This document discusses nutritional planning for pre-term neonates. It notes that pre-term neonates have unique nutritional needs due to higher rates of growth and metabolism. These include higher protein, energy, water, electrolyte and fatty acid requirements compared to term infants. The document outlines strategies for nutritional support including parenteral and enteral feeding, the importance of breastmilk and fortification, monitoring growth, and educating families. The overall aim is to ensure normal growth and neurodevelopmental outcomes for pre-term infants.

1. Nutritional Planning for Growth
& Development of Pre-term
Neonates
SPEAKR: Dr. Arnab Nandy
Post Graduate Trainee(MD)
Dept. of Paediatrics
North Bengal Medical College & Hospital
Presentation Date:12/29/2017

2. INTRODUCTION
• Preterm - < 37 completed weeks (259 days) of gestation
• Nutrition - one the most debated issues in the care of Pre-term Neonates
• DIFFICULT & CHALLENGING
- Prematurity
- Sickness
• Optimum long term outcome – structure and function of tissues & organ

3. UNIQUE NUTRITIONAL ASPECT
• Higher rate of protein synthesis & turnover
• Greater oxygen consumption during growth
• Energy requirement
• Higher organ:muscle mass ratio
• Insensible water loss
• Prone to hypo/hyper glycemia
• Higher rate of fat deposition

4. FEW BASIC STATS:
 Intrauterine growth rate ~15 g/kg/day
 Energy requirements -
Pre-term : 110–135 kcal/kg/day [Term : 96–120 kcal/kg/day]
 Protein requirement -
Body weight 1–1.8 kg: 3.5–4 g/kg/day
Body weight <1 kg: 4–4.5 g/kg/day
 Protein:Energy ratio -
Body weight 1–1.8 kg: 3.2–3.6 g/100 kcal (12.8–14.4%)
Body weight <1 kg: 3.6–4.1 g/100 kcal (14.4–16.4%)
 Body water composition-
Pre-term: 80-90%(ECF>ICF) [Term: 70-80%(ECF>ICF) ]
 Electrolyte requirement-
(in mEq/kg/day) Pre-term: Na+
1-3 K+
1-2
Term: Na+
6-8 K+
2-3
 Requiremant of LCPs-
DHA : 12–30mg/kg/day or 11–27 mg/100 kcal.
AA : 18–42mg/kg/day or 16–39 mg/100 kcal

5. IMPORTANCE OF NUTRITIONAL
PLANNING
• SHORT TERM:
- Increased vulnerability to
infection
- Free radical mediated damage
- Greater need for ventilator
support
• LONG TERM:
- Poor growth
- Poor neuro-developmental
outcome
- Prone to CVS disorder
- Poor cell growth (heart, kidney,
pancreas)

6. BASIC PLAN
• ONE aim : - Attain intra-uterine growth rate
• TWO objectives : - Normal growth & development
- Better long-term outcome(quality of life)
• THREE physiological goals:
- Nutrition promotion & growth monitoring
- Establishing enteral nutrition
- Transition to oral feeding

7. SELECTION OF MODE OF NUTRITION:
- Parenteral
- Enteral
HIGH RISK PRE-TERM NEONATES:
o <27 weeks or <1,000 g birthweight
o Haemodynamically unstable on inotropes
o High risk for NEC or Previous incidence of NEC
o Recent abdominal surgery
o Growth restricted infants with absent or reversed end diastolic flow

8. Algorithm adapted from
AIIMS Protocol in
Neonatology, CBS Publisher &
Distributors Pvt Ltd.

9. Algorithm adapted from AIIMS
Protocol in Neonatology, CBS
Publisher & Distributors Pvt. Ltd.

10. FEEDING RELATED MORBIDITIES:
• Feeding intolerance
• Necrotizing enterocolitis
• Prolonged TPN & Cholestasis
• Vitamin & Mineral deficiencies
• Osteopenia
• Prolonged hospitalisation
• Lack of full physical and intellectual potential

11. 1.PARENTERAL FEEDING
TPN
• INDICATION:
- Birth weight less than 1000 gm
- Birth weight 1000-1500 gm and anticipated to be not on significant
feeds for 3 or more days
- Birth weight more than 1500 gm and anticipated to be not on
significant feeds for 5 or more days
- Surgical conditions – NEC,TEF, Meconium ileus, Mal-rotation gut

12. o ROUTES:
1. Peripheral - short term
Can’t exceed 12.5% dextrose or 3.5% amino acids
2. Central - long term
o GENERAL GUIDELINES:
1. Minimal caloric req. to prevent catabolism– at least 40 kcal/kg/d
2. For growth, minimal requirements are 80 kcal/kg/d and protein
intake of >2 gm/kg/d .
3. For adequate growth, 100 kcal/kg/d of energy and protein
intake 3.5 g/kg/d for preterm infants

13. CONSTITUENTS:
 PROTEIN - Amino acids at 2-3 g/kg/d (max 3.5g/kg/d for pre-term)
 CARBOHYDRATE - Start with 4-6 mg/kg/min
Advance by 1-3 mg/kg/min daily upto maximum of 12 mg/kg/min
 FAT - A lipid intake of 0.25-0.5 g/kg/d is required to prevent essential
fatty acid deficiency, goal 3g/kg/d
(Deliver over 24 hours, do not allow lipids to exceed 60% of total
caloric intake)
 ELECTROLYTE & MINERALS – According to serum level
 TRACE ELEMENTS & VITAMINS -

14. Tables adapted from AIIMS
Protocol in Neonatology, CBS
Publisher & Distributors Pvt. Ltd.

15.  WEANING:
Tolerating >50 ml/kg/day of feedings
 DISCONTINUATION:
Parenteral nutrition may be stopped when the infant is tolerating
≥100-120 ml/kg of enteral feedings
or
receiving ≤25 cc/kg/d of PN.
STARTER TPN
- Aggressive nutrition support for the pre-term recommended.
- Nutrition support should be initiated within 3 days of birth and
should include protein
- Protein is well tolerated in the first hours of life
- Decrease the amount of time the infant is without a protein
source.

