1. Newborn
Nutrition
Dr Varsha atul Shah
Department of Neonatology
Singapore General Hospital

2. Newborn nutrition
 Newborns adapt rapidly from a relatively constant
intrauterine supply of nutrients to intermittent feeding
of milk
 Normal, full-term newborns double their birth-weight
by about 5 months of life and triple their birth-weight
by 1 year of life

3. Principles of nutritional support
 From 24/52 to 39/52 gestation fetal growth increases at a
rate of approximately 15 g/kg/D
 Term neonates loss about 5 to 10% of their birth-weight in the first
10 days to 2weeks of life
 Preterm infant loss 10 to 20% of their birth-weight because of their
immature skin and kidneys, regain BW by 7-14 days
Term infants have sufficient glycogen and fat store to meet energy
demands while preterm infants rapidly deplete their limited
endogenous nutrient store and hence become hypoglycaemic and
catabolic

4. How to assess nutrient requirement
in preterm infants?
Use intrauterine growth charts
Use nutrient accretion rate data

5. Nutritional Goal
To achieve normal growth and development

6. Nutrient requirements
Energy (Eintake = E stored + Eexpended + Eexcreted )
 Healthy term babies grow well with intake of 90-120 kcal/kg/D
 125 - 140 kcal/kg/D is the energy required by preterm infants to achieve
a growth rate of 15 g/kg/D
 Conditions that result in increased energy requirements include; CLD,
steroid therapy and infection etc

7. Nutrient requirements
Water
 Infant’s water requirements depend on gestational age,
postnatal age and environmental conditions (phototherapy,
radiant warmer)
 Term infants ingest 140-180 mls/kg/D of fluid
 Preterm infants may require fluid intake of up to 200 ml/kg/
D in the first week of life. Conversely fluid restriction may be
necessary for infants with RDS, CLD CHF, PDA or renal
insufficiency

8. Protein
 Recommended allowance:15-20 % of daily calories
 If energy intake is low, dietary protein cannot be utilized fully for
tissue synthesis hence azotemia can occur
 Term infants : 2.2 g/kg/D can be achieved through
 VLBW infants: 3-3.5 g/kg/D protein supplement
 ELBW infants: 3.6-3.8 g/kg/D eg. Promod

9. Fat
 Recommended daily intake: 50% of daily calories for preterm
infants <1750 grams, 30-40% for term and more mature infants
 Fat intake of > 60% of total calories may lead to ketosis
 EFA must be provided in the diet
 Preterm infants vulnerable to EFA deficiency because of
insufficient fat absorption, increased fat requirement and rapid
brain growth and myelinization and limited adipose reserves
 Fat digestion and absorption is limited in preterm infants because
of bile salt deficiency secondary to reduced synthesis and
ineffective ileal resorption of bile acids

10. Carbohydrates
 Carbohydrate constitute 40-50% of total daily calories
 Almost all the CHO in the human milk and infant formula is
lactose
 Preterm formula contains 50% lactose and 50% glucose
 Intestinal mucosal lactase activity is active by the 28th week.
Glycosidase activity is also active in preterm infants hence these
infants tolerate preterm formula

11. Minerals
Accretion of Ca, Phosphorus, Mg and iron is maximal at the third
trimester of pregnancy. Preterm infants are prone to mineral
deficiency because of this as well as difficulty in estabilizing aedquate
enteral intake of the early weeks of life. The daily recommended
allowance for preterm infants :
 Sodium/Potassium : 2-3 mEq/kg/D
 Ca : 210 mg/kg/D
 Phorphorus : 140 mg/kg/D
 Magnesium : 10 mg/kg/D

12. The quantity of iron in the breast milk is
less compared to infant formula.

13. Vitamins
 Are essential metabolic cofactors
 Toxicity can occur with fat-soluble vitamin because it can be
stored in the tissues
 Toxicity with water-soluble vitamin is unusual because of
high renal clearance and low storage capacity
 Vitamin content in breast milk changes with course of
lactation
 Preterm infants have no reserve for vitamins, hence prone to
deficiency

14. Vitamins
Daily recommended intake:
 Vitamin A : 1500 iu/kg/D
 Vitamin D : 400 iu/kg/D
 Vitamin E : 6-12 iu/kg/D
 Vitamin K : 0.5-1 mg

15. Trace elements
 Are accumulated during the third trimester, hence
preterm infants are prone to deficiency states
 Most preterm formula have adequate amount of trace
elements.

