This document provides guidelines on neonatal nutrition and fluid management. It discusses the goals of ensuring growth, fluid homeostasis, normal electrolyte levels, and providing macro/micronutrients. For premature infants, it notes their higher fluid content and lack of stores. Guidelines are given for fluid intake and adjustments based on output and monitoring. Enteral feeding should begin with trophic feeds and slowly increase intake. Total parenteral nutrition provides calories and nutrients. Complications of feeding methods and developing feeding skills are also outlined. Breastfeeding is recommended where possible, with techniques and supports discussed.

1. Neonatal nutrition
MILI SARKAR
Dietician

2. Goals
• Ensure continuation of growth by giving
enough calories
• Provide balance in fluid homeostasis
• keep electrolytes normal range
• Avoid imbalance in macro-nutrients
• Provide micro-nutrients and vitamins

3. General facts about neonatal fluid
and nutrition
• Last trimester of pregnancy
– Fat and glycogen storing
– Iron reserves
– Calcium and phosphorous deposits
• Premature babies more fluid (85%-95%),
10% protein, 0.1% fat. No glycogen stores
• Insufficient protein & calories is life
threatening to the sick

4. Guidelines fluid management
• 80 cc/kg/day, increase to 100-120cc/kg/d with
increase IWL
• Increase to 100cc/kg/d 2nd day
– add sodium 2-4 mEq/kg/d and K= 2 mEq/kg/d.
– Calcium may be added
• after 2nd day adjust according to
– urine output 2-3cc/kg/hour with 110-140cc/kg/d
– Specific gravidity 1.008-1.012,
– watch weight change,
– total in/out

5. Nutritional pathway for premature
infant
• Day1, parenteral glucose 5-7mg/kg/minute
– Watch blood sugar
– Electrolytes check at 24 hours
– Consider trophic feeding
• Day2, TPN if not feeding
• Day 3 or more: enteral feeding slowly increased
20cc/kg/day
– 1.5kg= 30cc/day =2.5cc every 2 hours
• Day10-20, full nutrition

6. Energy use in body
• Resting energy use 45 kcal/kg/d
• Minimal activity 4 kcal/kg/d
• Occasional cold stress 10 kcal/kg/d
• Fecal loss of energy 15 kcal/kg/d
• Growth 4.5kcal/gm 40-45 kcal/kg/d
• Total 110-120 kcal/kg/d

7. Distribution of energy sources
• Glucose 16.3gm = 55 kcal/kg/d…. 50%
• Protein 3.1gm =12.5 kcal/kg/d…12%
• Fat 4gm = 40 kcal/kg/d…38%
• Total 108 kcal/kg/d

8. Total parenteral nutrition (TPN)
• growth of 10-15gm/kg/day weight gain
– 3gm/kg/d protein (amino acid)
– 3gm/kg/d fat (Fatty acid)
– 16gm/kg/d Dextrose 10-25%
(carbohydrate)
• this will give100-120 k. calories /kg/day

9. others
• Minerals
– Zinc, copper, molybdenum, chromium,
selenium
– Calcium, phosphorous, Magnesium
– Na, K
• Vitamins
– Fat soluble
– Water soluble

10. Biochemical testing for patient on
TPN
• Urine glucose
• Triglyceride
• BUN, Albumin
• Ca, P, Mg, creatinine, Na, Cl, CO2
• direct (conjugated) bilirubin, ALT
• Trace element level

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

12. Feeding development
• Swallowing first detected at 11 weeks
• Sucking reflex at 24 weeks
• Coordinated suck-swallowing not
present till 32-34 weeks
• Swallowing to coordinate with respiration
– Respiration>60-80 NG feeding
– Respiration>80 high risk for aspiration (NPO)

13. WHO – BREAST FEEDING
Recommendation
The World Health Organization recommends
exclusive breastfeeding for the first six months
of life, with solids gradually being introduced
around this age when signs of readiness are
shown. Supplemented breastfeeding is
recommended until at least age two, as long
as mother and child wish.

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

15. Trophic Feeding
• Keeping infant fasting (NPO)
– 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

16. Enteral feeding
• 40-45% of calories are coming from
carbohydrates (Lactose or glucose
polymer)
• Protein requirement of infant is 2.2-4.0
gm/kg/d
• Protein is whey predominant 60:40

17. Breast feeding
• after delivery baby has metabolic reserves
• Hepatic glycogen
• Brown fat
• Extracellular and extra vascular water
• milk production is stimulated
• Try to get baby onto the breast within first
1-2 hours of life
• Colestrum ; high in protein &
immunoglobulin

18. Breast feeding
• Q2-3 hours = 8-12 feeds per day
– Quicker gastric emptying
– frequent breast stimulation and emptying increase milk supply
– Watch for feeding cues
• Duration
– 10 minutes or longer
– As long as swallowing continues
• Cluster feeds is normal
• Growth spurts
– Baby may feeds more frequently for 1-2 days
– Many growth spurts at 2wks, 6, wks, 2-3 months, and 5-6
months they feed more during them

