bernadette daelmans, who: feeding low birth weight babies - update on who guidelines

7/28/2019 Bernadette Daelmans, WHO: Feeding Low Birth Weight Babies - Update on WHO Guidelines

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Feeding low birth weight babies:

Update on WHO guidelines

Bernadette Daelmans,

Coordinator Policy, Planning and Programmes

Department of Maternal, Newborn, Child and Adolescent Health (MCA)


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Outline

Definition of LBW and effective interventions

Principles and process of guideline development

Illustration of process with one example: choice of mother's milk

versus formula

Summary of recommendations:

Choice of milk

Supplements

When and how to feed

Frequency and progression of feeds

Overview of other newborn guidelines


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Definitions

Low Birth Weight infant: infant with birth weight< 2500 gram regardless of gestational age.

Preterm infant: infant born before 37 weeks of gestational

age.

Small for Gestational Age (SGA) infant: birth weight

below the 10th percentile for gestational age, usually a

result of IUGR.

Preterm and SGA infant


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35% of globalunder-five deaths

are associated withundernutrition*

Major causes of death in children under 5 (2010)

LBW directly or

indirectly contribute

to 60 80 % of all

newborn deaths


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Burden and distribution (2006)

Global prevalence of LBW: 15.5%, e.g., about 20.6 million LBWbabies born each year

South-Central Asia: 27.1%

Asia (other): 5.9% 15.4%

Africa: 14.3%

LAC: 10%

Oceania: 10.5%

North America: 7.7%

Europe: 6.4%

Source: Optimal feeding of LBW infants: technical review (2006)


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Improved care of LBW infants

Improved childbirth care

Antenatal maternal steroids Attention of early warming, drying and resuscitation

Extra care at home

Appropriate feeding, including additional support for

breastfeeding, expressed breast-milk feeding Keeping the infant warm, including skin-to-skin care

Early recognition and care-seeking for infections

Facility based care for very small infants

Appropriate feeding, including I/G expressed BM feeding

Thermal care, including Kangaroo mother care

Oxygen and continuous positive airway pressure


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Developmental readiness

32 36 weeks:

Infants should be able to attach, suck and extend tongueappropriately and begin breastfeeding

35 37 weeks:

Full breastfeeding maturation between 35 37 weeks

Demand feeding may be possible for some infants between 32

36 weeks


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Guidelines development: principles

Systematically developed, based on all availableevidence

Clear, unambiguous recommendations, but stating the

quality of evidence on which they are based

Strength of recommendation based on the balance of

benefits and risks, values and preferences, and costs

Should take into account the range of circumstances inwhich they will be used


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Guidelines development: principles

Systematically developed, based on all availableevidence

Clear, unambiguous recommendations, but stating the

quality of evidence on which they are based

Strength of recommendation based on the balance of

benefits and risks, values and preferences, and costs

Should take into account the range of circumstances inwhich they will be used


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2. Scoping the guidelines:

key questions and critical

outcomes

1. Establishing WHOSteering Group and

independent Guidelines

Development Group3. Systematic reviews andsynthesis of evidence4. Grading quality of

evidence using GRADE

7. Field testing,

implementation and

6. Peer-review and

finalization

5. Formulation of

recommendations by GDG:Benefits, Harms,

values and preferences,

t

Process of guideline development


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Examples of PICO questions

What should Low Birth Weight Babies be fed?

In LBW infants (P), what is the effect of feeding mother's own milk

(I) compared with feeding infant formula (C) on critical outcomes -

mortality, severe morbidity, neurodevelopment and anthropometric

status (O)?

In LBW infants who cannot be fed mother's own milk (P), what is

the effect of feeding donor human milk (I) compared with feeding

infant formula (C) on critical outcomes (O)?