16. Types of enteral feeds
Human milk (provides 67 kcal/100 ml)
Infant formula (provides 67 kcal/100ml)
Preterm formula (provides 81 kcal/100 ml)
Transitional formula
Specialized formula eg. Pregestimil
Anti-reflux formula
Soy formula
Lactose free formula

17. Soy protein-based formula is NOT
indicated in:
baby <1800g

18. Additives to Infant Formula
 Nucleotides
 LCPUFAs
 Taurine
 Iron
 Prebiotics
 Probiotics (bifidobacteria, lactobacillus,
saccharomyces, streptococcus thermophilus)

19. Enteral feeding method
Breast feeding
Bottle feeding
Oral gastric feeding
Naso-gastric feeding
Transpyloric feeding

20. Human milk
 It is the preferred milk for term infant
 When fortified, it is also the nutritionally optimal diet for
preterm infants
 Milk produced by women who delivered prematurely contains
increased amount of protein, sodium and zinc but decreased
amount of Vitamin A. The composition changes to approach
that of term milk after a few weeks
 Human milk contain factors protective of infection –
leucocytes, immunoglobulins, lactoferrin, lysozymes and
complement

21. Human milk
 Human milk has growth and differentiation factors that may
promote intestinal maturation (epidermal growth factor)
 Human milk also contain enzymes eg bile salt-stimulated lipase
 Composition of breast milk varies with mother’s health and
nutritional status
 Protein, sodium, mineral and immunoglobulin contents are highest
in colostrum, intermediate in transitional milk and lowest in the
mature milk
 ‘Hindmilk’ (milk expressed at the end of a feeding) has the highest
fat

22. AAP Recommendations
for Breastfeeding
 Human milk for all infants from 0-6 months
 Breastfeeding to begin within 1 hour of delivery
 Frequent nursing 8-12x/day
 No supplements unless medically indicated
 Start weaning after 4-6 months
 Introduce each food type gradually
 Human milk plus solid food from 6-12 months
 Reduce milk feeds correspondingly

23. Benefits of Breastfeeding
 Infant
 Nutritional composition-less obesity
 Growth and development-improves cognitive function
 Acute illness-reduces diarrhoea,otitis media, pneumonia
 Chronic diseases-reduces atopy, allergies
 Maternal effects
 Body composition and metabolism
 Reduces breast and ovarian cancer
 Reduces perimenopausal osteoporosis and fracture
 Child spacing
 Economic factors
 Psychosocial aspects-skin to skin contact, bonding

24. Contraindications to Breastfeeding
 Miliary TB
 Cancer of breast
 Galactosemia
 Maternal drug abuse
 Maternal medication eg. chemotherapy
 Maternal HIV infection

25. Problems associated with Breastfeeding
 Underfeeding
 Vitamin K low- higher incidence of
hemorrhagic disease of the newborn
 Iron low- need to supplement if still on full
breastfeeding after 6 months
 Prolonged unconjugated hyperbilirubinemia

26. Recognised benefits of breastfeeding include all of
the following EXCEPT:
Lesser risk of haemorrhagic disease of the
newborn.

