Nutritional Support Nutritional Support of the VLBW Infantof the VLBW Infant

Dr Varsha Atul ShahDr Varsha Atul Shah

ObjectivesObjectivesFollowing self-study of the slide presentation and reading of the Following self-study of the slide presentation and reading of the

Nutritional Nutritional Support of the Very Low Birth Weight (VLBW) InfantSupport of the Very Low Birth Weight (VLBW) Infant Toolkit, the Toolkit, the

participant participant will have/be able to:will have/be able to: Recognize that nutrition during critical periods in early life Recognize that nutrition during critical periods in early life

may permanently affect the structure and/or function of the may permanently affect the structure and/or function of the infant’s organs and tissues;infant’s organs and tissues;

Identify three physiological goals of VLBW infant nutrition Identify three physiological goals of VLBW infant nutrition management;management;

List suggested best practices for the major aspects of infant List suggested best practices for the major aspects of infant nutrition promotion, including parenteral nutrition, nutrition promotion, including parenteral nutrition, establishing enteral nutrition, human milk/breastfeeding, establishing enteral nutrition, human milk/breastfeeding, transition to oral feeding and discharge planning;transition to oral feeding and discharge planning;

Recognize that new research has only reinforced prior best Recognize that new research has only reinforced prior best practices;practices;

Demonstrate knowledge and skills necessary to establish and Demonstrate knowledge and skills necessary to establish and support breastfeeding.support breastfeeding.

Gold Standard of Growth for Gold Standard of Growth for VLBW InfantsVLBW Infants

To approximate the in utero growth of a To approximate the in utero growth of a normal fetus of the same post-normal fetus of the same post-conceptional age.conceptional age.– Body weightBody weight– Body compositionBody composition

AAP Committee on Nutrition: Nutritional needs AAP Committee on Nutrition: Nutritional needs of low birth weight infants. of low birth weight infants. PediatricsPediatrics 1985;75:9761985;75:976

AAP Committee on Nutrition: Nutritional needs AAP Committee on Nutrition: Nutritional needs of the preterm infant, in Kleinman RE (ed): of the preterm infant, in Kleinman RE (ed): Pediatric Nutrition HandbookPediatric Nutrition Handbook, ed 5, Elk , ed 5, Elk Grove Village, IL, AAP, 2004, p 23-54.Grove Village, IL, AAP, 2004, p 23-54.

Unique Nutritional Aspects Unique Nutritional Aspects of the VLBW Infantof the VLBW Infant

Higher organ:muscle mass ratioHigher organ:muscle mass ratio Higher rate of protein synthesis and Higher rate of protein synthesis and

turnoverturnover Greater oxygen consumption during Greater oxygen consumption during

growth growth Higher energy cost due to Higher energy cost due to

transepidermal water losstransepidermal water loss Higher rate of fat depositionHigher rate of fat deposition Prone to hyperglycemiaProne to hyperglycemia Higher total body water contentHigher total body water content

Unique Nutritional Aspects of Unique Nutritional Aspects of VLBW infants - Brain GrowthVLBW infants - Brain Growth

Brain Growth over 8 weeks:Brain Growth over 8 weeks:At 28 wksAt 28 wks 100% Increase100% IncreaseAt term At term 40% Increase 40% IncreaseAt 3 moAt 3 mo 25% Increase 25% Increase

Preventing Feeding-Related Preventing Feeding-Related Morbidities in VLBW InfantsMorbidities in VLBW Infants

Necrotizing enterocolitisNecrotizing enterocolitis OsteoporosisOsteoporosis Vitamin and mineral deficienciesVitamin and mineral deficiencies Feeding intoleranceFeeding intolerance Prolonged TPN and related cholestasisProlonged TPN and related cholestasis Prolonged hospitalizationProlonged hospitalization Lack of full physical and intellectual Lack of full physical and intellectual

potentialpotential

Optimizing Long Term Optimizing Long Term OutcomeOutcome

NutritionalNutritional Programming:Programming:Nutrition during critical periods Nutrition during critical periods

in early life may permanently in early life may permanently affect the structure and/or affect the structure and/or function of organs or tissues.function of organs or tissues.

