Module: Enteral feeding of the High

Risk Newborn - Session 1

Competency Based Training Module for Physicians
Neonatal Health Care Modules
Enteral Feeding of the
High Risk Newborn

Jayashree Ramasethu, M.D.
Georgetown University Hospital
Washington, D.C.

Module: Enteral feeding of the High
Risk Newborn - Session 1
Module Overview: Purpose
The purpose of this module is to provide
facilitators with a sound, competency based
training methodology which if implemented
as designed, will result in physicians
attaining the knowledge, skills and
competencies to provide appropriate enteral
nutritional support for high risk neonates.
Module: Enteral feeding of the High
Risk Newborn - Session 1
Module Overview: Purpose
Physicians will learn to:
Identify newborn infants at risk for feeding difficulties
Determine the appropriate route and type of feeding,
including selection of milk and supplements.
Initiate enteral feeding in at - risk newborns at the
appropriate time, and advancement of feeds appropriately.
Identify and manage feeding intolerance
Identify and manage necrotizing enterocolitis.

Module: Enteral feeding of the High
Risk Newborn - Session 1
Module Overview: Story
Providing adequate nutritional support by the enteral route
to neonates with problems is a challenge.
Feeding may be limited by immaturity, illness or both.
The initiation and advancement of feeds, the selection of
milk for feeding, and the route of feeding are to be
considered carefully in each case.
The final goal is to achieve nutritional support by the
enteral route in order to provide optimal growth and
development.

Module: Enteral feeding of the High
Risk Newborn - Session 1
Learning objectives
+ Define feeding difficulties in sick or at- risk
neonates.
+Assess when to start enteral feeds, including
contraindications to feeding.
+Define trophic feeding, indications and strategy.
+Understand appropriate advancement of enteral
nutrition.
+Identify the nutritional and caloric contents of
various milks.
Module: Enteral feeding of the High
Risk Newborn - Session 1
Learning objectives
eSelect the appropriate route of feeding
e oral
e tube feeding- gastric or transpyloric feeds,
continuous or bolus feeds
eUnderstand the goals of nutritive feeds, and
the monitoring of nutrition and growth.
eAssess and manage feeding intolerance.
eIdentify necrotizing enterocolitis
Module: Enteral feeding of the High
Risk Newborn - Session 1
The best feeding is
Breast feeding
Breast feeding
Breast feeding

For Term & Preterm
babies!
Module: Enteral feeding of the High
Risk Newborn - Session 1
High Risk Newborns may not be able to
breastfeed (or even tolerate enteral nutrition)
Prematurity
Perinatal asphyxia
Respiratory distress
Sepsis
Hemodynamic instability
Paralytic ileus
Intestinal obstruction
Craniofacial abnormalities
cleft lip
cleft palate

Module: Enteral feeding of the High
Risk Newborn - Session 1
Sick newborns may need intravenous nutrition
until they are stable enough to have enteral feeds
But intravenous nutrition :
is expensive
is more complicated
requires more laboratory testing and monitoring
has more complications

Module: Enteral feeding of the High
Risk Newborn - Session 1
Feeding
Trophic effect on intestinal mucosa
Starvation thinning of intestinal mucosa, villus
shortening, reduction of enzyme activity
Enteral feeding increased DNA synthesis,
increased intestinal mucosal mass
Maturation of intestinal muscular function
Endocrine and metabolic effects


Module: Enteral feeding of the High
Risk Newborn - Session 1
Enteral Nutrition in High Risk Newborns:

When to feed
How to feed
What to feed

Module: Enteral feeding of the High
Risk Newborn - Session 1
When to feed: as early as possible
Early Feeding
+ feeding intolerance
Full enteral nutrition established earlier!
+ days of parenteral nutrition
+ cholestasis
+ days in hospital
No increase in incidence of NEC

Module: Enteral feeding of the High
Risk Newborn - Session 1





Initiation of
enteral feeds

_Hemodynamically stable
_No ileus
_No significant acidosis
_No significant PDA


Module: Enteral feeding of the High
Risk Newborn - Session 1
How to feed:
based on gestational age and clinical condition



Oromotor skills - normal development
Gag reflex: 18 weeks gestation
Sucking reflex
non nutritive 30-32 weeks
uncoordinated 32-34 weeks
coordinated 35-36 weeks
Rooting reflex: 37 weeks
Module: Enteral feeding of the High
Risk Newborn - Session 1
How to feed:

Oral feeding: breast (or bottle)
at least 33 weeks gestation
no respiratory distress ( rate<60/min)
Tube feeding
less than 33 weeks gestation
neurological impairment (abnormal suck/
swallow)
respiratory distress (no hypoxia)
on a ventilator


