Nicola Pritchard
Oct 2020

 Immediate risk of hypoglycaemia
 High protein requirement
◦ Rapid protein deficiency if on dextrose
 Known long-term adverse effects of poor nutrition
◦ Poor growth
◦ Poorer neuro developmental outcome
◦ Reduced tolerance to infection
 Poor neutrophil function
 Reduced Ig A response

 High energy expenditure
 Respiration
 Sepsis
 Heat generation
 Growth
 Switch from continuous to intermittent supply
 Variable oxygenation
 Increased use of anaerobic metabolism
 Gut immaturity limiting enteral tolerance

We are aiming for Intra-Utero Growth Rates
 ENERGY
 110-130 kcalories/kg/day
 AMINO ACIDS
 At least 2.5g/kg/day ideally >4g/kg/day
 FATS
 3-4g/kg/day
 Adequate vitamins/iron/phosphate

 10% Dextrose
 150mls/kg/day = 51kcal/kg/day
 <40% of a infants daily calorie requirement
Imagine being on a
800kcal/day diet with
no vitamins, iron
protein or fats
when you are
unwell and trying
to gain weight and grow…

 Requirements 3.5-4.5g/kg day
 On10% dextrose
Loose up to 1g protein/kg/day
 Can be seen
◦ Poor weight gain
◦ Poor head growth
◦ Low urea levels
◦ Low albumin
◦ Peripheral oedema

Term
Breast
milk
Preterm
Breast
milk
Fortified
Breast
milk
Preterm
Formula
NEDPF Term
formula
High
Energy
Term
Formula
150mls/kg/day
Calories 88% 75% 75% 88% 80% 88% 90%
Protein 70% 90% 57% 88% 68% 88% 75%
165mls/kg/day
Calories 92% 82% 97% 97% 88% 82% 120%
Protein 79% 100% 97% 97% 75% 63% 82%
180ml/kg/day
Calories 100% 90% 100% 100% 100% 70% 68%
Protein 86% 100% 100% 100% 81% 69% 90%

Breast feeding
unless
contraindicated

Why Breast feed?
 Immediate Benefits
 Nutritionally complete
 Hormones
 Growth factors
 Nucleotides
 Enzymes eg Lactase
 LC PUFA
 Live cells

Breast feeding -Longterm
 Long term Benefits
 Small effect BP (2mmHg)
 22% reduction in adult obesity
 Reduced cholesterol
 19-27% reduction IDDM
 39% reduction NIDDM
 36% reduction SIDS
 4.9 points IQ

Exclusive Breast Feeding UK
Infant Feeding Survey 2010
 81% Initiation rates
 46% exclusive at 1 week (69% mixed feeding)
 23% exclusive at six weeks (55% mixed feeding)
 1% at five months (34% mixed feeding)
 Reduction
 Second baby
 Socioeconomic
 Education
 Age of mother
ONS 2010(published 2012)

Economic Model
Paediatric Savings
IF : 45% exclusively breastfeeding at 4 months
and 75% of babies breastfed at NNU discharge
 3,285 less GI infection hospital admissions
10,637 fewer GP visitations
 £3.6 million annual savings
 5,916 less LRTI infection-related hospital
22,248 fewer GP consultations
 £6.7 million annual savings
 21,045 fewer AOM-related GP visits
 £750,000 annual savings

NEC Cost Savings
361 less cases
Increased Breast
Feeding
Potential savings
 Discharged on breast milk in
NNU increase 35% to 50%
 Increase to 75% at discharge
 Any breastmilk increase from
the current 35% to 100%
 Decreased NEC = 2.3 million/yr
 Decreased NEC = 6million/yr
 Decreased NEC = 10million/yr

UNICEF Baby Friendly
 Breast feeding Policy
 Education and Advice
 Early first feed
 Skin-to-skin
 Privacy
 Adequate rest, food and drink
 Support for expressing
 Formula milk should not be given to breastfed
babies unless medically indicated.
 Avoid dummies

When should a new mother
be advised against breast-
feeding?
 Diagnosis of galactosaemia
 Pregestamil or soya formula
 +/- HIV
 +/- Hepatitis B
 IMPORTANT WHO Advice
 All infants must be managed individually; insufficient
growth or other adverse outcomes not to be ignored

Mastitis
 Women should be offered assistance & advice
 Positioning and attachment
 Continue breastfeeding and/or hand
expression
 Analgesia compatible with breastfeeding
 Increase fluid intake.

