In the name of Allah

Enteral Nutrition of Preterm

Baby
Mohamed Khashaba
Prof. of Pediatrics/Neonatology
Head of NICU, MUCH
 Objectives

1. Stress the importance and challenges of

preterm nutrition.
2. Focus or general guidelines to feeding in
preterm and high risk babies.
• Improved perinatal care has resulted

in survival of large number of LBWT

infants requiring prolonged nutritional

support.
• Nutrition of LBWT infants represents

a continuing challenge.
I. Why is nutrition of preterm baby

important?

II. What are the general guidelines to

enteral feedings?

III. Feeding in selected situations

I. Why is nutrition of

preterm baby important?

n Unmatched rate of fetal growth.
n Nutritive & energy stores are laid down in the 3rd
trimester.
n Immaturity of digestive, absorptive, metabolic
and excretory functions.
n Adverse effects of malnutrition.
n Potential catastrophic diseases.
n Unanswered questions.
1- Unmatched rate of fetal growth
 Fetal Growth Rate

• Weight of 22 weeks fetus: 500 gms

• Weight of 27 weeks fetus: 1000 gms
• Weight of 31 weeks fetus: 1500 gms
• TPN is not the sole logic continuation of
fetal nutrition through placenta in utero.
• Swallowed amniotic fluid has a role in
nutrition of the fetus especially during 3rd
trimester.
2- Nutritive & energy stores are laid

down in the 3rd trimester.

Between 29 and 40 weeks gestation:
• Protein content rises from 8.8% to 12%
• F at content rises from 1% to 13.1%
• Glycogen stores rise from 10 mg/gm liver to 50
mg/gm.
3-Immature digestive, absorptive,

metabolic and excretory functions.

 Functional Immaturity of GIT

• Immature suck pattern: short bursts followed

by swallows.
• Poor tone of inferior esophageal sphincter.
 Functional Immaturity of GIT
Gastric activity and emptying

1. Diminished smooth muscle mass.

2. Reduced propulsive activity.
3. Less mature autonomic innervations.
4. Blunted hormonal & enzymatic response.
4- Adverse effects of malnutrition
• Many LBWT infants & almost all ELBWT
babies experience significant growth
retardation during NICU stay (Lemons et al.,
2001)
n Nutritional inadequacies have long term neuro
developmental outcome Lucas et al., 1990.
n Under nutrition affects pulmonary maturity,
growth and immunity.
n Impaired insulin secretion leading to
hyperglycemia.
 Vitamin A

• Deficiency predispose to CLD & susceptibility

to sepsis.
 Vitamin E

• Antioxidant.
• Facilitate phagocytosis & heme synthesis.
• Important for ROP prevention.
• Protective role in IVH & BPD.
 Trace Minerals

• Preterms have low stores at birth.

• 8 trace elements are essential.
• Deficiency affect cell growth, enzyme system
& heme synthesis.
5- Potential catastrophic diseases as NEC

and acute conditions e.g respiratory

distress, hypoxia.
6- Many questions remain partially or

completely unanswered.
A. How quickly should enteral feeding be
advanced, and in what manner?

B. How should feeding protocols be altered by

specific factors.
I. General guidelines to enteral

feedings.
1. Parenteral nutrition should begin early and
continue till full enteral feeds are reached.
2. Minimal enteral feeds should be started early.
3. Breast milk is preferable “fortified”.
4. Slow advancement of feeds.
5. Observation of signs of intolerance.
6. Attention to sensory needs.
7. Keep accurate records of intake.
 Contraindications of enteral
feeding

Downs’s score > 6

Hypotension
Gastrointestinal obstruction or
NEC
A 5 minute Apgar score of 4
 Method of feeding
.Cup feeding
.Syringe feeding
Nasogastric versus orogastric
.feeding
.Direct breast feeding
 2. Minimal Enteral Feeds
(Gut priming-trophic feeds)

1. Reduces feeding intolerance.

2. Reduces incidence of jaundice.
3. Reduces time to full enteral feeds attainment.
 2.Minimal Enteral Feeds
(Gut priming- trophic feeds)

