11

After Discharge FormulaAfter Discharge Formula(For Preterm Infants)(For Preterm Infants)

Aryono Hendarto,* Idham Amir,** Rinawati Rohsiswatmo,** Aryono Hendarto,* Idham Amir,** Rinawati Rohsiswatmo,**

Division of Nutrition & Metabolic Diseases*, Division of Neonatology**Division of Nutrition & Metabolic Diseases*, Division of Neonatology**

Dept. of Child Health Dept. of Child Health

Medical School -University of IndonesiaMedical School -University of Indonesia

JakartaJakarta

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IntroductionIntroduction

Preterm infant :Preterm infant :

Is unable to feed and has a GI Is unable to feed and has a GI system less ready to receive enteral system less ready to receive enteral nutritionnutrition

Greater nutritional requirements, Greater nutritional requirements, greater risk of GI infection, and not greater risk of GI infection, and not enough breast milkenough breast milk

33

Nutritional goalNutritional goal

Transition period: The provision of sufficient nutrients

to prevent deficiencies and catabolism

Stable growing period: Growth and nutrient-retention rates

similar to those that would have been achieved in utero

44

When to feedWhen to feed

Depend on the infants conditionDepend on the infants condition

- Stable CV and respiratory status- Stable CV and respiratory status

- Evidence of gut function- Evidence of gut function

- Take several days to achieve stability - Take several days to achieve stability

IV dextrose should be initiated IV dextrose should be initiated

TPN if feed not within 3 daysTPN if feed not within 3 days

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Nutrition during hospitalizationNutrition during hospitalization

Parenteral NutritionParenteral Nutrition

Vena central accessVena central access

Vena perifer accessVena perifer access

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Continued Nutrition during……Continued Nutrition during……

Enteral nutritionEnteral nutrition- Throphic feeding (minimal enteral - Throphic feeding (minimal enteral

feeding)feeding) * * 10 ml/kg BB/day 10 ml/kg BB/day * Premature breast milk/Expressed * Premature breast milk/Expressed

Breast Milk ( EBM)Breast Milk ( EBM) **“Half strength”“Half strength” standard term standard term

formulaformula

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Continued nutrition during……Continued nutrition during……

- - Transitional period nutritionTransitional period nutrition

* Premature breast milk* Premature breast milk

* Standard term formula* Standard term formula

* * “Half strength” “Half strength” preterm preterm formulaformula

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Continued nutrition during…Continued nutrition during…

- Stable growing period nutritionStable growing period nutrition

* Premature breast milk + HMF* Premature breast milk + HMF

* Preterm formula* Preterm formula

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How to feedHow to feed

Infant 1-1.5 kg Infant 1-1.5 kg 2 hourly feed, 2 hourly feed, intermittent orogastricintermittent orogastric

Infant < 1 kg Infant < 1 kg hourly feed or by hourly feed or by continuous drip continuous drip

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How much to feedHow much to feed

First day 60 ml/kg/day First day 60 ml/kg/day

Daily volume increased 20 or 30 Daily volume increased 20 or 30 ml/kg/dayml/kg/day

Eventual feed volume Eventual feed volume 180 180 ml/kg/day ml/kg/day two weeks to two weeks to achieve achieve depend on degree of depend on degree of tolerancetolerance

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EBM advantagesEBM advantages

1.1. NutritionalNutritional

Protein : Increased protein in EBMProtein : Increased protein in EBM Present lactalbuminPresent lactalbumin Immune protein presentImmune protein present

Fat Fat : Correct distribution & : Correct distribution & structurestructure Presence of lipasePresence of lipase Presence of PUFA’SPresence of PUFA’S

Carbohydrate : lactose and Carbohydrate : lactose and oligosaccharidesoligosaccharides

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…………EBM advantagesEBM advantages

2.2. Gastrointestinal Gastrointestinal

GIT growth factorsGIT growth factors

Oligopeptides promote motilityOligopeptides promote motility

Protection against NECProtection against NEC

3.3. Host defence / immunity Host defence / immunity

Against infectionAgainst infection

Decrease in atopyDecrease in atopy

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……EBM advantagesEBM advantages

4.4. Developmental outcomeDevelopmental outcome

Higher score on developmental Higher score on developmental testingtesting

5.5. Psychological benefit for Psychological benefit for mother and babymother and baby

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EBM disadvantagesEBM disadvantages