27. Nursing Feeding Guidelines
 Choice of nutrition for newborn is in accordance
to the parent’s wishes
 Breastfeeding should always be encouraged
 Consult mother before offering formula milk to
infant

28. Feeding of Healthy Newborn

29. Full term healthy baby required
 90 – 120 kcal / kg / day
Intake of fluid targeted at
 140 – 180 ml / kg / day

30. Benefits of breast milk to the baby
 Breast milk and human colostrum are made for babies and is the best first
food
 Easily digested and well absorbed
 Contains essential amino acids
 Rich in polyunsaturated essential fatty acids
 Carbohydrate content in human milk is higher than cow’s milk.
 Better bioavailability of iron and calcium
 Lesser risk of haemorrhagic disease of the newborn
 The quantity of iron in the breast milk is less compared cow’s milk
formula.

31. Problems associated with Breastfeeding
 Underfeeding
 Vitamin K low- higher incidence of
hemorrhagic disease of the newborn
 Iron low- need to supplement if still on full
breastfeeding after 6 months
 Prolonged unconjugated hyperbilirubinemia

32. Contraindications to Breastfeeding
 Miliary TB
 Galactosemia
 Maternal drug abuse
 Maternal medication eg. chemotherapy
 Maternal HIV infection

33. Nursing Feeding Guidelines
 Choice of nutrition for newborn is in accordance
to the parent’s wishes
 Breastfeeding should always be encouraged
 Consult mother before offering formula milk to
infant

34. Benefits of breast milk (contd.)
 Protects against infection
 Prevents allergies
 Better intelligence
 Promotes emotional bonding
 Less heart disease, diabetes and lymphoma

35. Protection against infection
1. WBC in
1. Mother mother’s
infected body make
antibodies
to protect
mother
1. Some WBCs
go to breast
1. Antibody to and make
mother’s infection antibodies
secreted in milk to there
protect baby

36. Benefits to mother
 Helps in involution of uterus
 Delays pregnancy
 Decreases mother’s workload, saves time and
energy
 Lowers risk of breast and ovarian cancer
 Helps regain figure faster

37. Benefits to family
 Contributes to child survival
 Saves money
 Promotes family planning
 Environment friendly

38. Anatomy of breast
Myoepithelial cells
Epithelial cells
ducts
Lactiferous sinus
Nipple
Areola
Montgomery gland
Alveoli
Supporting tissue
and fat

39. Physiology of lactation
 Hormonal secretions in the mother
 Prolactin helps in production of milk
 Oxytocin causes ejection of milk
 Reflexes in the baby – rooting, sucking &
swallowing

40. Prolactin production
Enhanced by
 How early the baby is put to the breast
 How often and how long baby feeds at breast
 How well the baby is attached to the breast

41. Prolactin reflex
Hindered by
 Delayed initiation of breastfeeds
 Prelacteal feeds
 Making the baby wait for feeds
 Dummies, pacifiers, bottles
 Certain medication given to mothers
 Painful breast conditions

42. Prolactin “milk secretion” reflex
Enhancing factors Hindering factors
Emptying
of breast
Bottle feeding,
Sucking
Incorrect positioning,
Painful breast
Expression
of milk
Night
feeds
Prolactin in Sensory impulse
blood from nipple

43. Oxytocin “milk ejection” reflex
Oxytocin contracts
myoepithelial cells
Sensory impulse from
nipple to brain
Baby sucking

44. Oxytocin reflex
Stimulated by Inhibited by
•Thinks lovingly of baby •Worry
•Sound of the baby •Stress
•Sight of the baby •Pain
•CONFIDENCE •Doubt

45. Feeding reflexes in the baby
Rooting reflex
Mother learns to position Sucking reflex
baby
Baby learns to take breast
Swallowing reflex

46. Composition of preterm and full term milk
(g/dl)
Full Term Preterm
Fat 3.5
3.5
1.0 Protein 2.0
7.0 Lactose 6.0

47. How breast milk composition varies
Colostrum Foremilk Hindmilk
Fat
Protein
Lactose

48. For successful breastfeeding
 A willing and motivated mother
 An active and sucking newborn
 A motivator who can bring both mother and newborn together
( health professional or relative )

