1. Enteral Nutrition in Infants

2. PICU-associated malnutrition
Metabolic stress response
Estimations of energy requirement
Prescription and Delivery
Preexisting deficiency/reduced somatic stores
***talk about when RD sees pt; the royal children’s hospital in australia median of 37.7% of daily EER (n= 42); half pts achieved EER after median of 7d. (fluid restriction main issue)
Mehta and Duggan (2009), Hulst et al. (2006), Rogers et al. (2003)

3. Nutrition Goals for the PICU
Meet energy requirement
Minimize protein catabolism
Wt gain not the goal post-injury (CRP <2mg/dL = anabolism)
Mehta and Duggan (2009)

4. Preterm definition
Preterm: birth date before 37 completed weeks gestation.
Gestational age: time elapsed between the first day of the last menstrual period and the day of delivery.
Number of weeks preterm: 40 weeks minus gestational age. 
Chronological age: time elapsed since birth. 
Postmenstrual age: gestational age plus chronological age in weeks.
Corrected age: chronological age minus number of weeks preterm.

5. Birth weight
Birthweight is the first weight of the newborn obtained after birth (ideally within one hour of delivery). 
Low birthweight (LBW)<2500 g. 
Very low birthweight (VLBW)<1500 g.
Extremely low birthweight (ELBW) <1000 g.

6. Which weight?
Use the patient’s actual weight when calculating nutrient requirements, unless the actual weight is lower than the birth weight

7. Energy Expenditure
Pediatric patients may not exhibit significant hypermetabolism post-injury
Decreased physical activity, decreased insensible losses, and transient absence of growth during the acute illness may reduce energy expenditure
Newborns undergoing major operations have a transient 20% increase in energy expenditure that returns to baseline within 12H without complications; 25-30% accounted for activity; talk about Hasbro Children’s Hospital, n = 44
Mehta, N. and Duggan, C. (2009); Mehta, N. et al. (2009); Hardy Framson et al. (2007); Vasquez Martinez et al. (2004); Hardy et al. (2002); Briassoulis et al. (2000); Letton et al. (1995), Agus and Jaksic (2002)

8. Energy Requirements
Standard equations to predict energy needs unreliable
Indirect calorimetry is the gold standard to accurately predict REE
Hardy et al. (2002), Vazquez Martinez et al. (2004), Fung (2000), Sy et al. (2008), Briassoulis et al. (2000), Verhoeven et al. (1998)

9. DRI vs. REE Age DRI (kcal/kg) REE (kcal/kg) 0-3 mon 102 54 4-6 mon 8280 51
13-35 mon 56
3 y 85 57
4 y 70 47
5-6 y 65
7-8 y 60

10. Kcal Requirements Age kcal/kg/d 0-3 month 120 kcal/kg/d 3-6 month
1-2 year
70 kcal/kg/d
Over 2 year
60kcal/kg/d

11. Kcal Requirements: Intubated > 12 months
Kcal goal = REE
WHO, Schofield, White equations
3y: ~60kcal/kg
4-8y: ~50kcal/kg
Activity and injury factors not routinely used
(exception): REE x 1.2 for intubated burn pts
Kcal used for growth in older children ~ <5%
Agus and Jaksic (2002), Hardy Framson et al. (2007)

12. Kcal Requirements: Extubated
Kcal goal = DRIs for age/gender
Catch up growth may be necessary
(DRI x IBW) ÷ actual wt (kg)

13. Determining Caloric Requirements

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

15. Protein Requirements Age DRI (normal) PICU 0-6mon 1.52g/kg/day
1.2
2-3
13-23mon
1.05
24mon-3y
1.5-2
4-13y
0.95
14-18y
0.85
1.5
***may require further increases in protein provision with burns, ECMO, bacterial sepsis

16. Enteral Nutrition Whenever possible, feed the gut
GALT/reduce risk for bacterial translocation
Trophic feeds: ≤20ml/kg/day
Continuous feeds
Advance by 0.5-1ml/kg Q4-6H

17. Infant Formulas Term formulas: standard concentration 20kcal/30ml
Preterm formulas: 24kcal/30ml
Preterm transitional formulas: 22kcal/30ml
Can increase up to 30kcal/30ml
Increase concentration by 2kcal/30ml increment
Use infant formulas to concentrate MBM in term AGA pts, not HMF

19. Other Formula Considerations
≥10yr: can use adult formula
Standard Isotonic with Fiber
Standard Isotonic
High Calorie 1.5
***Children >10yr w/ MRCP or with malnutrition may still require pediatric product due to wt age <10yrs

20. Preterm Infants

21. 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

22. 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

23. 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

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

25. 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

26. 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

27. 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)

28. Preterm> 1500 gram Aim to feed at least 180ml/kg/day BMF.
Some babies will tolerate volumes of up to 220ml/kg/day and in cases of poor growth.
Monitor growth and supplement with breast milk fortifier (BMF) where necessary.  
Infants receiving unfortified BMF will require MV, iron, folic acid, phosphate and sodium supplementation 

29. High risk infants <27 weeks or <1000g birth weight
haemodynamically unstable on inotropes 
previous NEC or high risk for NEC
recent abdominal surgery 
growth restricted infants with absent or reversed end diastolic flow 

30. 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
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

31. What to Feed?

32. What to Feed?

33. Intorlerance
Infants <1000g: >2ml gastric aspirates every four hours (10-20ml/kg/day). 
Infants >1000g: >3ml gastric aspirates every four hours (15-20ml/kg/day). 
vomiting 
bile-stained aspirates
abdominal distension 
abdominal discolouration 
blood per rectum 
increase in stool frequency 

34. Route of feeding
There is no evidence to suggest an advantage of continuous feeding over bolus feeding
Continuous feeding (rather than bolus feeding) may be useful in infants with gut resection, severe respiratory problems and high output stomas. Infants receiving naso-jejunal feeds must be fed continuously
Most infants <35 weeks gestation will require orogastric, or naso-gastric tube feeding

35. Milk Feeds

36. 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

37. 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)

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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

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

47. 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

48. 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

49. Causes of Diarrhea in Enterally Fed Children

50. 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%

51. 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.

52. 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.

53. Nutritional Support of the VLBW Infant

54. 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

55. 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

56. 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

57. 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

58. 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

59. Establishing Enteral Feedings

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

61. 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.

62. 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.

63. Transition to Oral Feedings

64. 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.

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