Module: Enteral feeding of the High
Risk Newborn - Session 1
How to feed:
Tube feeding

Nasogastric or orogastric tube feeds
intermittent or continuous
Nasojejunal / transpyloric tube feeds
severe reflux
delayed gastric emptying
continuous feeds only


Module: Enteral feeding of the High
Risk Newborn - Session 1
Procedure: Placement of Orogastric or
Nasogastric tube
Use size 5 ( for babies less than 2 kg) or size 8 (for
babies more than 2 kg) feeding tube
Tube may be silastic ( best), polyurethane or PVC
Measure distance from nose or mouth to ear
opening, and then down to xiphisternum.
Pass tube down nose or mouth to pre- determined
distance + 1- 2 cms.
Check placement by injecting air into tube and
auscultating over stomach, or by aspirating
stomach contents. Tape into place.
Module: Enteral feeding of the High
Risk Newborn - Session 1
Procedure: Placement of
transpyloric tube
Use only size 5 silastic tube
Polyurethane or PVC tubes harden with
time and can cause perforation of
duodenum.
Module: Enteral feeding of the High
Risk Newborn - Session 1




What to feed:
Choice of milk for initial feeds

Colostrum or Maternal milk
_isotonic
_low renal solute load
_immunologic advantages
_psychosocial advantages

Module: Enteral feeding of the High
Risk Newborn - Session 1
Advantages of human milk
decreases infections
decreases allergic disease
increases IQ?
decreases adult obesity/ HTN/DM
cost / availability




Module: Enteral feeding of the High
Risk Newborn - Session 1


Advantage of
human milk
in the NICU

easily digested
better tolerance
decreases infection rate
decreases hospitalization
better outcomes
For mother: psychosocial wellbeing

Module: Enteral feeding of the High
Risk Newborn - Session 1
Composition of human milk
Colostrum Preterm Mature Milk
Calories Kcal / dl 67 67 67
Protein g/dl 3.1 1.4 1.05
Lactose g/dl 4.1 6.6 7.2
Fat g/dl 2 -2.5 3.5- 4 3.5 - 4.5
Module: Enteral feeding of the High
Risk Newborn - Session 1
Is Human Milk alone adequate for the
growing preterm infant?
15 day old preterm infant
150 ml/ kg /day of mothers milk
= 90 -100 kcal / kg/day
= 2- 2.5 g/kg/day of protein
Module: Enteral feeding of the High
Risk Newborn - Session 1
Estimated caloric requirement of a
growing preterm infant (AAP 1985)
Kcal / kg / day
Resting metabolic rate 50
Cold stress 10
Activity 15
Synthesis / thermic effect of food 8
Fecal loss 12
Growth 25
Total 120
Aim: 120 Kcal/ kg/day, 3 to 3.8 g protein/ kg/day
Module: Enteral feeding of the High
Risk Newborn - Session 1
Rate of weight gain in fetus highest between 26 and 36 weeks
Aim:
Growth of the preterm infant should be similar to
intrauterine growth of a fetus at the same gestational age,
approximately 15g/kg/day.
Module: Enteral feeding of the High
Risk Newborn - Session 1
Additives
Human milk fortifier : carbohydrate
protein, minerals,
vitamins
MCT oil: 1 cc = 7.7 Kcal
Canola oil: 1 cc = 8 kcal
Promod 1 tsp: 1 g whey protein
Polycose: glucose polymers
Module: Enteral feeding of the High
Risk Newborn - Session 1
Nutrient Distribution
Nutrient Caloric range Maximum calories
Protein 8-12 % 20%
Carbohydrate 40-55% 60%
Fat 35-50% 60%
Module: Enteral feeding of the High
Risk Newborn - Session 1
Nutrient Composition of Preterm Human Milk
with Human Milk Fortifier (from Berseth CL, Pediatrics 2004)
Nutrients Preterm Human
Milk (100 ml)
PHM + HMF
(100 ml + 4 packets)
Energy, kJ 277 336
Protein, g 1.6 2.7
Fat, g 3.5 4.5
Carbohydrate, g 7.3 7.5
Vitamin A, IU 48 998
Vitamin D, IU 8 158
Vitamin E, IU 0.4 5.0
Vitamin K, IU 2.0 6.4
Calcium, mg 25 115
Phosphorus, mg 14.5 64.5
Iron, mg 0.09 1.53
Zinc, mg 0.37 1.09
Module: Enteral feeding of the High
Risk Newborn - Session 1
Preterm Formula
Formula Kcal
/30 ml
Protein
gm/dl
Fat
gm/dl
CHO
gm/dl
Calcium
mg/dl
Phosphate
mg/dl
Human
milk
20 1.1 4.5 7.1 33 15
Enfamil
premature
20 2.0 3.4 7.4 112 56
Enfamil
premature
24 2.4 4.1 8.9 134 68
Module: Enteral feeding of the High
Risk Newborn - Session 1
Fortified human milk versus
preterm formula ( Schanler Pediatrics 1999)
Gest: 28 1 weeks Birth Wt: 1.07 0.17 kg