19. Breast feeding
• Ineffective if baby sucks from nipple only
• Nipple and areola must be drawn deeply
into baby’s mouth
• Listen for infant swallowing
– DOL#1: intermittent swallows
– DOL#2 on: 1 swallow : 1-3 jaw excursions

20. Maternal factor of low milk
• Gestational diabetes
• Hypothyroid
• Retained placental fragments
• Dehydration, hemorrhage, hypertension, infection
• Previous breast surgery
• Lack of prenatal engorgement
• Psychosocial
– Previous unsatisfactory experience
– Lack of partner support
– Post-partum depression
– Separation from infant

21. Milk is what you eat
• Mom’s need extra 500kcal/day if breast
feeding
• Caffeine
– Limit to 1-2 cups/day
– Babies may become overstimulated, fussy
• Spicy and gassy foods reflects

22. Infant illness that affect breast
feeding
• Prematurity
– Co-ordinated suck-swallow-breathing reflexes at 32-34 weeks
• SGA, IUGR
• Twins
• Cleft lip and Palate, Micrognathia, Ankyloglossia, Macroglossia
• Jaundice
• Neuromotor problems
• Birth asphyxia
• Cardiac lesions
• Infection
• Surgical problems

23. Do I have to wake my baby to
feed?
• Should wake baby during first 2-3 weeks
while milk supply is being established
• Once milk supply good and baby back to
birth weight can allow baby to go 5 hours
during a 24 hour period without a feed
• If milk supply decreasing should reinstitute
night time feed

24. Is my milk enough???
• 8-12 feeds per day to 6-8 weeks of age
• Frequent swallowing
• Adequate urine output (2-6 times/day)
• Adequate stooling
• Yellow stools by DOL#4
• Weight loss no greater than 8% of BWT
• Weight gain 15-30 grams/day
• Good skin turger, moist mucous membranes
• Contentment 1.5-2 hours after feeds

25. Enough milk
• Breasts feel full before and softer after
feeds
• Milk leaks from contralateral breast during
suckling
• Sensation of milk ejection ⇒ pins and
needles
• Absent nipple trauma and pain
• Profound state of relaxation in mom during
suckling

26. Human milk
• Human milk is Ideal food for full term
infant
• Inadequate components for premature
infant <1500gm (human milk fortifier
needed to be added)
– Protein
– Vitamin D
– Calcium
– Phosphorous
– Sodium

27. Breast feeding
• Foremilk
• Hind milk

28. Nonnutritive sucking
• Pacifier
– In premature
• ?/ no effect (wt gain, hospitalization, improved
oxygenation, faster oral feeding)
• May give infant comfort and calm more
quickly
• In term infant nipple confusion with bottle
and pacifier against breast feeding

29. Breast milk substitutes
Exactly there is no equal substitute for
Mothers Milk
Occasionally the artificial milk have to be
given to adopted babies or those who lost
mother .
Liquid milk consumed by the family should
be utilized, the powder should be strongly
discouraged.

30. Premature formulas
• lack natural standard
• 50% lactose and rest glucose polymer
• Protein
– 150% in amount of term formula
– Whey predominant
• Fat 50% LCT 50%MCT.
• Higher Ca, P, higher Ca : P ratio of 2:1
• Long chain polyunsaturated fatty acids

31. Standard infant formula
• 100% lactose
• Fat is all long chain triglyceride
• Protein is whey 60%, casein 40%
• Iron fortified 12mg/liter and low iron versus
low 1.5mg/liter (should not give it)
• Ready to feed or prepare from powder

32. Soy formulas
• Lactose free
– Primary and secondary lactase defeciency
– Galactosemia
• Carbohydrate is sucrose or corn syrup
• Fat is vegetable oil such as coconut oil
• Not recommended in very low birth weight
infant related to weight gain and
osteopenia.

33. Case two
• 3.5 Kg mother wants to breast feed her
infant. She is primi-gravida
– Is small amount of milk in first 3ds enough
– How to encourage her to continue breast
feeding
– Signs of successful breast feeding
– For how long breast feeding to continue
– Discuss AAP guideline
– Baby jaundice at 2 weeks

34. Case 3
• 1.4 kg baby born at 30 week and has RDS
– Discuss fluid management in first 3 days
– How to feed him
• Amount
• Rate of increase
• Type of formula
• Risks of fast feeding

35. Conclusion
I have insufficient milk to feed my child" or "my baby is
having an aversion to breast. He simply turns his face
away "Scientists have proven from time to time that these
statements are not true.
Many mothers expect that breast milk must flow just like
bottle milk.
THEY OFTEN FORGET THAT BOTTLE MILK IS
LIFELESS & BREAST Milk ARE FULL OF LIFE.
"IF THERE IS A WILL THERE IS MILK ALWAYS" is a
ALWAYS
medical dictum

36. The end !
Thank you for
completing this
module