4b- dr. adamkin - post discharge stanford newyork · • resp complications prime morbidities of lp...
TRANSCRIPT
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High-Energy and Protein Diet Increases Brain and Corticospinal Tract Growth in Term and Preterm
Infants After Perinatal Brain Injury Dabydeen etal Ped Jan 2008
• Prospective double blind, randomized, 2 stage group sequential study
• Controlled for gestation, gender, brain lesion ≤ 32 or > 32 weeks • Neonatal encephalopathy or white matter disease
• 120% recommended average intake vs 100% intake
• Study initiated at term and continued for 12 monthsPrimary outcome: OFCOther measures: • growth axonal diameters in corticospinal tract
(transcranial magnetic stimulation)• weight gain• length
ResultsDabydeen etal Ped Jan 2008
• Study terminated after 16 patients (because > 1 SD OFC* at 12 months) with Hi Energy and Protein Intake
• Axonal diameters in corticospinal tract, length/weight also significantly increased
*additional nutrition given early in development to preterm infants which increased OFC >1SD reduced incidence of CP at age 7 – 8 years by ninefold (Lucas etal Lancet 1990, Lucas et al BMJ 1998)
012345678
3 6 9 12
mo. corrected age
axon
al d
iam
eter no consent
groupaverageenergy grouphigh energygroup
.26 .06 .017 .001
µm
normal subjects
RESULTSAXONAL DIAMETER IN THE CORTICOSPINAL PROJECTION TO THE MOTOR
NEURONS OF THE BICEPS
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High Energy and Protein Diet Conclusions
• Infants with significant perinatal/brain damage have increased nutritional requirements in the first postnatal year
• Decreased postnatal brain growth may exacerbate their impairment
• Waiting for measures of cognitive ability in these patients to determine if strategy has lasting benefit.
CATCH-UP GROWTH and METABOLIC SYNDROME RISK
ADULT Onset Disorders
Hypertension Diabetes
Obesity
Heart Disease
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Infant Weight Gain and School-age BP and Cognition in Former Preterm Infants
N=911 IHDP 8 centers, Boston born 1980’s Median BW 1.87, GA 34 weeks
27% <32 weeks (SGA – 37%)
Wts – at term, 4, 12mos CA. Primary predictor wt gain term – 1yrBP x 3 at 6.5 years
WISC III at 8 years (normal ≥ 85)
Linear regression “infant weight gain” as the 12 month weight z scores adjusted for the term weight z score (using CDC curves)
Represents ∆ from term to 12 mos
Belfort et al Ped June 2010
ResultsWT BP @6.5y WISC III @8yrs
±SD ±SD Z score median @ 12 mo -0.7
Interquartile range (-1.5-0.0) 104.2 918.4 18
Adjusting for gender, GA, race, maternal education, income, age, mother’s IQ, smoking
For each Z score additional weight gain from term to 12 monthsSystolic BP 0.7mm Hg higherWISC III 1.9 points higher
Belfort et al Ped June 2010
Infant Weight Gain and School Age BP/Cognition in Former Preterm
Post Discharge Implications• Preterm Infants across the full range demonstrated
better cognitive outcomes with faster weight gains not just ELBW infants. Late Preterm?
• From 4-12 mos better HC growth was associated with better cognition (~3pts)
• Increased weight and length had independent effects on IQ
• Caught up by age 8
Modest neurodevelopmental advantages of more rapid weight gain first year, especially first 4 mos (wt,L) of life and only small BP related effects (only >32weeks)
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Treatment Recommendations
• Formula-fed preterm infants should be fed nutrient-enriched discharge formula in the first year of life to replenish nutrient deficits and promote growth
– Duration of use varies depending on
• Clinical history
• Degree of postnatal growth failure
• Bone health
• Proportional growth
• Growth in breast-fed premature infants should be closely monitored
– Employ individual feeding strategies as needed to optimize proportional growth
Post-discharge Nutrition Choices
with Human Milk
• Human milk
– Human milk alone
– Fortified human milk with post-discharge powder
– Supplemental bottles of post-discharge formula
– Liquid fortifier
Reasons for Fortification
1) Postnatal Growth Failure
2) Metabolic Bone Disease
52
CA = corrected age.Aimone A, et al. J Pediatr Gastroenterol Nutr. 2009;49:456-466.
