Feeding of Low Birth Weight Infants 050508

AIIMS- NICU protocols 2008
Feeding of Low Birth weight Infants
M. Jeeva Sankar, Ramesh Agarwal, Satish Mishra, Ashok Deorari, Vinod a!l,
Division of Neonatology, Department of Pediatrics All India Institute of Medical Sciences Ansari Nagar, New Delhi 11 !"
Address for "orres#onden"e$ rof Vinod a!l Professor & Head Department of Pediatrics All India Institute of Medical Sciences Ansari Nagar, New Delhi 1100 ! "mail# $inodpaul%neonatalhealth&com
%onfli"t of interest$ None
Downloaded from www.newbornwhocc.org
A&stra"t
'ptimal feeding of low (irth weight )*+,- infants impro$es their immediate sur$i$al and su(se.uent growth & de$elopment& +eing a heterogeneous group comprising term and preterm neonates, their feeding a(ilities, fluid and nutritional re.uirements are .uite different from normal (irth weight infants& A practical approach to feeding a *+, infant including choice of initial feeding method, progression of oral feeds, and nutritional supplementation (ased on her oral feeding s/ills and nutritional re.uirements is (eing discussed in this protocol& 0rowth monitoring, management of feed intolerance, and the essential s/ills in$ol$ed in feeding them ha$e also (een descri(ed in detail& Key words: #ow $irth weight, %eeding, &'pression of $reast mil(, %ortification, )rowth monitoring
I'(R)D*%(I)'
0lo(all1, a(out 12 million infants are (orn with a (irth weight of 3 400g e$er1 1ear& 1 5hough these low (irth weight )*+,- infants constitute onl1 a(out 167 of the total li$e (irths, the1 account for 809207 of total neonatal deaths& Most of these deaths can (e pre$ented with e:tra attention to warmth, pre$ention of infections and more importantl1, optimal feeding&
F++DI', )F LB- I'FA'(S$ -./ IS I( IM )R(A'(0

Nutritional management influences immediate sur$i$al as well as su(se.uent growth and de$elopment of *+, infants& "$en simple inter$entions such as earl1 initiation of (reastfeeding and a$oidance of pre9lacteal feeding ha$e (een shown to impro$e their sur$i$al in resource restricted settings&; "arl1 nutrition could also influence the long term neurode$elopmental outcomes< malnutrition at a $ulnera(le period of (rain de$elopment has (een shown to ha$e deleterious effects in e:perimental animals&6
F++DI', )F LB- I'FA'(S$ .)- IS I( DIFF+R+'(0

5erm infants with normal (irth weight re.uire minimal assistance for feeding in the immediate postnatal period 9 the1 are a(le to feed directl1 from mothers= (reast& In contrast, feeding of *+, infants is relati$el1 difficult (ecause of the following limitations# . 5hough ma>orit1 of them are (orn at term, a significant proportion are (orn premature with inade.uate feeding s/ills& 5he1 might not (e a(le to (reastfeed and would re.uire other methods of feeding such as spoon or gastric tu(e feeding& 2. !. 5hese infants are prone to ha$e significant illnesses in the first few wee/s of life< the underl1ing condition often precludes enteral feeding& Preterm $er1 low (irth infants )?*+,- infants ha$e higher fluid re.uirements in the first few da1s of life due to e:cessi$e insensi(le water loss& ". Since intrauterine accretion of nutrients occurs mainl1 in the later part of the third trimester, ?*+, infants )usuall1 (orn (efore ; wee/s gestation- ha$e low (od1 stores at (irth& Hence, the1 re.uire supplementation of $arious nutrients& "$en term *+, infants who are li/el1 to (e growth restricted need higher calories for @catch9up= growth& #. +ecause of the gut immaturit1, the1 are more li/el1 to e:perience feed intolerance necessitating ade.uate monitoring and treatment&
R)()%)L F)R F++DI', LB- I'FA'(S

In this protocol, we intend to address the following issues in feeding the *+, infants# . How to decide the initial method of feeding in a gi$en *+, infantA & Bor infants initiated on modes other than (reastfeeding# a& How to progress to (reastfeedingA (& ,hat mil/ to (e gi$enA c& How much mil/ to (e gi$enA ;& ,hat supplements are re.uiredA 6& How to assess the feeding ade.uac1 and monitor the growthA 4& How to identif1 and manage feed intoleranceA
D+%IDI', (.+ I'I(IAL M+(.)D )F F++DI',