Alan Lucas, 1990Alan Lucas, 1990

Early Diet Influences Early Diet Influences Long-term Health and Long-term Health and

DiseaseDiseaseBreastfeeding leads to reduction in Breastfeeding leads to reduction in

diastolic blood pressure in later years of diastolic blood pressure in later years of 3.2 mmHg, 3.2 mmHg, a greater impact that seen by other a greater impact that seen by other public health measures including:public health measures including:– Weight loss (-2.8 mmHg)Weight loss (-2.8 mmHg)– Alcohol reduction (-2.1 mmHg)Alcohol reduction (-2.1 mmHg)– Salt restriction (-1.3)Salt restriction (-1.3)– Exercise (-0.2 mmHg)Exercise (-0.2 mmHg)

Early Diet Influences Early Diet Influences Long- term Health and Long- term Health and

DiseaseDiseaseAdverse effects of growth Adverse effects of growth

acceleration in humans include:acceleration in humans include:– ObesityObesity– Elevated blood pressureElevated blood pressure– Insulin resistance and diabetesInsulin resistance and diabetes– IGF-1 concentrationsIGF-1 concentrations– Cardiovascular mortalityCardiovascular mortality

Nutritional Care/Outcomes in Nutritional Care/Outcomes in VLBW Infants - Potential VLBW Infants - Potential

ImprovementsImprovements Human milkHuman milk ““Early” TPNEarly” TPN

– Prevent protein deficitPrevent protein deficit– Prevent EFA deficiencyPrevent EFA deficiency

GI priming/MEN/Trophic feedsGI priming/MEN/Trophic feeds– Prevent GI atrophy effectsPrevent GI atrophy effects– Faster realization of full enteral feedsFaster realization of full enteral feeds

Fortification/SupplementationFortification/Supplementation– Starting earlierStarting earlier– Continuing longerContinuing longer

Benefits of Human Milk - Benefits of Human Milk - Reduced InfectionsReduced Infections

Otitis media – with a reduction in the Otitis media – with a reduction in the frequency and duration of ear infections frequency and duration of ear infections in breastmilk versus formula fed in breastmilk versus formula fed newbornsnewborns

Respiratory tract illnesses including Respiratory tract illnesses including respiratory synctial virus infectionrespiratory synctial virus infection

Gastrointestinal illnessGastrointestinal illness Urinary tract infectionsUrinary tract infections Infant botulismInfant botulism

Benefits of Human Milk -Benefits of Human Milk -Reductions in Chronic Reductions in Chronic

DiseasesDiseases ObesityObesity Allergies/atopyAllergies/atopy Type 1 juvenile onset diabetesType 1 juvenile onset diabetes Crohn’s diseaseCrohn’s disease LymphomaLymphoma

Benefits of Human Milk Benefits of Human Milk for Preterm Infantsfor Preterm Infants

Host DefenseHost Defense Gastrointestinal DevelopmentGastrointestinal Development Special NutritionSpecial Nutrition Neurodevelopmental OutcomeNeurodevelopmental Outcome Physically & Psychologically Physically & Psychologically

Healthier MotherHealthier Mother

Immunoglobulins : 90% IgA and Immunoglobulins : 90% IgA and sIgAsIgA

More IgA in preterm milkMore IgA in preterm milk Concentration decreases over timeConcentration decreases over time IgA found in stool of breastfed infants IgA found in stool of breastfed infants

unchanged: lines intestine to protectunchanged: lines intestine to protect Increased urinary excretion of IgA Increased urinary excretion of IgA

with breastmilkwith breastmilk

Incidence of Necrotizing Incidence of Necrotizing Enterocolitis by Type of FeedEnterocolitis by Type of FeedNecrotizing EnterocolitisNecrotizing Enterocolitis

Type of feedType of feed IncidenceIncidence ProportionProportionEBMEBM 1.2 %1.2 % 3/2533/253

EBM + PTFEBM + PTF2.5 %2.5 % 11/43711/437PTFPTF 7.2 %7.2 % 17/23617/236

Statistical Comparison:Statistical Comparison:PTF v. PTF + EBMPTF v. PTF + EBM p < .005p < .005PTF v. EBMPTF v. EBM p < .001p < .001

Lucas & Cole, Lancet 1990;336:1519Lucas & Cole, Lancet 1990;336:1519

GI Benefits of Human Milk for GI Benefits of Human Milk for the Preterm Infantthe Preterm Infant

