Recent Advances in Pediatrics (Special Volume 25): Perspectives in Neonatology Suraj Gupte
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Part 1
Spotlight: Neonatal Nutrition

Nutrition in the Newborns: An Overview1

Pankaj Barabde
Satish Tiwari

ABSTRACT

Nutrition in the newborn may be very challenging on most of the occasions. Inadequate physical development, lack of fully developed neurological reflexes, separation from the mother for special neonatal care and associated anomalies may result in further difficulties. Adequate nutrition, starting in early life is most important factor for proper cognitive and physical growth of each and every child. Hence, it is important that we make all the efforts in providing a proper, balanced, nutritious feeding to the babies specially those who are on the edge of viability or in the compromised state of growth and development. Exclusive breastfeeding, the most effective international preventive health intervention for newborns and infants six months, has widely acknowledged benefits across economic strata with respect to infant nutrition, gastrointestinal function, host defense, neurodevelopment, and psychological well-being for full-term and premature infants. Though term infants rapidly adapt from a relatively constant intrauterine supply of nutrients to intermittent feedings of milk, preterm infants with limited nutrient reserves, immature metabolic pathways, and increased nutrient demands are at increased risk of potential nutritional compromise.
Key Words: BPD, CHD, Cleft palate, Enteral feeding, Gatroesophageal reflux, IEM disorders, Necrotizing enterocolitis, Nutritional requirements, Orofacial malformations, Palady feeding, Parenteral feeding.  
INTRODUCTION
Each year approximately 10 million childhood deaths occur, largely due to diarrhea, malnutrition, malaria, acquired immunodeficiency syndrome, pneumonia, and measles 90% in the 42 poorest countries in the world. Exclusive breastfeeding through six months of age has the potential to prevent 13% of these deaths and is the most effective international preventive health intervention for children under age 5 years.1 Human milk has widely acknowledged benefits across economic strata with respect to infant nutrition, gastrointestinal function, host defense, neurodevelopmental, and psychological well-being for full-term and premature infants.2
Term infants rapidly adapt from a relatively constant intrauterine supply of nutrients to intermittent feedings of milk. Preterm infants, however, are at increased risk of potential nutritional compromise. These infants are born with limited nutrient reserves, immature metabolic pathways, and increased nutrient demands.2 Increasing incidence of orofacial congenital malformations and IEM disorders, cause more difficulty in feeding of newborns.
 
NUTRITIONAL NEEDS OF A NEWBORN
These depend on weight and days of life of newborn. We can provide nutrition to babies by mother's milk, intravenous fluids and total parenteral nutrition (TPN).
 
Fluid Requirements
Maintenance of fluid and electrolyte balance is essential for normal cell and organ function during intrauterine development and throughout extrauterine life. Requirements vary substantially from infant to infant and in the same infant over time; therefore intakes must be individualized and frequently reassessed. The primary goals are to maintain the appropriate ECF volume, ECF and intracellular fluid osmolality and ionic concentrations.3, 4 Maintenance fluid requirement as per the day of life is shown in Table 1.1.
 
Caloric Requirements
The caloric needs of non-growing preterm babies during first week of life are 70 to 80 kcal/kg/day.
Additional calories are needed for growth (25 kcal/kg/day), activity (15 kcal/kg/day), cold stress (10 kcal/kg/day), and fecal loss (about 12 kcal/kg/day). After first 1 to 2 weeks of life most preterm babies require 120 to 150 kcal/kg/day to maintain satisfactory growth velocity. After post-conceptional maturity of 40 weeks, the caloric needs decrease from 100–120 kcal/kg/day.5
 
Protein, Carbohydrate, Fat, Vitamin and Mineral Requirements
Table 1.2 shows daily requirements of proteins, carbohydrates, fat, vitamins and minerals in newborn period.
Table 1.1   Estimated maintenance fluid requirements
Fluid requirements (mL/kg/day)
Birth-weight (g)
Day 1
Day 2
Day 3–6
≥ Day 7
<750
100–140
120–160
140–200
140–160
750–1000
100–120
100–140
130–180
140–160
1000–1500
80–100
100–120
120–160
150
>1500
60–80
80–120
120–160
150
3
Table 1.2   Daily requirement of proteins, carbohydrates, fat, vitamins and minerals6, 7
Nutrient
Unit
Nutrient intake
AAP-CON
Protein
g/kg/day
3.5–4
ELBW infants
g/kg/day
3.8–4.4
VLBW infants
g/kg/day
3.4–4.2
Carbohydrate
g/kg/day
10–14
ELBW infants
g/kg/day
9–20
VLBW infants
g/kg/day
7–17
Fat
g/kg/day
5–7
ELBW infants
g/kg/day
6.2–8.4
VLBW infants
g/kg/day
5.3–7.2
Docosahexaenoic acid
ELBW infants
mg/kg/day
>21
VLBW infants
mg/kg/day
>18
Arachidonic acid
ELBW infants
mg/kg/day
>28
VLBW infants
mg/kg/day
>24
Vitamins
Vitamin A
IU/kg/day
700–1500
90–270
Vitamin D
IU/day
400
400
Vitamin E
IU/kg/day
6–12
>1.30
Vitamin K
µg/kg/day
8–10
4.8
Vitamin C
mg/kg/day
18–24
42
Thiamine
µg/kg/day
180–240
>48
Riboflavin
µg/kg/day
250–360
>72
Pyridoxine
µg/kg/day
150–210
>42
Niacin
mg/kg/day
3.6–4.8
>0.3
Pantothenate
mg/kg/day
1.2–1.7
>0.36
Biotin
µg/kg/day
3.6–6
>1.8
Folate
µg/kg/day
25–50
39.60
Minerals
Sodium
mEq/kg/day
3–5
2–3
Potassium
mEq/kg/day
2–3
1.7–2.5
Chloride
mEq/kg/day
3–7
2–3
Calcium
mg/kg/day
100–220
210
Phosphorus
mg/kg/day
60–140
110
Magnesium
mg/kg/day
7.9–15
Iron
mg/kg/day
2–4
2–3
Zinc
µg/kg/day
1000–3000
>300
Copper
µg/kg/day
120–150
108
Selenium
µg/kg/day
1.3–4.5
Chromium
µg/kg/day
0.1–2.25
Manganese
µg/kg/day
0.7–7.5
>6
Iodine
µg/kg/day
10–60
6
4
Taurine
mg/kg/day
4.5–9
Carnitine
mg/kg/day
2.9
Inositol
mg/kg/day
32–81
Choline
mg/kg/day
14.4–28
 