It is essential to categoriCe *+, infants into two ma>or groups D sic( and healthy 9 (efore deciding the method of feeding& Sick infants 5his group constitutes infants with significant respirator1 distress re.uiring assisted $entilation, shoc/ re.uiring inotropic support, seiCures, s1mptomatic h1pogl1cemiaEh1pocalcemia, electrol1te a(normalities, renalEcardiac failure, surgical conditions of gastrointestinal tract, necrotiCing enterocolitis )N"F-, h1drops, etc& 5hese infants are usuall1 started on intra$enous )I?- fluids& "nteral feeds should (e initiated as soon as the1 are hemod1namicall1 sta(le with the choice of feeding method (ased on the infants= gestation and clinical condition )see $elow-& It is important to realiCe that enteral feeding is important e$en in sic/ neonates& 'ral feeds should not (e dela1ed in them without an1 $alid reason& "$en infants with respirator1 distress andEor on assisted $entilation can (e started on enteral feeds once the initial acute phase is o$er and the infants= color, saturation and perfusion ha$e impro$ed& Similarl1, sepsis )unless associated with shoc/EscleremaEN"F- is not a contraindication for enteral feeding& Feeding in healthy LBW infants "nteral feeding should (e initiated immediatel1 after (irth in health1 *+, infants with the appropriate feeding method determined (1 their gestation and oral feeding s/ills& Maturation of oral feeding skills: +reastfeeding re.uires effecti$e suc/ing, swallowing and a proper coordination (etween suc/Eswallow and (reathing& 5hese comple: s/ills mature with increasing gestation )*a$le 1+,
"
AIIMS- NICU protocols 2008 5he fetus is a(le to swallow amniotic fluid (1 as earl1 as 11 to 1 wee/s gestation& Mouthing can (e o(ser$ed at 14 wee/s (ut the coordinated suc/ing mo$ements are not usuall1 present until a(out 2 wee/s gestation& Single suc/s can (e recorded manometricall1 at 2 wee/s and suc/ing (ursts (1 ;1 wee/s gestation& A mature suc/ing pattern that can ade.uatel1 e:press mil/ from the (reast is not present until ; 9;6 wee/s gestation&4 Howe$er, the coordination (etween suc/Eswallow and (reathing is not full1 achie$ed until ;G wee/s of gestation& 5he maturation of oral feeding s/ills and the choice of initial feeding method at different gestational ages are summariCed in *a$le 1, 5a(le 1 Mat!ration of oral feeding skills and the "hoi"e of initial feeding method in LB- infants1 Gestational age 2 34 weeks 34567 weeks Maturation of feeding skills No proper suc/ing efforts No propulsi$e motilit1 in the gut Suc/ing (ursts de$elop No coordination (etween suc/Eswallow and (reathing Slightl1 mature suc/ing pattern Foordination (etween (reathing and swallowing (egins Mature suc/ing pattern More coordination (etween (reathing and swallowing Initial feeding method Intra$enous fluids 'ro9gastric )or naso9gastrictu(e feeding with occasional spoonEpaladai feeding Beeding (1 spoonEpaladai-cup +reastfeeding
63568 weeks 968 weeks
How to decide the initial feeding method 5raditionall1, the initial feeding method in a *+, infant was decided (ased on her (irth weight& 5his is not an ideal wa1 (ecause the feeding a(ilit1 depends largel1 on gestation rather than the (irth weight& Howe$er, it is important to remem(er that not all infants (orn at a particular gestation would ha$e same feeding s/ills& Hence the ideal wa1 in a gi$en infant would (e to e$aluate if the feeding s/ills e:pected for hisEher gestation are present and then decide accordingl1 )%igure 1-& All sta&le LB- infants, irres#e"tive of their initial feeding method sho!ld &e #!t on their mothers: &reast. (he immat!re s!"king o&served in #reterm infants &orn &efore 68 weeks might not meet their dail; fl!id and n!tritional re<!irements &!t hel#s in ra#id mat!ration of their feeding skills and also im#roves the milk se"retion in their mothers => on!nutriti"e sucking#?. S$oon%$aladai feeding In our unit, we use paladai feeding in #./ infants who are not a$le to feed directly from the $reast, 5he steps of paladai feeding are descri(ed in Panel 1,0
>34 weeks
Initiate Breastfeeding
)&serve if$ 1& Positioning &attachment are good
32-34 weeks
2. A(le to suc/ effecti$el1 and long

enough )a(out 10914 min-
/es 'o Breastfeeding
Start feeds by spoon/paladai
28-31 weeks
)&serve if$ . Accepting well without spillingEcoughing & A(le to accept ade.uate amount
/es 'o Spoon/paladai feeding
Start feeds by OG/ G t!be
)&serve if$ 1& ?omitingE a(dominal distension occurs 2. 5he pre9feed aspirate e:ceeds H 47 of feed $olume
"28 weeks
'o Gastri$ t!be feeding /es Start I# fl!ids
Figure &: 'eciding the initial feeding method in LBW infants
Intra!gastric tu(e feeding 5he steps of intra9gastric tu(e feeding are gi$en in Panel !, Some of the contro$ersial issues in gastric tu(e feeding are discussed (elow# aso!gastric "s) oro!gastric feeding: Ph1siological studies ha$e shown that naso9gastric )N0- tu(e increases the airwa1 impedance and the wor/ of (reathing in $er1 preterm infants&G Hence, oro9gastric tu(e feeding might (e prefera(le in these infants& /e employ only oro1gastric tu$e feeding in our unit, Downloaded from www.newbornwhocc.org $
AIIMS- NICU protocols 2008 Intermittent (olus "s) continuous intra!gastric feeding: 5here are no differences in the time to reach full enteral feeding E somatic growth E incidence of N"F (etween infants fed (1 intermittent (olus or continuous intra9gastric feeding&2 Studies ha$e shown that gastric empt1ing and duodenal motor responses are enhanced in infants gi$en continuous intra9gastric feeding&! +ut a ma>or disad$antage of this method is that the lipids in the mil/ tend to separate and stic/ to the s1ringe and tu(es during continuous infusion resulting in significant loss of energ1 and fat content& /e use intermittent $olus feeding in our unit, anel 7$ Ste#s of *aladai Feeding@
1& & ;& 6& 4& 8& G& 2& !& 10& 11& 1 & Place the infant in up9right posture on mother=s lap Ieep a cotton nap/in around the nec/ to mop the spillage& 5a/e the re.uired amount of e:pressed (reast mil/ (1 using a clean s1ringe Bill the paladai with mil/ little short of the (rim< Hold the paladai from the sides< D' N'5 put 1our finger Place it at the lips of the (a(1 in the corner of the mouth 5ip the paladai to pour a small amount of mil/ into the infant=s mouth Beed the infant slowl1< heEshe will acti$el1 swallow the mil/ Jepeat the process until the re.uired amount has (een fed If the infant does not acti$el1 accept and swallow, tr1 to arouse himEher with gentle stimulation ,hile estimating the mil/ inta/e, deduct the amount of mil/ left in the cup and the amount of estimated spillage ,ash the paladai with soap and water and then put in (oiling water for 0 minutes to steriliCe (efore ne:t feed
anel 3$ Ste#s of Intra5gastri" (!&e Feeding@

