np[nmp

1. Nicola Pritchard
Oct 2020

2.  Immediate risk of hypoglycaemia
 High protein requirement
◦ Rapid protein deficiency if on dextrose
 Known long-term adverse effects of poor nutrition
◦ Poor growth
◦ Poorer neuro developmental outcome
◦ Reduced tolerance to infection
 Poor neutrophil function
 Reduced Ig A response

4.  High energy expenditure
 Respiration
 Sepsis
 Heat generation
 Growth
 Switch from continuous to intermittent supply
 Variable oxygenation
 Increased use of anaerobic metabolism
 Gut immaturity limiting enteral tolerance

5. We are aiming for Intra-Utero Growth Rates
 ENERGY
 110-130 kcalories/kg/day
 AMINO ACIDS
 At least 2.5g/kg/day ideally >4g/kg/day
 FATS
 3-4g/kg/day
 Adequate vitamins/iron/phosphate

6.  10% Dextrose
 150mls/kg/day = 51kcal/kg/day
 <40% of a infants daily calorie requirement
Imagine being on a
800kcal/day diet with
no vitamins, iron
protein or fats
when you are
unwell and trying
to gain weight and grow…

7.  Requirements 3.5-4.5g/kg day
 On10% dextrose
Loose up to 1g protein/kg/day
 Can be seen
◦ Poor weight gain
◦ Poor head growth
◦ Low urea levels
◦ Low albumin
◦ Peripheral oedema

8. Term
Breast
milk
Preterm
Breast
milk
Fortified
Breast
milk
Preterm
Formula
NEDPF Term
formula
High
Energy
Term
Formula
150mls/kg/day
Calories 88% 75% 75% 88% 80% 88% 90%
Protein 70% 90% 57% 88% 68% 88% 75%
165mls/kg/day
Calories 92% 82% 97% 97% 88% 82% 120%
Protein 79% 100% 97% 97% 75% 63% 82%
180ml/kg/day
Calories 100% 90% 100% 100% 100% 70% 68%
Protein 86% 100% 100% 100% 81% 69% 90%

9. Breast feeding
unless
contraindicated

10. Why Breast feed?
 Immediate Benefits
 Nutritionally complete
 Hormones
 Growth factors
 Nucleotides
 Enzymes eg Lactase
 LC PUFA
 Live cells

11. Breast feeding -Longterm
 Long term Benefits
 Small effect BP (2mmHg)
 22% reduction in adult obesity
 Reduced cholesterol
 19-27% reduction IDDM
 39% reduction NIDDM
 36% reduction SIDS
 4.9 points IQ

12. Exclusive Breast Feeding UK
Infant Feeding Survey 2010
 81% Initiation rates
 46% exclusive at 1 week (69% mixed feeding)
 23% exclusive at six weeks (55% mixed feeding)
 1% at five months (34% mixed feeding)
 Reduction
 Second baby
 Socioeconomic
 Education
 Age of mother
ONS 2010(published 2012)

13. Economic Model
Paediatric Savings
IF : 45% exclusively breastfeeding at 4 months
and 75% of babies breastfed at NNU discharge
 3,285 less GI infection hospital admissions
10,637 fewer GP visitations
 £3.6 million annual savings
 5,916 less LRTI infection-related hospital
22,248 fewer GP consultations
 £6.7 million annual savings
 21,045 fewer AOM-related GP visits
 £750,000 annual savings

14. NEC Cost Savings
361 less cases
Increased Breast
Feeding
Potential savings
 Discharged on breast milk in
NNU increase 35% to 50%
 Increase to 75% at discharge
 Any breastmilk increase from
the current 35% to 100%
 Decreased NEC = 2.3 million/yr
 Decreased NEC = 6million/yr
 Decreased NEC = 10million/yr

15. UNICEF Baby Friendly
 Breast feeding Policy
 Education and Advice
 Early first feed
 Skin-to-skin
 Privacy
 Adequate rest, food and drink
 Support for expressing
 Formula milk should not be given to breastfed
babies unless medically indicated.
 Avoid dummies

16. When should a new mother
be advised against breast-
feeding?
 Diagnosis of galactosaemia
 Pregestamil or soya formula
 +/- HIV
 +/- Hepatitis B
 IMPORTANT WHO Advice
 All infants must be managed individually; insufficient
growth or other adverse outcomes not to be ignored

17. Mastitis
 Women should be offered assistance & advice
 Positioning and attachment
 Continue breastfeeding and/or hand
expression
 Analgesia compatible with breastfeeding
 Increase fluid intake.