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GRADE tables: mother's milk vs. formula

Pooled effect size

(95% CI)Overall quality

DirectnessConsistencyPrecisionLimitations in

methods

DesignOUTCOME

(No. of studies)

OR 0.82

(0.72 to 0.93)

LOW

Most evidence from

developed countries

(-0.5)

No serious

inconsistency

(0)

Some

imprecision

(-0.5)

No serious

limitations

(0)

Obs. studies

(-1.0)

Mortality

(4 studies)

OR 0.40

(0.31 to 0.52)

MODERATE

Most evidence from

developed countries

(-0.5)

No

inconsistency

(0)

No

imprecision

(0)

No serious

limitations

(0)

Most of the

studies obs.

(-1.0)

Severe infection

or NEC

(8 studies)

Mean difference 5.2

points (3.6, 6.8)

LOW

Most evidence from

developed countries

(-0.5)

No serious

inconsistency

(0)

No

imprecision

(0)

Limitations in

outcome

measurement

(-0.5)

All

observational

studies

(-1.0)

Neuro-

development

(6 studies)

MD in SD score:

Weight: -0.27

(-0.59, 0.05)

Length: -0.47

(-0.79, -0.15)

VERY LOW

Study from developed

country setting

(-0.5)

Single study

(-1.0)

Some

imprecision

(-0.5)

Limitations in

analysis

(-0.5)

All

observational

studies

(-1.0)

Anthropometri

c status

(1 study)


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Evidence to recommendations:

mother's milk vs. formula

Importantbenefits: mortality (18% reduction) LOW QUALITY

severe infections or necrotizing enterocolitis (60% reduction) MODERATE

mental development scores (5.2 points higher) LOW QUALITY

Harms lower length at 9 months (0.47 cm lower) VERY LOW QUALITY

Policy makers, health care providers and parents in developing

country settings are likely to give a high value to the benefits

Observed benefits are clearly worth the costs.


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Recommendation

Low birth weight infants, including those with very

low birth weight, should be fed mothers own milk

Strong recommendation

Based on moderate quality evidence of reduced

severe morbidity and low quality evidence of

reduced mortality and improved neurodevelopment


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Summary of recommendations

LBW and VLBW infants should be fed mother's own breastmilk. If

the mother is not able to breastfeed, donor milk should be given

LBW should be put to the breast as soon as clinically stable after

birth

LBW should be exclusively breastfed on demand for 6 months

Daily oral Vitamin A or routine zinc supplementation is not

recommended for LBW infants who are breast-milk fed


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Summary of recommendations

LBW and VLBW who cannot be given breast milk should be fedstandard infant formula

LBW infants who can not be breastfed, but can swallow should be

fed by cup and spoon (or cup with beak), based on hunger cues,but at least every 3 hours

If breastmilk feeding is not possible after discharge, the infantshould continue to receive infant formula until 6 months of age


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Special considerations for VLBW

A VLBW infant who is breast-milk fed should be given the followingsupplements:

a) Vitamin D (400 i.u. 1000 i.u. per day) until 6 months of age

b) Calcium (120 140 mg/kg/day) for the first months of life

c) Phosphorus (60 90 mg/kg/day) for the first months of life

d) Iron (2 -4 mg/kg/day) from 2 weeks to 6 months of age

A VLBW infant who fails to gain weight despite adequate breast

milk feeding should be given human-milk fortifiers, preferably

human-based milk

If a VLBW infant fed standard formula fails to gain weight, preterm

formula should be given.


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Special considerations for VLBW

VLBW infants should be fed 10ml/kg/d of enteral feeds, ofpreferably expressed breast milk, from the first day of life, with

remaining fluid needs met by intravenous fluids

If a VLBW infants needs to be given intragastric tube feeding, this

should be given as intermittent bolus feeds, by either oral or nasal

feeding

If a VLBW infant is fed by intragastric tube, feed volumes can be

increased by up to 30ml/kg/d with careful monitoring for feed

intolerance


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List of recommendations: Choice of milk

StrongLow birth weight (LBW) infants, including those with very low birth weight, should be

fed mothers own milk

1.

Strong

situational

LBW infants, including those with very low birth weight, who cannot be fed mother's

own milk should be fed donor human milk (recommendation relevant for settings

where safe and affordable milk banking facilities are available or can be set-up)

2.