1& & ;& 6& #. $. +efore starting a feed, chec/ the position of the tu(e Jemo$e the plunger the s1ringe )ideall1 a sterile s1ringe should (e usedFonnect the (arrel of the s1ringe to the end of the gastric tu(e Pinch the tu(e and fill the (arrel of the s1ringe with the re.uired $olume of mil/ Hold the tu(e with one hand, release the pinch and ele$ate the s1ringe (arrel *et the mil/ run from the s1ringe through the gastric tu(e (1 gra$it1< D2 N2* force mil( through the gastric tu$e $y using the plunger of the syringe G& Fontrol the flow (1 altering the height of the s1ringe& *owering the s1ringe slows the mil/ flow, raising the s1ringe ma/es the mil/ flow faster 2& It should ta/e a(out 10914 minutes for the mil/ to flow into the infant=s stomach %. '(ser$e the infant during the entire gastric tu(e feed& Do not lea$e the infant unattended& Stop the tu(e feed if the infant shows an1 of the following signs# (reathing difficult1, change in colourE loo/s (lue, (ecomes flopp1, and $omiting 0. Fap the end of the gastric tu(e (etween feeds< if the infant is on FPAP, the tu(e is prefera(l1 left open after a(out half an hour . A$oid flushing the tu(e with water or saline after gi$ing feeds&
&
R),R+SSI)' )F )RAL F++DS

All *+, infants, irrespecti$e of their gestation and (irth weight, should ultimatel1 (e a(le to feed directl1 from the mothers= (reast& Bor preterm *+, infants started on I? fluidsE'0 tu(eEpaladai feeding, the steps of progression to direct and e:clusi$e (reastfeeding are summariCed in %igure !, 5erm *+, infants started on I? fluids )(ecause of their sic/ness- can (e put on the (reast once the1 are hemod1namicall1 sta(le&
Infants on I# fl!ids% If hemod1namicall1 sta(le Start tro#hi" feeds (1 '0 tu(e & Monitor for feed intolerance If accepting well 0raduall1 in"rease the feed vol!me (a#er and sto# IV fluids Infants on OG t!be feeds At ;09; wee/s= PMA (r; s#oon feeds once or twice a da1 Also, #!t on mother:s &reast and allow NNS If accepting spoon feeds well
0raduall1 in"rease the fre<!en"; and amo!nt of spoon feeds Red!"e ), feeds accordingl1 Infants on spoon/paladai feeds
!t them on mother:s &reast (efore each feed '(ser$e for good attachment & effecti$e suc/ing If a(le to (reastfeed effecti$el1
#
(a#er and sto# spoon feeds once the mother is confident
Figure +: *rogression of oral feeding in *reterm LBW infants

,I-. intra"enous/ 0G. oro!gastric tu(e/ *M1. $ostmenstrual age/ S. non!nutriti"e sucking2 3 4erm and near!term sick infants started on I- fluids can (e initiated on (reastfeeding once they are hemodynamically sta(le/

#
Some infants may ha"e to (e gi"en s$oon feeding for some $eriod e"en after they start acce$ting (reastfeeding
S#e"ial sit!ations
56tremely low (irth weight infants: 5he1 are usuall1 started on parenteral nutrition from da1 1& "nteral feeds in the form of trophic feeding or minimal enteral nutrition )M"N- are initiated once the infant is hemod1namicall1 sta(le& Burther ad$ancement is (ased on the infant=s a(ilit1 to tolerate the feeds )See AIIMS protocol on 3Minimal enteral nutrition4-&10 Se"ere I7G8 with antenatally detected 'o$$ler flow a(normalities: Betuses with a(normal Doppler flow such as a(sentEre$ersed end diastolic flow )AEJ"DB- in the um(ilical arter1 are li/el1 to ha$e had mesenteric ischemia in utero, After (irth, the1 ha$e a significant ris/ of de$eloping feed intolerance and N"F& 11 5he timing of initiation of oral feeds in these infants is contro$ersial& ,e usuall1 dela1 feeding up to 629G hours in preterm )3;4 wee/s=- infants with AEJ"DB& Infants on 9*1*%"entilation: 5hese infants can (e started on '0 tu(e feeds once the1 are hemod1namicall1 sta(le& +ut it is important to lea$e the tu(e open intermittentl1 to reduce gastric distension&
%.)I%+ )F MILA F)R LB- I'FA'(S