18. Advantages of
Pre-term Maternal Milk
 Higher macrophages and Ig A
 More energy, lipid, LC PUFA, Protein, iron and
phosphate and vitamins
 Skin to skin – Maternal Ig A transfer

19.  Early expression < 6 hours and definitely < 24 hours
 Regular expression ( 8x in 24hrs)
 Mum and baby together
 Consider from 32 weeks if well (be led by feeding cues not gestation) alongside
NGT to maintain nutrition
 Non-nutritive sucking when ngt feeding
 Skin to skin kangaroo care daily if possible (with good thermal care)
 Frequent small feeds
 Monitor growth
 Mixed evidence re cup/bottle/ngt and BF at discharge
 However mum needs to be with baby for him or her to learn to breast feed
Focus on:
Ensuring maximum mum and baby time together with adequate good quality
breast feeding support
Supporting Breast feeding
Preterm Infants

20. Milk Banks
Collection of donor “drip milk” from term mothers
 Positive
 79% reduction in NEC
 But
 NOT preterm milk
 Often fore rather than hind milk
 Lower protein, sodium zinc and copper
 Loss of “live” immune protection
 Viral infection risk

22. Preterm Formula
 Standard preterm formula
 Usually until 2-2.5kg
 More calories and protein than breast milk
 Amino acids similar to breast milk
 LC PUFA
 Vit D
 Prebiotics

23. NEC Risk
Formula vs EBM
 Exclusively formula fed
 6 x rate of NEC
 Mixed BF and formula
 3 x rate of NEC
 Breast Milk
 Matures GI tract
 Alters bowel flora
 Source of growth factors
 Matures and provides immune factors

24. How to feed the Preterm Infant
 EARLY
 Start iv nutrition Day 1 (<30 weeks < 1500g)
 Start enteral feed by day 1-2 unless unstable or high NEC
risk
 Ventilation or UAC is not contra-indication
 EBM is best
 Consider waiting or start preterm formula?
 Trophic /Minimal enteral feeds
 1ml/kg/hour 0R 20mls/kg/day
 Early start, slow progression
 Increase 10-30mls/kg/day

25. TPN
 Aim:
 90% of those infants < 30 weeks and < 1500g
receive PN within 48 hours

26. Why Trophic Feeding
Non-nutritional <25% of total feed requirement
(10-20mls/kg)
 Theoretical Benefits
 maturation of intestinal digestive, absorptive, motor
 stimulates gastro intestinal immune function
 improves cholestasis
 prevention of intestinal bacterial overgrowth and
bacterial translocation (pre and probiotics)
 prevents luminal atrophy and increase mucosal
mass(growth factors)

27. Why Trophic Feeding
 Cochrane REVIEW
 Total hospital stay
 days to achieve full enteral nutrition
 No days feeds withheld due to intolerance
 Normalises hormonal function
 switches off insulin production
 Some evidence to support reduced infection rates
Risks
 NEC is not increased by feeds with or without UAC

28. Other Preterm Feeding Issues
 Orogastric vs Nasogastric (Obligate nose breathers)
 Transpyloric (Cochrane 2008 no difference)
 No statistically significant differences NEC, perforation or aspiration
pneumonia
 Continuous vs Bolus (Cochrane Nov 2011 Insuff evidence)
 Demand vs Timed (Cochrane 2008 Insuff evidence)
 Non-nutritive sucking
 Developmental progress
 Reflux ???......(Gaviscon)

29. Pre-term:
Post Discharge Formula
 Most pre term infants discharged small for
gestation
 Rapid growth – high calorific requirement
 Can consume 300mls/kg/day normal formula
 Not an issue if tolerated
 Increased risk of long-term growth failure
 Better catch up
 Theoretically better brain growth – but not proven

30. Post discharge Formula
ESPHGAN position statement May 2006
 If appropriate wt for gestn: Breast or term
formula
 Post discharge formula if not
 How long?
 At least until CGA 40 weeks
 Possibly until CGA 52 weeks
 EG Nutriprem 2
 Halway between preterm and term formula
 NB No evidence of difference in growth in Cochrane review 2007