Weak

situational


own milk or donor human milk should be fed standard infant formula

(recommendation relevant for resource-limited settings).VLBW infants who cannot be fed mother's own milk or donor human milk should

be given preterm infant formula if they fail to gain weight despite adequate feeding

with standard infant formula.

3.

Weak

situational


own milk should be fed standard infant formula from the time of discharge until 6

months of age (recommendation relevant for resource-limited settings).

4.

Weak

situational

Very Low Birth Weight (VLBW) infants who are fed mothers own milk or donor

human milk should not be routinely given bovine-milk based human milk fortifier.

VLBW infants who fail to gain weight despite adequate breast milk feeding should

be given human milk fortifiers, preferably those that are human-milk based.

5.*

*


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WeakVLBW infants should be given vitamin D supplements at a dose ranging from

400 i.u to 1000 i.u. per day until 6 months of age

6.**

WeakVLBW infants who are fed mothers own milk or donor human milk should be

given daily calcium (120-140 mg/kg/day) and phosphorus (60-90 mg/kg/day)

supplementation during the first months of life

7.**

WeakVLBW infants fed mothers own milk or donor human milk should be given 2-

4 mg/kg/day iron supplementation starting at 2 weeks until 6 months of age

8.**

WeakDaily oral vitamin A supplementation for LBW infants who are fed mother's

own milk is not recommended at the present time because there is not enough

evidence of benefits to support such a recommendation.

9.

WeakRoutine zinc supplementation for LBW infants who are fed mother's own milkis not recommended at the present time because there is not enough evidence of

benefits to support such a recommendation.

10.

List of recommendations: Supplements


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List of recommendations: when and how to feed

StrongLBW infants who are able to breastfeed should be put to the breastas soon as possible after birth when they are clinically stable.11.

Weak

situational

VLBW infants should be given 10ml/kg/day of enteral feeds,

preferably expressed breast milk, starting from the first day of life,

with the remaining fluid requirement met by intravenous fluids

(recommendation relevant for resource-limited settings).

12.*

*

StrongLBW infants should be exclusively breastfed until 6 months of age13.

Strong

situational

LBW infants who need to be fed by an alternative oral feeding

method should be fed by cup (orpalladai which is a cup with a beak)

or spoon.

14.

WeakVLBW infants requiring intragastric tube feeding should be given

bolus intermittent feeds

15.*

*

WeakIn VLBW infants who need to be given intragastric tube feeding, the

intragastric tube may be placed either by oral or nasal route,

depending upon the preferences of health care providers

16.*

*

f


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List of recommendations:

frequency and progression of feeds

Weak

situational

LBW infants who are fully or mostly fed by an alternative oral

feeding method should be fed based on infants hunger cues, except

when the infant remains asleep beyond 3 hours of the last feed

(recommendation relevant to settings with adequate number of health

care providers)

17.

WeakIn VLBW infants who need to be fed by an alternative oral feedingmethod or given intragastric tube feeds, feed volumes can be

increased by up to 30 ml/kg/day with careful monitoring for feed

intolerance

18.**


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Implications for programmes

Policies: update national policies, clinical care standards. Make linkageswith other policies such as on KMC

Health workerskills and competencies: update training materials anddesign ways for on-going education

Commodities: weighing scales, equipment to support milk expression,cups and spoons, supplies for intragastric and intravenous feeding, standard

and preterm formula, micronutrient supplements, milk banking facilities

Community awareness

Service delivery: agree on indicators and monitor quality


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Guidelines updated 2010 - 2013

Care of the newbornimmediately after birth

Newborn resuscitation

Newborn immunization

Postnatal care

Care of the preterm and low

birth weight baby

Management of neonatalsepsis

Management of neonatal

seizures

Management of neonataljaundice

Management of necrotizing

enterocolitis

Care of the HIV-exposed

newborn


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Thank you

WHO: Optimal feeding of

bernadette daelmans, who: feeding low birth weight babies - update on who guidelines

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