49. Successful breastfeeding
 Have a written breastfeeding policy
 Motivate mother from antenatal period
 Put to breast within 30 minutes of birth
 Promote rooming -in of mother and baby
 Promote frequent breastfeeding

50. Successful breastfeeding (contd.)
 Don’t give prelacteal feeds
 Don’t use bottle to feed
 Support mother in breastfeeding the baby
 Arrange mother craft classes in health facilities
 Treat breastfeeding problems early
 Exclusive breastfeeding till 6 months
 Addition of home-based semisolids after 6 months

51. Position of baby in relation to the
mother
 The baby’s whole body should face the mother and be close
to her
 The baby’s head and neck should be supported, in a straight
line with his body, to face the breast
 Baby’s abdomen should touch mother’s abdomen, to be as
close as possible to his mother

52. Signs that a baby is attached well at the
breast
 The baby’s mouth is wide open
 The baby’s chin touches the breast
 The baby’s lower lip is curled outward
 Usually the lower portion of the areola is not
visible

53. Signs that a baby is attached well at the breast
lower lip is curled outward baby’s mouth is wide open
chin touches lower portion of
the breast the areola is not
visible

54. Treatment of inverted nipple
Treatment should begin after birth
 Syringe suction method
 Manually stretch and roll the nipple
between the thumb and finger several
times a day
 Teach the mother to grasp the breast
tissue so that areola forms a teat, and
allows the baby to feed

55. Sore nipple
Causes
 Incorrect attachment : Nipple suckling
 Frequent use of soap and water
 Candida (fungal) infection
Treatment
 Continue breastfeeding and correct the
position & attachment
 Apply hind milk to the nipple after a
breastfeed
 Expose the nipple to air between feeds

56. Breast engorgement
Causes
 Delayed and infrequent breastfeeds
 Incorrect latching of the baby
Treatment
 Give analgesics to relieve pain
 Apply warm packs locally
 Gently express milk prior to feed
 Put the baby frequently to the breast

57. Causes of “Not enough milk”
 Not breastfeeding often enough
 Too short or hurried breastfeeding
 Night feeds stopped early
 Poor suckling position
 Poor oxytocin reflex (anxiety, lack of confidence)
 Engorgement or mastitis

58. Management of “Not enough milk”
 Put baby to breast frequently
 Baby to be correctly attached to breast
 Build mother’s confidence
 Use galactogogues judiciously
Adequate weight gain and urine frequency 5-6 times a day are
reliable signs of enough milk intake

59. Expressed breast milk
Indications
 Sick mother, local breast problems
 Preterm / sick baby
 Working mother
Storage
 Clean wide-mouthed container with tight lid
 At room temperature 8-10 hrs
 Refrigerator – 24 hours, Freezer - 20° C – for 3 months

60. Ten steps to successful breastfeeding
Every facility providing maternity services and care for newborn
infants should
 Have a written breastfeeding policy that is routinely communicated
to all health care staff
 Train all health care staff in skills necessary to implement this
policy
 Inform all pregnant women about the benefits and management of
breastfeeding

61. Ten steps to successful breastfeeding
(contd….)
 Help mothers initiate breastfeeding within half hour of
birth
 Show mothers how to breastfeed, and how to maintain
lactation even if they are separated from their infants
 Give no food or drink, unless medically indicated
 Practice rooming-in : allow mothers and infants to remain
together 24 hrs a day

62. Ten steps to successful breastfeeding
(contd….)
 Encourage breastfeeding on demand
 Give no artificial teats or pacifiers (also called
dummies or soothers) to breastfeeding infants
 Foster the establishment of breastfeeding support
groups and refer mothers to them on discharge
from the hospital.

63. Bottle Feeding
Parents can share caring for newborn
Higher incidence of allergic reaction(cow)
Problem with powder concentration
Cow milk not acceptable for infant feeding.
Too much protein,calcium,phosphate, sodium,
potassium

64. Parenteral Nutrition (PN)
Infused via peripheral or central vein
Indication:
When extended period >7days of inability to take enteral feedings