Insufficient nutrient and calories for Insufficient nutrient and calories for growthgrowth

Insufficient mineralInsufficient mineral

Increased anxiety for the mother if her Increased anxiety for the mother if her supply is failing supply is failing

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Breast milk + fortifier Breast milk + fortifier advantagesadvantages

Increased protein and calories Increased protein and calories

Increased mineralIncreased mineral

No increased in fluid volumeNo increased in fluid volume

Additional sodium prevents Additional sodium prevents

hyponatraemiahyponatraemia

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Continued Breast milk……Continued Breast milk……

Increased in feed osmolality

Hypercalcaemia

Fortification :

not introduced before 10 days

not until full feed volume are established

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When Premature Infants To Be When Premature Infants To Be DischargedDischarged

Body weight Body weight 1800 g 1800 g

Stable : no underlying diseaseStable : no underlying disease

GrowthGrowth

Parents are ready for the babyParents are ready for the baby

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Assessing nutritional Assessing nutritional adequacyadequacy

Anthropometric measurements

To compare growth rate with approximate intrauterine growth rate standards

Expected mean weight gain

<1 kg BW : Gain 15-18 g/kg/d, > 2-4 weeks

1-2 kg BW : Gain 12-15 g/kg/d, 10-14 days

> 2 kg BW : Gain 8-12 g/kg/d, 7-10 days

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Catch up growthCatch up growth

Refers to the increase in growth velocity Refers to the increase in growth velocity

following a period of impaired growthfollowing a period of impaired growth

A rate of growth greater than average for A rate of growth greater than average for

post conceptual agepost conceptual age

A preterm infant who achieves a weight gain A preterm infant who achieves a weight gain

velocity that is at the 90velocity that is at the 90thth percentile of percentile of

expected weight gain for corrected ageexpected weight gain for corrected age

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Expected rate of weight gain per Expected rate of weight gain per dayday

20 grams/day from term to 3 months corrected age20 grams/day from term to 3 months corrected age

15 grams/day from 3-6 months corrected age15 grams/day from 3-6 months corrected age

10 grams/day from 6-9 months corrected age 10 grams/day from 6-9 months corrected age

6 grams/day from 9-12 months corrected age6 grams/day from 9-12 months corrected age

Height 1 cm/monthHead circumference 0.5cm/week

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Correction in growth Correction in growth parameterparameter

Should be continued:Should be continued:

- 18 months for HC- 18 months for HC

- 24 months for Weight- 24 months for Weight

- 42 months for height- 42 months for height

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Nutrients need post Nutrients need post dischargedischarge

CaloryCalory : 120 kcal/kgbw/day: 120 kcal/kgbw/day

Multivitamins until reach 3500-4000 gramsMultivitamins until reach 3500-4000 grams

Discontinued multivitamins should be Discontinued multivitamins should be follow by supplementation of vit Dfollow by supplementation of vit D

Fluoride supplementation at 6 monthsFluoride supplementation at 6 months

Iron supplementation until 6 monthsIron supplementation until 6 months

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Suggested daily enteral intakes for Suggested daily enteral intakes for stable preterm infantstable preterm infant

NutrientNutrient Term infantTerm infant Preterm infantPreterm infant

EnergyEnergy 108 kcal/kg108 kcal/kg 105-130 kcal/kg105-130 kcal/kg

ProteinProtein 2.2 g/kg2.2 g/kg 3.0-4.0 g/kg3.0-4.0 g/kg

Vitamin AVitamin A 600 mcg600 mcg 210-450 mcg210-450 mcg

Vitamin DVitamin D 25 mcg25 mcg 3.75-10 mcg3.75-10 mcg

Vitamin EVitamin E 3 mg3 mg 6-12 mg/kg6-12 mg/kg

CalciumCalcium 67 mg/kg67 mg/kg 120-130 mg/kg120-130 mg/kg

PhosphorusPhosphorus 50 mg/kg50 mg/kg 60-140 mg/kg60-140 mg/kg

IronIron 1.0 mg/kg1.0 mg/kg 2.0-3.0 mg/kg2.0-3.0 mg/kg

ZincZinc 0.83 mg/kg0.83 mg/kg 1 mg/kg1 mg/kg

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Problems after dischargeProblems after discharge

