Evidence-Based: Guidelines For Optimization of Nutrition For The Very Low Birthweight Infant
Evidence-Based: Guidelines For Optimization of Nutrition For The Very Low Birthweight Infant
Evidence-Based: Guidelines For Optimization of Nutrition For The Very Low Birthweight Infant
evidence-based medicine
Author Disclosure
Dr Murgas Torrazza
has disclosed no
financial relationships
relevant to this article.
Dr Neu has disclosed
that he serves as
Educational Gaps
1. Patients often do not receive optimal protein intake in the neonatal intensive care
unit (NICU) (i.e. protein initiated at 3.5 to 4 g/kg per day via parenteral nutrition in
the first hour after birth).
2. Patients often do not receive optimal lipid intake in the NICU (i.e. lipids initiated at 3
g/kg per day via parenteral nutrition on day one).
3. Temporary adjustment of lipids to 1 g/kg per day or use of alternative lipid solutions
may be needed in infants with parenteral nutrition associated liver disease.
4. Although used frequently, the assessment of gastric residuals may not be useful
indicators of feeding intolerance and/or risk of necrotizing enterocolitis.
a consultant to Abbott
Nutrition, Mead
Abstract
Inadequate nutrition of the preterm infant, especially the very low birthweight
(VLBW) and extremely low birthweight (ELBW) infant, has long-lasting adverse consequences. Despite advancement in many aspects of clinical care of VLBW/ELBW infants, there is signicant variability between neonatologists in the means of providing
nutrition. More uniform guidelines based on the best available scientic evidence are
needed. The objective of this review is to provide the neonatologist with evidencebased guidelines for the nutritional management of VLBW/ELBW infants.
Fonterra Foods; he
receives honoraria
from Nestle and
Danone; and he has
research grants with
Covidien and Gerber.
This commentary does
contain a discussion of
an unapproved/
investigative use of
a commercial product/
device.
Learning Objectives
1. Establish adequate enteral and parenteral nutrition in the very low birthweight or
extremely low birthweight infant from the day of birth.
2. Understand the rationale behind providing calories, proteins, and lipids as soon as
possible after birth.
3. Discuss the potential risk of delays in enteral feedings and the complications of
prolonged parenteral nutrition and ways to avoid them.
4. Understand the importance of establishing nutritional
guidelines with the best evidence available.
Abbreviations
AA:
BUN:
DHA:
ELBW:
MCT:
NEC:
PMA:
PN:
PNALD:
REE:
VLBW:
Introduction
amino acid
blood urea nitrogen
docosahexaenoic acid
extremely low birthweight
medium chain triglyceride
necrotizing enterocolitis
postmenstrual age
parenteral nutrition
parenteral nutrition associated liver disease
resting energy expenditure
very low birthweight
Associate Editor. Professor of Pediatrics, College of Medicine, University of Florida, Gainesville, FL.
evidence-based medicine
Nutrient Requirements
The balance of protein, lipid, and carbohydrate in adequate
amounts will allow us to safely provide enough protein and
energy intake avoiding hyperglycemia and minimizing
postnatal growth failure.
The resting energy expenditure (REE) of a VLBW/
ELBW infant is approximately 50 kcal/kg per day. We
need to add to this the energy losses due to metabolic activity. (4) It is estimated that if the infant is fed enterally
the fecal loss of energy is on average 10 kcal/kg per day
and to maintain growth, the preterm infant needs (REE
2) energy loss. If the infant is fed enterally, he or she
will require approximately 110 to 120 kcal/kg per day,
and if fed parenterally the infant will require approximately 80 to 100 kcal/kg per day. (5)(6)(7)
The fetus accretes approximately 2.5 g/kg per day of
protein at 26 weeks gestation, and protein losses are approximately 1 g/kg per day in these infants. (8)(9) The
placenta supplies approximately 3.5 g/kg per day of
amino acid (AA) to the developing fetus, and a preterm
delivery will abruptly interrupt this AA supply and protein
accretion. The developing gastrointestinal tract is not
nutrition
Parenteral Nutrition
Table.
evidence-based medicine
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Figure 2. Feeding algorithm. If waiting for breast milk (BM) availability, initiation of feedings should not be delayed by more than 24
hours. CBC[complete blood count; CRP[C-reactive protein; IVF[intravenous fluids; KUB[abdominal x-ray; NG[nasogastric; OG[
orogastric. a,b In infants with a low Apgar score < 3, hypoxic-ischemic encephalopathy stage 2 or 3, or hypotensive, consider holding
off on initiating feeding for 48 hours or provide lower volumes. c For infants receiving trophic feedings, expect residuals to be the same
amount as feeding volume. Nonbilious residuals should be refed as part of total feeding volume. d Currently, in most NICUs, ampicillin
and gentamicin would be first-line antibiotics. Metronidazole administration should be considered in severe cases or if surgery is
needed. May consider screening laboratory results (CBC/CRP) and/or scheduling frequent KUBs. If abnormal, treat as NEC.
