Low Birth Weight feeding

Neocon Nursing workshop 2021

Dr Jyothi Prabhakar
Consultant KIMS
Pranamam!!!!!!!!
Scenario…1
• 38 weeks /2.2 kg at birth , baby girl, normal delivery ,discharged after
72 hrs , referred on day 5 with poor activity, poor suck..
• Weight at admission: 1.5kg
• RBS at admission : 15 mg%

• On follow up at 2 years…developmental delay..blind

Scenario….. 2
• 36 weeks/3.5 kg/IDM…born by Normal vaginal delivery
• Discharged after 48 hrs

• Referred on day 6…with seizures and jaundice

• At admission wt 2.6 kg
• RBS 60, TSB 25 mg%, Sodium 185meq/L
• At 3 years ….child is CP…recurrent seizures…hearing impaired.
Scenario….3
• 28 weeks/1 kg at birth….
• Stormy course…
• Long NICU stay
Were these situations avoidable????

•
YES
Nutritional guidelines on LBW: NITI Aayog
(2018)
• In India, about 7.5 million infants are born LBW every year

• The nutritional management of LBW infants is important as it

influences not only their immediate survival, but also
subsequent growth and long-term neurodevelopment.
2 different categories
PRETERMS
IUGR
TERM/IUGR
Term/LBW feeding..scenario 1
• IUGR/SGA
• IUGR---high risk of in utero deterioration, perinatal mortality, poor
postnatal outcomes…needs longterm follow up..
• Fetal adaptation to hypoxia/placental insufficiency.

• Rarely…Chromosomal, TORCH

• FGR; close Monitoring starts in utero

Problems of IUGR neonates..
• Risks of asphyxia/ MAS/PPHN
• Hypothermia
• Hypoglycemia
• Polycythemia/thrombocytopenia
• Hypocalcemia
• Breast Feeding problems
• Feed intolerance
 Mothers need more support and motivation
• Skin –skin contact
• Lactational Support in the early sensitive hours
• Monitor feeding…

• Breast feeding support :Baby issues and maternal—flat nipples, nipple sore,
breast engorgement
• Emotional support

• Nutritional support/ formula feeds may be needed.

• Regular RBS monitoring for 48-72 hours
 Planned discharge
• Mother confident in breast feeding
• Not more than expected weight loss
• RBS more than 60 (prefeed)
• Urine 1-2 times/day, stools 2 to3 times /day and transitional
• Bilirubin
• Thermal regulation
• Other routines, blood tests/vaccination
• Review within first week/early SOS
• Predischarge counselling….warning signs..
LBW/PRETERM …
Preterms..
• Decision on feeding is mainly determined by the gestation

• If gestation can’t be determined birth weight can be used

and baby should be monitored during feeding
Scenario .2 (36 weeks/3.5kg/IDM)
Definitions of gestation
Late Preterm babies
• Late Preterms…..to emphasize the risk of immaturity related complications.

• Respiratory distress, infections, apnoea’s, life threatening events

• Hypothermia, jaundice

• Hypoglycemia, poor feeding, weight loss, early malnutrition

• Delayed discharge and risk of readmissions

Feeding concerns….

Poorer rates of breastfeeding initiation and

duration compared to term infants.

• Discharge only after lactation is established

Planned discharge

• RBS monitoring , Bilirubin..other routines

• Weight, urine ,stools
• Should be discharged only when lactation is established ( 34
weeks – 2 weeks min, 35 weeks -1week min, 36 weeks 4 days
minimum).
• At increased risk of infections
• Follow up.

• Reference: Stewart DL, Barfield WD, AAP COMMITTEE ON FETUS AND NEWBORN. Updates on an At-Risk Population: LatePreterm and Early-Term
Infants. Pediatrics. 2019;
Need for supplements
• Late Preterms less than 2.5 kg should receive 1 to 2 mg/kg of iron till 6 months

• Vitamin D at least 400 IU till 1 year

Moderate preterms(32 -34 weeks /1500-
2000gm)
• Needs NICU admission
• Encourage breast milk expression
• Try feeding by paladai
• Ensure safety: baby is able to suck and swallow without coughing or
chocking
 Proactive nutritional support
• Immaturity ,poor suck, un coordinated suck swallow breath organization, choking

• Challenges in latching and milk supply.

• Encourage breast milk expression ensuring sterility
• Mother baby separation –encourage mothers in NICU

• Extra vigilance, ensure hemodynamic stability, lactation support, KMC

• Pacifiers, may have negative effect.
• Formula feeds only if medically indicated
 How much to feed?
• 60ml/kg on day 1
• Increase daily by 15 to 20 ml/kg
FORMULA FEED PREPARATION
• Clean hands
• Clean surface
• Clean bottles/paladai
• Bottle/paladai sterilization
• Well boiled/lukewarm water
• Discard remaining feeds
• Clean utensils and sterilize
Supplements for babies less 1800gm

Supplements Govt of India AAP Esphgan

Calcium and Pho Ca 120-140mg/kg/d 150 to 220 Ca 120-140mg/kg/d

P 60-90 once total 75 to 140 P 60-90 once total
vol of feed is vol of feed is
100ml/kg/d 100ml/kg/d
Till Term Till Term
Vit D 400 to1000IU/d till 200 to 400 800 to 1000
6 months
Iron 2mg/kg/day till 6 2 to3 mg/kg/d
months
Very preterm < 32 weeks/<1500

• NICU admission
• Warmer/incubator
• Respiratory support
• Orogastric feeds
• IV fluids
• Early Parent participation

• KMC

• Supplements

• NNS/Pacifier---
• Gradual transition to paladai/DBF
Preterm nutrition ..ELBW

3 stages • Infants receiving early and

adequate parenteral nutrition
regain birth weight more quickly
• Early aggressive nutrition stage
and experience improved weight
gain and head growth
• Growing care stage

• Postdischarge stage
Parenteral Nutrition
Early enteral feeds /MEN

Minimal enteral nutrition

• Early EBM • Maturation of gut immunity,
• Early parent participation enzymes, motility
• Emotional support to mothers Early achievement of full feeds
• KMC
Oral colostrum care

• 0.1 to 0.2 ml of colostrum to

each cheek

• Reduces sepsis,NEC,shorter
length of hospital stay
NNS

• Improves suck swallow

coordination
• Facilitates transition to oral
feeds, early attainment of full Swallow and suck develops
feeds early 14 to 15 weeks!!!!
• Early hospital discharge
• Consistent swallow by 22-24
weeks
Choice of milk
1.MOM
• Reduced sepsis/NEC
• Better cognitive outcomes

2.PDHM: decrease NEC/days to full feed

3.Preterm formula: improved growth

increased risk of NEC
Standard feeding regimen
• Choice of milk?
• When to start?
• How much to start?
• How much to increase daily?
• At What intervals?
• When to start fortifiers?
• When to start mineral supplements, iron?
Growth monitoring

Fenton’s chart Intergrowth chart

Weight
Transition to oral feeds

 Most preterm babies will show readiness for transition to oral feeds by 32- 34 weeks

 Techniques which promote transition to oral feeds: KMC, non -nutritive sucking, oral
pacifiers

 Nipple shields have been tried to assist poor latch

 More important is babies should be monitored during oral feeds/NNS/DBF

Learning points
• LBW babies even they are term
born needs extra care , lactation
assistance, planned discharge and
long term follow up to ensure
normal growth and development

• Preterms need more intensive

monitoring and care based on
their gestation , more lactational
support and long term follow up