Advantages of
Pre-term Maternal Milk
 Higher macrophages and Ig A
 More energy, lipid, LC PUFA, Protein, iron and
phosphate and vitamins
 Skin to skin – Maternal Ig A transfer

 Early expression < 6 hours and definitely < 24 hours
 Regular expression ( 8x in 24hrs)
 Mum and baby together
 Consider from 32 weeks if well (be led by feeding cues not gestation) alongside
NGT to maintain nutrition
 Non-nutritive sucking when ngt feeding
 Skin to skin kangaroo care daily if possible (with good thermal care)
 Frequent small feeds
 Monitor growth
 Mixed evidence re cup/bottle/ngt and BF at discharge
 However mum needs to be with baby for him or her to learn to breast feed
Focus on:
Ensuring maximum mum and baby time together with adequate good quality
breast feeding support
Supporting Breast feeding
Preterm Infants

Milk Banks
Collection of donor “drip milk” from term mothers
 Positive
 79% reduction in NEC
 But
 NOT preterm milk
 Often fore rather than hind milk
 Lower protein, sodium zinc and copper
 Loss of “live” immune protection
 Viral infection risk

Preterm Formula
 Standard preterm formula
 Usually until 2-2.5kg
 More calories and protein than breast milk
 Amino acids similar to breast milk
 LC PUFA
 Vit D
 Prebiotics

NEC Risk
Formula vs EBM
 Exclusively formula fed
 6 x rate of NEC
 Mixed BF and formula
 3 x rate of NEC
 Breast Milk
 Matures GI tract
 Alters bowel flora
 Source of growth factors
 Matures and provides immune factors

How to feed the Preterm Infant
 EARLY
 Start iv nutrition Day 1 (<30 weeks < 1500g)
 Start enteral feed by day 1-2 unless unstable or high NEC
risk
 Ventilation or UAC is not contra-indication
 EBM is best
 Consider waiting or start preterm formula?
 Trophic /Minimal enteral feeds
 1ml/kg/hour 0R 20mls/kg/day
 Early start, slow progression
 Increase 10-30mls/kg/day

TPN
 Aim:
 90% of those infants < 30 weeks and < 1500g
receive PN within 48 hours

Why Trophic Feeding
Non-nutritional <25% of total feed requirement
(10-20mls/kg)
 Theoretical Benefits
 maturation of intestinal digestive, absorptive, motor
 stimulates gastro intestinal immune function
 improves cholestasis
 prevention of intestinal bacterial overgrowth and
bacterial translocation (pre and probiotics)
 prevents luminal atrophy and increase mucosal
mass(growth factors)

Why Trophic Feeding
 Cochrane REVIEW
 Total hospital stay
 days to achieve full enteral nutrition
 No days feeds withheld due to intolerance
 Normalises hormonal function
 switches off insulin production
 Some evidence to support reduced infection rates
Risks
 NEC is not increased by feeds with or without UAC

Other Preterm Feeding Issues
 Orogastric vs Nasogastric (Obligate nose breathers)
 Transpyloric (Cochrane 2008 no difference)
 No statistically significant differences NEC, perforation or aspiration
pneumonia
 Continuous vs Bolus (Cochrane Nov 2011 Insuff evidence)
 Demand vs Timed (Cochrane 2008 Insuff evidence)
 Non-nutritive sucking
 Developmental progress
 Reflux ???......(Gaviscon)

Pre-term:
Post Discharge Formula
 Most pre term infants discharged small for
gestation
 Rapid growth – high calorific requirement
 Can consume 300mls/kg/day normal formula
 Not an issue if tolerated
 Increased risk of long-term growth failure
 Better catch up
 Theoretically better brain growth – but not proven

Post discharge Formula
ESPHGAN position statement May 2006
 If appropriate wt for gestn: Breast or term
formula
 Post discharge formula if not
 How long?
 At least until CGA 40 weeks
 Possibly until CGA 52 weeks
 EG Nutriprem 2
 Halway between preterm and term formula
 NB No evidence of difference in growth in Cochrane review 2007