Post discharge nutrition in preterm infants Post discharge nutrition in preterm infants

has receive relativity little attention has receive relativity little attention

Body weight & length below 3Body weight & length below 3th th percentale percentale

post dischargepost discharge

> 30% preterm infants remained below > 30% preterm infants remained below

1010thth at 18 months at 18 months

> 20% at 7-8 year follow up> 20% at 7-8 year follow up

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Continued Problems After……Continued Problems After……

Undermineralised bonesUndermineralised bones

Low zinc statusLow zinc status

Nutrition for convalescent premature Nutrition for convalescent premature

infant should promote “catch up” infant should promote “catch up”

growthgrowth

In general catch up growth occurs first In general catch up growth occurs first

in HC followed by Weight & heightin HC followed by Weight & height

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Nutrition post dischargeNutrition post discharge

Preterm breast milk is not sufficient Preterm breast milk is not sufficient

for premature infant regarding to for premature infant regarding to

increase protein needs and low increase protein needs and low

contain of vitamin and mineralcontain of vitamin and mineral

Should be fortifiedShould be fortified

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Continued nutrition post…….Continued nutrition post…….

Growth rate infants with Preterm BF Growth rate infants with Preterm BF similar to in utero growthsimilar to in utero growthAfter 30 days Preterm BF have low After 30 days Preterm BF have low contain of protein, Ca, P, Mg, Zn and contain of protein, Ca, P, Mg, Zn and Vitamin D.Vitamin D.

(Atkinsons, J Pediatr 1981 & 1982; Spencer (Atkinsons, J Pediatr 1981 & 1982; Spencer

BMJ 1982; Chessex, J Pediatr 1983)BMJ 1982; Chessex, J Pediatr 1983)

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Common practice in US & UKCommon practice in US & UK

1.1. Standard formula (67 kcal/100 ml) afterStandard formula (67 kcal/100 ml) after

dischargedischarge

2.2. Standard preterm formula (81 kcal/100ml)Standard preterm formula (81 kcal/100ml)

to term & standard term formula to term & standard term formula

thereafter thereafter

(Cooke et al, Pediatr Rev 1998)(Cooke et al, Pediatr Rev 1998)

Nutrition post dischargeNutrition post discharge

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Infant with standard term formula Infant with standard term formula post dischargepost discharge

Poorer weight gainPoorer weight gain

Reduced head growthReduced head growth

Reduced linear growthReduced linear growth

Lower IQLower IQ

(Lucas, Lancet 1990; Lucas, Arch Dis Child (Lucas, Lancet 1990; Lucas, Arch Dis Child

1992)1992)

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Prolonged feeding of preterm Prolonged feeding of preterm formula after dischargedformula after discharged

Hypervitaminosis D & Hypervitaminosis D & HypercalcemiaHypercalcemia

( Kuroume, Pediatrics 1993)( Kuroume, Pediatrics 1993)

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Post discharge formulaPost discharge formula

Nutrient level intermediate between Nutrient level intermediate between standard and preterm formulastandard and preterm formula

Fulfills the European Community Fulfills the European Community Directive requirements for the Directive requirements for the composition of term infant formula composition of term infant formula

Predominantly increase in protein, Predominantly increase in protein, only modest increase in energyonly modest increase in energy

Contains increase in mineral, Contains increase in mineral, particularly Ca, P, zincparticularly Ca, P, zinc

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Formula composition (per 100 ml )Formula composition (per 100 ml )

FactorsFactors Standard Standard formulaformula

Post discharge Post discharge formulaformula

Preterm Preterm formulaformula

Energy (kcal)Energy (kcal) 6767 7272 8181

Protein (g)Protein (g) 1.451.45 1.851.85 2.32.3

Calcium (mg)Calcium (mg) 3535 7070 9999

Phosphorus Phosphorus (mg)(mg)

2929 3535 5454

Magnesium Magnesium (mg)(mg)

5.25.2 5.25.2 8.08.0

Vitamin D (ug)Vitamin D (ug) 1.01.0 1.21.2 22

Zinc (mg)Zinc (mg) 0.50.5 0.880.88 1.61.6

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PDFPDF TFTF9 months9 months weightweight 8.838.83 8.26*8.26* heightheight 71.971.9 70.4*70.4* occipito-frontooccipito-fronto 46.146.1 46.246.2 circumference (cm)circumference (cm)18 months18 months weightweight 10.7710.77 10.5110.51 heightheight 81.781.7 80.2*80.2* occipito-frontooccipito-fronto 48.248.2 48.848.8 circumference (cm)circumference (cm)

