Educational Feature

Nutrition and Growth in the Premature InfantJudy Philbrook, RNC, NNP

Nutrition and growth of the premature infant are hot topics in my unit.  We are participating in the Vermont Oxford Network iNICQ Value Compass Internet Collaborative Series and have identified three areas of concern. One of these is Extra-Uterine Growth Restriction.  We will be tracking days to
regain birth weight, average weight gain per day, head circumference, and discharge weights.

Some of the things that we have done to improve growth include 1) beginning TPN  and Lipids in the first 24 hours of life, 2) encouraging mothers to breast- feed, 3) beginning gastrointestinal (GI) priming feedings within the first 24 hours, 4) beginning enteral feedings sooner, 5) advancing and
maintaining caloric intake, 6) discontinuing lipids when the enteral calories are >80/kg/day and discontinuing TPN when the enteral intake is greater than 120ml/kg/day, and 7) posting updated growth charts at the bedside weekly so that we can monitor growth.    

To touch briefly on these-We will soon be able to hang a stock solution of TPN on admission. We initially started TPN within 24 hours with 1 gm/kg/day of protein, but have increased this to 1.5 gm/kg/day as well as lipids at 1.5 gm/kg/day.

Mothers are encouraged to breast-feed during initial consultation (if any) and when updated on their infant. GI priming is the introduction of colostrum as soon as it is available after birth (preferably within the first 24 hours).  Breast-milk is preferred, but if it is not available, 24 calorie per ounce premature formula can be used.  Colostrum is rich in IgA (protects against infection) and has a higher content of protein and fat compared to mature breast-milk. Feedings are given by bolus. The amount is 0.5ml every 8 hours for babies who are less than 750 grams and 1ml every 8 hours for babies 751 to 1000 grams. The rationale for GI priming is to stimulate gut maturation and motility and hormone release. When babies are not fed, their guts atrophy and subsequent feedings may be less safe. Early feeding shortens the time to full feeds and discharge as well as reduces serious infections. Also, it has been found that early feedings do not increase the incidence of necrotizing enterocolitis.

Trophic feedings are started as before - when the baby is stable. Some criteria for this may include normal blood pressure, 12 hours or more after the last surfactant or indomethicin dose, normal exam, and infrequent spells. Trophic feeds are ideally started at 48-72 hours after birth and are
continued for 48-72 hours before advancing. For babies who weigh less than 750 grams, these feeds are started at 0.5ml/hour and given for 3 hours and then stopped for one hour.   Feedings are advanced 20ml/kg/day in one step. Bolus feeds are started when the baby weighs 1100 grams (every 2 hours; every 3 hours at 1300 grams).  IV fluids are stopped earlier to prevent infection.  

Growth charts are generated through our computer program. They can be referred to while doing daily notes and are posted at the bedside and referenced during morning rounds.

We'll keep you posted on results!
 

References for Nutrition and Growth:
Schanler, R., Shulman, R., Lau, C., Smith, E., & Heitkemper, M. (1999)
Feeding strategies for premature infants: randomized trial of
gastrointestinal priming and tube feeding method. Pediatrics, 103(2),
434-39.

Wilson, D., Cairns, P., Halliday, H., Reid, M., McClure, G. & Dodge, J.
(1997). Randomised controlled trial of an aggressive nutritional regimen in
sick very low birthweight infants. Arch Disease in Child Fetal Neonatal Ed.,
77, F-4 to F-11.   

References for an earlier Educational Feature:

Advocate Health Care, “Wolff-Parkinson-White Syndrome”, January 13, 2006 from http://www.advocatehealth.com 

State Government Victoria-Department of Human Services, “WPW”, January 11, 2006 from http://www.betterhealth.vic.gov.au/  

Medline Plus Medical Encyclopedia: Wolff-Parkinson-White Syndrome, January 13, 2006 from http://www.nlm,nih.gov/medlineplus/ency/article/000151.htm  

Avery, Mary Ellen, MD and Taeusch, H. William, Jr., MD, “Schaffer’s Diseases of the Newborn”, 1984 by W.B. Saunders Company

Mayo Clinic, “Wolff-Parkinson-White Syndrome”, January 13, 2006 from http:/www.mayoclinic.com  

Merck Manuals of Medical Information-online medical library-second home edition, January 13, 2006 from www.merckmanual.com  

Arnsdorf, Morton F., MD, MACC and Podrid, Philip J. MD, “Epidemiology of the Woff-Parkinson-White Syndrome”, January 13, 2006 from http://www.update.com  

Lexi-Comp Online, “Adenosine: Pediatric drug information”, January 11, 2006 from http://www.update.com

Giardiana, Elsa-Grace, MD, “Clinical Use of Amiodarone”, January 13, 2006 from http://www.update.com  

Giardiana, Elsa-Grace, MD and Zimetbaum, Peter, MD, “Major Side Effects of Amiodarone”, January 12, 2006 from http://www.update.com

References for Nutrition and Growth:

Schanler, R., Shulman, R., Lau, C., Smith, E., & Heitkemper, M. (1999)
"Feeding strategies for premature infants: randomized trial of
gastrointestinal priming and tube feeding method." Pediatrics, 103(2),
434-39.

Wilson, D., Cairns, P., Halliday, H., Reid, M., McClure, G. & Dodge, J.
(1997). "Randomized controlled trial of an aggressive nutritional regimen in
sick very low birth weight infants". Arch Disease in Child Fetal Neonatal Ed.,
77, F-4 to F-11.