Always respond to feeding cues where possible
Consider FULLY RESPONSIVE if > 34 weeks
Remember that “late pre terms” 34-36 weeks
 May not fully empty the breast
 Sleepiness or fatigue,
 Difficulty maintaining a latch because their oro-buccal coordination and
swallowing mechanisms are not fully matured
 Encourage post feed expression to encourage milk production
 Monitor weight and health (pre and post discharge)
AND
 Birth> 1500g and > 30 weeks
 Tolerating 3 hourly feeds
 At least 4 sucking feeds
 Waking and showing feeding cues
 No weight gain concern
 No active medical problems
 Blood sugar stable at 6 hours between feeds
Responsive Feeding

For more vulnerable preterm infants
WHY?
Do not demonstrate predictable demand-feeding behaviours until
close to term
WHO?
 Not yet fully on all sucking feeds
 Feeding cues but <4 sucking feeds
 Born with risk factors for growth
 Birth < 1500g or < 30 weeks gestation
 Slow or not gaining weight on full responsive feeding
 High nutritional requirements
 Eg Chronic lung disease, cardiac disease,
Modified Responsive

What the Mum’s want to know

Pre and Probiotics
 Breast fed infants colonised within 12-24 hrs
 Bifidobacteria and Lactobacilli
 Fermentation of carbohydrates
 Causes fall in colonic pH
 Favours growth of non-pathogenic species
 Improved mucosal barrier

Pre and Probiotics
Prebiotics
Currently Added
Probiotic
Some evidence
 Non-digestable
oligosaccharides
 Mimics breast milk
 Promotes bowel flora
similar to breast fed
infants
 Introduced recently into
preterm formula
 The Preterm Prebiotic Study Imperial College
Neena Modi, ?Improved feed intolerance
 Live microbial food
supplement
 Colonise GI tract
 Synthesise
 Short chain fatty acids
 Amino acids
 ?Infection risk
 ?How much
 ?Regulation
 ?Which organism

Prebiotics in Formula
 Stool flora similar to breast fed infants
 ?Reduction in diarrhoeal episodes
 Prebiotics for prevention of allergic disease or
food reactions
 Insufficient evidence COCHRANE 2008

Probiotics & Preterm Infants
 Reduces the occurrence of NEC (stage 2) and death <1500g
 No evidence of significant reduction of nosocomial sepsis
 However most at risk infants <1000g
 Insufficient evidencce
 Risk of bacteraemia in smaller infants?
 Cochrane 2008 review of 1425 no cases of sepsis
 Several case reports septicaemia with Lactobacillus
Cochrane 2008

PIPS study 2016
 A multi-centre, double blind, placebo-controlled
randomised trial of probiotic administration in
 Preterm infants (<31 weeks)
 Single probiotic strain Bifidobacterium breve
• Theory
Reduce translocation of bacteria from GI tract
Therefore reduce rates of complications such as
NEC
• Outcomes – no difference
Episodes of NEC
Late onset sepsis
Death
• HOWEVER Meta analysis have consistently shown
NEC reduction

When to Start Sucking feeds?
 Liase with Nurses
 What should you consider?
 Respiratory stability
 Temperature stability
 Weight gain
 Post gestational age
 Time between feeds
 Safe swallow?
 How can sucking/breast feeding be encouraged?
 Non nutrative sucking
 Kangaroo care
 Rest periods

Normal Development
 Post gestational Age
 11 weeks Sucking movements
 15 weeks Swallowing movements
 28 weeks Sucking bursts
but uncoordinated
 32-34 weeks Suck swallow respiratory
coordination begins. Breast
feeding can be established
 37 weeks Mature suck swallow

 Good evidence any nutritional guideline
improves growth outcomes
 Joint collaboration
◦ Consultant
◦ Senior Nursing Staff
◦ ANNP
◦ Junior doctor
◦ Southampton nutrition guidelines
◦ SIFT results

5%
15%
35%
23%
12%
7.5%
2.5%
42%
33%
21%
5%
2%
0 0
0
2
4
6
8
10
12
14
16
18
20
0 centiles 1 centile 2 centiles 3 centiles 4 centiles 5 centiles 6 centiles
2010 2015