Post discharge growth in Post discharge growth in boysboys

*P<.05 (Lucas et al, Pediatrics 2001)

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PDFPDF TFTF9 months9 months weightweight 7.897.89 7.757.75 heightheight 69.869.8 69.269.2 occipito-frontooccipito-fronto 45.145.1 45.145.1 circumference (cm)circumference (cm)18 months18 months weightweight 9.649.64 9.729.72 heightheight 79.579.5 79.379.3 occipito-frontooccipito-fronto 46.946.9 47.247.2 circumference (cm)circumference (cm)

Post discharge growth in Post discharge growth in girlsgirls

*P<.05 (Lucas et al, Pediatrics 2001)

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PDFPDF SFSF 95% CI95% CI

Bone width (cm)Bone width (cm)

Before dischargeBefore discharge

3 months3 months

9 months9 months

0.3680.368

0.6030.603

0.6840.684

0.3600.360

0.5620.562

0.6100.610

0.023 – 0.0390.023 – 0.039

0.039 – 0.1210.039 – 0.121

0.004 – 0.1410.004 – 0.141

Bone mineral content Bone mineral content (mg/cm)(mg/cm)

Before dischargeBefore discharge

3 months3 months

9 months9 months

35.135.1

84.384.3

112.1112.1

34.934.9

64.064.0

95.395.3

-7.9 – 8.3-7.9 – 8.3

6.2 – 34.26.2 – 34.2

13.2 – 40.413.2 – 40.4

Bone width & mineral content of the radius before discharge and at 3 & 9 corrected age)

(Bishop et al, Arch Dis Child, 1993)

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Comparison 0f 1000 mlComparison 0f 1000 ml

NutrientNutrient SFSF PDFPDF PFPF MaxMax

Vit A (IU)Vit A (IU) 23002300 27602760 28002800 50005000

Vit D (IU)Vit D (IU) 400400 640640 800800 10001000

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Low risk-LBW InfantLow risk-LBW Infant

•Infant discharge weight > 2000 g•Birth weight > 1500 g

BF recommendation

• BF on demand

• Supplement with

standard formula

if BF insufficient

Formula feeding

recommendation

• Offer standard 67 kkcal/100

ml with iron supplementation

until 1 year corrected age

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Moderate risk-LBW InfantModerate risk-LBW Infant

•Infant discharge weight < 2000 g•Birth weight > 1500 g

Exclusive

BF

Formula feeding recommendation

• Provide transitional formula (72

kkcal/100 ml) up to 9 mo

BF recommendations:

• Suppl BF w/ HMF until infant BW 1850-2400 g

• Suppl BF w/ transitional formula

• Alternative: increase caloric density w/ standard formula

to 9 mos corrected age or good catch up growth

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High risk-LBW InfantHigh risk-LBW Infant

Category definition:•Infant discharge < 2000 g•BW < 1500 g•History of TPN & diuretics•Demonstrated poor growth•Elevated alkaline phosphatase (>500 U/L)

Exclusive BF

BF recommendation:

•Suppl w/ HMF•Suppl BF w/ transitional formula •Increase caloric density of BF w/ standard formula

Formula feeding recommendation:

•Provide a 81 kkcal/100 ml premature formula until infant weight 1850-2000 g•Change to a 72 kcal/100 ml discharge formula until 9 mo corrected age•If catch up growth is achieved change to standard formula

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SummarySummary

Nutrition post discharge should promote Nutrition post discharge should promote

“catch up” growth“catch up” growth

Preterm Breast Milk still the proper Preterm Breast Milk still the proper

nutrition for preterm infant, however should nutrition for preterm infant, however should

be fortifiedbe fortified

Post discharge infants need specials Post discharge infants need specials

formula when ever BF insufficientformula when ever BF insufficient

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Continued SummaryContinued Summary

Post discharge formula showed Post discharge formula showed

advantages compare to standard formula.advantages compare to standard formula.

Further study needed to determine the Further study needed to determine the

precise nutrient requirement for infant precise nutrient requirement for infant

after discharge from the hospitalafter discharge from the hospital