1. Nutritional support in NICU/PICU A Norouzy Assistant Professor in Clinical Nutrition Mashad Medical School

2. NICU

3. Energy and protein goals: TPN Term: – Energy: 80-100 kcal/kg/day – Protein: 2.5-3.5 g/kg/day Pre-term: – Energy: 90-100 kcal/kg/day – Protein: 2.5-3.5 g/kg/day

4. Energy and protein goals: enteral Term: – Energy: 108 kcal/kg/day – Protein: 2.2 g/kg/day Pre-term: – Energy: 120 kcal/kg/day – Protein: +3 g/kg/day

5. IV Lipids Preterm infants can develop EFA deficiency within 72 hours of birth Dose: 0.5-1 g/kg/day to achieve 3 g/kg/day maximum 60% of total energy

6. Amino Acids Start 1.5-3 g/kg/d Advance: 0.5-1 g/kg/d Goal: 2.5-4 g/kg/d Monitor: renal function, albumin

7. Dextrose <1000 g: glucose infusion rate: 4-6 mg/kg/min 1000-1500 g: GIR: <8 mg/kg/min GIR goal: <12 mg/kg/min GIR>14: converts CHO to fat in liver

8. Vanilla TPN order Start with amino acids ASAP Dextrose: 8-18 g/kg/d AA: 1.5-3 g/kg/d Fat: 0.5-1 g/kg/d Calcium: 150-200 mg/kg/day Phosphorous: 0.3-0.5 mmol/kg/d MVI & trace elements

9. Tapering TPN/PPN Start from lipids Keep AA until last

10. Enteral nutrition BMF or formula Trophic feed or full feed

11. Barriers and Challenges of Nutrition Support Metabolic vs nutrition support Wasting specific lesions (pre-operative nutritional status) Hemodynamic instability Severe hypotensive gut Fluid restriction Enteral vs parenteral Philosophy nutrition support will do more harm than good in immediate post-operative period Urgency to remove central line

12. Too Little vs Too Much Diamond 1995

13. Too Little vs Too Much Sedation Paralysis Intubation/ventilation + inotropes + wasting

14. Determining Caloric Requirements

15. Tools Used for Determination Indirect calorimetry Underlying disease process Biochemistrys and nitrogen balance Published papers (reference charts) Nutritional status

16. Route of Administration: Enteral vs Parenteral Indications for TPN: SBS Ileus Severe dysmotility NEC Unable to provide adequate support with enteral nutrition The gut can be used in critical illness

17. Journal of Pediatric Gastroenterology and Nutrition. 41: S1-S4

18. TPN initiation dependent on age, size, nutritional status, disease, surgery or medical intervention In small preterm infants starvation for 1 day may be detrimental Older children can wait up to 7 days dependent on circumstance Journal of Pediatric Gastroenterology and Nutrition. 41: S1-S4 Espghan Guidelines

19. Enteral: Enteral Nutrition Advantages: Decreased cost Decreased metabolic abnormalities Decreased infectious risk Promotes GI integrity Stimulates enteric secretions, hormones and blood flow Decreased bacterial translocation

20. Enteral: Critically ill pediatric patients have multiple factors that decrease gastric emptying: Formula osmolarity Fat content Lipid carbon chain length Medications (narcotics, benzodiazepines, sedatives) Continuous feeds are best Small bowel feeds very successful

22. Causes of Diarrhea in Enterally Fed Children

23. Feeding the Hypotensive Patient Splancnic bed gets: 25% cardiac output at rest 30% of oxygen consumption is in the splancnic bed small intestine 44% * Arterial blood flow stomach 12% colon 17%

24. Feeding the Hypotensive Patient Villus tips suffer most damage during hypoxia they have the greatest digestive function. When we feed the gut, the selection of nutrients will alter the metabolic function and oxygen demand of the enterocyte.

25. Feeding the Hypotensive Patient There is the potential to do harm as the presence of food in the intestine may increase oxygen demand beyond available delivery of blood flow, leading to necrotic bowel.