All *+, infants, irrespecti$e of their initial feeding method should recei$e 'N*K (reast mil/& 5his can (e ensured e$en in those infants who are fed (1 paladai or gastric tu(e (1 gi$ing e:pressed (reast mil/ )mothers= own mil/ or human donor mil/-& 56$ressed (reast milk ,5BM2: All preterm infants= mothers should (e counseled and supported in e:pressing their own mil/ for feeding their infants& ":pression should ideall1 (e initiated within hours of deli$er1 so that the infant gets the (enefits of feeding colostrum& 5hereafter, it should (e done 9; hourl1 9 this would ensure that the infant is e:clusi$el1 (reastfed and also helps in maintaining the lactation in the mother& 5he steps of (reast mil/ e:pression are gi$en in Panel 5& ,e counsel mothers for e:pression of (reast mil/ soon after deli$er1 (1 demonstration and (1 using poster & $ideos )a$aila(le on our we(site# www&new(ornwhocc&org":pressed (reast mil/ can (e stored for a(out 8 hours at room temperature and for 6 hours in refrigerator& 'onor human milk: In centers where optimal mil/ (an/ing facilities are a$aila(le, donor human mil/ can (e used for feeding a *+, infant& At present, onl1 a few centers in India ha$e standardiCed human mil/ (an/ing facilities& Hence, it is not a practical option in most of the settings across India& S#e"ial sit!ations Sick mothers% contraindication to (reastfeeding: In these rare circumstances, the options a$aila(le are Downloaded from www.newbornwhocc.org %
AIIMS- NICU protocols 2008 1& Bormula feeds# a. Preterm formula D in ?*+, infants and b. 5erm formula D in infants weighing H1400g at (irth & Animal mil/# e&g& undiluted cow=s mil/ 'nce the mother=s condition (ecomes sta(le )or the contraindication to (reastfeeding no longer e:ists-, these infants should (e started on e:clusi$e (reastfeeding& anel 6$ Ste#s of eB#ression of &reast milk@
1& & 3. 5he mother should wash her hands thoroughl1& She should hold a clean wide mouthed container near her (reast& As/ her to gentl1 massage the (reast for 4910 minutes (efore e:pressing the mil/ )using the pulp of two fingers or with /nuc/les of the fist in a circular motion towards the nipple as if /neading dough-& Massage should not hurt her& 6& As/ her to put her thum( A+'?" the nipple and areola, and her first finger +"*', the areola opposite the thum(& She should support the (reast with her other fingers& 4& As/ her to press her thum( and first finger slightl1 inward towards the chest wall& 8& She should press her (reast (ehind the nipple and areola (etween her fingers and thum(& She must press on the lactiferous sinuses (eneath the areola& &. Press and release, press and release& 5his should not hurt9if it hurts, the techni.ue is wrong& It ma1 ta/e some time (efore mil/ starts coming& 2& As/ her to press the areola in the same wa1 from the SID"S, to ma/e sure that mil/ is e:pressed from all segments of the (reast& %. She should e:press one (reast first till the mil/ flow slows< then e:press the other side< and then repeat (oth sides&
0. Avoid ru((ing or sliding her fingers along the s/in& . Avoid s.ueeCing the nipple itself& Pressing or pulling the nipple cannot e:press the mil/&
.)- M*%. MILA IS () B+ ,IV+'0

It is essential to calculate the fluid re.uirements and feed $olumes for infants on paladai-gastric tu(e feeding& Fluid re:uirement: 5he dail1 fluid re.uirement is determined (ased on the estimated insensi(le water loss, other losses, and urine output& ":treme preterm infants need more fluids in the initial wee/s of life (ecause of the high insensi(le water loss& ,e usuall1 start fluids at 20 m* and 80 m*E/gEda1 for infants (irth weights of 31400g and 14009 400g respecti$el1& Burther re.uirements are calculated (1 dail1 estimation of weight lossEgain, serum sodium, urine output and specific gra$it1& 5he usual dail1 increment would (e a(out 149 0 m*E/gEda1 so that (1 the end of first wee/ 140 m*E/gEda1 is reached in (oth the categories& ,e usuall1 reach a ma:imum of 120m*E/gEda1 (1 da1 16 )Jefer to AIIMS protocol on 3%luids and electrolyte management in term and preterm neonates4=-&1
AIIMS- NICU protocols 2008 Feed "olume: After estimating the fluid re.uirements, the indi$idual feed $olume to (e gi$en (1 '0 tu(e or paladai ) 9hrl1E;9hrl1- should (e determined&
'*(RI(I)'AL S*
L+M+'(A(I)' I' LB- I'FA'(S
*+, infants, especiall1 those who are (orn preterm re.uire supplementation of $arious nutrients to meet their high demands& Since the re.uirements of ?*+, infants differ significantl1 from those with (irth weights of 14009 6!! grams, the1 ha$e (een discussed separatel1& S!##lementation for infants with &irth weights of 71CC531CCg 5hese infants are more li/el1 to (e (orn at term or near term gestation )H;6 wee/s-< hence, the1 do not re.uire multi9 nutrient supplementation or fortification of (reast mil/ )cf& ?*+, infants-& Howe$er, $itamin D and iron might still ha$e to (e supplemented in them& ,hile iron supplementation is mandator1 for all infants, $itamin D supplementation is contentious (ecause of the paucit1 of the data regarding its le$els and deficienc1 status in different populations& Some argue that the dail1 re.uirement of $itamin D is met usuall1 (1 de no$o s1nthesis in the s/in )following e:posure to sun light- and hence no supplementation is re.uired& ,H' does not recommend routine $itamin D supplementation in *+, infants&1; Howe$er, the American Academ1 of Pediatrics recommends $itamin D supplementation ) 00 ILEda1- e$en in term infants who are e:clusi$el1 (reast fed& Fonsidering that *+, infants are more at ris/ of osteopenia than health1 term infants, most neonatal units tend to supplement $itamin D in them&16 'ne has to assess the mothers= nutritional status, their e:posure to sun, and the infants= e:posure to sun (efore adopting a polic1 for their respecti$e unit)s-& /e supplement $oth vitamin D and iron in infants with $irth weights of 16 1!7"" grams8 vitamin D 9! started at ! wee(s and iron 9! mg-(g-day+ at ! months of life8 $oth are continued till 1 year of age )5a(le -, 5a(le '!tritional s!##lements for infants with &irth weights of 71CC538DD g
utrients
I:+ is
-itamin '3 Iron

3 See te6t
Method of s!##lementation Multi$itamin dropsEs1rup Iron dropsEs1rup
Dose 009600 ILEda1 mgE/gEda1 )ma:imum 14mgEda1-
-hen to start wee/s of life 8 D 2 wee/s of age
(ill when0 5ill 1 1ear of age 5ill 1 1ear of age
S!##lementation in VLB- infants