NUTRITIONAL IMPLICATIONS FOR THE TERM INFANT
Exclusive breastfeeding for the first 6 months is the benchmark. When direct breastfeeding is not possible, expressed breast milk should be provided. Breastfeeding enhances maternal involvement, interaction and bonding; provides species-specific nutrients to support normal infant growth; provides non-nutrient growth factors, immune factors, hormones, and other bioactive components that can act as biological signals; and can decrease the incidence and severity of infectious diseases, enhance neurodevelopment, decrease the incidence of childhood obesity and some chronic illnesses, and decrease the incidence and severity of atopic disease.8–11 Table 1.3 shows constituents of human milk.
There are many benefits of breast feeding to the infant as well as for mother. In mother breastfeeding reduces the risk of breast and ovarian cancer; also reduces the risk of cardiovascular diseases.12–20
Table 1.3   Representative values for constituents of human milk 9–11
Constituent (per liter)
Early milk
Mature milk
Energy (kcal)
650–700
Carbohydrate
Lactose (g)
20–30
67
Glucose (g)
0.2–1.0
0.2–0.3
Oligosaccharides (g)
22–24
12–14
Total nitrogen (g)
3.0
1.9
Non-protein nitrogen (g)
0.5
0.45
Protein nitrogen (g)
2.5
1.45
Total protein (g)
16
9
Casein (g)
3.8
5.7
β-Casein (g)
2.6
4.4
κ-Casein (g)
1.2
1.3
α-Lactalbumins (g)
3.62
3.26
Lactoferrin (g)
3.53
1.94
Albumin (g)
0.39
0.41
IgA (g)
2.0
1.0
IgM (g)
0.12
0.2
5
IgG (g)
0.34
0.05
Total lipids (%)
2
3.5
Triglyceride (% total lipids)
97–98
97–98
Cholesterol (% total lipids)
0.7–1.3
0.4–0.5
Phospholipids (% total lipids)
1.1
0.6–0.8
Fatty acids (weight %)
88
88
Total saturated fatty acids (%)
43–44
44–45
Palmitic acid (C16:0)
20
Monounsaturated fatty acids (%)
40
Oleic acid (C18:1ω9)
32
31
Polyunsaturated (PUFA) fatty acids (%)
13
14–15
Total ω3 fatty acids (%)
1.5
1.5
Linolenic acid (C18:3ω3)
0.7
0.9
Eicosapentaenoic acid (C22:5ω3)
0.2
0.1
Docosahexaenoic acid (C22:6ω3)
0.5
0.2
Total ω6 fatty acids (%)
11.6
13.06
Linoleic acid (C18:2ω6)
8.9
11.3
Arachidonic acid (C20:4ω6)
0.7
0.5
Water-soluble vitamins
Ascorbic acid (mg)
100
Thiamine (μg)
20
200
Riboflavin (μg)
400–600
Niacin (mg)
0.5
1.8–6.0
Vitamin B6 (mg)
0.09–0.31
Folate (μg)
80–140
Vitamin B12 (μg)
0.5–1.0
Pantothenic acid (mg)
2–2.5
Biotin (μg)
5–9
Fat-soluble vitamins
Retinol (mg)
2
0.3–0.6
Carotenoids (mg)
2
0.2–0.6
Vitamin K (μg)
2–5
2–3
Vitamin D (μg)
0.33
Vitamin E (mg)
8–12
3–8
Minerals
Calcium (mg)
250
200–250
Magnesium (mg)
30–35
30–35
6
Phosphorus (mg)
120–160
120–140
Sodium (mg)
300–400
120–250
Potassium (mg)
600–700
400–550
Chloride (mg)
600–800
400–450
Iron (mg)
0.5–1.0
0.3–0.9
Zinc (mg)
8–12
1–3
Copper (mg)
0.5–0.8
0.2–0.4
Manganese (μg)
5–6
3
Selenium (μg)
40
7–33
Iodine (μg)
150
Fluoride (μg)
4–15
 
BREASTFEEDING THE LATE PRETERM INFANT
Interventions to support breastfeeding in the late preterm infant include providing
  1. Positive personal support to the mother,
  2. Hands-on assistance with latch and infant positioning during each feed,
  3. Encouragement of milk expression manual or using a breast pump after each feed and every 2 to 3 hours (8 to 10 times per day) for 10 to 15 minutes, and
  4. Continuing bedding-in and skin-to-skin contact as often as possible.
Within hours of birth, the mother can be taught to hand-express colostrum to feed the baby, and within 24 hours of birth she can begin breast milk expression every 2 to 3 hours after breastfeeding. Infant interventions include waking the infant to feed and providing supplementation with or after each feeding at least every 2 to 3 hours with expressed colostrum or breast milk. The infant may appear sleepy and not awake spontaneously for feeds, so he or she should be waked on this schedule and supplemented after each breastfeed using a supplemental nursing system, katori-spoon, cup, or syringe, to give a standardized quantity of milk. Some clinicians recommend 3 to 5 mL/kg per feed every 2 to 3 hours after day 1, whereas others recommend a schedule of 5 to 10 mL per feed on day 1, 10 to 20 mL per feed on day 2, 20 to 30 mL on day 3, and so forth, based on breastfeeding ability. This trio of nursing at the breast followed by supplementation (or simultaneous with nursing if a supplemental nursing system is used) and then maternal milk expression comprises “triple feeds,” a bridge to successful lactation for the at-risk maternal-infant dyad. In this manner the mother's milk supply is not at risk or diminished because of ineffective or infrequent sucking, and the physiologically immature infant is guaranteed sufficient intake. Whether intervention is required or breastfeeding appears to proceed smoothly, a breastfeeding management plan for discharge should be established before discharge.27
 
