Enteral feeding for neonates

and infants Caitlin Watson

Monash Children’s Hospital

Enteral Feeding for

Neonates & Infants

Caitlin Watson

Paediatric Dietitian

Fluid Nutrition

Fluid Requirements – Paediatrics

Fluid Requirements – Special Care Nursery

Nutritional Requirements – Paediatrics

Age EER (kcal/day) x 4.18 = kJ/day

0-3 months [ (89 x wt (kg) – 100) + 175 kcal ] x 4.18

4-6 months [ (89 x wt (kg) – 100) + 56 kcal ] x 4.18

7-12 months [ (89 x wt (kg) – 100) + 22 kcal ] x 4.18

1-3 years [ (89 x wt (kg) – 100) + 20 kcal ] x 4.18

Age Boys MJ/day Girls MJ/day

3-10 years BMR = (0.095 x Wt) +

2.110

BMR = (0.085 x Wt) + 2.033

10-18 years BMR = (0.074 x Wt) +

2.754

BMR = (0.056 x Wt) + 2.898

Age g/kg/day AI / RDI % Energy

All 0-6 mths 1.43g AI Infants:

7.5-12%

Older

children:

5-15%

All 7-12 mths 1.60g AI

All 1-3 yrs 1.08g RDI

All 4-8 yrs 0.91g RDI

9-13 yrs M: 0.95g F: 0.87g RDI

14-18 yrs M: 0.99g F: 0.77g RDI

Dietary Reference Intakes [IOM 2006]

Schofield Equations [1985]

Normal Protein Requirements [NHMRC 2006]

Age Protein (g/kg/day) Protein (% energy)

0-2 years 2.0-3.0g 9-12%

2-12 years 1.5-2.0g 9-12%

13-18 years 1.5g 9-12%

Increased Protein Requirements [ASPEN 2009]

Nutritional Requirements – Special Care Nursery

Preterm Enteral Requirements

Nutrient ESPGHAN 2009

Preterm <1800g

TSANG 2005

Extremely Low Birthweight

TSANG 2005

Very Low Birthweight

Day 0 Transition Growing Day 0 Transition Growing

Energy kJ/kg 460 – 565 210 - 250 375 - 420 545 - 630 210 - 250 315 - 375 460 - 545

Fluids ml/kg - 90 - 120 90 - 140 160 - 220 70 - 90 90 – 140 135 - 190

Protein g/kg

ELBW 4.0 – 4.5

2.0 3.5 3.8 – 4.4 2 3.5 3.4 – 4.2 VLBW 3.5 – 4.0

CHO g/kg 11.6 – 13.2 7 8 – 15 9 – 20 7 5 – 12 7 - 17

Fat g/kg 4.8 – 6.6 1 1 – 3 6.8 – 8.4 1 1 – 3 5.3 – 7.2

Nutritional Requirements – Special Care Nursery

Nutrient ESPGHAN 2009

Preterm <1800g

TSANG 2005

Extremely Low Birthweight

TSANG 2005

Very Low Birthweight

Day 0 Transition Growing Day 0 Transition Growing

Energy kJ/kg 460 - 500 165 - 210 315 - 355 440 - 480 165 – 210 250 - 290 375 - 420

Fluids ml/kg - 90 -120 90 – 140 140 – 180 70 – 90 90 – 140 120 - 160

Protein g/kg 1.5 – 4.0 2 3.5 3.5 – 4.0 2.0 3.5 3.2 – 3.8

CHO g/kg <18 7 8 – 15 13 – 17 7 5 – 12 9.7 - 15

Fat g/kg 0.25 – 4 1 1 – 3 3 – 4 1 1 – 3 3 – 4

Preterm Intravenous Nutrition Requirements

Why is nutrition important?

Adequate nutrition is important for;

• Optimising growth and development

• Preventing malnutrition

Increased length of hospital stay

Increased complications including infection risk

Reduced quality of life

Over nutrition may be associated with;

• Poor tolerance of feeding regimen

• Difficulties weaning from mechanical ventilator support in ICU setting related to ↑ CO2

production

Case Study 1

Scenario

• 4 month old girl

• Admitted with bronchiolitis

• General paediatric team has requested fluids at 2/3 maintenance

• Weight 6.4kg

Fluid Requirements

• Full maintenance = 4mls/kg/day for first 10kg

= 26mls/hr (624mls/day)

• 2/3 maintenance = 17mls/hr (408mls/day)

Case Study 1

Nutritional Requirements

• Energy = 2197kJ/day (343kJ/kg)

• Protein = 9.2g/day (1.43g/kg/day)

Feeding Plan

• Expressed Breast Milk (EBM) at 17mls/hr x 24 hours via nasogastric tube (NGT)