31. Always respond to feeding cues where possible
Consider FULLY RESPONSIVE if > 34 weeks
Remember that “late pre terms” 34-36 weeks
 May not fully empty the breast
 Sleepiness or fatigue,
 Difficulty maintaining a latch because their oro-buccal coordination and
swallowing mechanisms are not fully matured
 Encourage post feed expression to encourage milk production
 Monitor weight and health (pre and post discharge)
AND
 Birth> 1500g and > 30 weeks
 Tolerating 3 hourly feeds
 At least 4 sucking feeds
 Waking and showing feeding cues
 No weight gain concern
 No active medical problems
 Blood sugar stable at 6 hours between feeds
Responsive Feeding

32. For more vulnerable preterm infants
WHY?
Do not demonstrate predictable demand-feeding behaviours until
close to term
WHO?
 Not yet fully on all sucking feeds
 Feeding cues but <4 sucking feeds
 Born with risk factors for growth
 Birth < 1500g or < 30 weeks gestation
 Slow or not gaining weight on full responsive feeding
 High nutritional requirements
 Eg Chronic lung disease, cardiac disease,
Modified Responsive

33. What the Mum’s want to know

34. Pre and Probiotics
 Breast fed infants colonised within 12-24 hrs
 Bifidobacteria and Lactobacilli
 Fermentation of carbohydrates
 Causes fall in colonic pH
 Favours growth of non-pathogenic species
 Improved mucosal barrier

35. Pre and Probiotics
Prebiotics
Currently Added
Probiotic
Some evidence
 Non-digestable
oligosaccharides
 Mimics breast milk
 Promotes bowel flora
similar to breast fed
infants
 Introduced recently into
preterm formula
 The Preterm Prebiotic Study Imperial College
Neena Modi, ?Improved feed intolerance
 Live microbial food
supplement
 Colonise GI tract
 Synthesise
 Short chain fatty acids
 Amino acids
 ?Infection risk
 ?How much
 ?Regulation
 ?Which organism

36. Prebiotics in Formula
 Stool flora similar to breast fed infants
 ?Reduction in diarrhoeal episodes
 Prebiotics for prevention of allergic disease or
food reactions
 Insufficient evidence COCHRANE 2008

37. Probiotics & Preterm Infants
 Reduces the occurrence of NEC (stage 2) and death <1500g
 No evidence of significant reduction of nosocomial sepsis
 However most at risk infants <1000g
 Insufficient evidencce
 Risk of bacteraemia in smaller infants?
 Cochrane 2008 review of 1425 no cases of sepsis
 Several case reports septicaemia with Lactobacillus
Cochrane 2008

38. PIPS study 2016
 A multi-centre, double blind, placebo-controlled
randomised trial of probiotic administration in
 Preterm infants (<31 weeks)
 Single probiotic strain Bifidobacterium breve
• Theory
Reduce translocation of bacteria from GI tract
Therefore reduce rates of complications such as
NEC
• Outcomes – no difference
Episodes of NEC
Late onset sepsis
Death
• HOWEVER Meta analysis have consistently shown
NEC reduction

39. When to Start Sucking feeds?
 Liase with Nurses
 What should you consider?
 Respiratory stability
 Temperature stability
 Weight gain
 Post gestational age
 Time between feeds
 Safe swallow?
 How can sucking/breast feeding be encouraged?
 Non nutrative sucking
 Kangaroo care
 Rest periods

40. Normal Development
 Post gestational Age
 11 weeks Sucking movements
 15 weeks Swallowing movements
 28 weeks Sucking bursts
but uncoordinated
 32-34 weeks Suck swallow respiratory
coordination begins. Breast
feeding can be established
 37 weeks Mature suck swallow

41.  Good evidence any nutritional guideline
improves growth outcomes
 Joint collaboration
◦ Consultant
◦ Senior Nursing Staff
◦ ANNP
◦ Junior doctor
◦ Southampton nutrition guidelines
◦ SIFT results

42. 5%
15%
35%
23%
12%
7.5%
2.5%
42%
33%
21%
5%
2%
0 0
0
2
4
6
8
10
12
14
16
18
20
0 centiles 1 centile 2 centiles 3 centiles 4 centiles 5 centiles 6 centiles
2010 2015

