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Nutritional strategies for the very low birthweight infant
\"The goal of nutritional management in VLBW and ELBW infants is the achievement of postnatal growth at a rate that approximates the intrauterine growth of a normal fetus at the same postconceptional age. In reality, however, growth lags considerably after birth; although non-nutritional factors are involved, nutrient deficiencies are critical in explaining delayed growth. This practical clinically-oriented pocketbook reviews and summarises all available clinical evidence. It enables the reader to implement parenteral or enteral feeding plans, with the goals of reducing postnatal weight loss, earlier return to birthweight, and improved catch-up growth. Both nutrient balance and growth and the impact on neurodevelopment and health outcomes are evaluated. With many tables and algorithms to summarise key data and management strategies, Nutritional Strategies for the Very Low Birthweight Infant is an invaluable guide for all healthcare professionals caring for premature babies\"--Provided by publisher.
Book
Use of human milk and fortification in the NICU
Human milk is the gold standard to provide nutritional support for all healthy and sick newborn infants including the very low birth weight (VLBW) infant (<1500 g). It has both nutritional and anti-infective properties which are especially important for these infants at risk for sepsis and necrotizing enterocolitis. Human milk alone is insufficient to meet the nutritional needs for VLBW infants, especially protein and minerals. There is a conundrum between achieving the nutritional, immunologic, developmental, psychological, social, and economic benefit with human milk vs. the inadequate growth with unfortified human milk for VLBW leading to nutritional inadequacy, growth failure and poor neurodevelopmental outcome. The use of multicomponent fortifiers to increase calories and provide additional protein, vitamins, and minerals has been associated with short-term benefits in growth. Most current fortifiers are derived from cow’s milk, however there are concerns regarding a possible association between the use of cow’s milk-based fortifier and NEC. There is also an exclusive human milk diet with a fortifier derived solely from human milk. There are three approaches for fortifying human milk and include fixed dosage or “blind fortification”, adjustable fortification using the blood urea nitrogen as a surrogate for protein nutriture to modify dosage of fortification, and targeted, individualized fortification that is based on periodic human milk analysis.
Journal Article
COMMENTARY: Searching for biomarkers and regulators of growth in very preterm infants with new fortifiers
In this issue of Pediatric Research Holgerson et al. report measurements of plasma glucose-regulatory hormones in 225 very preterm infants (VPIs) showing that these hormone levels were minimally affected by a novel bovine colostrum fortifier and did not seem to be appropriate biomarkers of early postnatal growth for individual VPIs.
Journal Article
Nutritional Strategies for the Very Low Birthweight Infant
The goal of nutritional management in VLBW and ELBW infants is the achievement of postnatal growth at a rate that approximates the intrauterine growth of a normal fetus at the same postconceptional age. In reality, however, growth lags considerably after birth; although non-nutritional factors are involved, nutrient deficiencies are critical in explaining delayed growth. This practical clinically-oriented pocketbook reviews and summarises all available clinical evidence. It enables the reader to implement parenteral or enteral feeding plans, with the goals of reducing postnatal weight loss, earlier return to birthweight, and improved catch-up growth. Both nutrient balance and growth and the impact on neurodevelopment and health outcomes are evaluated. With many tables and algorithms to summarise key data and management strategies, Nutritional Strategies for the Very Low Birthweight Infant is an invaluable guide for all healthcare professionals caring for premature babies.
eBook
Pragmatic Approach to In-Hospital Nutrition in High-Risk Neonates
Extremely low birth weight infants may experience periods of moderate to severe undernutrition during the acute phase of their respiratory problems. This undernutrition contributes to early growth deficits in these patients and may have long-lasting effects, including poor neurodevelopmental outcome. Early postnatal intravenous amino-acid administration and early enteral feeding strategies will minimize the interruption of nutrient intake that occurs with premature birth. These two strategies will prevent intracellular energy failure, allow the administration of more non-protein energy, as well as enhance overall nutritional health, as evidenced by less postnatal weight loss and earlier return to birth weight, and improved overall postnatal growth and outcome.
Journal Article
Prediction of Extrauterine Growth Retardation (EUGR) in VVLBW Infants
BACKGROUND:
Long-term growth failure in very very low birth weight (VVLBW) infants is a common complication of extreme prematurity. Critical illnesses create challenges to adequate nutriture.
PURPOSE:
To identify predictors of extrauterine growth retardation (EUGR) in VVLBW infants and to evaluate their nutritional intake and subsequent growth.
STUDY DESIGN:
A 4-year retrospective chart review of 221 infants ≤1000 g birth weight and ≤29 weeks gestational age who were admitted within 24 hours of birth, were free of major congenital anomalies and survived at least 7 days. Daily intakes and anthropomorphic data were collected and analyzed. Significant events during hospitalization were documented.