26. Parenteral Metabolic Complications: Amino acids – toxic Carbohydrate – Hepatic stenosis – Cholestasis -  alk phos -  GGT -  bili Fat – depressed immune function – Reduced bacterial clearance – Increased triglycerides

27. Total Parenteral Nutrition central vs peripheral line 1000 vs 2000 mosmols/L ++ electrolyte increases osmolarity severe fluid restrictions 15+ % protein, 45% carbohydrate, 40% fat (8-10 mg/kg/min

28. Biochemistries in PICU Serum albumin, urea, triglycerides, magnesium – ↓ Mg – 20% – ↑ trig – 25% – ↑ urea – 30% – ↓ albumin – 52% ↑ uremia → ↓ SD scores for weight and arm circumference between admission and discharge ↑ triglycerides → > ventilator dependence days and length of stay than children with triglyceride levels Journal of Nutritional Biochemistry 17 (2006) 57-62

29. Nutrition Support in the ICU is not generic but: 1.Patient specific 2.Disease specific 3.Macro and Micronutrient specific 4.Biochemically specific 5.Stage specific

30. Nutritional Support of the VLBW Infant

31. Gold Standard of Growth for VLBW Infants To approximate the in utero growth of a normal fetus of the same post-conceptional age. – Body weight – Body composition

32. Unique Nutritional Aspects of the VLBW Infant Higher organ:muscle mass ratio Higher rate of protein synthesis and turnover Greater oxygen consumption during growth Higher energy cost due to transepidermal water loss Higher rate of fat deposition Prone to hyperglycemia Higher total body water content

33. Preventing Feeding-Related Morbidities in VLBW Infants Necrotizing enterocolitis Osteoporosis Vitamin and mineral deficiencies Feeding intolerance Prolonged TPN and related cholestasis Prolonged hospitalization Lack of full physical and intellectual potential

34. Optimizing Long Term Outcome Nutritional Programming: Nutrition during critical periods in early life may permanently affect the structure and/or function of organs or tissues. Alan Lucas, 1990

35. Nutritional Care/Outcomes in VLBW Infants - Potential Improvements Human milk “Early” TPN – Prevent protein deficit – Prevent EFA deficiency GI priming/MEN/Trophic feeds – Prevent GI atrophy effects – Faster realization of full enteral feeds Fortification/Supplementation – Starting earlier – Continuing longer

36. Benefits of Human Milk - Reduced Infections Otitis media – with a reduction in the frequency and duration of ear infections in breastmilk versus formula fed newborns Respiratory tract illnesses including respiratory synctial virus infection Gastrointestinal illness Urinary tract infections Infant botulism

37. GI Benefits of Human Milk for the Preterm Infant Gastrointestinal development – Reduces intestinal permeability faster – Induces lactase activity – Multiple factors to stimulate growth, motility and maturation of the intestine – Human milk empties from the stomach faster than artificial milks – Less residuals and faster realization of full enteral feedings

38. Benefits of Human Milk for the VLBW Infant Special nutritional needs – Different quantity and quality of proteins – Fats: Cholesterol, DHA, ARA – Carbohydrates designed for human infants – Lower osmolality/renal solute load – Other factors: e.g. erythropoietin, EGF

39. Parenteral Nutrition for VLBW Infants

40. Best Practice Parenteral nutrition, including protein and lipids, should be started within the first 24 hours of life. Parenteral nutrition should be increased rapidly so infants receive adequate amino acids (3.0-4.0 gm/kg/day) and calories (85- 110 kcal/kg/day) as quickly as possible.

41. Best Practice Start parenteral lipids within the first 24 hours of life. Lipids can be started at doses as high as 2 g/kg/d. Lipids can be increased to doses as high as 3.0-3.5 g/kg/day over the first few days of life.

42. Establishing Enteral Feedings

43. Best Practice Human milk should be used whenever possible as the enteral feeding of choice for VLBW infants.

44. Best Practice Enteral feeds, in the form of trophic or minimal enteral feeds (also called GI priming), should be initiated within 1-2 days after birth, except when there are clear contraindications such as a congenital anomaly precluding feeding (e.g. omphalocele or gastroschisis), or evidence of GI dysfunction associated with hypoxic-ischemic compromise.

45. Best Practice – Pumps delivering breastmilk should be oriented so that the syringe is vertically upright, and the tubing (smallest caliber and shortest possible) should be positioned and cleared to prevent sequestration of fat. – Enteral feeds should be advanced until they are providing adequate nutrition to sustain optimal growth (2% of body weight/day). For infants fed human milk this could mean as much as 170 - 200+ mL/kg/day.

46. Best Practice VLBW infants fed human milk should be supplemented with protein, calcium, phosphorus and micronutrients. Multinutrient fortifiers may be the most efficient way to do this when feeding human milk. Formula fed infants may also require specific caloric and micronutrient supplementation.

47. Human Milk and Breastfeeding

48. Transition to Oral Feedings

49. Early attachment is beneficial for milk production and mother-child bonding. Skin-to skin contact may strengthen the mother-infant dyad and lead to longer breastfeeding periods over the first two years of life. Non-nutritive breastfeeding can stimulate milk volume and improve breastfeeding success rates.

50. Best Practice Infants should be transitioned from gavage to oral feedings when physiologically capable, not based on arbitrary weight or gestational age criteria.