NUTRITIONAL IMPLICATIONS FOR THE PREMATURE INFANT
The nutritional adequacy of human milk for premature infants may be limited for several reasons. The energy and protein contents of breast milk aliquots brought to the neonatal nursery by the mother are highly variable.21 The most variable nutrient in human milk is fat, the content of which differs during lactation, throughout the day, from mother to mother, and within a single milk expression.22 Because human milk is not homogenized, the fat content separates from the body of milk during standing and may be lost if continuous tube feeding is used. In fact, much of the variation in energy content of milk as used in the nursery is a result of differences in and/or losses of fat in the unfortified milk.23, 24 Although concentrations of protein, sodium, and zinc decline through lactation, the nutrient needs of the premature infant remain higher than those of term infants until sometime after term postmenstrual age. Therefore, the physiologic decline in milk concentration of protein and micronutrients precedes any reduction in the infant's needs and results in an inadequate nutrient supply from human milk for the premature infant. With feeding of unfortified human milk, protein insufficiency is manifested by declines in growth rates and by lowered biochemical indicators of protein status (blood urea nitrogen and serum prealbumin).25–27 The absolute inadequate intake of calcium and phosphorus results in a progressive decrease in serum phosphorus and increases in serum calcium and alkaline phosphatase activity compared with infants fed preterm formula.28, 29 Follow-up of premature infants fed unfortified human milk find reduced linear growth at 18 months and relationships to adolescent height.30 Thus, premature infants weighing less than 1500 g at birth should receive human milk fortifier (as shown in table 1.4), a multi-nutrient supplement designed to meet their nutritional needs and prevent clinical deficiency diseases and growth failure. The fortifier adds not only protein, calcium, phosphorus, and calories but other micronutrients. The addition of multi-nutrient fortifiers to human milk resulted in short-term improvements in weight gain, increments in length and head circumference, and bone mineral content during hospital stay.31–33
Table 1.4   Nutrient composition of human milk and selected fortified human milk34
Preterm Human Milk (1 week)
Mature Preterm Human Milk (1 month)
Mature Preterm Human Milk + Human Milk Fortifier
Volume, mL
100
100
100
Energy, kcal
67
69
83
Protein, g
2.4
1.5
2.5–2.6
Whey/casein (%)
70/30
70/30
70/30
Fat, g
3.8
3.6
4.0–4.6
8
Medium-chain triglycerides (%)
2
2
11–17
Carbohydrate, g
6.1
6.7
7.1–8.5
Lactose (%)
100
100
80–85
Calcium, mg
25
29
119–146
Phosphorus, mg
14
9.3
59–76
Magnesium, mg
3.1
2.4
3.4–9.4
Sodium, mEq (mmol)
2.2
0.9
1.6
Potassium, mEq (mmol)
1.8
1.3
2–2.9
Chloride, mEq (mmol)
2.6
1.5
1.9–2.6
Zinc, μg
500
215
935–1215
Copper, μg
80
51
95–221
Vitamin A, IU
560
227
847–1177
Vitamin D, IU
4
1.2
122–151
Vitamin E, mg
1.0
0.3
3.5–4.9
 
ENTERAL NUTRITION
The structural and functional integrity of the gastrointestinal (GI) tract is dependent upon the provision of enteral nutrition. Withholding enteral feeding after birth places the infant at risk for all the complications associated with luminal starvation, including mucosal thinning, flattening of the villi, and bacterial translocation. Trophic feedings (also referred to as “gut priming” or “minimal enteral feedings”) may be described as feedings that are delivered in very small volumes (approximately 10 to 20 mL/kg/day) for the purpose of induction of gut maturation rather than nutrient delivery.2, 35
Benefits associated with trophic feedings are:
  1. Improved levels of gut hormones
  2. Less feeding intolerance
  3. Earlier progression to full enteral feedings
  4. Improved weight gain
  5. Improved calcium and phosphorus retention
  6. Fewer days on PN.
Guidelines for the use of trophic feedings are:
  1. Begin as soon after birth as possible, ideally by day of life 2 to 3.
  2. Use full-strength colostrum/human milk or full-strength 20 kcal/oz preterm formula at a volume of 10 to 20 mL/kg/day. Administer trophic feedings every 3, 4, 6, or 8 hours.
    9
  3. Do not use trophic feedings in infants with severe hemodynamic instability, suspected or confirmed necrotizing enterocolitis (NEC), evidence of ileus, or clinical signs of intestinal pathology.
 