4. Induces release of intestinal hormones.

5. Direct trophic effects on GIT.
 Indications of gut priming

Extremely LBW
Umbilical artery catheter in place
Unstable baby with sepsis
Unstable baby with asphyxia
 3- Breast Milk

A. Incidence of NEC is 6 times higher in formula fed.

B. Better cognitive & intellectual development.
C. LC-PUFA may have important role in brain &
retinal development.
D. Better tolerance.
 4- Advancement of Feeds

• Rapid advancement (>20 ml/kg/day) is

associated with increased risk of NEC.
 4- Advancement of Feeds

1. Assess the nurse’s report.

2. Feeding order : precise & clear.
3. Avoid advancing both volume & number of
feeds at the same time.
4. Nasogastric tube need not be removed for
early enteral feeding.
 5- Feeding Problems

Indicate possible GI pathology:

2. Bile-stained residuals.
3. Distended abdomen.
4. Guiac positive stool.
5. Significant residuals.
6. Significant systemic symptoms.
 Abnormal gastric residual volume

 Abnormal gastric residual volume

has been defined as follows: >2
mL/kg per feeding
 OR >50 percent of the volume of
feeds over the last three hour
 quality of the gastric residual
 Gastric residuals that are green, or
bilious, could indicate intestinal
obstruction,
 but more often indicate
overdistention and retrograde reflux
of bile into the stomach.
 quality of the gastric residual
 A blood tinged residual could indicate
an inflammatory process,
 but may only be due to a slight
mucosal irritation from the indwelling
gastric tube.
 Possible Causes of Feeding Intolerance

1. NEC.
2. Sepsis.
3. Hemodynamic problems.
4. Hypoxemia.
5. Electrolyte disturbances.
6. High theophylline serum levels.
 Feeding Intolerance
Possible Options

1. Decrease amount of each feed.

2. Switch to more dilute formula.
3. Change the interval between feeds.
4. Switch to predigested formula.
5. Change to continuous gastric drip.
6. Start parenteral nutrition & NPO.
 6- Attention to Sensory Needs

• Feeding should represent a pleasurable

experience.
• Use of non nutritive sucking.
• Rocking the baby between feeds.
 7- Non Nutritive Sucking

1. May have an effect on weight gain & gastric

motility & metabolic rate.

2. Facilitate transition to oral feeding.

(Pinelli, 2000)
 When the infant tolerates at least
100 mL/kg per day or has fed
unfortified human milk for at least
one week, the caloric density of milk
is increased by either switching to
preterm formula. or adding human
milk fortifier.
 Average daily energy requirements
for enteral fed premature infants are
120 kcal/kg per day

 Total energy needs in infants with

chronic illness, such as
bronchopulmonary dysplasia,
increase up to 150 kcal/kg per day
 Growth Parameters
 Weight minimum increment of 15/kg
per day.
 Once the infant reaches 2.0 kg, the
daily weight gain of 20 to 30 g/d
should be the goal
 Length minimum increment of 1 cm
per week.
 Head circumference minimum
increment of 1 cm per week
 Biochemical assessment
 Bone mineral status: serum calcium,
phosphorus, and alkaline
phosphatase activity.
 Protein status: serum albumin and
urea nitrogen.
 The hemoglobin and reticulocyte
count
I. Feeding in Selected Situations
 Feeding of Ventilated Babies

1. Babies kept NPO until need for ventilatory

assistance is minimized & baby stable.
2. Post-extubation NPO (4-12 hrs.).
3. Low UAC is a relative contraindication.
 Feeding of Perinatal Asphyxia Babies

NPO until stability:

2. Bowel sounds are present.
3. Abdominal examination is benign.
4. Passed meconium.
5. Stable hemodynamically.
 Feeding After Exchange Transfusion

• NPO for 24 hrs. after line is removed.

 Necrotizing Enterocolitis

• Feeding should be withheld for 2 weeks

minimum.
• Total parenteral nutrition should be
immediately started.
 Objectives

1. Stress the importance and challenges of

preterm nutrition.
2. Focus or general guidelines to feeding in
preterm and high risk babies.