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Conclusions
PN must be started immediately after birth with an adequate amount of nutrients; at least 3.5 to 4 g/kg per
day of proteins and 3 g/kg per day of lipids. Enteral nutrition should be started in the rst 24 hours with human milk preferably at 10 to 20 mL/kg per day of
volume intake. Enteral feeds fortication will enhance
growth and should be added once feeds are at a volume
intake of 100 mL/kg per day. Advancement of feeds
following an algorithm and establishment of guidelines
results in better outcomes for the VLBW/ELBW infants.
evidence-based medicine
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References
1. Ehrenkranz RA, Younes N, Lemons JA, et al. Longitudinal
growth of hospitalized very low birth weight infants. Pediatrics.
1999;104(2 pt 1):280289
2. Ehrenkranz RA, Dusick AM, Vohr BR, Wright LL, Wrage LA,
Poole WK. Growth in the neonatal intensive care unit inuences
neurodevelopmental and growth outcomes of extremely low birth
weight infants. Pediatrics. 2006;117(4):12531261
3. Stephens BE, Walden RV, Gargus RA, et al. First-week protein
and energy intakes are associated with 18-month developmental
outcomes in extremely low birth weight infants. Pediatrics. 2009;
123(5):13371343
4. DeMarie MP, Hoffenberg A, Biggerstaff SL, Jeffers BW, Hay
WW Jr, Thureen PJ. Determinants of energy expenditure in
ventilated preterm infants. J Perinat Med. 1999;27(6):465472
5. Zlotkin SH, Bryan MH, Anderson GH. Intravenous nitrogen
and energy intakes required to duplicate in utero nitrogen accretion
in prematurely born human infants. J Pediatr. 1981;99(1):115120
6. Ziegler EE, Thureen PJ, Carlson SJ. Aggressive nutrition of the
very low birthweight infant. Clin Perinatol. 2002;29(2):225244
7. Ibrahim HM, Jeroudi MA, Baier RJ, Dhanireddy R, Krouskop
RW. Aggressive early total parental nutrition in low-birth-weight
infants. J Perinatol. 2004;24(8):482486
8. Ziegler EE. Meeting the nutritional needs of the low-birthweight infant. Ann Nutr Metab. 2011;58(suppl 1):818
9. Ziegler EE, ODonnell AM, Nelson SE, Fomon SJ. Body
composition of the reference fetus. Growth. 1976;40(4):329341
10. Cowett RM, Oh W, Schwartz R. Persistent glucose production
during glucose infusion in the neonate. J Clin Invest. 1983;71(3):
467475
11. Van Kempen AA, Romijn JA, Ruiter AF, et al. Adaptation of
glucose production and gluconeogenesis to diminishing glucose
infusion in preterm infants at varying gestational ages. Pediatr Res.
2003;53(4):628634
12. Chessex P, Blanger S, Piedboeuf B, Pineault M. Inuence of
energy substrates on respiratory gas exchange during conventional
mechanical ventilation of preterm infants. J Pediatr. 1995;126(4):
619624
13. Van Aerde JE, Sauer PJ, Pencharz PB, Smith JM, Swyer PR.
Effect of replacing glucose with lipid on the energy metabolism of
newborn infants. Clin Sci (Lond). 1989;76(6):581588
14. Kashyap S, Schulze KF, Ramakrishnan R, Dell RB, Heird WC.
Evaluation of a mathematical model for predicting the relationship
between protein and energy intakes of low-birth-weight infants and
the rate and composition of weight gain. Pediatr Res. 1994;35(6):
704712
15. Ziegler EE. Protein requirements of very low birth weight
infants. J Pediatr Gastroenterol Nutr. 2007;45(suppl 3):S170S174
16. Ridout E, Melara D, Rottinghaus S, Thureen PJ. Blood urea
nitrogen concentration as a marker of amino-acid intolerance in
neonates with birthweight less than 1250 g. J Perinatol. 2005;25
(2):130133
17. Thureen PJ. Early aggressive nutrition in very preterm infants.
Nestle Nutr Workshop Ser Pediatr Program. 2007;59:193204;
discussion 204198
18. Vlaardingerbroek H, Veldhorst MA, Spronk S, van den Akker
CH, van Goudoever JB. Parenteral lipid administration to very-lowbirth-weight infantsearly introduction of lipids and use of new
lipid emulsions: a systematic review and meta-analysis. Am J Clin
Nutr. 2012;96(2):255268
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1. You are caring for a newborn 26-week-gestational-age male. He is requiring mechanical ventilation, and he is
being started on parenteral nutrition. Which of the following is true regarding his nutrition/energy
requirements?