Feeding Methods
These should be individualized based on gestational age, clinical condition, and feeding tolerance.
  1. Nasogastric/orogastric feedings: Many authors utilize nasogastric tube feedings more frequently, as orogastric tubes tend to be more difficult to secure.
    1. Indications:
      1. Infants <34 weeks' gestation, as most do not yet have the ability to coordinate suck-swallow-breathe patterns.
      2. Infants with impaired suck/swallow coordination due to conditions such as encephalopathy, hypotonia and maxillofacial abnormalities.
    2. Bolus versus continuous: Studies may be found in support of either method and, in practice, both are utilized. Initiate with bolus feedings divided every 3 to 4 hours. If difficulties with feeding tolerance occur, lengthen the amount of time over which a feeding is given by placing on a syringe pump for 30 to 120 minutes.6
  2. Transpyloric feedings:
    1. Indications: There are only a few indications for transpyloric feedings.
      1. Infants intolerant to nasogastric/orogastric feedings.
      2. Infants at increased risk for aspiration.
      3. Severe gastric retention or regurgitation.
      4. Anatomic abnormalities of the GI tract such as microgastria.
    2. Other considerations:
      1. Transpyloric feedings should be delivered continuously, as the small intestine does not have the same capacity for expansion as does the stomach.
      2. There is an increased risk for fat malabsorption, as lingual and gastric lipase secretions are by-passed.
      3. These tubes are routinely placed under guided fluoroscopy.
  3. Gastrostomy feedings: Infants with neurological impairment and/or those who are unable to take sufficient volumes through breast/tube/katori-spoon feeding to maintain adequate growth/hydration status can be given feeding by gastrostomy.
 
Macronutrient and Micronutrient Requirements in the Enterally-fed Premature
  1. Proteins: The estimated protein and energy requirements to achieve fetal growth is shown in Table 1.5 and recommended enteral protein intake for infants weighing <1000 g and >1000 g is shown in Table 1.6.
    10
    Table 1.5   Estimated protein and energy requirements to achieve fetal growth36
    Weight (g)
    Protein (g/kg/d)
    Energy (kcal/kg/d)
    500–700
    4.0
    105
    700–900
    4.0
    108
    900–1200
    4.0
    119
    1200–1500
    3.9
    125
    1500–1800
    3.6
    128
    1800–2200
    3.4
    131
    Table 1.6   Recommended enteral protein intakes for very low-birth weight infants37–39
    g/kg/d
    Canadian Pediatric Society, 1995
    Birth weight <1000 g
    3.5–4.0
    Birth weight ≥1000 g
    3.0–3.6
    Life Sciences Research Office, 2002
    3.4–4.3
    AAP Committee on Nutrition, 2004
    3.5–4.0
    ESPGHAN, 2010
    Weight up to 1000 g
    4.0–4.5
    Weight 1000–1800 g
    3.5–4.0
  2. Carbohydrates: The main carbohydrate in human milk is lactose, supplying nearly half of the total calories and in intravenous fluids is dextrose. The caloric value of dextrose is 3.4 kcal/g. Lactase (β-galactosidase) is an intestinal enzyme that hydrolyzes lactose to glucose and galactose in the small intestine. Despite lower levels of intestinal lactase activities in premature infants, premature infants are able to efficiently digest lactose. Nonetheless, many infant formulas designed for premature infants supply glucose polymers. Glucose polymers are digested by α-glucosidases; the activity level of these enzymes approximates adult levels much sooner than β-galactosidase, which theoretically makes glucose polymers easier for the premature infant to digest than lactose. Glucose polymers also have an advantage in that they increase caloric density without a rise in osmolality. Recommended carbohydrate intake for premature infants is 11.6 to 13.2 g/kg per day.35 This amount of intake will provide sufficient glucose to meet needs for total energy expenditure as shown in Table 1.7.
    Table 1.7   Estimated energy requirements for premature infants
    Factor
    kcal/kg/d
    Energy expenditure
    Resting metabolic rate
    40–60
    Activity
    0–5
    Thermoregulation
    0–5
    Synthesis/energy cost of growth
    15
    11
    Energy stored
    20–30
    Energy excreted
    15
    Total energy requirement
    90–120
  3. Fats: Fat provides a substantial source of energy for growing premature infants. Premature infants have low levels of pancreatic lipase, bile acids, and lingual lipase. Human milk, however, supplies a variety of lipases, including lipoprotein lipase, bile salt esterase, and non-activated lipase. The composition of dietary fat affects absorption and digestion. The absorption of fatty acids increases with decreasing chain length and with the degree of unsaturation. Consequently, medium-chain triglycerides (6- to 12-carbon chain length) are hydrolyzed more readily than long-chain triglycerides. In contrast to formulas designed for term infants, premature infant formulas supply medium-chain triglycerides. Human milk supplies 8 to 12% of fat as medium-chain triglycerides. Recommended intake for lipid in enterally fed premature infants ranges between 4.8 and 6.6 g/kg per day. Of this amount, medium-chain triglycerides should be less than 40% of total intake.35
  4. Vitamins, minerals and trace elements: Recommended oral intake of vitamins, minerals and trace elements for preterm infants is shown in Tables 1.8 and 1.9 respectively.
    Table 1.8   Recommended oral intake of vitamins for preterm infants35, 39
    Vitamin (per 100 kcal)
    AAP
    ESPGHAN
    Fat Soluble
    Vitamin A (IU)
    467–1364
    1210–2466
    Vitamin D (IU)
    100–364
    100–350 (800–1000/d)
    Vitamin E (IU)
    4–10.9
    2–10 mg alpha TE
    Vitamin K (μg)
    5.3–9.1
    4–25
    Water Soluble
    Vitamin B6 (μg)
    100–191
    41–330
    Vitamin B12 (μg)
    0.2–0.27
    0.08–0.7
    Vitamin C (mg)
    12–21.8
    10–42
    Biotin (μg)
    2.4–5.5
    1.5–15
    Folic acid (μg)
    17–45
    32–90
    Niacin (mg)
    2.4–4.4
    0.345–5
    Pantothenate (mg)
    0.8–1.5
    0.3–1.9
    Riboflavin (μg)
    167–327
    180–365
    Thiamin (μg)
    120–218
    125–275
    12
    Table 1.9   Recommended oral intake of minerals and trace elements for preterm infants35, 39
    Mineral/Trace Element (per 100 kcal)
    AAP
    ESPGHAN
    Calcium (mg)
    67–200
    110–130
    Chloride (mEq)
    2–6.5
    1.7–4.6
    Magnesium (mg)
    5.3–13.6
    7.5–13.6
    Phosphorus (mg)
    40–127
    55–80
    Potassium (mEq)
    1.3–2.7
    1.5–4.1
    Sodium (mEq)
    2–4.6
    1.7–2.7
    Iron (mg)
    1.33–3.64
    1.8–2.7
    Chromium (μg)
    0.07–2.05
    0.027–1.12
    Copper (μg)
    80–136
    90–120
    Fluoride (μg)
    1.4–55
    Iodine (μg)
    6.7–54.5
    10–50
    Manganese (μg)
    0.5–6.8
    6.3–25
    Molybdenum (μg)
    0.2–0.27
    0.27–4.5
    Selenium (μg)
    0.9–4.1
    4.5–9
    Zinc (mg)
    0.34–2.7
    1–1.8
 