Gastrointestinal developmentGastrointestinal development– Reduces intestinal permeability fasterReduces intestinal permeability faster– Induces lactase activityInduces lactase activity– Multiple factors to stimulate growth, Multiple factors to stimulate growth,

motility and maturation of the motility and maturation of the intestineintestine

– Human milk empties from the stomach Human milk empties from the stomach faster than artificial milksfaster than artificial milks

– Less residuals and faster realization of Less residuals and faster realization of full enteral feedingsfull enteral feedings

Factors in Breastmilk That Factors in Breastmilk That May Promote GI MaturationMay Promote GI Maturation Epidermal Epidermal

growth factorsgrowth factors Nerve growth Nerve growth

factorsfactors Somatomedin-CSomatomedin-C Insulin-like Insulin-like

growth factorsgrowth factors InsulinInsulin CortisolCortisol

ThyroxineThyroxine NucleotidesNucleotides TaurineTaurine GlutamineGlutamine LactoseLactose Amino sugarsAmino sugars CytokinesCytokinesGroer & Walker. Advances in Groer & Walker. Advances in

Pediatrics 1996; 43:335-Pediatrics 1996; 43:335-358358

Time Needed to Attain Full Time Needed to Attain Full Enteral Feeds in 95% of VLBW Enteral Feeds in 95% of VLBW

InfantsInfantsType of feedType of feed Number of daysNumber of daysExpressed breastmilkExpressed breastmilk 2020Standard formulaStandard formula 4545Preterm formulaPreterm formula 4848

Lucas & Cole. Lancet 1990;336:1519Lucas & Cole. Lancet 1990;336:1519

Benefits of Human MilkBenefits of Human Milkfor the VLBW Infantfor the VLBW Infant

Special nutritional needsSpecial nutritional needs– Different quantity and quality of Different quantity and quality of

proteinsproteins– Fats: Cholesterol, DHA, ARAFats: Cholesterol, DHA, ARA– Carbohydrates designed for Carbohydrates designed for

human infantshuman infants– Lower osmolality/renal solute loadLower osmolality/renal solute load– Other factors: e.g. erythropoietin, Other factors: e.g. erythropoietin,

EGFEGF

Human Milk and Retinopathy Human Milk and Retinopathy of Prematurity in VLBW of Prematurity in VLBW

InfantsInfants 145 VLBW (<1500gm) Jan 1992-Feb 1993145 VLBW (<1500gm) Jan 1992-Feb 1993 Incidence of ROPIncidence of ROP

– Human Milk Human Milk 37.3%37.3% p<0.005p<0.005– FormulaFormula 63.8%63.8%

Incidence of ROP at dischargeIncidence of ROP at discharge– Human MilkHuman Milk 22.3%22.3% p<0.0007p<0.0007– FormulaFormula 53.4%53.4%

Multiple Regression Analysis:Multiple Regression Analysis:– feeding correlated with ROP incidence and severityfeeding correlated with ROP incidence and severity– dose response relationshipdose response relationship– even small vol. (<20%) of human milk protectiveeven small vol. (<20%) of human milk protective

Hylander et al. J Perinatol 2001; 21:356-362

General General PrinciplesPrinciples

Poor growth during antenatal or postnatal Poor growth during antenatal or postnatal life is associated with increased risk to life is associated with increased risk to

long-term health.long-term health. Significant growth restriction occurs during Significant growth restriction occurs during

the in-hospital phase of post-natal growth the in-hospital phase of post-natal growth among VLBW infants. among VLBW infants.

Maximizing volume of feeding and nutrient Maximizing volume of feeding and nutrient fortification has been shown to improve fortification has been shown to improve overall growth. overall growth.

Due to high relative growth rate Due to high relative growth rate standardizing the response to poor or standardizing the response to poor or suboptimal growth should improve overall suboptimal growth should improve overall growth. growth.

Best Practice #1.1Best Practice #1.1Establish consistent, Establish consistent,

comprehensive, multidisciplinary comprehensive, multidisciplinary nutritional monitoring as an nutritional monitoring as an

integral component of improving integral component of improving nutrition outcomes in the nutrition outcomes in the

neonatal population.neonatal population.

Best Practice #1.2Best Practice #1.2Establish standards of nutritional Establish standards of nutritional

practice based on best evidence practice based on best evidence or expert opinion if evidence is or expert opinion if evidence is

lacking. Track nutritional lacking. Track nutritional continuous quality improvement continuous quality improvement (CQI) data and use it to modify (CQI) data and use it to modify and improve current practices and improve current practices

and outcome.and outcome.

