasting. Early enteral feeds result in faster achievement of full enteral feeds [15].
Men: should be started on day1 with expressed mother’s breast milk (EMBM - best choice) or donor expressed breast milk (DEBM - 2nd choice) with 1ml initially 6-8hrly for 3days followed by 1224ml/kg/day as 2hrly feeds for the next 3days (along with parenteral nutrition). Feeds should be given as intermittent bolus feeds through orogastric tube, [16] Stocks 1980/[17] Hawes J 2004. Breast milk is ideal for MEN, and it protects from sepsis and NEC, [18] Lucas A 1990. Breast milk with prebiotics and probiotics exerts favourable effects on gut [19]. Johnson MJ suggested screening tool for nutritional risk for preterm infants in NICU as low, intermediate and high-risk strategy [20]. Both EMBM and DEBM should be given in full strength. EMBM has several advantages - preterm breast milk contains more protein, fat, energy and sodium, provide secretory IgA and antibodies, neutrophils, pre-pro and postbiotics, intestinal growth factors, healthy gut colonization, vitamin A, Zinc, better long-term neuro developmental outcome [21] lower sepsis and better survival rate in early infancy [22].
The advantages of MEN include the following [23] 1) Low feeding intolerance 2) Gut maturation 3) Early attainment of full enteral feeds 4) Stimulates gut motility 5) Less phototherapy 6) Early weight gain and discharge 7) Better bone mineralisation.
Nutritional feeds in EPTI should be started on day 5 or 6 with 12-24ml/kg/day. Thus, 1ml of EMBM every 2hrly should be introduced and advanced with 1ml per feed every 24hr until full enteral feeds of 150-180ml/kg/day is reached. Monitoring and judicious vigilance is needed during the transition from PN to full attainment of enteral nutrition (milk intake of > 100ml/kg/D).
A multicentre RCT trial (Speed of increasing Milk Feeds Trial,
SIFT trial) [24] was conducted for judging the better feeding policy between slow (18ml/kg/day) and fast (30ml/kg/day) feeding increments for PTI. This study showed no associated increased risk for NEC in fast feeding group. Sisk PM 2008 [25] showed guidelines for incremental increase in feeds based on GA as follows
Table 2
Human milk composition is variable, dynamic and lowered protein content for EPTI [26] (Ballard 2013). Fortification is aimed to improve micro and macronutrient composition of breast milk with preserved advantages (P/E ratio 3.6gm/120kcal) of EDBM. Extreme low birth weight babies who fed on exclusively breast milk attain lower mean weight for age at 2kg, (Lucas 1984). Powdered human milk fortifier (Lactodex HMF in India) should be added (1 sachet in 25ml of breast milk and administer immediately or within 20minutes of reconstitution to avoid increasing osmolality by maltodextrins) when baby receives > 100-150ml/kg/day of EMBM.
Common in EPTI due to disordered peristalsis, immature gut, poor gastric emptying and dysadaptation to enteral feeds especially formula feeds.
Common features of feeding intolerance are - abdominal distension, large gastric residual volumes (GRV - > 2 - 3 ml/kg or > 50% of previous feeding volume), new visible intestinal loops, abdominal skin discolouration, hemodynamic instability, hypo-hyperglycaemia and positive stool test for blood. It may be an early warning sign of NEC.
Withheld the feeds if GRV is more than > 30-50% on two occasions with non-reassuring clinical status for 24hrs and reintroduce if clinical condition is reassuring.
Usually based on changes in body weight and fluctuations in energy intake. Both static assessment - a balance between intake and output and dynamic assessment - growth velocity over time is significant for all EPTI. MJ Johnson 2014 advised ABCDE approach for nutritional assessment in neonates [27] - A. Anthropometry, B.Biochemistry, C. Clinical, D. Dietary and E. Evaluation.
Should include daily recordings of weight, input - output charts and constant supervision. Weight is the most commonly recorded measurement in NICU and comprises baby’s lean mass, fat and extracellular fluid. Daily weight recording can be plotted on Fenton growth chart. Weekly recordings should include head circumference (HC > 0.9cm/week) and length (> 1cm/week) and mark on growth charts (NICHD growth observation curve). HC is the surrogate measure of brain growth.
Should include daily recording of blood glucose - initially 6-12hrly, urinary glucose, serum electrolytes (initially), weekly recording of serum electrolytes (3-4times/week followed by weekly), blood urea [ < 2mmol/l = inadequate protein intake, 3times/week later weekly], serum albumin( < 1.6mmol/l = protein deficiency), Liver function tests, hematocrit, haemoglobin, reticulocyte count, triglycerides (4hrs after increase in dose, later weekly < 200mg/ dl), bone markers (alkaline phosphatase > 900IU/L and phosphate < 1.8mmol/l or < 4mg/dl = metabolic bone disease).
Should be carried daily for hydration status, general health and for signs suggestive of any disease status.
Should include daily calculation of macro-micronutrients for both enteral and parenteral nutrition.
Should be done daily and weekly for adequacy of nutrients, hydration and growth.
ELBW babies who grow at > 18gm/kg/day in weight, > 0.9cm/ wk in HC and > 1cm/wk in length had better neuro developmental outcome [28] (Ehrenkranz 2006).
Catch up growth is an increased growth rate on nutritional provision after a transient period of growth lag secondary to nutritional inadequacy or illness. It may be associated with increased insulin resistance and cardiovascular risk at later age [28].
PTI with adequate weight for post menstrual age (PMA) should be kept on breastfeeding with periodic growth monitoring [31]. Babies with inadequate weight for PMA at discharge should receive fortified human breast milk or nutrient enriched post discharge formula (introduce NEPDF 22/30 - when 2-2.5kg wt) until 52weeks of PMA to provide better P: E ratio at 3gm/100kcal [30]. Nutrient enriched preterm formula (NEPTF 24/30) fed infants got better cognitive outcomes [32] in male babies (Lucas 1998) at 7-8years age. The preterm formula NEPTF 24/30 milk is intended for babies < 2kg weight or < 35wks GA.
Preterm infants especially ELBW and VLBW are at risk of developing EUGR and NEC. Early aggressive parenteral nutrition along with early enteral nutrition preferably with breast milk (MEN followed by nutritional feeds) is essential and mandatory for achieving optimum growth, prevention of NEC and better longterm outcomes. Breast milk either from own mother or donor mother is the choice of milk for preterm infants. Providing correct protein energy ratio is essential for enhanced protein utilization and attaining optimum growth. Once full nutritional feeds are achieved, fortification of breast milk and or introduction of nutrition enriched post discharge formula from nicu discharge along with supplementation of long chain PUFA (52 weeks PMA) is recommended.
There are no conflict of interest for this study.
There are no sponsors for this study.
Copyright: © 2022 Chakradhar Maddela. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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