Transcript Document 7469706

Infant Nutrition
Jennifer Levy, MD
Children’s Hospital of Oakland
Overview
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Fetal Energy Expenditure & Sources
Neonatal Energy Expenditure & Requirements
Proteins
Fats
Carbohydrates
Vitamins
Human Milk
Formulas
Parenteral Nutrition
Fetal Energy
• Estimated Fetal Energy Expediture = 35 to 55
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kcal/kg/day
Energy Sources
1. Maternal glucose (2/3)
2. Placental lactate (1/4)
3. Maternal amino acids
Neonatal Energy
Form of Energy
Caloric Expenditure
Resting Metabolic Rate*
Activity
Cold Stress
Nutrition Processing
50 kcal/kg/day
15 kcal/kg/day
10 kcal/kg/day
50 kcal/kg/day
Total
120 kcal/kg/day
Proteins
Milk Source
Whey-to-Casein Ratio
Colostrum
80:20
Mature Milk
55:45
Formula
20:80
Preterm Formula
60:40
Fats
• Placental transfer of essential and non-
essential fatty acids
• Fat stores are formed by lipogenesis from
glucose
• Most poorly digested macronutrient
Fats
Types of Fatty Acids
• Stearic, Oleic, and Palmitic are common
• Linoleic and Linolenic are the most common
• Long-chain polyunsaturated (LCPUFA)
• Short and Medium Chain Triglycerides (MCT)
Carbohydrates
Lactose
• Enhances absorption of calcium and
magnesium
• Promotes intestinal growth of lactobacilli
Vitamins
Water Soluble Vitamins
• Vitamin B Complex and Vitamin C
• Generally not formed from precursors
• Daily intake required
• No accumulation (except Vitamin B12)
• Cross placenta by active transport
Vitamins
Fat-soluble vitamins
• Vitamins A, D, E, K
• Synthesized from precursors
• Daily intake not usually required
• Not easily excreted and can accumulate
• Placental transfer by simple or facilitated
diffusion
Vitamin Deficiencies
Vitamin B12 and Folate
• Vitamin B12 is synthesized by GI microorganisms and is
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required for folate metabolism
Risk of B12 deficiency in breast-fed infants of vegetarian
mothers who do not ingest dairy or eggs
Risk of folic acid deficiency in infants fed evaporated or
goat’s milk
Megaloblastic anemia and hypersegmented neutrophils
Vitamin Deficiencies
Vitamin D Deficiency
• Vitamin D regulates the concentration of calcium
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and phosphorus in the bloodstream and bone
Important for bone mineralization and growth
Deficiency results in osteopenia -> rickets
Hypocalcemia -> tetany, seizures
Vitamin Deficiencies
Vitamin E Deficiency
• Vitamin E has antioxidant properties and is
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recommended to be taken concurrently with iron
administration to protect from iron-induced
hemolysis
Manifests with anemia and reticulocytosis
Vitamin Deficiencies
Vitamin K
• Required for carboxylation of prothrombin into
the active form
• Newborns are predisposed:
- Initial lack of microorganisms that synthesize Vitamin K
- Immature newborn liver
• Maternal medications
• Breast fed infants
• Associated with hemorrhagic disease of the
newborn
Iron Deficiency
• Microcytic anemia
• Associated with short term and long term
neurodevelopmental deficits
• Preterm infants more susceptible due to
small iron stores at birth, high growth
velocity, and phlebotomy loss
Human Milk
Physiology
• Prolactin is secreted by maternal anterior
pituitary throughout pregnancy
• At delivery, the decrease in estrogen and
progesterone leads to increased milk
production and delivery
• Milk ejection is mediated by oxytocin from
the posterior pituitary
Human Milk
Immunologic and Antibacterial Factors
• Secretory IgA
• Protective and bactericidal enzymes
• Lactobacilli growth is increased
• Colostrum has increased lymphocytes,