43. 5%
18%
61%
8% 8%
16%
56%
20%
8%
0%
49%
12%
37%
2%
0%
0%
10%
20%
30%
40%
50%
60%
70%
Breastfed Breastfed + formula Formula Hydrolysed formula Unknown
2010 2013 2015
< 32 weeks
Receiving breast milk on discharge
2015 60%
2017 72.6%
2018 74% ( National 59.6%)
2019 64%

44. High
• Preterm <28 weeks OR ELBW < 1000g
• Severe IUGR (weight < 2nd centile with AREDF) <35 weeks
• Post NEC or GI abnormality
• Hypotensive/unstable ventilated neonates
Medium
• Moderate IUGR (weight < 9th AND AREDF) <35 weeks
• Baby on inotropes or indomethacin/ibuprofen
Low
• Preterm 28-36+6 weeks, otherwise well
• VLBW 1000 -1500g
• AREDF / IUGR >35 weeks
• Term Infants >37 weeks

45. High
• Breast Milk (Nutriprem 1 but consider waiting for EBM)
• Start Trophic feeds when stable: 10-20mls/kg/day hourly
• Increase by 10mls/kg every 12 hours
• Continue until 180mls/kg unless feed intolerance
• Move to 2-4 hourly as tolerated
Medium
• Breast milk ( Nutriprem 1)
• Day 1: 20mls/kg/day hourly feeds
• Increase by 15mls/kg every 12 hours
• Continue until 150 -180mls/kg unless feed intolerance
• Move to 2-4 hourly as tolerated
Low
• Breast milk (Nutriprem 1 or term formula if >36 weeks)
• Start at 2-4 hourly feeds
• Increase by 30mls/kg every 24 hours
• Continue until 150 -180mls/kg unless feed intolerance

46. Slower increase 18mls/kg/day
No increased line infection
TPN 2 days longer
Faster increase 30mls/kg/day
No increased NEC
 Advantage
◦ reduced NEC risk
 Disadvantage:
◦ increased duration of TPN
◦ line associated sepsis
◦ TPN related liver disease
◦ ?Longer hospital stay
 Advantage
◦ decreased duration of TPN
◦ Decreased line associated
sepsis and liver disease
◦ ?cheaper
 Disadvantage
◦ increased NEC risk

47.  2004 Cochrane review Kuschel and Harding
◦ 13 randomised controlled trials
◦ Outcomes for preterm infants fed with fortified EBM
◦ Use of fortifier was associated with
 Improved weight gain
 Improved linear growth
 Improved head growth
◦ No significant increase in adverse outcomes, including NEC
◦ However studies did not include sicker infants

48.  At risk
◦ < 1kg (ELBW)
◦ < 28 weeks
◦ Previous GI surgery or NEC
 Fortified milk
 Symptoms of abdominal obstruction
 Milk curd blocking ileum

49. <1.5 kg
AND < 32 weeks
•Breast milk
•Consider BMF once
>150mls/kg
•Aim for minimum
165mls/kg
•Further increase to
180mls/kg if poor
weight gain
>1.5kg
AND < 32 weeks
•Breast Milk
•Increase to
180mls/kg
•Consider BMF if
poor growth or
tolerance
>2kg OR > 34
weeks
•Breast milk
•Increase to
165mls/kg
•Increase to
180mls/kg of poor
growth
EBM with fortifier is equivalent to Preterm formula (Nutriprem )
therefore 165mls/kg of preterm formula may be adequate for growth

50.  Step down from preterm formula
 Available on prescription after discharge
 For infants on a preterm formula or a
supplement for breast fed infants

51. Who? When
Consider for formula fed
 Infants <34 weeks
AND
 Birth weight < 1.8kg
AND
 No growth concerns
◦ Maintaining centile line on
a Nutriprem 1
 >1.8kg
OR
 >36 weeks
OR
 1 week (min 48hrs)
prior to discharge

52.  Continue preterm formula (Nutriprem1)
 ?Increase volume
 Medical review for reasons for poor growth
 If pre discharge needs nutritional plan for
going home

53.  Post term with good growth
 Breast feeding or EBM with good growth
 At clinic follow up after discharge
 Consider if
◦ Corrected gestational age > 6 months
◦ Post weaning
◦ Growth on birth centile feeding good volumes