RESULTS:
Mean energy and protein intakes during hospitalization did not reach recommendations of 120 kcal/kg/d and 3.0 g/kg/day.
In utero
growth rates could not be consistently reached or sustained. As expected, BW (as measured by BW percentile score) was highly predictive of EUGR (
p
<0.001). When the independent effect of other predictors of EUGR was considered, only days of total parenteral nutrition (
p
<0.001) and HC percentile at return to birth weight (
p
<0.001) made a significant contribution to the prediction of EUGR, once the effect of BW was taken into account.
Journal Article
Postnatal Malnutrition of Extremely Low Birth-Weight Infants With Catch-Up Growth Postdischarge
Objective:
To assess nutritional intakes and subsequent growth of extremely low birth-weight (BW) infants.
Study Design:
Chart review of 69 extremely low BW infants stratified into two groups by BW: ≤750 g (group 1;
n
=27) or 751 to 1000 g (group 2;
n
=42). Dietary intakes, weights, and head circumferences (HC) were collected through discharge and at 1 month postdischarge. The differences between goals and intakes were calculated weekly during hospitalization. Descriptive comparisons were made between growth parameters at birth, discharge, and follow-up.
Results:
Total energy and protein deficits were inversely related to BW. Both groups exhibited extrauterine growth retardation while hospitalized. After discharge, the rates of weight gain and HC growth increased, leading to some growth recovery at follow-up.
Conclusions:
Existing feeding methods resulted in sizeable deficits in energy and protein, particularly for the smallest infants. Changing current practices to limit these deficits is essential to improving postnatal growth.
Journal Article
Standard infant formulas
Term infant formulas do not meet the nutritional requirements for VLBW infants. Yet many preterm babies may be discharged on term formulas and some even receive them in the NICU. The carbohydrate in standard infant formula is 100% lactose and the fat is all long-chain triglycerides of vegetable origin, usually soy and coconut oils. Most standard formulas are whey-predominant, with 60% of the protein whey and 40% casein. Standard formulas are available in both iron-fortified and non-iron-fortified (or “low iron”) forms. Iron-fortified formula contains elemental iron 12 mg/L or approximately 2.0 mg/kg per day for an infant receiving approximately 108 kcal/kg/d. Low-iron formula contains elemental iron 1.5 mg/L or 0.2 mg/kg per day.Most standard infant formulas are available as ready-to-feed, liquid concentrate, and powder. The concentrate and the powder provide the option of concentrating the formula to a higher caloric density. Concentrations above 1 kilocalorie per milliliter or 30 kilocalories per ounce are not recommended because of the high renal solute load that results from the decrease in free water intake. As the formula is concentrated, the osmolality increases to approximately the same degree as the concentration. Thus, for a 20 kcal/oz formula with an osmolality of 300 mOsm/kg H2O, if concentrated 135% or to a 27 kcal/oz formula, the osmolality increases to approximately 405 mOsm/kg H2O. This concentration of term formula is not an accepted strategy for nutrient-enhancing a VLBW infant in the NICU. The chapter on hypercaloric feeding strategies (Chapter 22) discusses acceptable milks where over concentrating is not a likely hazard for small preterm infants.
Book Chapter
Fluid and electrolyte management (Na, Cl and K)
The 24-week fetus is composed of 90% total body water (TBW). Cell membranes separate intracellular water and extracellular water spaces. Sixty-five percent of TBW is in the extracellular (ECW) compartment and 25% is intracellular (ICW). As gestation proceeds towards term, TBW decreases to 74% of total body weight and the extracellular and intracellular volumes are 40% and 35%, respectively. Potassium (K+) is the major ion of the ICW and potassium's intracellular concentration is impaired by insufficient supplies of oxygen and energy. The major ion of ECW is sodium (Na+) and the major anion is chloride (Cl−).The preterm infant is in a state of relative extracellular fluid volume with an excess of TBW compared with the full-term infant. VLBW infants are vulnerable to imbalances between intra- and extracellular compartments. The dilute urine and negative sodium balance the first few days after birth in the preterm infant is an appropriate adaptive response to extrauterine life. Therefore, the initial diuresis is physiologic, reflecting changes in interstitial fluid volume. This diuresis should be considered in the estimation of daily fluid needs. As a result, a gradual weight loss of 10–15% in a VLBW infant during the first week of life is expected without adversely affecting urine output, urine osmolality, or clinical status. Provision of large volumes of fluid to provide increased nutrition, for example, 160 to 180 mL/kg/d, does not prevent this weight loss and appears to increase the risk of the development of patent ductus arteriosus, intraventricular hemorrhage, bronchopulmonary dysplasia (BPD), and necrotizing enterocolitis (NEC).
Book Chapter