PARENTERAL NUTRITION (PN)
Effective nutritional support of premature and critically ill infants is largely dependent on parenteral nutrition, especially in early postnatal life. Initial goal for PN is to provide adequate calories and amino acids to prevent negative energy and nitrogen balance. Goals thereafter include the promotion of appropriate weight gain and growth, while awaiting the attainment of adequate enteral intake.6, 40 Daily parenteral intake of proteins, carbohydrates, fats, electrolytes and minerals for ELBW and VLBW infants is shown in Table 10.
 
A. Indications
  1. Infants with a birth weight <1,500 g. For these infants, this is often done in conjunction with slowly advancing enteral nutrition.
  2. Infants with a birth weight of ≥1,501 g for whom significant enteral intake is not expected for >3 days.
  3. Operated cases of congenital malformations in whom babies are kept nil by mouth for > 3 days.
  4. Necrotizing enterocolitis (NEC).
 
B. Peripheral Versus Central
  1. Parenteral solutions may be infused through peripheral veins or a central vein, usually the superior or inferior vena cava. The AAP recommends that peripheral solutions maintain an osmolarity between 300 and 900 mOsm/L. 13Because of this limitation, peripheral solutions often cannot adequately support growth in extremely low-birth-weight (ELBW) infants. Central PN allows for the use of more hypertonic solutions but also incurs greater risks, particularly catheter-related sepsis.
  2. Central PN to be warranted under the following conditions:
    1. Nutritional needs exceed the capabilities of peripheral PN.
    2. An extended period (e.g. >7 days) of inability to take enteral feedings, such as in infants with necrotizing enterocolitis (NEC) and in some postoperative infants.
    3. Imminent lack of peripheral venous access.6
Table 1.10   Suggested daily parenteral intakes for ELBW and VLBW infants41
Component (units/kg/day)
ELBW < 1000 g
VLBW < 1500 g
Day 1
Transition (2–7 days)
Growing (> 7 days)
Day 1
Transition (2–7 days)
Growing (> 7 days)
Energy (kcal)
40–50
70–80
100–110
40–50
60–70
90–100
Protein (g)
2–3
3.5
3.5–4
2–3
3.0–3.5
3.0–3.5
Glucose (g)
7–10
8–15
13–17
7–10
8–15
13–17
Fat (g)
1
1–3
3–4
1
1–3
3
Na (mEq)
0–1
2–4
3–7
0–1
2–4
3–5
Potassium (K) (mEq)
0
0–2
2–3
0
0–2
2–3
Chloride (mEq)
0–1
2–4
3–7
0–1
2–4
3–7
Calcium (mg)
20–60
60
60–80
20–60
60
60–80
Phosphorus (mg)
0
45–60
45–60
0
45–60
45–60
Magnesium (mg)
0
3–7.2
3–7.2
0
3–7.2
3–7.2
 
C. Monitoring during Parenteral Nutrition
As PN can lead to many hazardous complications, it requires strict monitoring. Table 1.11 shows suggested monitoring during Parenteral Nutrition.
Table 1.11   Suggested monitoring during parenteral nutrition
Parameter
Frequency
Weight
Daily
Length and head circumference
Weekly
Serum glucose
1 per shift during 1st week, then daily
Serum Na, K, Cl, BUN (blood urea nitrogen), Ca, P, Mg, hematocrit
Alternate days during 1st week, then weekly
Alkaline phosphatase, ALT (Alanine aminotransferase), GGT (gamma-glutamyl transferase), fractionated bilirubin
Weekly
14
 