Fortified human milk (n=19)
Human milk (n=20)
Study Day 1
0
2000
4000
6000
8000
10000
12000
4 mo CA 6 mo CA 12 mo CA Study Day 1 4 mo CA 6 mo CA 12 mo CA
0
50
60
70
80
90
2635 ± 611
2723 ± 359
5998 ± 1250
6642 ± 678
6800 ± 1299
7564 ± 845
9835 ± 1152
8648 ± 1438
45.0 ± 3.3
46.3 ± 1.8
63.6 ± 2.6
60.9 ± 3.664.1 ± 3.6
67.4 ± 2.5
76.5 ± 2.9
72.7 ± 4.2
Group x time P=0.0035 Group x time P=0.0059
Leng
th (c
m)
Wei
ght (
g)
Weight Length
Fortification of Human Milk Post Dischargen = 19 half of feeds fortified for three monthsn = 20 human milk alone out to 12 mos CA
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Fortified Human Milk Improves Head Circumference in the First Year of Life (<1250g)
4 mo CA30
35
40
45
50
6 mo CA 12 mo CAStudy Day 1
Hea
d C
ircum
fere
nce
(cm
)
Group x time P=0.0149
33.5 + 1.4
34.1 ± 1.2
42.6 ± 0.9
41.2 ± 1.8
44.5 ± 0.9
42.8 ± 1.6
46.0 ± 1.4
47.0 ± 1.1
Human milk Fortified human milk
Aimone A, et al. J Pediatr Gastroenterol Nutr. 2009;49:456-466.
Head Circumference (cm)
Nutrition Management Options
for Human-Milk-Fed VLBW
Infants at NICU Discharge
Groh-Wargo and M Thompson ICAN 2014
No longer pumping with Mother – Baby Situation
no stored EBM Still pumping with significant stored EBM
No longer
Baby w/risk factors Baby w/o risk pumping but w/ Still pumping
factors significant stored with little or no
EBM stored EBM Mother interested Mother not interested
PTDF in feeding the baby in feeding the baby at
PF24; transition to Baby w/o risk at the breast the breast
PDF at 3.5 kg Baby w/ risk factors
factors
FHM for several HM alternated
weeks with tran- with PDF with Mother inter- Mother not Baby w/ risk Baby w/o Baby w/ risk Baby w/o
sition to PDF when transition to ested in feed- interested in factors risk factors factors risk factors
stores of EBM PDF when stores ing the baby feeding the
exhausted of EBM at the breast baby at the
exhausted breast
Baby w/ risk Baby w/o risk Baby w/ risk Baby w/o risk
factors factors factors factors
60-90ml/day
PFHP24 from bottle PDF from bottle PFHP24 alt with EBM PDF alt with EBM FHM from a bottle PF30 “booster” FHM from a bottle 60-90ml/day PF30
atl with direct BF; alt with direct BF; from bottle; transition from bottle; cont. For ≥ 1/2 of the (divided) with for≥ ½ of the feed- “booster” (divided)
transition to PDF at lactation support to PDF at 3.5kg; cont pumping 8-10 X the feedings until HM until 3.5kg ings until 3.5 kg then with HM until 3.5
3.5 kg; lactation sup- to get baby to the pumping 8-10 X/day /day to improve 3.5 kg then BF; PDF then plain HM; HM alt with PDF; kg then plain HM;
port to get baby to breast; continue to improve supply supply in 3:1 ratio; lacta- lactation sup- cont. pumping continue pump-
the breast; continue pumping tion support to port to move ing
pumping move from pumping from pumping
to breastfeeding to breastfeeding
FHM for several
weeks with
transition to
PDF when
stores of EBM
exhausted
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Feeding Type
(kcal/oz)
Volume (ml) Protein (g) Calcium (mg) Phosphorus
(mg)
Zn (µg)
HM (20) 180 1.6 40 23 360
Enriched HM (24) 150 1.9 55 32 513
HM alternated with PDF 170 2.6 91 52 910
HM alternated with FHM
(average 22)
165 2.6 122 69 1050
HM alternated with PFHP24
(average 22)
165 3 132 70 1129
HM plus 60 – 120mL PF30
“booster”
165 2.1 – 2.8 84 – 132 48 – 74 726 - 1123
FHM (24) 150 3.4 188 106 1610
Nutritional
recommendations
135 – 200 2.5 – 3.1 70 – 140 35 – 90 1100 - 2000
Comparison of Intake for Selected Nutrients (per kg/d) from Human-Milk Based Feeding Options
for VLBW at NICU Discharge: 2 kg Infant Receiving ~120kcal/kg/day
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•
Symmetrical EUGR 1) PTF 24 calstrategy for 2 mos then PDF. 2) MBM must be fortied……..