5%
18%
61%
8% 8%
16%
56%
20%
8%
0%
49%
12%
37%
2%
0%
0%
10%
20%
30%
40%
50%
60%
70%
Breastfed Breastfed + formula Formula Hydrolysed formula Unknown
2010 2013 2015
< 32 weeks
Receiving breast milk on discharge
2015 60%
2017 72.6%
2018 74% ( National 59.6%)
2019 64%

High
• Preterm <28 weeks OR ELBW < 1000g
• Severe IUGR (weight < 2nd centile with AREDF) <35 weeks
• Post NEC or GI abnormality
• Hypotensive/unstable ventilated neonates
Medium
• Moderate IUGR (weight < 9th AND AREDF) <35 weeks
• Baby on inotropes or indomethacin/ibuprofen
Low
• Preterm 28-36+6 weeks, otherwise well
• VLBW 1000 -1500g
• AREDF / IUGR >35 weeks
• Term Infants >37 weeks

High
• Breast Milk (Nutriprem 1 but consider waiting for EBM)
• Start Trophic feeds when stable: 10-20mls/kg/day hourly
• Increase by 10mls/kg every 12 hours
• Continue until 180mls/kg unless feed intolerance
• Move to 2-4 hourly as tolerated
Medium
• Breast milk ( Nutriprem 1)
• Day 1: 20mls/kg/day hourly feeds
• Increase by 15mls/kg every 12 hours
• Continue until 150 -180mls/kg unless feed intolerance
• Move to 2-4 hourly as tolerated
Low
• Breast milk (Nutriprem 1 or term formula if >36 weeks)
• Start at 2-4 hourly feeds
• Increase by 30mls/kg every 24 hours
• Continue until 150 -180mls/kg unless feed intolerance

Slower increase 18mls/kg/day
No increased line infection
TPN 2 days longer
Faster increase 30mls/kg/day
No increased NEC
 Advantage
◦ reduced NEC risk
 Disadvantage:
◦ increased duration of TPN
◦ line associated sepsis
◦ TPN related liver disease
◦ ?Longer hospital stay
 Advantage
◦ decreased duration of TPN
◦ Decreased line associated
sepsis and liver disease
◦ ?cheaper
 Disadvantage
◦ increased NEC risk

 2004 Cochrane review Kuschel and Harding
◦ 13 randomised controlled trials
◦ Outcomes for preterm infants fed with fortified EBM
◦ Use of fortifier was associated with
 Improved weight gain
 Improved linear growth
 Improved head growth
◦ No significant increase in adverse outcomes, including NEC
◦ However studies did not include sicker infants

 At risk
◦ < 1kg (ELBW)
◦ < 28 weeks
◦ Previous GI surgery or NEC
 Fortified milk
 Symptoms of abdominal obstruction
 Milk curd blocking ileum

<1.5 kg
AND < 32 weeks
•Breast milk
•Consider BMF once
>150mls/kg
•Aim for minimum
165mls/kg
•Further increase to
180mls/kg if poor
weight gain
>1.5kg
AND < 32 weeks
•Breast Milk
•Increase to
180mls/kg
•Consider BMF if
poor growth or
tolerance
>2kg OR > 34
weeks
•Breast milk
•Increase to
165mls/kg
•Increase to
180mls/kg of poor
growth
EBM with fortifier is equivalent to Preterm formula (Nutriprem )
therefore 165mls/kg of preterm formula may be adequate for growth

 Step down from preterm formula
 Available on prescription after discharge
 For infants on a preterm formula or a
supplement for breast fed infants

Who? When
Consider for formula fed
 Infants <34 weeks
AND
 Birth weight < 1.8kg
AND
 No growth concerns
◦ Maintaining centile line on
a Nutriprem 1
 >1.8kg
OR
 >36 weeks
OR
 1 week (min 48hrs)
prior to discharge

 Continue preterm formula (Nutriprem1)
 ?Increase volume
 Medical review for reasons for poor growth
 If pre discharge needs nutritional plan for
going home

 Post term with good growth
 Breast feeding or EBM with good growth
 At clinic follow up after discharge
 Consider if
◦ Corrected gestational age > 6 months
◦ Post weaning
◦ Growth on birth centile feeding good volumes