D. Potential Complications Associated with Parenteral Nutrition
  1. Cholestasis may be seen and is more often transient than progressive.
    1. Risk factors include:
      1. Prematurity
      2. Duration of PN administration
      3. Duration of fasting (lack of enteral feeding also produces bile inspissation and cholestasis)
      4. Infection
      5. Narcotic administration
    2. Treatment:
      1. Attempt enteral feeding. Even minimal enteral feedings may stimulate bile secretion.
      2. Avoid overfeeding with PN.
  2. Metabolic bone disease: The use of earlier enteral feedings and central PN, with higher calcium and phosphorus ratios, has reduced the incidence of metabolic bone disease. However, this continues to be seen with the prolonged use of PN in place of enteral nutrition.
  3. Metabolic abnormalities: Azotemia, hyperammonemia, and hyperchloremic metabolic acidosis has become uncommon since introduction of the current crystalline amino acid solutions. These complications may occur, however, with protein intakes exceeding 4 g/kg/day.6
  4. Metabolic abnormalities related to lipid emulsions:
    1. Hyperlipidemia/hypertriglyceridemia: The incidence tends to be inversely related to gestational age at birth and postnatal age. A short-term decrease in the lipid infusion rate usually is sufficient to normalize serum lipid levels. Try to maintain serum triglyceride levels below 200 mg/dL.
    2. Indirect hyperbilirubinemia. Because free fatty acids can theoretically displace bilirubin from albumin-binding sites, the use of lipid emulsions during periods of neonatal hyperbilirubinemia has been questioned. Recent research, however, suggests that infusion of lipid at rates up to 3 g/kg/day is unlikely to displace bilirubin. However, during periods of extreme hyperbilirubinemia, rates <3 g/kg/day should be provided.
    3. Sepsis has been associated with decreased lipoprotein lipase activity and impaired triglyceride clearance. Therefore, during a sepsis episode, it may be necessary to temporarily limit the lipid infusion to approximately 2 g/kg/day if the triglyceride level is >150 mg/dL.
    4. The potential adverse effects of lipid emulsions on pulmonary function, the risk of broncho-pulmonary dysplasia, and impaired immune function remain subjects of debate.
Because of the concern about toxic products of lipid peroxidation, lipid emulsions should also be protected from both ambient and phototherapy lights.15
 
FEEDING IN SPECIFIC DISEASES/SITUATIONS
 
Congenital Anomalies
The need for special feeding techniques is determined by the type of anomaly (i.e. cleft lip, cleft palate, Pierre Robin syndrome) and the child's oral ability of sucking and swallowing.41 If a child is unable to latch and suck at breast then feeding with Katori-spoon or other methods may be tried. Variety of nipples and feeders like—
  1. Lamb's nipple
  2. Ross nipple
  3. Nipple with razor inserted to show technique for enlarging the nipple
  4. Mead Johnson feeder
  5. Breck feeder, etc. can also be used in such situations.
Anomaly
Method
Oral –facial
Breastfeeding, Breck feeder, Ross or Mead Johnson feeder, cross cut nipple, Lamb's nipple.
Alimentary canal
Gavage feeding – nasal or duodenal, hyperalimentation, gastrostomy
 
Cleft Lip and Cleft Palate
When cleft occurs only in the soft palate, most infants can feed successfully after minor adjustments have been made in the feeding method. However, if the cleft is in the hard palate, the infant may have a normal sucking motion, but there will be no suction (negative pressure); special techniques will be needed for feeding. As infant sucks, the care takers should gently pulsate the bulb on the Breck feeder or squeeze the bottle when using a Mead Johnson feeder. Palada or katori spoon can also be used for feeding of neonate with cleft lip and cleft palate. When a standard nipple is used with bottle feeding, a crosscut on the top of the nipple facilitates flow. Nasal regurgitation can be reduced by placing the infant in a semi-reclined position while feeding. When breastfeeding, the mother may need to apply gentle pressure to her breast and hold her breast in a V shape to keep the nipple extended.41
 
Hypotonic Baby
Hypotonic babies often have feeding problems that result from abnormal or underdeveloped control of the oro-pharyngeal structures, contributing to an uncoordinated and/or weak suck. Breastfeeding helps with normal mouth and tongue coordination. Breastfeeding has also been shown to be protective against the development of ear and respiratory infections. Assess the baby's ability to latch, suck, and transfer milk. This assessment should involve personnel specifically trained in breastfeeding evaluation and management. Use of a sling or pillows to support the infant in a flexed position allows the mother to use her hands to support both her breast and the infant's jaw simultaneously. The “Dancer hand” position may be helpful to the mother to try because it supports both her breast and her baby's chin and jaw while the baby is nursing.4216
zoom view
Fig. 1.1:
Dancer hand position in breastfeeding. Note that it involves cupping mother's breast in the palm of her hand (holding her breast from below), with the third, fourth, and fifth fingers curling up towards the side of her breast to support it, while simultaneously allowing the baby's chin to rest on the web space between her thumb and index finger.
This involves cupping her breast in the palm of her hand (holding her breast from below), with the third, fourth, and fifth fingers curling up towards the side of her breast to support it, while simultaneously allowing the baby's chin to rest on the web space between her thumb and index finger (Fig. 1.1). The thumb and index finger can then give gentle pressure to the masseter muscle, which stabilizes the jaw. Additionally, pulling the jaw slightly forward may allow the infant to better grasp the breast and form a seal. The other hand is free to be used to support the baby's neck and shoulders. Other strategies to help the infant latch and transfer milk may also be effective. Some mothers facilitate milk transfer with the technique of breastfeeding used in conjunction with hand compression. Instead of placing the thumb and index finger on the baby's jaw for support (Dancer position), the fingers are kept proximal to the areola, and milk is hand expressed as the baby suckles. A thin silicon nipple shield may be useful, if production is generous (500 mL/day) and mothers learn how to keep the reservoir filled by synchronizing breastfeeding with hand compression or using a nursing supplementation device simultaneously inside the shield. By making the mother aware of various techniques, aids, and ideas, she is empowered to experiment and discover the best repertoire to fit her and her baby's individual needs.42
Consider alternative modes of feeding if the baby is unable to nurse at the breast or sustain adequate suckling, including the use of a cup or a spoon. 17The use of a nursing supplementation aid alone (without a nipple shield) may not be as helpful, as it works best with a baby who has an effective latch, the lack of which is often one of the significant problems of hypotonic infants.
 
Pierre Robin Syndrome
It is associated with retrognathic jaw and tongue as well as U-shaped cleft that extends into the primary palate. The degree of airway obstruction and the presence of tongue-tie determine the feeding approach. If there is tongue tie, the infant usually will maintain an airway only with proper positioning. When there is airway obstruction, a nasopharyngeal endotracheal tube must be passed to keep the tongue forward. The infant must be prone at all times with blanket roll under the chest or hips to keep the mandible forward.41 During the first 2 weeks of life, feeding is often very difficult and it may be necessary to pass a nasogastric tube.
 