macrophages, and immunoglobulins
Human Milk
Electrolytes
• Decreased Na, K, Ca, Ph, Cl, and Mg
Protein
• As breast milk matures, protein decreases
• Amino acids are lower
Fats
• 50% calories
• Triglycerides are variable
Human Milk
Premature Milk
• Increased protein
• Increased electrolytes
• Inadequate protein, calcium, phosphorus,
and vitamin D for premies
• Need to supplement with human milk
fortifier (2 packets/ 50ml = 24kcal/30mL)
Human Milk
Benefits
• Decreased IDDM, IBD, NEC, obesity
• Decreased infections
• Improved neurodevelopmental outcome
Contraindications (in US)
• Infection
• Galactosemia
• Drugs
Nutritional Supplements
Preterm
BM
IRON
Full term
P. Form
BM
Formula
2w-2mos
Fe Fortified
6mos
Fe Fortified
HMF (ICN)
None
Vit D
None
(2-4 mg/kg/day)
Vitamins
(200IU/day)
Fluoride
(0.25-0.5 mg/day)
----------after 6 months---------------
Formulas
Classification by
Carbohydrate
Source
Type of
Carbohydrate
Formula
Lactose
Enfamil,
Neosure,
Similac
Alimentum,
Isomil,
Portagen
Sucrose and
glucose
polymers
Glucose
polymers
Enfamil
Lactofree,
Neocate,
Nutramigen,
Pregestimil
Premature Formulas
Similac Special Care and Enfamil Premature Lipil
• 24kcal/30 mL or 20kcal/30mL
• Reduced lactose (50%) and glucose polymers
• 50% MCT, ARA and DHA added
• Higher protein content
• Higher calcium and phosphorus content
• Increased caloric density
• Use in infants less than 1800g or 32 weeks GA
Premature Discharge Formulas
Neosure or Enfacare Lipil
• 22 kcal/30mL
• Increased protein
• Increased calcium and phosphorus
content
• Increased caloric content
• Give until 9 months PCA
TPN
• Recommend 80-90 kcal/kg/day
• Most calories are provided by lipids and
glucose
• Glucose infusion rate: 6-8mg/kg/min
GIR: 0.167 x concentration x rate
weight
TPN
Carbohydrates
• Mostly glucose
• 1g CHO provides 3.4 kcal
• With increasing glucose concentration,
increasing osmolarity
• Should provide 55-65% of total kilocalories
• Maximum concentration is 12.5% peripherally
TPN
Fats
• 1 g fat provides 9 kcal (20% solution
provides 2 kcal/1 ml)
• Should provide 30-50% of total calories
• Limit to 3g/kg/day
• Monitor serum TG levels
TPN
Proteins
• Goal is to prevent negative energy and nitrogen balance
• Required early in life to achieve goals
• 1g of protein provides 4 kcal
• Should provide 7-10% of total calories
Calcium and Phosphorus
• Ratio should be 1.3:1 to 1.7:1
• Risk of bone demineralization
• Cysteine prevents precipitation
Sample TPN for Just Born
LBW Infants
Adapted from Nutrition and Gastroenterology Clinical Review Committee, 2002
Component
Quantity
Amino Acids
2.4g/100mL
Glucose
5-10g/100mL
Calcium gluconate
500-650mg/100mL
MVI-Pediatric
2mL/kg/day
Heparin
1 U/mL
Lipid
5mL/kg/day
Monitoring Parenteral Nutrition
Daily
• Weight
• Urine for glycosuria
• Intake and Output
• Serum electrolytes (initially)
• Serum glucose (advanced dextrose)
• Serum triglycerides (advancing lipids)
Monitoring Parenteral Nutrition
Weekly
• Serum glucose, electrolytes, Ca, Phos, and
Mg
• Serum albumin and total proteins
• Liver function tests, bilirubin (T & D)
• Serum triglycerides
• Complete blood count
TPN Supplements for
Premature Infants
• Insulin infusions
• Vitamin A
• Cysteine hydrochloride
• Carnitine
• Glutamine
TPN
Complications
• Cholestasis
• Metabolic Acidosis
• Hyperglycemia
• Metabolic Bone Disease
• Nosocomial Infections
• Complications of fat
Early Feeding for Preterm and
Sick Infants
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Begin at day 2-3 if stable
Human milk 12-24 mL/kg/day
Reduced hospital stay
Reduced sepsis and sepsis evaluations
Reduced days to full feedings
Increased calcium and phosphorus absorption
No increased incidence of NEC
Fewer infants with central venous catheters