16. 2.ENTERAL FEEDING
• BEST METHOD for nutrition
• Initiate at the EARLIEST possible
• TROPHIC FEED
• Modes: - NG/OG/NJ feeding
- Katori-Spoon(KS) feeding
- Direct breast feeding
• Amount: Aim to feed at least 150 ml/kg (ideally 180 ml/kg/day)

17. FREQUENCY:
- Smaller infants should receive hourly feeds and increase to three- to
four-hourly intervals as the infants grows
- There is no evidence to suggest an advantage of continuous feeding
over bolus feeding
- Continuous feeding - infants with gut resection, severe respiratory
problems and high output stomas, receiving naso-jejunal fed continuously
WHEN TO START:
- Enteral TROPHIC feeds should be introduced with in day 1-2 of life
unless a clear contraindication
- Monitor for feed intolerance & any other complication
ADVANTAGE OF EARLY ENTERAL FEED:
- Promotes gut maturity
- Better long-term developmental outcome

18. Breast milk VS. Formula feed:
Breast milk is the feed of choice for preterm infants
The benefits of human milk for preterm infants are well documented
immune protection – resulting in less sepsis and NEC
superior nutrient bioavailability & osmolarity compared to formula
improved feed tolerance
neurodevelopmental advantages compared to formula fed infants
better long-term health outcomes
FORTIFICATION of breast milk for pre-term neonate
- Greater demand due to high turnover
- Inadequate body store

19. Table adapted from Nutrition & Child Development by KE Elizabeth

20. Table adapted from Nutrition & Child Development by KE Elizabeth

21. COMMENCEMENT OF FORTIFICATION:
BMF should be commenced in stable preterm neonates when 100-150 ml/kg/day
EBM has been tolerated for 48 hours.
In infants >1500g fail to grow as expected on EBM alone consider fortifying feeds:
with BMF if they are still <37 weeks gestation
with standard infant formula powder if they are term and >2.5 kg
WEANING OF FORTIFICATION:
Fortification of EBM in neonates <1,500 g should continue until the infant is ≥40
weeks or attain 2kg weight and thriving.
PRETERM FORMULA-
Neonates <2,000 g <35 weeks, who are not receiving human milk, should receive a preterm
formula
Partially hydrolysed formula (PHF), extensively hydrolysed formula (EHF) and amino
acid formula (AAF)

22. Table adapted from Nutrition & Child Development by KE Elizabeth

23. Table adapted from AIIMS Protocol
in Neonatology (internet), CBS
Publisher & Distributors Pvt. Ltd.

24. http://www.indianpediatrics.net/jan2004/jan-63-67.htm*Breast milk/100ml

25. http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/nutrition-enteral-nutrition-preterm-infant

26. Adapted from AIIMS Protocol in
Neonatology (internet), CBS
Publisher & Distributors Pvt. Ltd.

27.  PRE-TERM <1.5kg : - BMF
- Fortification better than supplementation with specific nutrients
 PRE-TERM neonate with birth weight of 1.5-2.5kg (likely to be >32 weeks):
- May not require BMF
- Mother’s milk meet their requirement
- Supplementation of specific nutrients
INFERENCE OF ENTERAL NUTRITION IN PRETERM
Table adapted from AIIMS Protocol
in Neonatology (internet), CBS
Publisher & Distributors Pvt. Ltd.

28. IMPROVISED PLAN
• ONE aim: - Ensure normal growth rate
• ONE objective: - Normal neuro-developmental outcome
• ONE goals: - Involving mother & other family members to adopt
corrective measures and better quality of life

29.  IMPLEMENTATION:
- Thriving well
- > 40 weeks PMA
- Achieved ≥ 2 kg weight
- Meeting discharge criteria
 COMPONENTS:
- Nutritional supplementation
- Growth monitoring
- Addressing inadequate weight gain
- Educating mother & family members

30. 1.NUTRITIONAL SUPPLEMENTATION:
- Mother’s milk is BEST
- Fortification not routine unless indicated
- Formula fed when situation insists
- Supplementing specific nutrients
Table adapted from AIIMS
Protocol in Neonatology, CBS
Publisher & Distributors Pvt. Ltd.

31. 2.GROWTH MONITORING:
- Correction of age
- Maintaining growth chart
(Wright’s , Ehrenkranz’ , Fenton chart)
3. ADDRESSING INADEQUATE WEIGHT GAIN:
- EARLY detection
- APPROPIATE reasoning
- PROPER intervention
4. EDUCATING MOTHER & FAMILY MEMBERS:

32. http://www.ucalgary.ca/fenton/2013chart
Growth Monitoring:

33. APROPIATE CARE & ATTENTION
FOR PRE-TERM NEONATE
RESULTS IN SAME OUTCOME LIKE
A HEALTHY TERM NEONATE
THANK YOU