Chapter 9 Infant Nutrition: Conditions and Interventions Nutrition Through the Life Cycle Judith E. Brown

Key Terms • Children with Special Health Care Needs Infants, children or adolescents with, or at risk for, a physical or developmental disability, or with a chronic medical condition • Low-Birthweight (LBW) Weighing <2500 g • Very Low Birthweight (VLBW) <1500 g • Extremely Low Birthweight (ELBW) <1000 g

Infants at Risk • Key questions regarding infants: – How is the baby growing?

– Is the diet providing all required nutrients?

– How is the infant being fed?

Infants at Risk • Families of infants with special health care needs should be considered – Emotional impact of having sick newborn may be overwhelming to parents – Healthcare providers must be sensitive to parents’ emotional needs

Energy and Nutrient Needs • Energy Needs – May be the same, more or less depending on the special needs – Increased calories required for • Difficulty breathing •Infections • Temperature regulation •Fever • Recovery from surgery – Decreased calories recommended for spina bifida or Down syndrome

Energy and Nutrient Needs • Energy Needs – AAP suggests 120 cal/kg for preterm infants – The European Society for Gastoenterology and Nutrition gives a caloric range of 95-165 cal/kg – Recovering infants may need as much as 180 cal/kg

Energy and Nutrient Needs • Protein Requirements – 2.2 g/kg adequate if growth or digestion are not affected – 3.0-3.5 g/kg required for preterm or recovery from illness – 4 g/kg may be needed for ELBW • Form of protein – Hydrolyzed protein or single amino acid formulas – Specific amino acid formulas such as for PKU

Energy and Nutrient Needs • Fats – Provide up to 55% calories from fat – Low-fat diet rarely required – Medium-chain triglycerides (MCT) beneficial to VLBW and ELBW infants because of low pancreatic and liver enzymes – Essential fatty acids and DHA and AA important

Energy and Nutrient Needs • Vitamins and Minerals – May need additional vitamins and minerals to support “catch-up” growth or during recovering from illness – Human-milk fortifiers provide additional calories and nutrients – Preterm infant formulas may have higher amounts of vitamins and minerals

Growth • Tracking growth reflects nutritional status for most infants • Additional methods to use if underlining conditions exist include: – Growth charts for specific conditions – Biochemical indicators – Body composition – Head circumference – Medications that impact growth

Growth • Growth in Preterm Infants – “Neonatal Research Network Growth Observational Study Research Network” tracks infant BW between 501 and 1501 g – Infant Health and Development Growth Charts: • For LBW Premature • For VLBW Premature • Correction for Gestational Age – Gestation-adjusted age calculated by subtracting GA at birth from 40 weeks

Growth • Does Intrauterine Growth Predict Outside Growth?

– Depends on: • Intrauterine environment • Fetal origins theory • Other factors like air pollution • Interpretation of growth – Based on a pattern of weight gain

Growth • Interpretation of Growth – Rate of growth frequently used to measure improvement in preterm or sick infants – Microcephaly or macrocephaly may affect body composition and growth – Great variability in growth of infants

Nutrition for Infants with Special Health Care Needs • Health conditions in infants interfere with growth and development • Nutrition plays an important role in: – Preventing illness – Maintaining health – Treating conditions in infancy

Nutrition for Infants with Special Health Care Needs

Common Nutritional Problems • Nutrition Risks to Development • Developmental delays—range of symptoms reflecting slow development such as: – Slow growth and/or – Feeding problem

Common Nutritional Problems • Down syndrome– – Incidence is 13 per 10,000 live births – Developmental delays seen in infancy • Nutrition concerns include: – Weak facial muscles cause feeding difficulty – Overweight common—close monitoring of growth – Low amount of movement resulting in reduced caloric needs

Severe Preterm Birth and Nutrition • Incidence and prognosis – About 60,000 VLBW born in U.S. each year – Survival rate ~ 90% – Nutrition support generally required – High metabolic rates • Preterm infants fed by nutrition support – Parenteral—nutrients delivered directly to the bloodstream – Enteral—nutrients delivered directly to GI tract

Severe Preterm Birth and Nutrition • How sick babies are fed • Conditions that require parenteral feeding – Gastrointestinal problems may interfere with oral feeding – Damage or inflammation to GI tract from necrotizing enterocolitis (NEC)

Severe Preterm Birth and Nutrition • How sick babies are fed • Conditions that require enteral feeding – Gastrointestinal reflux, constipation, spitting up, vomiting, etc.

• Types of enteral tube feeding – Oral-gastric (OG) – Transpyloric – Gastrostomy – Jejunostomy

Severe Preterm Birth and Nutrition • Food Safety – Vital for preterm infants with immature immune systems

Severe Preterm Birth and Nutrition • What to feed preterm infants – Breastmilk – Human-milk fortifier – Preterm infant formulas • Vary in caloric content • MCT oil • Whey protein

Severe Preterm Birth and Nutrition

Severe Preterm Birth and Nutrition

Severe Preterm Birth and Nutrition • Preterm infants and feeding – Challenges in feeding VLBW or ELBW infants include: • Fatigue • Low tolerance of volume • “Disorganized feeding”

Infants with Congenital Abnormalities and Chronic • GI tract disorders Illness – Diaphragmatic hernia – displacement of the intestines up into the lungs – Tracheoesophageal atresia – incomplete connection between the esophagus and the stomach • Cleft lip and palate – upper lip and roof or mouth are not formed completely

Infants with Congenital Abnormalities and Chronic • Genetic disorders Illness – Small subset of congenital anomalies – Includes: • Galactosemia • Maple syrup urine disease • Urea cycle disorders • Fat-related and carbohydrate disorders • Disorders sensitive to high-dose vitamins • Renal or Bone genetic disorders

Feeding Problems • Seen in 40-45% of VLBW infants • Feeding problems may cause frustration to families • Recommendations for introducing solids and weaning with preterm infants are based on corrected gestational age • Table 9.5 lists Signs of feeding problems in high-risk infants

Nutrition Interventions • Frequent growth assessment • Monitor intake • Adjust feeding frequency/volume • Adjust timing or nursing, snacks or meals • Assess feeding position and support • Nutrient density to facilitate eating • Parent education • Observe parent-infant interactions • Consider developmental abilities

Infant Formulas for Special Needs • Special infant formulas may be used for some conditions.