5hese infants who are usuall1 (orn (efore ; 9;6 wee/s gestation ha$e inade.uate (od1 stores of most of the nutrients& ":pressed (reast mil/ has inade.uate amounts of protein, energ1, calcium, phosphorus, trace elements )iron, Cinc- and $itamins )D, " & I- that are una(le to meet their dail1 recommended inta/es )*a$le 5-& Hence, these Downloaded from www.newbornwhocc.org
AIIMS- NICU protocols 2008 infants need multi9nutrient supplementation till the1 reach term gestation )60 wee/s postmenstrual age-& After this period, their re.uirements are similar to those infants with (irth weights of 14009 6!! grams& Multi9nutrient supplementation can (e ensured (1 one of the following methods# 1& Supplementing indi$idual nutrients D e&g&, calcium, phosphorus, $itamins, etc& & +1 fortification of e:pressed (reast mil/# a. Bortification with human mil/ fortifiers )HMB(& Bortification with preterm formula 5a(le ; Re"ommended Dietar; Allowan"e in reterm VLB- infants and the +stimated Intakes with FortifiedE!nfortified .!man Milk
RDAF =*nitsEkgEda;? At dail; intake of 74C mLEkg )nl; eB#ressed &reast milk# 11G 3.8@ 11&8 8&2 86.3 33.3 820 6.1 1&! 6@.3 26& 31.G @ C.@ Deficient in protein, calcium, phosphorus, and $itamins +1, +8 and D< Minc content is slightl1 less than the JDA +BM fortified with La"todeB5.MF =8gE7CCmL? 166 6.3 18&26 G&1 ; 11 ;;02 !0; 8&; G!&6 148& 114&G 140 0&!8 Deficient in protein +BM fortified with reterm form!la =8gE7CCmL? 14; 6.8 14&42 !&08 7C6 13 !20 8C ;&8 ;1 486& 1 6@ 0&!8 Deficient in calcium, phosphorus, $itamin D, and folic acid< protein is slightl1 less&
+nerg; =k"al? rotein =g? %ar&oh;drates =g? Fat =g? %al"i!m =mg? hos#hor!s =mg? Vitamin A =I*? Vitamin D =I*Eda;? Vitamin + =I*? Vitamin B7 =m"g? ?itamin + )mcg?itamin +8 )mcgFoli" a"id =m"g? Hin" =mg? Remarks
10491;0 ;&496&0 10916 4&69G& 10 110 !09 G0 600 H1&; H 62 HG H6 ;!&8 H0&8
3 11*90 +;;<14 # Based on $reterm mature milk ,8'1. recommended dietary allowance/ 5BM. e6$ressed (reast milk2
Su$$lementing (reast milk with minerals and "itamins: 5he following nutrients ha$e to (e added to the e:pressed (reast mil/ to meet the ?*+, infants= high re.uirements# . Falciuma and phosphorusa )1609180 mgE/gEd & G0920 mgE/gEd respecti$el1 for infants on "+M2. ?itamin D( )600 ILEda1-, $itamin + comple: and Cinc( )a(out 0&4mgEda1- D usuall1 in the form of multi$itamin drops
a b
"&g& Syr, 2stocalcium 9)la'oSmith;line <o,+, Syr, 2ssopan1D 9**; =ealthcare+ "&g& De'vita drops )5ridoss Fo&-, >isyneral1?inc drops )*ifeon Fo&-, De'vita drops )5ridoss Fo&-
AIIMS- NICU protocols 2008 !. Bolate )a(out 40 mcgE/gEda1- c ". Iron 9 mgE/gEda1-d =owever, one has to remem$er that supplementation of minerals and vitamins would not meet the high protein re@uirements of these infants )5a(le ;-, Hence, this method is usuall1 not preferred& 5o a$oid a(normal increase in the osmolalit1, these supplements should (e added at different times in the da1& Fortification with HMF: Bortification of e:pressed (reast mil/ with HMB increases the nutrient content of the mil/ with out compromising its other (eneficial effects )such as reduction of N"F, infections, etc&-& ":perimental studies ha$e shown that the use of fortified human mil/ results in net nutrient retention that approaches or is greater than e:pected intrauterine rates of accretion in preterm infants&18 5hough there are concerns a(out the increase in osmolalit1, clinical studies ha$e not shown an1 significant ad$erse effects following fortification of human mil/& 5he Fochrane re$iew on fortification found short term impro$ement in weight gain, linear and head growth with out an1 increase in ad$erse effects such as N"F&1G 5he standard preparations of human mil/ fortifiers )HMB- used in de$eloped countries are not a$aila(le in India& 5he onl1 preparation a$aila(le 9#actode'1=M%, Aapta(os, .rett B <o, #td8 As, 1 -1 per sachet+ has some limitations# inappropriatel1 high $itamin A, no iron, etc& Short of other options, it ma1 still ha$e to (e used in ?*+, infants& 'ne stud1 from Fhandigarh has reported (etter growth with its use&12 As seen from *a$le 5, preterm >#./ infants on e'pressed $reast mil( fortified with =M% do not re@uire any supplementation 9e'cept for iron+, Fortification with $reterm formula: 5he other option a$aila(le for fortification is preterm formula )e&g& De'olac Special <are NWockhardt Co.O, Pre1#actogen NNestle Fo&O-& 5he recommended concentration is C.8g #er 7CmL of (reast mil/& 5hough more economical than fortification (1 HMB, this method has two ma>or draw(ac/s 9 it is difficult to measure such small amounts of formula powder and the JDA of some minerals and $itamins )e&g& calcium, phosphorus, $itamin D, folic acid- are not met e$en after fortification& ,hile the former pro(lem can (e managed to a certain e:tent (1 using a small scoop of 1g siCe for 4m* of mil/, the later is circum$ented (1 additional supplementation 9*a$le 5+, 5he recommended dietar1 allowances )JDA- and the estimated inta/es with fortified human mil/ are gi$en in *a$le 5& Fortification%su$$lementation in -LBW infants = Summary:
c d
"&g& %olium 9Speciality Meditech <o, + %olvite ),1eth *ederle Fo&"&g& %errochelate 9Al$ert David <o,+ *onoferon 9&ast India Fo&-
AIIMS- NICU protocols 2008 5he protocol for nutritional supplementation in ?*+, infants until 60 wee/s PMA and (e1ond is descri(ed in *a$les 7 B 6, /e use =M% fortification for all preterm 9C5! wee(s+ >#./ infants, It is started once they reach 16 m#-(g-day of enteral feeds in the dose recommended $y the manufacturer 97g D! sachetsE -1 m# of e'pressed $reast mil(+, ,e start iron at 698 wee/s in the dose of mgE/gEda1& If =M% is unavaila$le or parents could not afford it, we fortify &.M with preterm formula 9 ,7g-1 m#+, Since calcium, phosphorus, and $itamin D inta/es are low e$en after fortification with formula, we supplement these nutrients additionall1 )*a$le 7+& ,e also add Cinc and iron as mentioned (efore& We continue fortification till the infant reaches <; weeks *M1 or attains +kg ,whiche"er is later2)
5a(le 6 '!tritional s!##lementation in VLB- infants till 8C weeks MA