Choanal Atresia
Choanal atresia is a blockage of the nasal airways due to unilateral or bilateral overgrowth of nasal cartilage. Until surgical correction, maintenance of an airway during feeding is critical. A plastic airway may be placed through a nipple for the infant to suck without compromising air exchange.41 Bilateral obstruction necessitates the use of gavage feeding until surgical correction. However with a unilateral choanal atresia, if nasal passage is kept clear of mucus and the infant is fed in an upright position, palada feeding/ katori spoon may also be used.
 
Macroglossia
Macroglossia is an enlarged tongue caused by either vascular or endocrine disorders (e.g. cretinism, Beckwith Wiedemann syndrome). The tongue may be so large that oral feedings are not possible and a gastrostomy is needed. If sucking and swallowing can be coordinated without aspiration, feeding can be attempted. The longer Lamb's nipple is placed towards the back of the tongue with the infant in an upright position. The caretaker's hand that is holding the bottle can help to close the infant's mouth.
 
Systemic Diseases
 
Gastroesophageal Reflux (GER)
Episodes of GER are common in both preterm and full-term infants.
  1. Introduction of enteral feeds: Emesis can be associated during the introduction and advancement of enteral feeds in preterm infants. These episodes are most commonly related to intestinal dysmotility secondary to prematurity and will respond to modifications of the feeding regimen.6
    1. Temporary reductions in the feeding volume, removal of nutritional additives, lengthening the duration of the feeding (sometimes to 18the point of using continuous feeding), and temporary cessation of enteral feeds are all possible strategies depending upon the clinical course of the infant.
    2. Rarely, specialized thick formulas are used when all other feeding modifications have been tried without improvement. In general, these formulas should only be used for short periods of time with close nutritional monitoring.
    3. Infants who have repeated episodes of symptomatic emesis that prevent achievement of full-volume enteral feeds may require evaluation for anatomic problems such as malrotation or Hirschsprung's disease. In general, radiographic studies are not undertaken unless feeding problems have persisted for 2 or more weeks, or unless bilious emesis occurs.
  2. Established feeds: Preterm infants on full-volume enteral feeds will have occasional episodes of symptomatic emesis. If these episodes do not compromise the respiratory status or growth of the infant, no intervention is required other than continued close monitoring of the infant. If symptomatic emesis is associated with respiratory compromise, repeated apnea, or growth restriction, therapeutic maneuvers are indicated.
    1. Positioning: Reposition the infant to elevate the head and upper body, in either a prone or right side down position.
    2. Feeding intervals: Shortening the interval between feeds to give a smaller volume during each feed may sometimes improve signs of GER. Infants fed by gavage may have the duration of the feed increased.
    3. Metoclopramide: Infants who remain clinically compromised from GER after positioning and feeding interval changes can have a therapeutic trial of metoclopramide. The metoclopramide should be discontinued after 1 week if there is no improvement in clinical status.6
  3. Apnea: Studies using pH probes and esophageal manometry have not shown an association between GER and apnea episodes. Treatment with promotility agents should not be used for uncomplicated apnea of prematurity.
 
Necrotizing Enterocolitis (NEC)
Nutritional support of the patient with NEC focuses around providing complete parenteral nutrition (PN) during the acute phase of the disease, followed by gradual introduction of feeds after the patient has stabilized and the gut has been allowed to heal.43–46
  1. Parenteral nutrition: For at least 2 weeks after the initial diagnosis of NEC, the patient is kept nil by mouth and receives total PN.
  2. Initiation of feeds: If the patient is clinically stable after a minimum 2 weeks of bowel rest, feeds are introduced at approximately 10 to 20 mL/kg/day, preferably with human milk, although a standard formula appropriate for the gestational age of the patient may also be used.
    19
  3. Feeding advancement: If trophic feedings (10 to 20 mL/kg/day) are tolerated for 24 to 48 hours, gradual advancement of feeding volume is continued at approximately 10 mL/kg every 12 to 24 hours for the next 2 to 3 days.46, 47 If this advancement is tolerated, further advancement proceeds. Supplemental PN is continued until enteral feeds are providing ≥75% of goal volume.
  4. Feeding intolerance: Signs of feeding intolerance include large gastric residuals, emesis, abdominal distension, and increased numbers of apnea episodes. Reduction of feeding volume or cessation of feeding is usually indicated. If these clinical signs prevent attainment of full-volume enteral feeds despite several attempts to advance feeds, radiographic contrast studies may be indicated to rule out intestinal strictures. This type of evaluation would typically take place after 1 to 2 weeks of attempting to achieve full-volume enteral feeds.
  5. Enterostomies: If one or more enterostomies are created as a result of surgical therapy for NEC, it may be difficult to achieve full nutritional intake by enteral feeds. Depending on the length and function of the upper intestinal tract, increasing feeding volume or nutritional density may result in problems with malabsorption, dumping syndrome, and poor growth.
    1. Refeeding: Output from the proximal intestinal enterostomy can be refeed into the distal portion of the intestine through the mucous fistula. This may improve the absorption of both fluid and nutrients.
    2. PN support: If growth targets cannot be achieved using enteral feeds, continued use of supplemental PN may be indicated depending on the patient's overall status and liver function. Enteral feeding should be continued at the highest rate and nutritional density tolerated, and supplemental PN should be given to achieve the nutritional goals and growth outcomes as previously outlined.
 