A. The resting energy expenditure for this infant is approximately 80 kcal/kg per day.
B. The fecal loss of energy is approximately 30 kcal/kg per day.
C. His requirement for protein accretion for optimal growth is 3.5 to 4 g/kg per day.
D. If he has a central line, his glucose infusion should be maximized to 15 mg/kg per minute.
E. The infant should be started on enteral feedings of donor breast milk at 120 mL/kg per day, and parenteral
nutrition can be used only if there is feeding intolerance.
2. Your neonatal intensive care unit (NICU) has started to use a stock solution of parenteral nutrition fluid. There
is a newborn 30-week-gestational-age infant for whom you have established umbilical arterial and venous
access. Which of the following is true regarding management of parenteral nutrition for this patient?
A. The blood urea nitrogen should be followed closely, and if it exceeds 25 mg/dL, the protein concentration
should be lowered to 1 g/kg per day.
B. The stock parenteral nutrition fluid should have at least 3 g per 80 mL of amino acids.
C. Lipids should be started on the second day at 0.5 mg/kg per day and advanced gradually by 0.5 mg/kg per
day every other day to a goal of 3 g/kg per day.
D. Amino acid and lipid infusion should be avoided until the second day after delivery in order to avoid
interference with respiratory function.
E. The initial fat provision should be via a 5% or less concentrated lipid solution.
3. A 5-week-old 25-week-gestational-age female had necrotizing enterocolitis earlier in her clinical course and
remains dependent on parenteral nutrition. The blood urea nitrogen level is 30 mg/dL. She has also developed
cholestatic jaundice, which appears to be due to prolonged parenteral nutrition. Which of the following is an
appropriate step in her nutrition regimen?
A. Protein infusion should be decreased to 2g/kg per day until the blood urea nitrogen level decreases below
25 mg/dL.
B. Lipid infusion should be halted indefinitely until the direct bilirubin level decreases to normal levels.
C. Although liver function has traditionally been followed for patients on parenteral nutrition, there is no
basis for this testing, and the nutrition regimen should not be adjusted based on the finding of cholestasis.
D. If available, lipid solutions containing predominantly omega-3 fatty acids, and less or no omega-6 fatty
acids, may provide an alternative source of lipid nutrition that may minimize liver disease.
E. While anecdotal reports link lipid infusion to liver disease, there is not clear evidence regarding this link,
and as liver disease may be due to malnutrition, the lipid concentration should be increased.
4. A 1-day-old 31-week-gestational-age male has respiratory distress syndrome and is on mechanical
ventilation. He has an umbilical line catheter in place and is receiving parenteral nutrition. The mother has
expressed a small amount of colostrum/breast milk. Which of the following is an appropriate aspect of
nutrition management for this infant?
A. The patient can now be started on enteral feedings at 10 to 20 mL/kg per day with maternal breast milk,
and addition of donor human milk if there is not yet enough maternal breast milk.
evidence-based medicine
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B. Enteral feedings can be started once the patient has been extubated and noted to be stable from
a respiratory standpoint.
C. As parenteral nutrition provides adequate nutrition at this stage during the first week after delivery,
enteral feedings should be withheld until 4 to 6 days after delivery in order to avoid increasing the risk of
necrotizing enterocolitis.
D. Once this infant has completed his course of parenteral nutrition, human milk should provide adequate
nutrition for this infant until he is discharged from the hospital, except for the need for iron
supplementation.
E. During the course of hospitalization for this preterm infant, infant formula should be used only in cases
when the mother has HIV or hepatitis infection.
5. A 4-week-old 28-week-gestational-age infant is in room air, having occasional apnea and bradycardia events,
and is transitioned to full enteral feedings by gavage. Which of the following regarding transition to oral
feeding is correct?
A. Due to the risk of aspiration and exacerbation of apnea, oral feedings should not be attempted until 37
weeks postmenstrual age.
B. In order to promote breastfeeding, bottle-feeding should be avoided at all costs until the infant has been
evaluated to have a good latch and suck when breastfeeding for at least 1 week.
C. Oral skills and readiness should be assessed throughout the entire hospital course until discharge, as early
interventions to improve oral intake can impact outcomes.
D. Cup-feeding is more likely to reduce reflux and shorten hospital length of stay.
E. Breastfeeding should be avoided until 37 weeks postmenstrual age because it will prevent caloric
supplementation and not allow for the protein load required for growing preterm infants.
References
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