(;#e of feeding
)nl; eB#ressed &reast milkF

9alcium Start calcium supplements )1609180 mgE/gEda1- once the infant is on full enteral feeds 9e,g, Syr, 2stocalcium at >!&;mL-(g-d+ Start supplements )G0920 mgE/gEda1- once the infant is on full enteral feeds 9e,g, Syr, 2stocalcium at F11 m#-(g-d+ Start multi$itamin supplements once the infant is on full feeds )e&g& >iSyneral ?inc - De'vita drops at 0&4m*Eda19:sually o$tained from multivitamin drops and calcium supplements that contain vitamin D,+ Start supplements once the infant is on full feeds 9e,g,, %olvite-folium drops at ;)B mL-day+ Start iron ) mgE/gEd- at 698 wee/s of life 9e,g, *onoferon drops at ! drops-(g-day+
+BM fortified with Lactode6!HMF3

Not needed
+BM fortified with reterm form!la

Start calcium supplements to meet the JDA once the infant is on full enteral feeds 9e,g, Syr, 2stocalcium at ?!@mL-(g-d+ Start supplements to meet the JDA once the infant is on full enteral feeds 9e,g, Syr, 2stocalcium at ?!@mL-(g-d+ Not needed
*hos$horus
Not needed
Ainc and "itamins B&. B@ -itamin '
Not needed
Not needed
Folic acid
Not needed
Iron
Start iron ) mgE/gEd- at 698 wee/s 9e,g, *onoferon drops at ! drops-(g-day+
9:sually o$tained from multivitamin drops and calcium supplements that contain vitamin D+ Start supplements once the infant is on full feeds 9e,g,, %olvite-folium at ;)& mL-day+ Start iron ) mgE/gEd- at 698 wee/s of life 9e,g, *onoferon drops at ! drops-(g-day+
,*M1. $ostmenstrual age/ 5BM. e6$ressed (reast milk/ HMF. human milk fortifier2
ote: *he e'amples @uoted are only indicative8 Aeaders are encouraged to use similar products of their choice,
5a(le 4 '!tritional s!##lementation in VLB- infants after 8C weeks MA

utrients
-itamin '
Method of s!##lementation Multi$itamin dropsEs1rup
Dose 009600 ILEda1
(ill when0 5ill 1 1ear of age
"

Iron Iron dropsEs1rup mgE/gEda1 )ma:imum 14mgEda15ill 1 1ear of age
,rowth monitoring of LB- infants