All breast milk fed preterm infants < 34 weeks
require
 IRON : Sytron 1ml once daily
◦ From day 28 until age 1 year
 VITAMINS: Abidec 0.6mls once daily
◦ Once on full milk feeds
◦ From day 7 until age 2 years
◦ To ensure adequate vitamin D
◦ (Remember term breast fed infants need 0.3mls OD)

But not too well….
Everyone wants the babies to feed and grow well!
More than one way to
achieve this

Thank
you

 Options
◦ Increase volume 165mls/kg per day minimum
◦ Check for other reasons
◦ Fortify?
 Evidence for fortifying milk
◦ Short term improved weight gain
◦ No evidence for increase in NEC
◦ ? Osmolality

 Max volumes of EBM tolerated first
 Only use after first 2 weeks
 Fortify milk as close as possible to the feed
time.
 Assess closely for feed intolerance
 Change only one thing at a time
 Do not use if strong FHx of atopy
 Don’t add to preterm or term formula

 What is feed intolerance
◦ Aspirates
 >2mls/kg/hour
 >50% of last 3 hours of feeds
 Increased from previous pattern
◦ Vomiting
◦ Abdominal distention
◦ Abdominal tenderness
◦ Abnormal stools
◦ Systemic signs eg apnoea/lethargy/bradycardia

 Significance/Severity
 CAUSE!
◦ Sepsis
◦ NEC
◦ PDA/Cardiac Failure
◦ Respiratory Deterioration
◦ GORD
◦ “CPAP” Belly
◦ Slow transit and BNO
◦ Immature gut
◦ Milk protein intolerance

 Investigate and treat - consider
◦ Septic screen
◦ Stool culture
◦ X-ray
◦ Contrast Study
◦ FOB (Interpret with caution)

 Treat cause if known
 Stop feeds –
◦ WITH PLAN
 Omit one feed
 Restart feeds at lower volume and more frequent
 Start antibiotics restart feeds within 12 hours if stable
 Stabilise respiratory eg intubate and restart feeds within 4 hours
 NBM Start NEC regime
 Consider PN via CVL
 Consider suppository
 Consider Milk change

 Term Infant of an IDDM Day 3. Well
◦ Requiring 120mls/kg 20% dextrose to maintain
blood sugar
◦ Mum wants to breast feed as baby appears hungry?
 Why will milk feeds be a problem?
◦ Infant hyperinsulinaemic
◦ Feeds stimulate insulin secretion

 No oral feeds until at least 2 normal blood sugars on 10%
dextrose
 May need PN?? (should already have CVL)
 Hourly feeds until stable BMs
 Progress to full volume feeds
 Only increase time between feeds once off dextrose
 May need to only increase time between feeds 24 hourly
 Won’t be able to effectively breast feed until on 2-3 hourly
feeds
 Needs lots of parental counselling
 Often “stuck for days/weeks”

 Why?
◦ Sepsis
◦ NEC again??
◦ Perforation
◦ Slow transit
◦ Malabsorption/lactose intolerance
◦ Cows milk protein intolerance
◦ Stricture
◦ Small bowel overgrowth
◦ Post NEC surgery
 Short bowel

 Exclude sepsis
 Xray
 Contrast study
 Stool reducing substances (if diarrhoea)
 FOB
 Surgical Opinion
◦ Check op notes for length bowel affected and/or
removed

 Treat sepsis
 Surgical review
 Restart feeds lower volume and/or more frequent
 Suppository
 Slow regrade 10mls/kg/day is asymptomatic
 Consider alternative milks
◦ EBM only
◦ Lactose free
◦ Partially or fully Hydrolysed (with high MCT content)
◦ Elemental
◦ Use PN to bridge gap

◦ Maximise anti- failure treatment
◦ Adequate sodium?
◦ Increase volume cautiously
◦ Nasogastric feeds
◦ Higher calorie feeds
◦ May have bowel wall oedema and malabsorption

 Concentrating formula? - caution
◦ Powder first water second
◦ 0.8 kcal/mL
 SMA High Energy (0.9kcal/ml)
 Infatrini (1kcal/ml)
 Similac (1kcal/ml)
 Duocal – carbohydrate and fat
 Maxijul- carbohydrate

Breast Milk !!!
Understanding of feed increases and suspensions
NEC
Formula Options
Common nutritional questions

Thank
you