Feeding of premature and LBW babies Ute Feucht Paediatrician, Tshwane District Clinical Specialist Team 2nd World Breastfeeding Conference; 13 December 2016 Technical Session: Strengthening Care and Support Systems

INTRODUCTION Prematures & LBWs = high risk population Optimal nutrition is critical After birth: Management of acute illness Then gradual advancement of feeding to prevent complications Growth usually begins during 2nd week of life Quality of postnatal growth depends on type of feeds Recommendations designed to provide nutrients to approximate rate of growth for normal fetus of same post- conceptual age and to maintain normal homeostasis

DEFINITIONS PREMATURITY SMALL FOR GESTATIONAL AGE Birth before 37w of gestation SMALL FOR GESTATIONAL AGE Birth weight ≤ 10th percentile SYMMETRICAL GROWTH RETARDATION Weight, length & head circumference <10th percentile ASYMMETRICAL GROWTH RETARDATION Weight between 10th – 90th percentile, but length & HC <10th percentile Not all small babies are the same!

ASSESSMENT OF NUTRITIONAL STATUS First 2 years of life: Growth plotted using age corrected for prematurity Growth charts for prematurity developed for AGA infants and SGA infants After 2 years: Use standard growth charts for chronologic age Implementation?

GROWTH PATTERNS Catch-up growth Usually HC first, followed by weight & length Maximum growth occurs at 36-40 wks after conception If no catch-up growth in prematures with IUGR: Risk of developmental delay & other medical problems In adolescence More likely to be small and give birth to premature infants Balance: Guidelines ↔ Individualized patient care

COMPLICATIONS OF PREMATURITY GASTRO-INTESTINAL PROBLEMS RENAL IMMATURITY LIVER IMMATURITY PULMONARY IMMATURITY OTHER

GASTRO-INTESTINAL PROBLEMS Lack of coordinated suck & swallow (< 34w gestation) USE CUP / SYRINGE METHOD/TUBE Underdeveloped gastro-oesophageal sphincter: Increasing regurgitation & aspiration SMALL VOLUMES OF FEEDS Small stomach capacity and slow gastric emptying Aspiration and low tolerance for big volumes of feeds Low intestinal lactase activity: Lactose intolerance Low intraluminal bile salt concentrations: Fat malabsorption Iron absorption is often low: Anemia High permeability of gut predisposes to allergies

RENAL IMMATURITY Low glomerulo-filtration rate Ability to regulate fluid and electrolytes ↑ Excretion of sodium during first 10-14 days Hyponatremia & ↑ in urinary pH  metabolic acidosis Low tolerance for high RSL Dehydration Inefficient activation of vit D Rickets

LIVER IMMATURITY PULMONARY IMMATURITY Inability to synthesize cysteine and bile salts Inability to store glycogen Inability to denature bilirubin for excretion PULMONARY IMMATURITY Chronic pulmonary disease  Resorption of minerals from bone Calcium and phosphate requirements increase Respiratory insufficiency  Gut ischemia NEC

ROUTE OF FEEDS: Enteral Feeding BREAST or CUP NASOGASTRIC/ OROGASTRIC FEEDING Enteral feeding determined by infant’s ability to co-ordinate sucking, swallowing & breathing (32-34w) Very immature, weak and critically ill babies are fed by tube – even if >34w Bolus or continuous infusions Use of stomach maximizes digestive capability of gut GASTROSTOMY TUBES Indicated for infants who cannot swallow and suck for several months

Advantages of early enteral feeding ↓ Incidence of: Indirect hyperbilirubinemia Cholestatic jaundice Metabolic bone disease ↑ levels of gastrin & other enteric hormones Fewer day to achieve full enteral feeding ↑ WEIGHT GAIN Feeds should not be increased by more than 20ml/kg/d Supplements only added once feeds are at 100ml/kg/d Weight gain should be aimed at 15-30g/d

BREASTMILK FOR Prematures First 2 weeks – preterm milk has: ↑ fat, protein, Na, Mg, Cl, Zn, Cu, Fe & IgA, but ↓ lactose, Ca & PO4 180-200ml/kg/day provides sufficient nitrogen for growth At the end of 1st month: Protein is insufficient Metabolic complications of long-term unsupplemented BM Hyponatremia (4-5 weeks) Hypoproteinemia (8-12 weeks) Osteopenia (4-5 months) Zn deficiency (2-6 months) BM fortification is essential

Breastmilk FORTIFIERS Fortifiers provide additional protein, minerals & vitamins Na, Ca, PO4 & Mg should be supplemented Improved growth & adequate bone mineralization Recommended: <2 kg or <35 wks gestation Implementation needs to be practical for staff: Large tins vs individual sachets

PROGRESSION OF FEEDS Day 1 : 60-90 ml/kg/day given 2, 3 or 4 hourly 100-150 ml/kg/day in 1st week for bigger babies 150-200 ml/kg/day from the 2nd week Ill infants will progress slower and may need TPN to make up the nutritional needs TPN indicated when Patient does not tolerate >25% of nutritional needs via oral route If progress very slow in volume with enteral feeds After extensive gut surgery NEC

DISCHARGE Home Breastfed infants should receive fortifiers if born <34 wks or BW <1800g Baby tolerates full feeds enterally Baby needs to maintain body temp in open crib KMC speeds discharge as babies gain weight quicker and mother knows how to care for baby Steady infant weight gain at 20-30 g/d No recent changes in O2 administration or medication Parents able to provide for infant needs Weight should be about 1,8-2 kg Follow-up is critical

Thank You! Acknowledgements: Kalafong colleagues: Dr Elise van Rooyen, Ms Marlene Gilfillian, others Tshwane DCST Tshwane MCWH & Nutrition staff The many mothers and babies I have been privileged to work with over the years Photos courtesy of Dr Elise van Rooyen