• Provides 187kJ/kg/day (54% EER) and 0.7g/kg/day protein (49% EPR)

Practice Points

• Inadequate in both energy and protein

• If ongoing ↑ WOB and prolonged admission infants can quickly accumulate nutrient deficit

Increased risk of malnutrition

• Consider dietitian referral for additional calories

Fortification of EBM with infant formula (start 2.5% and ↑ to 6% depending on tolerance)

Case Study 1

Feeding Plan Energy Protein

kJ/kg % EER g/kg % EPR

EBM at 17mls/hr x 24 hours

(293kJ/100ml)

187 54 0.7 49

EBM + 2.5% infant formula

(350kJ/100ml)

223 65 0.8 57

EBM + 6% infant formula (420kJ/100ml) 267 78 1.1 77

Case Study 2

Scenario

• 7 day old baby girl

• Admit premature at 35 + 1/40

• Birth weight 2106g (50th centile CA)

• Large VSD with associated increased work of breathing

• Not yet regained birth weight

Fluid Requirements

• 120mls/kg/day as per cardiology

Case Study 2

Nutritional Requirements

• Energy = NRV x 1.2 = 515kJ/kg/day

• Protein = NRV x 1.2 = 1.7g/kg/day (3.6g/day)

Feeding Plan

• S26 Gold Newborn 32mls every 3 hours x 8 via NGT

• Provides 336kJ/kg (65% EER), 1.5g/kg protein (88% EPR)

Practice Points

• Inadequate in energy and protein

• Growth very important for cardiac surgery

• Preterm infants have limited nutrient stores

• Consider dietitian referral for additional calories

Concentrate infant formula to 350kJ/100ml then 420kJ/100ml if tolerating well

Case Study 2

Feeding Plan Energy Protein

kJ/kg % EER g/kg % EPR

S26 (280kJ/100ml)

32mls x 3/24 x 8

336 65 1.5 88

S26 (350kJ/100ml)

32mls x 3/24 x 8

420 82 1.8 105

S26 (420kJ/100ml)

32mls x 3/24 x 8

504 98 2.1 127

Case Study 3

Scenario

• 14 year old boy

• Admitted post appendectomy – Day 4

• Poor oral intake secondary to post-op complications

• Surgical team wanting NGT feeds

• Weight – 63kg (75 – 90th centile)

Fluid Requirements

• Full maintenance = 40mL + 20mL + 43mL

= 103mls/hr x 24 hours (2472mls/day)

Case Study 3

Nutritional Requirements

• Energy = 8.9MJ/day

• Protein = 63g/day

Feeding Plan

• Nutrison 1.0 at 100mls/hr x 24 hours

• Provides 10.4MJ/day (117% EER) and 96g/day protein (152% EPR)

Practice Points

• Over nourished

• Risk of poor tolerance with large volumes

• Consider dietitian referral for feeding plan

Supply appropriate nutrition

Additional fluid as water flushes in consultation with medical team

Case Study 3

Feeding Plan Water flushes Fluid Energy Protein

MJ/d % EER g/d % EPR

Nutrison 1.0

100mls/hr x 24 hours

10mls 4/24ly 2460mL 10.4 117 96 152

Nutrison 1.0

90mls/hr x 24 hours

50mls 4/24ly 2460mL 9.0 101 86 137

Additional considerations

• Fluids from other sources (IV infusions, medications, water flushes)

• Oral intake of food & fluids

• Pre-exiting malnutrition or growth failure

• Presence of comorbidities

Osmolality

• Osmolality is the number of molecules and ions per kilogram of a solution

• Fortification & concentrating feeds increases the osmolality of feeds

• Important consideration in feed tolerance

• Hyperosmolar feeds have an osmolality greater than that of bodily fluids

→ Creates an osmolality gradient attracting water from the body into the lumen of the GI tract

→ Drive diarrhoea, nausea & vomiting

→ Potential to lead to hypernatremia (serum sodium >146mmol/L) from water loss in excess of sodium

Osmolality

Documentation / identification

• Vomiting → accurate documentation of frequency, volume & colour

• Stool → accurate documentation of frequency, consistency, volume & bottom

• Weight

Nutritional management

• Stop all feed fortifications (i.e. higher concentration, additional formula fortification/polyjoule/calogen/liquigen)

Summary

• Be aware of patients at risk of undernutrition

Fluid restriction

Long admission

Increased nutrient requirements

Pre-existing growth failure or malnutrition

Co-morbidities

• Avoid over feeding

• Avoid hyperosmolar feeds for patients with vomiting or diarrhoea

• Target fluid ≠ target nutrition

Questions