54. All breast milk fed preterm infants < 34 weeks
require
 IRON : Sytron 1ml once daily
◦ From day 28 until age 1 year
 VITAMINS: Abidec 0.6mls once daily
◦ Once on full milk feeds
◦ From day 7 until age 2 years
◦ To ensure adequate vitamin D
◦ (Remember term breast fed infants need 0.3mls OD)

55. But not too well….
Everyone wants the babies to feed and grow well!
More than one way to
achieve this

57. Thank
you

59.  Options
◦ Increase volume 165mls/kg per day minimum
◦ Check for other reasons
◦ Fortify?
 Evidence for fortifying milk
◦ Short term improved weight gain
◦ No evidence for increase in NEC
◦ ? Osmolality

60.  Max volumes of EBM tolerated first
 Only use after first 2 weeks
 Fortify milk as close as possible to the feed
time.
 Assess closely for feed intolerance
 Change only one thing at a time
 Do not use if strong FHx of atopy
 Don’t add to preterm or term formula

61.  What is feed intolerance
◦ Aspirates
 >2mls/kg/hour
 >50% of last 3 hours of feeds
 Increased from previous pattern
◦ Vomiting
◦ Abdominal distention
◦ Abdominal tenderness
◦ Abnormal stools
◦ Systemic signs eg apnoea/lethargy/bradycardia

62.  Significance/Severity
 CAUSE!
◦ Sepsis
◦ NEC
◦ PDA/Cardiac Failure
◦ Respiratory Deterioration
◦ GORD
◦ “CPAP” Belly
◦ Slow transit and BNO
◦ Immature gut
◦ Milk protein intolerance

63.  Investigate and treat - consider
◦ Septic screen
◦ Stool culture
◦ X-ray
◦ Contrast Study
◦ FOB (Interpret with caution)

64.  Treat cause if known
 Stop feeds –
◦ WITH PLAN
 Omit one feed
 Restart feeds at lower volume and more frequent
 Start antibiotics restart feeds within 12 hours if stable
 Stabilise respiratory eg intubate and restart feeds within 4 hours
 NBM Start NEC regime
 Consider PN via CVL
 Consider suppository
 Consider Milk change

65.  Term Infant of an IDDM Day 3. Well
◦ Requiring 120mls/kg 20% dextrose to maintain
blood sugar
◦ Mum wants to breast feed as baby appears hungry?
 Why will milk feeds be a problem?
◦ Infant hyperinsulinaemic
◦ Feeds stimulate insulin secretion

66.  No oral feeds until at least 2 normal blood sugars on 10%
dextrose
 May need PN?? (should already have CVL)
 Hourly feeds until stable BMs
 Progress to full volume feeds
 Only increase time between feeds once off dextrose
 May need to only increase time between feeds 24 hourly
 Won’t be able to effectively breast feed until on 2-3 hourly
feeds
 Needs lots of parental counselling
 Often “stuck for days/weeks”

67.  Why?
◦ Sepsis
◦ NEC again??
◦ Perforation
◦ Slow transit
◦ Malabsorption/lactose intolerance
◦ Cows milk protein intolerance
◦ Stricture
◦ Small bowel overgrowth
◦ Post NEC surgery
 Short bowel

68.  Exclude sepsis
 Xray
 Contrast study
 Stool reducing substances (if diarrhoea)
 FOB
 Surgical Opinion
◦ Check op notes for length bowel affected and/or
removed

69.  Treat sepsis
 Surgical review
 Restart feeds lower volume and/or more frequent
 Suppository
 Slow regrade 10mls/kg/day is asymptomatic
 Consider alternative milks
◦ EBM only
◦ Lactose free
◦ Partially or fully Hydrolysed (with high MCT content)
◦ Elemental
◦ Use PN to bridge gap

70. ◦ Maximise anti- failure treatment
◦ Adequate sodium?
◦ Increase volume cautiously
◦ Nasogastric feeds
◦ Higher calorie feeds
◦ May have bowel wall oedema and malabsorption

71.  Concentrating formula? - caution
◦ Powder first water second
◦ 0.8 kcal/mL
 SMA High Energy (0.9kcal/ml)
 Infatrini (1kcal/ml)
 Similac (1kcal/ml)
 Duocal – carbohydrate and fat
 Maxijul- carbohydrate

73. Breast Milk !!!
Understanding of feed increases and suspensions
NEC
Formula Options
Common nutritional questions

75. Thank
you