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Nutrition for the Intrauterine Growth

Restricted Pre-Term Neonate

Rachel Brown
Dietetic Intern 2017
Hurley Medical Center
OUTLINE

Objectives
Patient Overview
Nutrition Assessment
Nutrition Diagnoses
Nutrition Interventions
Research
Conclusion/References
Questions
OBJECTIVES

1. Define intrauterine growth restriction


(IUGR) and associated maternal risk
factors.

2. List the macronutrient and micronutrient


needs of preterm infants.

3. Understand metabolic complications that


may occur in IUGR neonates later in life.

4. Recognize the clinical indications of


refeeding syndrome in IUGR neonates.
OVERVIEW:
PATIENT PROFILE

Sex: Male

Gestational Age at Birth:


30 w 3 days

Birth Weight: 895 gm

Mother: 25 y.o

Admitted to Hurleys NICU immediately after birth


OVERVIEW:
DIAGNOSES/PROBLEMS

In-utero:
Maternal preeclampsia
Placenta previa in 2nd trimester
Exposure to THC, tobacco, and opiates
Intrauterine Growth Restriction (IUGR)

After birth:
Preterm
Respiratory distress syndrome
Hypoglycemia
Hypophosphatemia
OVERVIEW:
INTRAUTERINE GROWTH RESTRCTION
Definition:
Rate of fetal growth that is less than normal for the growth potential of a
specific infant.

Maternal Condition Associated:


Malnutrition
Multiple gestation
Uterine and placental anomalies
Pre-eclampsia
Diabetes
Cigarette smoking, cocaine use, and other substance abuse

IUGR infants are at risk for increased rates of mortality, hypothermia, poor
glycemic control, electrolyte imbalances, and necrotizing enterocolitis.
NUTRITION ASSESSMENT:
ANTHROPEMETRICS

Birth Anthropometrics: (%iles based on Fenton growth charts)


Weight: 895 gm
4.54 %ile
Height: 35.5 cm
4.39 %ile
Head Circumference: 24 cm
0.35 %ile

Anthropometric Classifications:
Extremely Low Birth Weight (ELBW)
Small for Gestational Age (SGA)
Symmetrical SGA
NUTRITION ASSESSMENT:
GROWTH CHART

WEIGHT FOR AGE


NUTRITION ASSESSMENT:
GROWTH CHART
LENGTH FOR AGE
NUTRITION ASSESSMENT:
GROWTH CHART
HEAD CIRCUMFERENCE FOR AGE
NUTRITION DIAGNOSES

Increased nutrient needs (energy, protein, vitamins,


and minerals) related to increased demand as
evidenced by preterm birth and IUGR.

Altered nutrition related laboratory values (glucose


and phosphorus) related to undetermined etiology as
evidenced by low serum values.
NUTRITION INTERVENTION

Nutrition Recommendations:
Macronutrient:
Parenteral: 90 110kcal/kg 3.2 3.8g protein/kg
Enteral: 110 130kcal/kg 3.8 4.4g protein/kg

Micronutrient:
Parenteral: 400 600 mg Ca gluconate/kg
1 2 mMol Phos/kg 40 160 units vitamin D/kg
Enteral: 100 220 mg Ca/kg 60 140mg Phos/kg
2 4mg Fe/kg 400 units vitamin D/day
NUTRITION INTERVENTION TIMELINE