Infants fed fortified human milk
slower rate of weight gain ( 22 g vs 26 g/kg/d)
lower length increase ( 0.8 cms vs 1.0 cms)
decreased incidence of late onset sepsis
decreased incidence of NEC
discharged earlier ( 73 days vs 88 days)
Module: Enteral feeding of the High
Risk Newborn - Session 1
Specialized formulas
Short bowel syndrome,
malabsorption, etc
Alimentum: casein hydrolysate, free amino acids,
modified tapioca starch, sucrose, safflower and soy oil,
50% MCT
Pregestimil: casein hydrolysate, free amino acids,
modified corn starch, glucose, corn oil, 55% MCT
Neocate: free aminoacids, corn syrup solids and modified
corn starch, safflower, coconut and soy oils

Module: Enteral feeding of the High
Risk Newborn - Session 1
Feeding Protocols
Trophic feeds
Advancement of feeds
Monitoring for tolerance
Nutritional goals
Nutrition monitoring
Module: Enteral feeding of the High
Risk Newborn - Session 1
Trophic feeding
+ Start as soon as baby is stable 1-3 days
+ Human milk or formula 10 cc/ kg/day
+ Feed every 3 or 4 hours
+ Continue at same volume
+ Advance feeds when baby demonstrates
tolerance and is medically stable
( usually in 3 to 7 days)
Module: Enteral feeding of the High
Risk Newborn - Session 1
Advancement of feeds
Start at 10 ml / kg/day
Advance by 5 - 20 ml /kg /day
Time to full feeds
3 -5 days in baby > 2000g
10 -14 days in baby < 1250g

Module: Enteral feeding of the High
Risk Newborn - Session 1
Feeding Baby J
28 weeks gestation, 1200 g weight, RDS
Day 2: BP stable, RDS better, passed meconium, abdomen soft
Start feeds with MBM 1cc oro-gastric q6h
Day 3: CPAP, feeds to 2 cc every 3 hours
Day 4: nasal cannula oxygen, feeds to 4 cc every 3 h
Day 5: feeds to 6 cc every 3 hours (16 cc or 13 cc/kg increase)
Day 6,7,8: feeds by 2 cc every day to 12 cc every 3 hours
Day 9: 1 residual of 6 cc, then another of 8 cc, no abdominal distension
+ feeds to 10 cc q3h
Day 10: no residuals, advance feeds to 12 cc q3h..
Day 11, 12,13 : advance feeds to 15, 18 and 21 cc every 3 hours
Day 14: full feeds 24 cc every 3 hours


Module: Enteral feeding of the High
Risk Newborn - Session 1
Feeding Baby Girl J - wt 1.2 kg

24 cc MBM every 3 hours
= 160 cc / kg / day = 105 kcal/ kg/day
= 2.5 g / kg /day protein
Add HMF (human milk fortifier)
increase calories to 22 kcal /oz first
after 1-2 days increase calories to 24 kcal /oz
Goal: 120 kcal/ kg/day, 3 - 3.5 g/kg/day protein

Module: Enteral feeding of the High
Risk Newborn - Session 1
Vitamin supplementation in preterm
babies
Vitamin A 1500 IU/ kg/day
Vitamin D 400 IU/day
Vitamin E 6 -12 IU / kg/day
Vitamin K- IM at birth
Vitamin B complex
Vitamin C
Multivitamin drops 0.5- 1.0 ml/day
Module: Enteral feeding of the High
Risk Newborn - Session 1
Iron supplementation

2- 4 mg/ kg / day of dietary elemental iron
Preferably after 2 weeks of age
No later than 2 months of age



