1. 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

2. 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

3. 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!

4. 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?

5. GROWTH PATTERNS Catch-up growth
Usually HC first, followed by weight & length
Maximum growth occurs at 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

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

7. 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

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

9. 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

10. 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

11. 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

12. BREASTMILK FOR Prematures
First 2 weeks – preterm milk has:
↑ fat, protein, Na, Mg, Cl, Zn, Cu, Fe & IgA, but
↓ lactose, Ca & PO4
ml/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

13. 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

14. PROGRESSION OF FEEDS Day 1 : 60-90 ml/kg/day given 2, 3 or 4 hourly
ml/kg/day in 1st week for bigger babies
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

15. 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 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

16. 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