Implementation StrategiesImplementation Strategies Daily rounds and progress notes should Daily rounds and progress notes should

include a specific place for weight and include a specific place for weight and feeding adjustment and should address feeding adjustment and should address progress toward daily growth targets.progress toward daily growth targets.

Weekly measurement and plotting of Weekly measurement and plotting of weight, length and head circumference weight, length and head circumference should be done.should be done.

Standardize response to poor or Standardize response to poor or suboptimal growth.suboptimal growth.

Mother’s milk expression and collection Mother’s milk expression and collection should be encouraged, supported and should be encouraged, supported and monitored routinely.monitored routinely.

Parenteral Nutrition Parenteral Nutrition for VLBW Infantsfor VLBW Infants

Sophisticated techniques for providing Sophisticated techniques for providing short and long-term parenteral nutrition short and long-term parenteral nutrition

to critically ill infants have been to critically ill infants have been developed.developed. In-utero protein and energy gain is more In-utero protein and energy gain is more

than 4 gm/kg/day.than 4 gm/kg/day. Administration of 3 gm/kg/day of protein Administration of 3 gm/kg/day of protein

immediately after birth is safe and can immediately after birth is safe and can reduce the early protein deficit cumulated reduce the early protein deficit cumulated within the first week of life.within the first week of life.

Early administration of at least 1 Early administration of at least 1 gm/kg/day pf intravenous lipids will gm/kg/day pf intravenous lipids will prevent essential fatty acid deficiency.prevent essential fatty acid deficiency.

Best Practice #2.1Best Practice #2.1 Parenteral nutrition, including protein Parenteral nutrition, including protein

and lipids, should be started within and lipids, should be started within the first 24 hours of life. the first 24 hours of life.

Parenteral nutrition should be Parenteral nutrition should be increased rapidly so infants receive increased rapidly so infants receive adequate amino acids (3.0-4.0 adequate amino acids (3.0-4.0 gm/kg/day) and non-protein calories gm/kg/day) and non-protein calories (80-100 kcal/kg/day) as quickly as (80-100 kcal/kg/day) as quickly as possible.possible.

Best Practice #2.2Best Practice #2.2 Start parenteral lipids within the Start parenteral lipids within the

first 24 hours of life. Lipids can first 24 hours of life. Lipids can be started at doses as high as 2 be started at doses as high as 2 g/kg/d. Lipids can be increased g/kg/d. Lipids can be increased to doses as high as 3.0-3.5 to doses as high as 3.0-3.5 g/kg/day over the first few days g/kg/day over the first few days of life.of life.

Best Practice #2.3Best Practice #2.3 Discontinue parenteral nutrition, Discontinue parenteral nutrition,

with removal of central with removal of central catheters, as soon as adequate catheters, as soon as adequate enteral nutrition is established.enteral nutrition is established.

Implementation StrategiesImplementation Strategies Standardized policies, order sets and TPN Standardized policies, order sets and TPN

solutions should be used to provide solutions should be used to provide balanced, maintenance parenteral balanced, maintenance parenteral nutrition.nutrition.

Amino acids (of at least 2 gm/kg/day) and Amino acids (of at least 2 gm/kg/day) and intravenous lipid administration should be intravenous lipid administration should be started within the first 24 hours of lifestarted within the first 24 hours of life– Available pre-mixed TPN /TNA (Total Nutrition Available pre-mixed TPN /TNA (Total Nutrition

Admixture) may simply administration and Admixture) may simply administration and mixing issues.mixing issues.

Establishing Enteral Establishing Enteral FeedingsFeedings

Current research confirms that human milk (with Current research confirms that human milk (with appropriate fortification for the VLBW infant) is the appropriate fortification for the VLBW infant) is the

standard of care for preterm as well as term standard of care for preterm as well as term infants.infants.

The objective of feeding during the early The objective of feeding during the early days of life is to stimulate gut maturation, days of life is to stimulate gut maturation, hormone release and motility. hormone release and motility.

Early introduction of feedings shortens the Early introduction of feedings shortens the time to full feeds and discharge and does time to full feeds and discharge and does not increase the incidence of NEC.not increase the incidence of NEC.

Benefits of human milk include: key Benefits of human milk include: key digestive enzymes, immunologic digestive enzymes, immunologic protective factors, immunomodulators, protective factors, immunomodulators, anti-inflammatory factors, anti-oxidants, anti-inflammatory factors, anti-oxidants, growth factors, hormones and other bio-growth factors, hormones and other bio-active factors. active factors.