Jegular growth monitoring helps in assessing the nutritional status and ade.uac1 of feeding< it also identifies those infants with inade.uate weight gain& All *+, infants should (e weighed dail1 till the time of discharge from the hospital& 'ther anthropometric parameters such as length and head circumference should (e recorded wee/l1& +oth term and preterm *+, infants tend to lose weight )a(out 107 and 147 respecti$el1- in the first G da1s of life< the1 regain their (irth weight (1 10916 da1s& 5hereafter, the weight gain should (e at least 149 0gE/gEda1 till a weight of 9 &4 /g is reached& After this, a gain of 0 to ;0 gEda1 is considered appropriate&1! *+, infants should (e discharged after# o 5he1 reach ;6 wee/s gestation and are a(o$e 1600g AND o 5he1 show consistent weight gain for at least ; consecuti$e da1s& Growth charts: Lsing a growth chart is a simple (ut effecti$e wa1 to monitor the growth& Serial plotting of weight and other anthropometric indicators in the growth chart allows the indi$idual infant=s growth to (e compared with a reference standard& It helps in earl1 identification of growth faltering in these infants& 5wo t1pes of growth charts are commonl1 used for growth monitoring in preterm infants# intrauterine and postnatal growth charts& 'f these, the postnatal growth chart is preferred (ecause it is a more realistic representation of the true postnatal growth )than an intrauterine growth chart- and also shows the initial weight loss that occurs in the first two wee/s of life& 5he two postnatal charts that are most commonl1 used for growth monitoring of preterm ?*+, infants are# ,right=s and "hren/ranC= charts& 0, 1 ,e use either of these in our unit& 'nce the preterm *+, infants reach 60 wee/s PMA, ,H' growth charts should (e used for growth monitoring& Management of inade<!ate weight gain Inade.uate weight gain is a common and pertinent pro(lem in *+, infants& It starts at the time of initial admission and continues after discharge resulting in failure to thri$e and wasting in the first 1ear of life& 5he common causes are summariCed in Panel 7, Management of inade.uate weight gain consists of the following steps# 1& Proper counseling of mothers and ensuring ade.uate support for (reastfeeding their infants< includes assessment of positioningEattachment, managing soreEflat nipple etc&
AIIMS- NICU protocols 2008 2. ":plaining the fre.uenc1 and timing of (oth (reastfeeding and spoonEpaladai feeds# Infre.uent feeding is one of the commonest causes of inade.uate weight gain& Mothers should (e properl1 counseled regarding the fre.uenc1 and the importance of night feeds& A time9ta(le where mother can fill the timing and amount of feeding is $er1 helpful in ensuring fre.uent feeding& !. 0i$ing "+M (1 spoonEpaladai feeds after (reastfeeding also helps in preterm infants who tire out easil1 while suc/ing from the (reast& ". Proper demonstration of the correct method of e:pression of mil/ and paladai feeding# It is important to o(ser$e how the mother gi$es paladai feeds< the techni.ue and amount of spillage should (e noted& 5his should (e followed (1 a practical demonstration of the proper procedure& #. Initiating fortification of (reast mil/ when indicated 8& Management of the underl1ing condition)s- such as anemia, feed intolerance,etc& G& If these measures are not successful, increase either the a& "nerg1 )calorie- content of mil/ (1 adding MF5 oil, corn starch, etc& Infants on formula feeds can (e gi$en concentrated feeds )(1 reconstituting 1 scoop in 4 m* of water- 'J (& Beed $olume D to 00 m*E/gEda1& Panel 6 %a!ses of inade<!ate weight gain
7. Inade<!ate intake Breastfed infants: Incorrect feeding method )improper positioningEattachment-P *ess fre.uent (reastfeeding, not feeding in the night hoursP Prematurel1 remo$ing the (a(1 from the (reast )(efore the infant completes feedsInfants on s$oon %$aladai feeds: Incorrect method of feedingP )e&g& e:cess spillingIncorrect measurementEcalculation Infre.uent feeding Not fortif1ing the mil/ in ?*+, infants "nerg1 e:penditure in infants who ha$e difficult1 in accepting spoon feeds 3. In"reased demands Illnesses such as h1pothermiaEcold stressP, (ronchopulmonar1 d1splasia Medications such as corticosteroids 6. *nderl;ing diseaseE#athologi"al "onditions AnemiaP, h1ponatremia, late meta(olic acidosis *ate onset sepsis Beed intolerance andEor 0"J
3 9ommon conditions ,5BM. e6$ressed (reast milk/ G58. gastroeso$hageal reflu62
F++D I'()L+RA'%+
5he ina(ilit1 to tolerate enteral feedings in e:tremel1 premature infants is a ma>or concern for the pediatrician E neonatologist caring for such infants& 'ften, feed intolerance is the predominant factor affecting the duration of hospitaliCation in these infants& 5here are no uni$ersall1 agreed9upon criteria to define feed intolerance in preterm infants&1G ?arious clinical features that are usuall1 considered to (e the indicator)s- of feed intolerance are summariCed (elow )Panel 6-# Panel 4 Indicator,s2 of feed intolerance&C
S1mptoms# . ?omiting )altered mil/E(ile or (lood9stained-P & S1stemic features# letharg1, apnea Signs# . A(dominal distension )with or without $isi(le (owel loops-P
2. Increased gastric residuals# H m*E/g or an1 change from pre$ious pattern

;& 6& 4& A(dominal tenderness Jeduced or a(sent (owel sounds S1stemic signs# c1anosis, (rad1cardia, etc&
3 9ommon signs
'f these, $omiting, a(dominal distension, and increased gastric residual $olume form the @triad= for defining feed intolerance& -omiting: 5he characteristic of $omitus is important in assessing the cause# while altered mil/ is usuall1 innocuous, (ile9 or (lood9stained aspirate should (e thoroughl1 in$estigated& 1(dominal distension: It is essential to seriall1 monitor the a(dominal girth in all preterm *+, infants admitted in neonatal nurser1& 5his helps in earl1 identification of feed intolerance and eliminates the need for routine gastric aspirate& Gastric residual "olume: It indicates the rapidit1 of gastric empt1ing& Since se$eral factors )(oth s1stemic and localinfluence the gastric empt1ing, the residual $olume is a poor and non9specific indicator of fed intolerance& Measures to enhance the specificit1 9 (1 .uantif1ing the $olume and (1 using different cut9offs for defining feed intolerance 9 ha$e not (een found to (e much useful& Moreo$er, repeated gastric aspiration to loo/ for residuals could in>ure the delicate mucosa aggra$ating the local patholog1&
&
AIIMS- NICU protocols 2008 /e monitor the a$dominal girth every ! hours in all preterm #./ infants admitted in the nursery, We do not routinely as$irate the gastric contents (efore gi"ing ne6t feed) It is done only if there is an increase in a$dominal girth $y G! cm from the $aseline, Management of feed intolerance 5he common factors attri(uted to feed intolerance in preterm infants are# immature intestinal motilit1, immaturit1 of digesti$e enC1mes, underl1ing medical conditions such as sepsis, inappropriate feed $olume, and gi$ing h1perosmolar medicationsEfeedings, and importantl1, necrotiCing enterocolitis )N"F-& ,hile issues such as feed $olume and osmolalit1 can (e controlled to an e:tent, feed intolerance due to immaturit1 is rarel1 amena(le to an1 inter$ention< conser$ati$e management till the gut attains full maturit1 is often the onl1 option left& 5he steps in e$aluation and management of an infant with feed intolerance are gi$en in %igure 5,
%on"l!sion
'ptimal feeding of *+, infants is important for the immediate sur$i$al as well as for su(se.uent growth& Lnli/e their normal (irth weight counterparts, these infants ha$e $astl1 different feeding a(ilities and nutritional re.uirements& 5he1 are also prone to de$elop feed intolerance in the immediate postnatal period& It is important for all health care pro$iders caring for such infants to (e well $ersant with the necessar1 s/ills re.uired for feeding them& It is e.uall1 important to ha$e a protocol (ased approach to manage $arious issues that occur while feeding them&
In"rease in a&dominal girth &; 93 "m )R Vomiting =altered milk?
1s$irate the stomach contents 92$serve the nature and volume of gastric contents+
%learI ')( &ile5 or &lood5stained
Bile5 or &lood5stained as#irate E vomit
Aspirate $olume 2356mL or 2 31J of feed $olume
Aspirate $olume 3151CJ of feed $olume
Aspirate $olume 91CJ of feed $olume
*oo/ for local cause Fontinue feeds Monitor
Jeduce ne:t feed $olume )e.ual to the aspirate $olumeMonitor
,ithhold one or two feeds Monitor Jestart feeds
,ithhold feeds for 6962 hrs "$aluate for s1stemic and local causes
Feed intoleran"e re"!rs
Manage a""ordingl;
Assess clinical sta(ilit1 and e$aluate for s1stemic signs
'o s;stemi" signs and "lini"all; sta&le Fhec/ the position of '0 tu(e 5r1 changing the infant=s position )from supine to prone or right lateral decu(itus,ithhold feeds for 1 9 6 hrs and reassess
S;stemi" signs K
,ithhold feeds for 6962 hrs and "$aluate for s1stemic causes
Bigure ; 1$$roach to feed intolerance in LBW infants Downloaded from www.newbornwhocc.org %
%lini"all; sta&le )no s1stemic signs-
Referen"es
1& LNIF"B& State of the ,orld=s Fhildren 004& New Kor/# LNIF"B, 006& & +ang A, Jedd1 MH, Deshmu/h MD& Fhild mortalit1 in Maharashtra& "conomic Political wee/l1 00 <;G#6!6G984& ;& "dmond IM, Iir/wood +J, 5awiah FA, Ag1ei S'& Impact of earl1 infant feeding practices on mortalit1 in low (irth weight infants from rural 0hana& Q Perinatol& 002 Mar 8< N"pu( ahead of printO ". *e$its/1 DA, Strupp +Q& Malnutrition and the (rain# changing concepts, changing concerns& Q Nutr& 1!!4<1 4# 1 SD 0S #. 'mari 5I, Judolph FD& 0astrointestinal Motilit1& In# Polin JA and Bo: ,, )"ds-& Betal and Neonatal Ph1siolog1&
nd
edition& Philadelphia, ,+ Saunders Fo, 1!!2# pp& 11 49;2