Module: Enteral feeding of the High
Risk Newborn - Session 1
Feeding Intolerance
Stop enteral feeds and reassess:
Bilious ( or greenish residuals)
Increased residuals ( > 25% of a feed, or
more than the hourly rate if fed
continuously), or vomiting
Acute increase in abdominal girth > 2 cms
Frankly bloody or very watery stool
Other signs of illness
Module: Enteral feeding of the High
Risk Newborn - Session 1
Feeding Intolerance- assessment
Does baby appear well?
Is the abdomen soft?
Has the nature of the stool changed?
Is this the first episode of intolerance or has
this problem been increasing?
Module: Enteral feeding of the High
Risk Newborn - Session 1
Feeding Intolerance- management
If baby appears well, and the abdomen is
soft, may consider re-feeding after a brief
(2 to 6 hour period of observation).
If unsure, may discontinue enteral feeds for
24 hours and restart at a smaller volume.
If abdomen is distended, or tense, or stools
are bloody, discontinue feeds and obtain
Xray of the abdomen to rule out NEC.
Module: Enteral feeding of the High
Risk Newborn - Session 1
Necrotizing Enterocolitis (NEC)
Module: Enteral feeding of the High
Risk Newborn - Session 1
Necrotizing Enterocolitis (NEC)
Predisposing conditions:
Prematurity, perinatal asphyxia, formula feeding
Signs:
gastrointestinal: feeding intolerance, abdominal distension,
bloody stools
systemic: lethargy, temperature instability, apnea,
bradycardia, acidosis, DIC, hypotension
Radiological: intestinal dilatation, pneumatosis intestinalis,
ascites, perforation

Module: Enteral feeding of the High
Risk Newborn - Session 1
Necrotizing Enterocolitis (NEC)
Management:
Stop feeds, start IV fluids, place NG tube on
dependent drainage or low suction
Obtain blood culture, Complete blood
count, start antibiotics
Refer early to facility that can closely
monitor and manage these patients, and
perform surgery if necessary.

Module: Enteral feeding of the High
Risk Newborn - Session 1
Other feeding issues
Suck- swallow incoordination
Oro- tactile defensiveness
Gastroesophageal reflux

Module: Enteral feeding of the High
Risk Newborn - Session 1
Gastroesophageal
Reflux
e19 % of preterm babies on
treatment for reflux
eAssociated with apnea?
eAssociated with airway problems- wheezing,
stridor and recurrent aspiration
eTreatment: small volume feeds, positioning,
thickening of feeds, H2 receptor blockers, proton
pump inhibitors

Module: Enteral feeding of the High
Risk Newborn - Session 1
Monitoring nutrition
in high risk neonates

Module: Enteral feeding of the High
Risk Newborn - Session 1
Monitoring Growth in the VLBW infant

Weight 15g/ day
Length 1 cm/ week
Head circumference 1 cm / week
Hematocrit/ retic count Every 1-2 weeks
Albumin/ electrolytes Every 2 weeks
Calcium/ phosphorus Every 2 weeks
Alkaline phosphatase Every 2 weeks
Module: Enteral feeding of the High
Risk Newborn - Session 1
Post -discharge
nutrition

Usual discharge weight
for preterm infants : 1800 - 2000 g
At discharge
smaller than term infants
low body stores
deficient bone mineralization
greater energy needs
Module: Enteral feeding of the High
Risk Newborn - Session 1
Post -discharge nutrition monitoring
Monitor weight, length, head circumference
Plot on growth charts adjusted for preterm infants
Increased caloric needs
add formula powder to maternal milk
special transition formula
Multivitamins
Iron


Module: Enteral feeding of the High
Risk Newborn - Session 1
Recommendations for post discharge
nutrition for preterm infants
( J Perinatol May 2005)
< 1800 g: 24 Cal / oz milk
Change to 22 Cal/ oz at > 1800 g when
growth parameters are 25th percentile and
infant is gaining 15 to 40 g/day
Change to 20 Cal/ oz at 4 to 6 months
corrected gestation if all growth parameters
are above 25th percentile
Module: Enteral feeding of the High
Risk Newborn - Session 1
Simple rule:
Regular breast milk or formula if
age > 3 months old
weight > 3 kgs
serum albumin > 3g/ dl
alkaline phosphatase < 300 IU/ ml


Module: Enteral feeding of the High
Risk Newborn - Session 1
Module: Enteral feeding of the High
Risk Newborn - Session 1
Case 1
Preterm baby girl E, born at 33 weeks gestation.
Birth weight 1800 g.
Apgar scores 1- 9, 5- 9
Baby appears alert and active, has no respiratory
distress.
When will you initiate feeds?
What feeds will you order?
How will you monitor adequacy of nutrition?

Module: Enteral feeding of the High
Risk Newborn - Session 1
Case 2.
Preterm baby boy born at 32 weeks
gestation. Birth weight 1500g.
Apgar scores 17, 5-8
Baby has mild RDS and is on CPAP.
Discuss nutritional support for this baby.



Module: Enteral feeding of the High
Risk Newborn - Session 1
Case 3
Preterm boy in case 2 is now 8 days old. He has
been receiving tube feeds of maternal breast milk
at 10 cc every 3 hours.
At 9 am today he had 6 cc undigested milk in the
stomach. You decided to give only 4 ml and
reassess. At 12 noon he had 10 ml of greenish
aspirate, and his abdominal circumference has
increased by 2 cms. What will you do?