Best Practice #3.1Best Practice #3.1 Human milk should be used Human milk should be used

whenever possible as the enteral whenever possible as the enteral feeding of choice for VLBW feeding of choice for VLBW infants.infants.

Best Practice #3.2Best Practice #3.2 Enteral feeds, in the form of trophic Enteral feeds, in the form of trophic

or minimal enteral feeds (also called or minimal enteral feeds (also called GI priming), should be initiated GI priming), should be initiated within 1-2 days after birth, except within 1-2 days after birth, except when there are clear when there are clear contraindications such as a contraindications such as a congenital anomaly precluding congenital anomaly precluding feeding (e.g. omphalocele or feeding (e.g. omphalocele or gastroschisis), or evidence of GI gastroschisis), or evidence of GI dysfunction associated with dysfunction associated with hypoxic-ischemic compromise.hypoxic-ischemic compromise.

Implementation StrategiesImplementation Strategies Create a supportive environment to maximize Create a supportive environment to maximize

milk production in the early post-partum period.milk production in the early post-partum period. Teach mothers hand expression and collection Teach mothers hand expression and collection

techniques to maximize colostrum availability. techniques to maximize colostrum availability. Establish a relationship with a human milk bank Establish a relationship with a human milk bank

and procedures for obtaining heat-treated donor and procedures for obtaining heat-treated donor milk quickly.milk quickly.

Specific standardized feeding policies should be Specific standardized feeding policies should be available in each NICU.available in each NICU.

Reasons for withholding feedings should be Reasons for withholding feedings should be documented and discussed in rounds. documented and discussed in rounds.

Best Practice #7:Best Practice #7: Every mother of an infant Every mother of an infant admitted to the NICU should be provided with admitted to the NICU should be provided with an appropriate breast pump and the support an appropriate breast pump and the support

to use it effectively.to use it effectively.

Guidelines for advancing feeds have been Guidelines for advancing feeds have been shown to shown to

be associated with more consistent orders be associated with more consistent orders and and

responses to residuals between physicians, responses to residuals between physicians, faster faster

rates of advancement and lower rates of rates of advancement and lower rates of necrotizing necrotizing

enterocolitis.enterocolitis.

Best Practice #3.3Best Practice #3.3 NICU’s should standardize feeding NICU’s should standardize feeding

management based on best available management based on best available evidence.evidence.– NICUs should standardize their definition NICUs should standardize their definition

of feeding intolerance, with specific of feeding intolerance, with specific reference to acceptable residual volumes, reference to acceptable residual volumes, changes in abdominal girth and the changes in abdominal girth and the presence of heme-positive stools.presence of heme-positive stools.

– Enteral feeds should usually be given by Enteral feeds should usually be given by intermittent bolus, rather than intermittent bolus, rather than continuously, and by gastric, rather than continuously, and by gastric, rather than transpyloric administration.transpyloric administration.

Best Practice # 3.3 Best Practice # 3.3 continuedcontinued

– Pumps delivering breastmilk should be Pumps delivering breastmilk should be oriented so that the syringe is oriented so that the syringe is vertically upright, and the tubing vertically upright, and the tubing (smallest caliber and shortest possible) (smallest caliber and shortest possible) should be positioned and cleared to should be positioned and cleared to prevent sequestration of fat.prevent sequestration of fat.

– Enteral feeds should be advanced until Enteral feeds should be advanced until they are providing adequate nutrition they are providing adequate nutrition to sustain optimal growth (2% of body to sustain optimal growth (2% of body weight/day). For infants fed human weight/day). For infants fed human milk this could mean as much as 170 - milk this could mean as much as 170 - 200+ mL/kg/day.200+ mL/kg/day.

Best Practice # 3.4Best Practice # 3.4

VLBW infants fed human milk should VLBW infants fed human milk should be supplemented with protein, be supplemented with protein, calcium, phosphorus and calcium, phosphorus and micronutrients. Multinutrient micronutrients. Multinutrient fortifiers may be the most efficient fortifiers may be the most efficient way to do this when feeding human way to do this when feeding human milk. Formula fed infants may also milk. Formula fed infants may also require specific caloric and require specific caloric and micronutrient supplementation.micronutrient supplementation.