Broncho-pulmonary Dysplasia (BPD)
Preterm infants who have BPD have increased caloric requirements due to their increased metabolic expenditure, and at the same time have a lower tolerance for excess fluid intake.47, 48
  1. Fluid restriction: Total fluid intake is typically restricted from the usual 150 mL/kg/day to 140 mL/kg/day. In cases of severe BPD, further restriction to 130 and, rarely, 120 mL/kg/day may be required. Careful monitoring is required when fluid restrictions are implemented to ensure adequate caloric and micronutrient intake. Growth parameters must also be monitored so that continued growth is not compromised.47–52
  2. Caloric density: Infants with BPD will commonly require up to 30 kcal/oz feeds in order to achieve the desired growth targets. In fluid-restricted infants with severe BPD, the maximum density of 32 kcal/oz is used on an infrequent basis.
20
 
Congenital Heart Disease
The goal of feeding any infant or baby is to have steady and continued weight gain. This holds true for infants and babies with congenital heart disease (CHD), although appropriate weight gain may be more difficult. Babies with CHD often need more calories per day than babies with normal hearts, particularly if they are struggling with symptoms of congestive heart failure. This is because their bodies and hearts have to work harder to get blood and oxygen to all parts of their bodies. This causes them to burn more calories. Also, the act of eating can be difficult for babies with CHD. The coordinated suck, swallow, and breathing process can be very tiring, causing them to burn more calories.
In order to gain weight, babies with CHD need to take in more calories than their bodies are burning, but it is not always as easy as just having them eat more. Often, their stomachs cannot hold larger amounts of breast milk or other feed, or they just tire out before they can drink it all. A baby with CHD may require milk that is 24 to 30 calories per ounce. Breast milk can be fortified to increase the calories. To increase the calories of the breast milk, you would need to pump and then mix in the fortifier. Sometimes even with increased calories, babies with CHD are not able to take in enough by mouth to gain weight. In this case, your baby may need to have a nasogastric (NG) tube placed.
 
Nutritional Therapies in Selected Inborn Errors of Metabolism
Inborn errors of metabolism (IEMs) are hereditary disorders that affect the metabolism of a particular chemical compound. Devastating clinical manifestations and mental retardation often result from untreated IEM. Some metabolic diseases are treatable with nutrition therapy, which may consist of diet modification or restriction, diet supplementation and vitamin supplementation.53 Some of the IEMs, their therapy and dietary modifications are presented in Table 1.12.
Table 1.12   Nutritional therapies of some common IEM disorders53
Modify or Restrict Intake of
Vitamin or Cofactor Responsive
Medical /Commercial Food Products Available
Other Therapies
Phenylketonuria
Phenylalanine
If biopterin defect variant
Yes
Supplemental tyrosine during pregnancy
Tyrosinemia type 1
Phenylalanine, tyrosine methionine
No
Yes
4-hydroxyphenylpyruvate Dioxygenase inhibitor
Tyrosinemia type 2
Phenylalanine, tyrosine
No
Yes
…
Maple syrup urine disease
Leucine, valine, isoleucine
50% thiamine responsive
Yes
…
21
Isovaleric acidemia
Leucine
No
Yes
Supplemental glycine, carnitine, or both
Methylmalonic acidemia
Isoleucine, methionine, threonine, valine
Possible cobalamin responsive disorder
Yes
Supplemental carnitine
Propionic acidemia
Isoleucine methionine, threonine, valine
Possible role of biotin
Yes
Supplemental carnitine
Homocystinuria
Methionine
50% pyridoxine responsive
Yes
Supplemental cysteine, folate, betaine
Ornithine transcarbamylase deficiency
Protein
No
Yes
Supplemental citrulline, benzoate, phenylacetate, phenylbutyrate
Citrullinemia
Protein
No
Yes
Supplemental arginine, benzoate, phenylacetate, phenylbutyrate
Transferase galactosemia
Galactose (lactose)
No
No
Lactose free formula
Medium chain acyl coenzyme A defi.
…
No
No
Avoid fasting, supplemental carnitine
Abetalipoproteinemia
…
No
No
Supplemental medium chain triglycerides, vitamin A and E
Pyruvate carboxylase deficiency
…
Possible biotin or thiamine
No
Frequent feedings, alkali, biotin, thiamine
Glycogen storage disorders
Lactose, fructose, sucrose
No
No
Complex starches

KEY LEARNING POINTS

  • Breastfeeding is ideal food for the newborn, it is superior nutrition, lowers the risk of infection, strengthens emotional bonding, prevents many adulthood diseases which has fetal origin.
  • Nutrition plays a major role in the ultimate well-being of the increasing number of preterm infants who survive the early neonatal period.
  • The dilemma of feeding the preterm infant is that of attempting to provide sufficient nutrition by enteral and parenteral routes to assure optimal development without inducing additional morbidity and mortality secondary to the feeding.
    22
  • The nutritional requirements of young infants (preterm and full term) can be met better by recognizing their limitations in absorption and digestion. This support can be given with parenteral nutrition or specialized enteral feeding technique. Because parenteral solutions can provide complete nutritional support, they may be used for extended periods.
  • Babies with cleft palate may not be able to suck enough. Just supplement breastfeeding with spoon feeding or palada feeding. Both methods are best used with the baby in a fairly upright posture, resting on mother's arm.
  • Episodes of GER are common in both preterm and full-term infants. These are commonly related to intestinal dysmotility and will respond to modifications of the feeding regimen.
  • Nutritional support of the patient with NEC focuses around providing complete parenteral nutrition during the acute phase of the disease, followed by gradual introduction of feeds.
  • Preterm infants who have BPD and CHD have increased caloric requirements due to their increased metabolic expenditure, and at the same time have a lower tolerance for excess fluid intake.
  • Nutritional therapies will continue to be the cornerstone in the treatment of most of the IEM.
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