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

2. Objectives Define basic nutritional requirements for neonatal growth
Describe specific nutritional problems faced by low birthweight and premature infants
Determine components of TPN and be able to write fluid orders
Formulate an individualized plan for starting and advancing parenteral/enteral feeds

3. Goals of Nutrition
To achieve a postnatal growth at a rate that approximates the intrauterine growth of a normal fetus at the same post-conceptional age
Provide balance in fluid homeostasis and electrolytes
Avoid imbalance in macro-nutrients
Provide micro-nutrients and vitamins

4. Fetal nutrition Parenteral (mostly!) Stores are laid late in gestation
At 28 weeks, a fetus has:
20% of term calcium and phosphorus stores
20% of term fat stores
About a quarter of term glycogen stores

5. Adaptation to nutrition after birth
Gut adaptation is regulated by
Endocrine factors
Intraluminal factors
Breast milk hormones and growth factors
Bacteria

6. Normal output Daily stool and urine output guidance Day 0
1 wet nappy and meconium at least once a day
Day 1
2 wet nappies and meconium at least once a day
Day 2 & 3
3 or 4 wet nappies and changing stools at least once a day
Day 4+
5 or 6 heavy wet nappies and yellow stools at least once daily
A baby who is passing meconium at 3 or 4 days old may not be getting enough milk.
A baby who does not have yellow stools by day 5 may not be getting enough milk.
A baby who is not doing as many wet nappies each day as expected may not be getting enough milk.

7. Nutrition for the preterm or sick baby

8. So how to feed? Delay start? Use non-nutritive feeds? Increase slowly?
Use friendly bacteria?

9. Cochrane review: early vs late feeding
72 babies in 2 studies
Early feeders had
Fewer days parenteral nutrition
Fewer investigations for sepsis
No difference in
NEC
Weight gain

10. Cochrane review: rapid vs slow increase
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

11. Cochrane review: minimal enteral nutrition
380 babies in 8 studies
12 to 24 ml/kg/day for 5 to 10 days
MEN group
Faster to full enteral feeds
Shorter length of stay
No difference in NEC

12. Probiotics for preventing NEC
Systematic review of 1393 VLBW infants treated with a variety of organisms
Reduced risk of
NEC (RR 0·36, 95% CI 0·20–0·65)
Death (RR 0·47, 0·30–0·73)
Achieved full feeds faster
No difference in rates of sepsis
Deschpande et al, Lancet 2007

13. Feeding small or preterm infants: Choices
Human milk
Mother’s own
Banked donor milk
Fortified
Artificial
Term formula
Preterm formula
Parenteral Nutrition

14. Parenteral Nutrition

15. Parenteral Nutrition
If an infant can’t, won’t or shouldn’t be fed enterally
What’s in the bag?
Fluid
Carbohydrate
Protein
Fat
Minerals and Trace Elements

16. Energy Requirements Basal metabolic rate Physical activity
Specific dynamic action of food
Thermoregulation
Growth

17. Energy Requirements kcal/kg/day Basal metabolic rate 40
Physical activity 4+
Specific dynamic action of food (10%)
Thermoregulation variable
Growth
(To match in-utero growth of 15g/kg/day)

18. Protein
With glucose infusion alone, infants lose 1-2% of endogenous protein stores daily
1g/kg/day gives protein balance
2.5 to 3.5g/kg/day allows accretion
nb energy requirement
Safe to start soon after birth

19. Fat Energy source Essential fatty acid source (intralipid)
Cell uptake and utilisation of free fatty acids is deficient in preterm infants
Start at max 1g/kg/day, increasing gradually to 3g/kg/day (less if septic)

20. Benefits of PN Earlier, faster weight gain
Avoidance of problems associated with enteral feeds

21. Risks of PN Line associated sepsis
Line related complications (eg thrombosis)
Hyperammonaemia
Hyperchloraemic acidosis
Cholestatic jaundice
Trace element deficiency

22. Milk Feeds

23. Human milk advantages Protection from NEC Improved host defences
Protection from allergy and eczema
Faster tolerance of full enteral feeds
Better developmental and intellectual outcome

24. Human milk shortcomings if preterm
Human milk may not provide enough
Protein
Energy
Sodium
Calcium, phosphorus and magnesium
Trace elements (Fe, Cu, Zn)
Vitamins (B2,B6,Folic acid, C,D,E,K)

25. Breast milk fortifiers
Improved
short term growth
nutrient retention
bone mineralisation
Concerns
trend towards increased NEC

26. Term vs preterm formulas
Term formulas do not provide for preterm protein, calcium, sodium and phosphate requirements, even at high volumes
Term formula (vs preterm formula) fed infants
Grow more slowly
Have lower developmental score and IQ at follow up