Implementation Strategies Implementation Strategies Each NICU should discuss and agree on a Each NICU should discuss and agree on a

definition of feeding intolerance.definition of feeding intolerance. Staff should be educated on policies, plans Staff should be educated on policies, plans

and practice changes. and practice changes. NICU feeding policy should specify modes NICU feeding policy should specify modes

and methods of feeding as well as and methods of feeding as well as fortificationfortification– Reason for variance should be discussed and Reason for variance should be discussed and

documentation.documentation.

Human Milk and Human Milk and BreastfeedingBreastfeeding

Maximal human milk exposure for the Maximal human milk exposure for the vulnerable preterm infants during vulnerable preterm infants during

hospitalization is essential.hospitalization is essential. A concerted effort of a multidisciplinary team A concerted effort of a multidisciplinary team

is an excellent strategy to improve human is an excellent strategy to improve human milk exposure along with the development of milk exposure along with the development of a strong unit culture in support of human milk.a strong unit culture in support of human milk.

Early milk production is correlated with later Early milk production is correlated with later maintenance milk volume and lactation maintenance milk volume and lactation success.success.

Human milk is a body substance and Human milk is a body substance and therefore carries risks of transmission of therefore carries risks of transmission of infectious agents. Safe handling should infectious agents. Safe handling should minimize the risk to the VLBW infant. minimize the risk to the VLBW infant.

Best Practice # 4.1Best Practice # 4.1 Educate & advocate for human milk Educate & advocate for human milk

for NICU infants.for NICU infants.– Obstetric, perinatal, neonatal and Obstetric, perinatal, neonatal and

pediatric professionals should have the pediatric professionals should have the knowledge, skills and attitudes necessary knowledge, skills and attitudes necessary to effectively support the provision of to effectively support the provision of breastmilk to the VLBW infant.breastmilk to the VLBW infant.

– Mothers and families should be given Mothers and families should be given accurate information about human milk accurate information about human milk for VLBW infants, and their decisions for VLBW infants, and their decisions respected.respected.

Breastfeeding Breastfeeding ResourcesResources

InternationalInternational– ABM (Academy of Breastfeeding Medicine)ABM (Academy of Breastfeeding Medicine)– WHO/UNICEFWHO/UNICEF– ILCA (International Lactation Consultant Association)ILCA (International Lactation Consultant Association)– IBLCE (International Board of Lactation Consultant Examiners)IBLCE (International Board of Lactation Consultant Examiners)– Wellstart InternationalWellstart International– WABA (World Alliance for Breastfeeding Advocacy)WABA (World Alliance for Breastfeeding Advocacy)

NationalNational– AAP (American Academy of Pediatrics)AAP (American Academy of Pediatrics)– ACOG (American College of Obstetricians & Gynecologists)ACOG (American College of Obstetricians & Gynecologists)– AAFP (American Academy of Family Physicians)AAFP (American Academy of Family Physicians)– DHHS: Office of Women’s Health/Maternal-Child Health Bureau)DHHS: Office of Women’s Health/Maternal-Child Health Bureau)– March of DimesMarch of Dimes– WIC (Women, Infant, Children Supplemental Nutrition WIC (Women, Infant, Children Supplemental Nutrition

Program)/USDAProgram)/USDA– NIH (National Institutes of Health)NIH (National Institutes of Health)– CDC (Centers for Disease Control & Prevention)CDC (Centers for Disease Control & Prevention)

                                           

Academy of Breastfeeding Medicine

www.bfmed.org

Academy of Breastfeeding Medicine

Best Practice #4.2Best Practice #4.2 Mothers’ milk supply should be Mothers’ milk supply should be

established and maintained.established and maintained.

Best Practice # 4.3Best Practice # 4.3 Human milk should be handled Human milk should be handled

to ensure safety and maximal to ensure safety and maximal nutritional benefit to the infant.nutritional benefit to the infant.

Best Practice # 4.4Best Practice # 4.4 Obstetric, perinatal, and Obstetric, perinatal, and

neonatal professionals should neonatal professionals should counsel mothers when counsel mothers when breastfeeding may be of concern breastfeeding may be of concern or contraindicated.or contraindicated.