CriticalGrowth Epoch
Biochemical Markers To Follow
Post DischargeTarget Value
BUN ≥ 5 4-6 wks after d/c
Alkaline phosphatase* < 400 4-6 wks after d/c
Phosphorus > 4.5 4-6 wks after d/c
Hemoglobin >10 4-6 wks after d/c
& 3 months after d/c
Reticulocyte count With hemoglobin
Ferritin 50-250 3 mos after d/c
Lucas A, Brooke OG, Baker BA, Bishop N, Morley R. High alkaline phosphatase activity and growth in preterm neonates. Arch Dis Child. Jul 1989;64(7 Spec No):902-909
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Nutrition Discharge of the Preterm
Infant
What to consider for nutritional management?
• Anthropomorphic growth
• Body composition
• Bone status
• Iron status
• Vitamin status
• Neurodevelopmental outcomes
THE END
NEAR TERM INFANT
LATE PRETERM INFANT
X
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Definitions AAP
� Preterm
� <37 weeks’ gestation
� Late preterm
� 34-366/7 weeks’ gestation
� Early Term
� 37-38 weeks’ gestation
� Full term
� 37 – 41 6/7 weeks’ gestation
The late preterm infant is often treated like a full-term infant.
The late preterm infant is not a full-term infant!
“THE GREAT IMPOSTOR”
AAP = American Academy of Pediatrics
Engle WA et al Pediatrics 2007;120:1390-1401
“Late Preterm” Infants*
First day of LMP
1
0/7
Day #
Week #
259 260 274
36 6/7
294
41 6/7
Preterm Term Post term
239
34 0/7
Late Preterm
* Raju TNK. NIH Consensus Conference on “Optimizing Care and Outcome of the Near-Term Pregnancy and the Near-Term Newborn Infant”, 2005
Early Term
LPT “Quick Facts”• 3 x mortality rate vs term (7.7/1000 LB vs
2.5/1000)• 74% of all PTB’s; 8-9% births in US • 4 x risk of death from congenital anomalies
LPT vs Term• IUGR more common in LPT vs Term
• Resp complications prime morbidities of LP• IVH 0.2-1.4%; Term, not routinely screened
• CP increase 3 x vs Term
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The Late Preterm Infant
The Most Rapid Brain Weight Gain Is
Around 40 Weeks’ Gestation
Morgan PJ etal neurosci Biobehav Rev, 2002;26:471-483
Kinney HC Semin Perinatol, 2006;30:81-88
At 34 Weeks the Brain Is Two Thirds Of
Its Weight At Term
Adams-Chgapman I, Clin Perinatol 2006;33:947-954 Kinney HC Semin Perinatol 2006;30:81-88
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NUTRITION IN LATE PRETERM
(1) Consider fetal growth as appropriate for a particular gestational age
(2) Focus on LBM
(3) Consider age-appropriate accretion rates of protein, minerals and various essential nutrients
(4) Understand GI-tract development
(5) Consider cumulative nutrient deficit that accrues in the early days or weeks of life
(6) Adopt recommendations relative to PCA Lapillonne et alJofPed 2013
Nutritional Recommendations for Preterm Infants
Variables (per kg/d)
GA, weeks
<28 28-31 32-33 34-36 37-38 39-41
Fetal growth
Weight gain, g 20 17.5 15 13 11 10
Lean body mass gain, g
17.8 14.4 12.1 10.5 7.2 6.6
Protein gain, g 2.1 2 1.9 1.6 1.3 1.2
Requirements
Energy, kcal 125 125 130 127 115 110
Proteins, g 4 3.9 3.5 3.1 2.5 2
Calcium, mg120-140
120-140
120-140 120-140 70-120 70-120
Phosphorus, mg 60-90 60-90 60-90 60-90 35-75 35-75
Nutritional needs by GA (weeks)
The Journal of Pediatrics Volume 162, Issue 3, Supplement , Pages S90-S100, March 2013
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71
Range of Protein Intakes
2.1
3.1
3.6
4.0
“g protein/kg/d at150 mL/kg/d”“g protein/kg/d at150 mL/kg/d”
Term formula