Day of Life Feeding Interventions Overview


0 Starter TPN.
1-2 TPN advanced according to Hurley feeding protocol; substrates adjusted according to
serum lab values.
3-5 TPN at goal.
6-8 Enteral trophic feeds of 20 kcal breast milk begin at 2 cc q3 hours. TPN remains at goal.
TPN substrates adjusted according to serum lab values.
9-11 Enteral feeds of 20 kcal donor breast advanced by approx. 20 ml/kg/day.
12-16 Donor breast milk concentration increased to 22 kcal. Continue increasing feeds by 20
ml/kg/day. TPN decreased corresponding to increase in enteral feeds.
17 Donor breast milk concentration increased to 24 kcal. Continue increasing feeds by 20
ml/kg/day. Poly-vitamin started.
18 Switched from donor breast milk to Enfamil premature due to pt reaching 32 weeks GA.
19-25 Enfamil premature feeds reach goal of 150 ml/kg.
26 Feeds restricted to 140 ml/kg/day due to edema. Iron supplement started.
27 Started bottle feeds.
30 Lasix started. Feeds increased back to 150 ml/kg/day.
41 Ad lib feeds started of 24 kcal Enfamil premature.
49 Switched to Enfacare 22 kcal due to anticipated discharge.
NUTRITION INTERVENTION:
HYPOGLYCEMIA

1. Adjust % dextrose in TPN

Day of Life % Dextrose TPN Glucose Levels


0 10% <4
Reference Range:
1 12.5% 36
60-120
2-8 17.5% 36-74
9-13 20% 49-71

2. Adjust frequency of feeds


Feed every 2 hours rather than every 3 hours DOL 18-19
Abdominal distention noted, switched back to q 3 hours

3. Pharmacologic therapy
Prescribed by Pediatric Endocrinologist
Diazoxide given DOL 14-15, 18-19
NUTRITION INTERVENTION:
HYPOPHOSPHATEMIA

1. Adjust amount in TPN


Day of Serum Amount
Life Level in TPN
1 -- 0.3 mmol
Reference Range:
2 2.2 1.3 mmol
4.5-7.5
3 1.8 3.2 mmol
4 5.1 2.2 mmol
5 5.3 2.2 mmol

1. Human Milk Fortifier


21-79 mg/100kcal of phos depending on concentration

2. Enfamil Premature Formula


24 kcal concentration contains 90 mg phos/100 kcal
RESEARCH

Define refeeding syndrome


Refeeding syndrome and IUGR neonates
Population: VLBW infants admitted over a 10-year period (271
IUGR and 1982 non-IUGR)
Results: IUGR infants were significantly more likely to have
hypophosphatemia in the first post-natal week when compared to
non-IUGR infants.
Conclusion: Refeeding syndrome occurs in VLBW infants with
IUGR and born to mothers with preeclampsia. Close monitoring of
electrolytes, especially phosphorus, is warranted in this population.
RESEARCH

Population: 42 children exposed to IUGR and 464 unexposed


who were members of Kaiser Permanente of Colorado.
Method: Height and weight measurements since birth and
measures of abdominal adiposity and insulin resistance were
measured at average age of 10.6 (+/-1.3) years.
Results:
No differences in BMI after 1 year of age
IUGR children had higher waist circumference, higher insulin, higher
HOMA-IR, and lower adinoponectin levels in adolescence (independent of
other childhood and maternal factors)
Conclusion: Research supports fetal programming hypothesis.
Study Limitations
CONCLUSION

Adequate nutrition is of great importance to


neonates with IUGR.

VLBW IUGR infants are at increased risk of


displaying clinical symptoms of refeeding
syndrome

Close monitoring of lab values and making


appropriate interventions is essential.

IUGR infants may be at risk for metabolic


conditions with nutritional implications that
occur past their stay in the NICU into
adolescence and beyond.
REFERENCES

1. Ross JR, Finch C, Ebeling M, Taylor SN. Refeeding


syndrome in very-low-birth-weight intrauterine growth-
restricted neonates. Journal of perinatology : official journal
of the California Perinatal Association. 2013;33:717.
2. Crume TL, Scherzinger A, Stamm E, et al. The Longterm
impact of intrauterine growth restriction in a diverse US
cohort of children: The EPOCH study. Obesity.
2014;22:608-615.
3. Rosenberg A. The IUGR Newborn. Seminars in
Perinatology. 2008;32:219-224.
Questions?