Implementation StrategiesImplementation Strategies Hold regular CME, CEU and other inservice Hold regular CME, CEU and other inservice

activities related to lactation issues. activities related to lactation issues. Develop competencies regarding human milk Develop competencies regarding human milk

handling and usage.handling and usage. Designate a Director of Lactation as a resource Designate a Director of Lactation as a resource

person.person. Risk factors for insufficient lactation should be Risk factors for insufficient lactation should be

communicated to perinatal and post-partum staff communicated to perinatal and post-partum staff as well as to perinatal staff of referring facilities.as well as to perinatal staff of referring facilities.

Routine and standardized patient education Routine and standardized patient education should begin during pre-pregnancy OB/GYN visits should begin during pre-pregnancy OB/GYN visits and continue through pregnancy. and continue through pregnancy.

Remove formula company influences from the Remove formula company influences from the perinatal area.perinatal area.

Breastfeeding-Supportive Infant Environment?

Transition to Oral Transition to Oral FeedingsFeedings

Early attachment is beneficial Early attachment is beneficial for milk production and for milk production and mother-child bonding.mother-child bonding.

Skin-to skin contact may strengthen Skin-to skin contact may strengthen the mother-infant dyad and lead to the mother-infant dyad and lead to longer breastfeeding periods over longer breastfeeding periods over the first two years of life.the first two years of life.

Non-nutritive breastfeeding can Non-nutritive breastfeeding can stimulate milk volume and improve stimulate milk volume and improve breastfeeding success rates. breastfeeding success rates.

Best Practice #5.1Best Practice #5.1 Infants should be transitioned Infants should be transitioned

from gavage to oral feedings from gavage to oral feedings when physiologically capable, when physiologically capable, not based on arbitrary weight or not based on arbitrary weight or gestational age criteria.gestational age criteria.

Best Practice # 5.2Best Practice # 5.2 A definitive protocol for transition to A definitive protocol for transition to

oral feedings of human milk or oral feedings of human milk or formula does not currently exist. formula does not currently exist. NICU healthcare providers should NICU healthcare providers should make use of safe techniques for make use of safe techniques for which some evidence exists (skin-to-which some evidence exists (skin-to-skin care, non-nutritive skin care, non-nutritive breastfeeding, test-weighing, breastfeeding, test-weighing, alternate feeding methods) to alternate feeding methods) to effectively facilitate transition to full effectively facilitate transition to full oral feeding.oral feeding.

Implementation StrategiesImplementation Strategies Implement and encourage routine Implement and encourage routine

skin-to-skin time.skin-to-skin time. Measure lactation timeMeasure lactation time Measure breastfeeding frequency Measure breastfeeding frequency

and breastfeeding status at the time and breastfeeding status at the time of discharge. of discharge.

Discharge Planning Discharge Planning and and

Post-Discharge Post-Discharge NutritionNutrition

In the weeks prior to discharge In the weeks prior to discharge from the NICU an individualized from the NICU an individualized

nutritional plan should be nutritional plan should be prepared.prepared.

These plans should be coordinated between These plans should be coordinated between the family, neonatology, lactation the family, neonatology, lactation consultants, dieticians, nursing staff and if consultants, dieticians, nursing staff and if possible the primary care physician possible the primary care physician continuing to provide care following continuing to provide care following discharge.discharge.

Post-discharge nutrition, including the need Post-discharge nutrition, including the need for special diets, frequency of visits and for special diets, frequency of visits and monitoring of growth and biochemical monitoring of growth and biochemical markers is required. markers is required.

VLBW infants grow faster and have higher VLBW infants grow faster and have higher bone mineral content up to 1 year of age if bone mineral content up to 1 year of age if provided with additional nutrients including provided with additional nutrients including protein, calcium and phosphorus. protein, calcium and phosphorus.

Best Practice #6.1Best Practice #6.1 Nutritional discharge planning Nutritional discharge planning

should be comprehensive, should be comprehensive, coordinated and initiated early coordinated and initiated early in the hospital course. Planning in the hospital course. Planning should include appropriate should include appropriate nutrient fortification and nutrient fortification and nutritional follow-up.nutritional follow-up.

Best Practice #6.2Best Practice #6.2

Mothers should be encouraged Mothers should be encouraged to eventually achieve exclusive to eventually achieve exclusive breastfeeding after discharge breastfeeding after discharge while ensuring appropriate while ensuring appropriate growth for the infant.growth for the infant.

The End

Questions?Review the CPQCC Toolkit: Nutritional Support of the Very Low Birth Weight Infant.Available at: www.cpqcc.org