nd
$. Anon1mous& Beeding& In# Deorari AI, Paul ?I, Scotland Q, McMillan DD, Singhal N )"ds-& Practical Procedures for the New(orn Nurser1& edition& New Delhi, Sagar Pu(lishers, 00;# pp G19G2 &. Stoc/s Q& "ffect of nasogastric tu(es on nasal resistance during infanc1& Arch Dis Fhild& 1!20<44#1G9 1 2& Prem>i SS, Fhessell *& Fontinuous nasogastric mil/ feeding $ersus intermittent (olus mil/ feeding for premature infants less than 1400 grams& Fochrane Data(ase of S1stematic Je$iews 001, Issue 1& Art& No&# FD00121!& %. De?ille I5, Shulman JQ, +erseth F*& Slow infusion feeding enhances gastric empt1ing in preterm infants compared to (olus feeding& Flin Jes 1!!;<61#G2GA& 0. Mishra S, Agarwal J, Qee$asan/ar M, Deorari AI, Paul ?I& Minimal enteral nutrition& Indian Q Pediatr& 002<G4# 8G9!& . Dorling Q, Iemple1 S, *eaf A& Beeding growth restricted preterm infants with a(normal antenatal Doppler results& Arch Dis Fhild Betal Neonatal "d& 004<!0#B;4!98; 1 & Fhawla D, Agarwal J, Deorari AI, Paul ?I& Bluid and electrol1te management in term and preterm neonates& Indian Q Pediatr& 002<G4# 449! 1;& +ahl J& Personal Fommunication& ". A(rams SA& A(normalities of serum calcium and magnesium& In# Flohert1 QP, "ichenwald "F, Star/ AJ )"ds-& Manual of Neonatal Fare& 8th edn& Philadelphia# *ippincott ,illiams & ,il/ins 002< p442& #. American Academ1 of Pediatrics Fommittee on Nutrition# Nutritional needs of preterm infants& In# Ileinman J" )ed-# Pediatric Nutrition Hand(oo/ American Academ1 of Pediatrics& "l/ 0ro$e ?illage, I*, American Academ1 of Pediatrics, 006# pp ;946& 18& Schanler JQ, 0arCa F& Impro$ed mineral (alance in $er1 low (irth weight infants fed fortified human mil/& Q Pediatr 1!2G<11 #64 98 1G& Iuschel FA, Harding Q"& Multicomponent fortified human mil/ for promoting growth in preterm infants& Fochrane Data(ase of S1stematic Je$iews 1!!2, Issue 6& Art& No&# FD000;6;& Downloaded from www.newbornwhocc.org 20
AIIMS- NICU protocols 2008 12& Mu/hopadh1a1 I, Narnag A, Maha>an J& "ffect of human mil/ fortification in appropriate for gestation and small for gestation preterm (a(ies# a randomiCed controlled trial& Indian Pediatr& 00G Apr<66)6-# 289!0& %. Schanler JQ& "nteral Nutrition for the High9Jis/ Neonate& In# 5aeusch H,, +allard JA, 0leason FA )eds-# A$er1=s Diseases of the New(orn, 2th edn& Philadelphia, Saunders, 004, pp&106;980& 20. ,right I, Dawson QP, Ballis D, ?ogt ", *orch ?& New postnatal growth grids for $er1 low (irth weight infants& Pediatrics&1!!;<!1#! 98
21."hren/ranC JA, Kounes N, *emons QA, Banaroff AA, Dono$an "B, ,right **, et al& *ongitudinal growth of
hospitaliCed $er1 low (irth weight infants& Pediatrics 1!!!<106# 209!
AIIMS- NICU protocols 2008 AnneB!re 7$ oster on the #ro"ed!re of >+B#ression of Breast Milk:
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