27. Feeding preterm infants: aim
“To provide nutrient intakes that permit the rate of postnatal growth and the composition of weight gain to approximate that of a normal fetus of the same gestational age, without producing metabolic stress”
American Academy of Pediatrics Committee on Nutrition

28. Evidence Based Nutrition
RA Ehrenkranz, Seminars in Perinatology 2007 (31): 48-55

29. Catch-up Growth
Enhanced nutritional intake sufficient to allow ‘catch-up’ growth improves long term neurodevelopmental outcome

30. Body composition differences
Compared to term infants, ex-preterm infants fed at 120 kcal/kg/day
Have more body fat
Have a different fat distribution

31. Developmental Origins theory
Humans demonstrate ‘developmental plasticity’ in response to their environment
Part of cardiovascular risk may be explained by in-utero and postnatal growth

32. Developmental Origins theory
Geographically, coronary heart disease correlates with past neonatal mortality
In epidemiological studies, adult cardiovascular disease is associated with:
low birthweight
rapid early postnatal growth

33. Nutrition Assessment

34. How best to assess growth and nutrition?
Weight
Reflects mass of lean tissue, fat, intra- and extra-cellular fluid compartments
Length
More accurately reflects lean tissue mass
Head circumference
Correlates well with overall growth and developmental achievement

35. Laboratory assessment
TPN requires regular monitoring of acid base status, liver function, bone profile and electrolytes
In enterally fed infants, monitoring albumin, transferrin, total protein, urea, alkaline phosphatase and phosphate may be useful

36. Complication of TPN Infiltration under skin Infection
Liver dysfunction
Renal overload

37. Feeding development Swallowing first detected at 11 weeks
Sucking reflex at 24 weeks
Coordinated suck-swallowing not present till weeks
Swallowing to coordinate with respiration
Respiration>60-80 NG feeding
Respiration>80 high risk for aspiration (NPO)

38. Methods of feeding Oral feeding Naso-gastric (NG) feeding bolus
>32 weeks
Respiration<60-80
Try 20 minutes
Naso-gastric (NG) feeding bolus
NG feeding continuous
trans-pyloric
Gastrostomy feeding

39. Trophic Feeding Keeping infant fasting (NPO) Trophic feeding:
Decrease in intestinal mass
Decrease in mucosal enzyme
Increase in gut permeability
Trophic feeding:
small amount of feeding to prepare the intestine
release enteric hormones, better tolerance to feeds

40. Case
A 26 week female is born precipitously to a healthy 20 year old G1P1 with an uncomplicated pregnancy.
The baby is transferred to the NICU where a UAC and UVC are placed. You are getting ready to order fluids for this baby.
What is your goal growth for this infant?
What is this infant’s caloric requirement?
What fluids do you order?

41. Gastrointestinal Development
Fetal swallowing, motility in 2nd trimester
18 week fetus swallows 18-50ml/kg/day
Term ml/day
Fetal swallowing regulates the volume of amniotic fluid and controls somatic growth of the GI tract
Intestines double in length from weeks
Functionally mature gut by weeks
Intestine in final anatomic position by 20 weeks
Premature Infant GI tract:
Delayed gastric emptying seen in preterm
Breast milk, glucose polymers, prone positioning facilitate gastric emptying
Total gut transit time in preterm 1-5 days
Stooling delayed until after 3 days
 feeding volume ’s motility

42. Growth – General Facts Last trimester of pregnancy
Fat and glycogen storing
Iron reserves
Calcium and phosphoruos deposits
Premature babies more fluid (85%-95%), 10% protein, 0.1% fat.
No glycogen stores
The growth of VLBW infants lags considerably after birth

43. Growth Goals Weight: 20-30 g/day Length: ~1cm/week HC: 0.5cm/week
Correlates with brain growth and later development

44. Caloric Requirements for Growth
Preterm goal: ~120kcal/kg/day
Term goal: ~110kcal/kg/day
Total Fluid of enteral feeds required to deliver adequate calories for growth is ~150cc/kg/day

45. Total Parenteral Nutrition
Determine fluid requirement (mL/kg/day) for first day of life
Full-term infants: 60–80 mL/kg/day
Late preterm and preterm infants (30–37 weeks): 80 mL/kg/day
Very-preterm infants: 100–120 mL/kg/day
Determine Glucose Infusion Rate (GIR)
GIR: (% dextrose x IV rate ) ÷ (6 x wt in kg) Calculate GIR from known dextrose concentration (%).
Example: An infant weighs 2 kg and is receiving 100 ml/kg/day of dextrose 15% solution.
IV rate: 100 × 2 = 200 ml/day ÷ 24 = 8.3 ml/hr
GIR: (15% x 8.3 x ) ÷ 2 = 10.3mg/kg/min
(15% x 8.3 ) ÷ (6 x 2) = 10.3 mg/kg/min