Nutrient-enriched formula
Preterm formula 24
High-proteinpreterm formula 24
Prot req 2.0-3.1g/k/d
Human milk provides ~1.5 g/kg/d of protein
Infant Weight Gain and School-age BP and Cognition in Former Preterm Infants
N=911 IHDP 8 centers, Boston born 1980’s Median BW 1.87, GA 34 weeks
27% <32 weeks (SGA – 37%)
Wts – at term, 4, 12mos CA. Primary predictor wt gain term – 1yrBP x 3 at 6.5 years
WISC III at 8 years (normal ≥ 85)
Linear regression “infant weight gain” as the 12 month weight z scores adjusted for the term weight z score (using CDC curves)
Represents ∆ from term to 12 mos
Belfort et al Ped June 2010
ResultsWT BP @6.5y WISC III @8yrs
±SD ±SD Z score median @ 12 mo -0.7
Interquartile range (-1.5-0.0) 104.2 918.4 18
Adjusting for gender, GA, race, maternal education, income, age, mother’s IQ, smoking
For each Z score additional weight gain from term to 12 monthsSystolic BP 0.7mm Hg higherWISC III 1.9 points higher
Belfort et al Ped June 2010
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Infant Weight Gain and School Age BP/Cognition in Former Preterm
Post Discharge Implications• Preterm Infants across the full range demonstrated
better cognitive outcomes with faster weight gains not just ELBW infants. Late Preterm?
• From 4-12 mos better HC growth was associated with better cognition (~3pts)
• Increased weight and length had independent effects on IQ
• Caught up by age 8
Modest neurodevelopmental advantages of more rapid weight gain first year, especially first 4 mos (wt,L) of life and only small BP related effects (only >32weeks)
Human Milk Feeding For Preterm
Infants
Healthy
microbiome
Increased
immunologic
function
Decrease NEC
Breastfeeding And CognitionInfant feeding and childhood cognition at ages 3 and 7 years: effects
of breastfeeding duration and exclusivity. JAMA Pediatr 2013
• Prospective cohort (project ViVa) US Prebirth Cohort enrolled
mothers from 1999-2012, n=1312
• Duration of any breastfeeding to age 12 months
• Adjusted for sociodemographics, maternal intelligence, home
environment factors in linear regression
RESULTS IQ BENEFIT
• 0.35 points per month breastfeeding Verbal scale
• 0.29 points per month breastfeeding Nonverbal
• 0.24 points per month Visual Motor Abilities at age 3 greater with
women who consumed 2 or more servings fish/week
Breastfeeding an infant for the first year of life would be expected to
increase his or her IQ by about 4 points (0.3SD)
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Verbal IQ
Breastfeeding Failure in Late Preterm Infants
Jain (SAN)
Problems Establishing Breastfeeding in Late Preterm
• Sleeper, less stamina• Latch, suck, swallow difficulty• Difficulty maintaining body temperature• Delays in Bilirubin excretion• Respiratory instability
“R/O sepsis”…. Because they are acting like preterm
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Potential Risks Late Preterm Breastfeeding
– Hypothermia – Hypoglycemia– Excessive wt. loss – Exaggerated jaundice
– Kernicterus – Dehydration– Fever secondary to dehydration
– Breastfeeding failure– Rehospitalization
What Should We Feed LPT?• Those infants 34 -36 weeks can use a
Post Discharge Formula through term equivalent age.
• Would not routinely fortify breast fed• Consider fortification in the 34,35 weekers
who have been more ill and have growth faltered.
• Discharge these infants on MBM/PDF supplement if growth failure in place
DHA opinion