46. Total Parenteral Nutrition
Protein and amino acids
Start with 2- 3 g/kg/day
Increase 0.5–1.5 g/kg/day to a total of 3–4 mg/kg/day
Goal for premature infants: 4g/kg/day
Goal for term infants: 3g/kg/day
Source: trophamine
Calculate electrolytes to add to bag
DOL#1: dextrose in water with no eletrolutes is usually appropriate except in premies with low Ca stores who may require Ca
DOL#2: add electrolytes to the bag based on estimated daily requirements and BMP
Estimated Needs:
NaCl = 2-4 mEq/kg/day
KCl = 1-2 mEq/kg/day (NOTE: Do not supplement K until UOP >1cc/kg/hr, especially in premies)
CaGluconate = mg/kg/day (NOTE: mg not mEq and Ca cannot be infused at >200mg/kg/day through a central line)

47. Total Parentral Nutrition
Other added nutrients
Lipids
Cystein
Phosphrous
Magnesium
Trace Minerals
MVI
Heparin

48. Total Parenteral Nutrition
Central TPN
Peripheral TPN
Easy to meet nutrition needs
No limits on osmolarity
Little risk of phlebitis
Long term use
May require general anesthesia
Greater risk of infection
Increased cost
Greater risk of mechanical injury, air embolism, venous obstruction
Unable to meet needs for Ca/Phos needs
Maximum rate of Calcium gluconate is 200mg/kg/d
Maximum % dextrose is 12.5%
Short term use
Less risk for catheter related infections
Lower cost ?
Less risk of mechanical injury, air embolism, venous obstruction
Total Parenteral Nutrition

49. Enteral Nutrition Breast milk is best!
The American Academy of Pediatrics (2005) recommends breastfeeding for the first year of life.
Started when an infant is clinically stable
Absence of food in the GI tract produces mucosal and villous atrophy and reduction of enzymes necessary for digestion and substrate absorption
Trophic hormones normally produced in the mouth, stomach, and gut in response to enteral feeding are diminished.
Breastmilk and standard infant formula have 20kcal/30cc (30cc=1oz)
Specialized formulas and fortifiers allow caloric content to be increased

50. Breastmilk Preferred source of enteral nutrition
Very well tolerated by most infants
Improves gastric emptying time
Matures the mucosal barrier
Promotes earlier &  appearance of IgA
Vastly ’s incidence of NEC
More significant induction of lactase activity compared to formula fed premies
Composition:
Varies with gestation
Varies according to maternal diet
Varies within a feeding( fat in last ½ fdg)
Varies within the day( fat in PM over AM)

51. Enteral Nutrition in the NICU
Term:
If clinically stable, start PO ad lib feeds and advance as tolerated
Preterm
Feeds are often initiated with breastmilk, Sim 20 or SSC 24
Trophic tube feeds may be continuous or bolus and advanced gradually (10-20mL/kg/day)
Transition to bolus from continuous typically begins after achieving full feeds
PO feeds typically attempted around weeks, when premies develop suck and swallow coordination
Premies are often supplemented with TPN as they work up on feeds
Goal discharge formula is Neosure 22

52. What to Feed?

53. What to Feed?

54. NICU

55. Energy and protein goals: TPN
Term:
Energy: kcal/kg/day
Protein: g/kg/day
Pre-term:
Energy: kcal/kg/day

56. 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

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

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

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

60. Vanilla TPN order Start with amino acids ASAP Dextrose: 8-18 g/kg/d
AA: g/kg/d
Fat: g/kg/d
Calcium: mg/kg/day
Phosphorous: mmol/kg/d
MVI & trace elements

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

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

63. 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

64. Too Little vs Too Much
Diamond 1995

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

66. Determining Caloric Requirements

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

68. 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

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

70. Espghan Guidelines
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

71. 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

72. 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

74. Causes of Diarrhea in Enterally Fed Children

75. 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%

76. 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.

77. 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.

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

79. 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

80. 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

81. Nutrition Support in the ICU is not generic but:
Patient specific
Disease specific
Macro and Micronutrient specific
Biochemically specific
Stage specific

82. Nutritional Support of the VLBW Infant

83. 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

84. 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

85. 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

86. 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

87. 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

88. 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

89. 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

90. 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

91. Parenteral Nutrition for VLBW Infants

92. 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 ( gm/kg/day) and calories ( kcal/kg/day) as quickly as possible.

93. 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 g/kg/day over the first few days of life.

94. Establishing Enteral Feedings

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

96. 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.

97. 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 mL/kg/day.

98. 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.

99. Human Milk and Breastfeeding

100. Transition to Oral Feedings

101. 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.

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