Nutrition

Outline
• Breastfeeding
• Parenteral nutrition
• Vitamin and micronutrient in newborn
 Breastfeeding
• Breastfeeding is one of the most effective ways to ensure child
health and survival.
• Breast milk is the ideal food for infants.
• It is safe, clean and contains antibodies which help protect
against many common childhood illnesses
• However, contrary to WHO recommendations, fewer than half
of infants under 6 months old are exclusively breastfed.
• Breast milk provides all the energy and nutrients that the
infant needs for the first months of life
• Breastfeeding is recognized as the normative standard for
virtually all infants because of its health benefits to infants
and their mothers.
• There is broad consensus recommending exclusive
breastfeeding for approximately the first six months and
continued breastfeeding, along with the introduction of solid
foods, for at least one year after birth, as long as it is mutually
desired by mother and infant.
• The WHO recommends continued breastfeeding through at
least the child's second birthday.
• Exclusive breastfeeding is practiced by less than one-half of
mothers at three months postpartum and only one-quarter of
mothers at six months.
• These observations call for collaboration among mothers,
partners and families, communities, clinicians, health care
facilities, and employers to actively support optimal
breastfeeding.
 Assessing a breastfeeding
• Health workers treating sick young children have a responsibility to encourage
mothers to breastfeed and to help them overcome any difficulties.
• Take a breastfeeding history by asking about the baby’s feeding and behavior.
• Observe the mother while breastfeeding to decide whether she needs help.
• Signs of good attachment are
— more areola visible above baby’s mouth
— mouth wide open
— lower lip turned out
— baby’s chin touching the breast.
• How the mother holds her baby
— baby should be held close to the mother
— baby should face the breast
— baby’s body should be in a straight line with the head
— baby’s whole body should be supported.
Beneficial Properties of Human Milk
• WHO actively promotes breastfeeding as the best source of
nourishment for infants and young children, and is working to
increase the rate of exclusive breastfeeding for the first 6 months
up to at least 50% by 2025.
• In 2018, WHO revised the Ten Steps based on the 2017 guideline
on protecting, promoting and supporting breastfeeding in
facilities that provide maternity and newborn services.
• WHO has called upon all facilities providing maternity and
newborn services worldwide to implement the Ten Steps.
• The implementation guidance for BFHI focuses on integrating the
programme across healthcare systems to facilitate universal
coverage and ensure sustainability over time.
 10 steps of BF
Critical management procedures
1
– a. Comply fully with the International Code of Marketing of
Breast-milk Substitutes and relevant World Health Assembly
resolutions.
– b. Have a written infant feeding policy that is routinely
communicated to staff and parents.
– c. Establish ongoing monitoring and data-management
systems.
 2. Ensure that staff have sufficient knowledge, competence and
skills to support breastfeeding.
Key clinical practices

3. Discuss the importance and management of breastfeeding with pregnant women and
their families.
4. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to
initiate breastfeeding as soon as possible after birth.
5. Support mothers to initiate and maintain breastfeeding and manage common
difficulties.
6. Do not provide breastfed newborns any food or fluids other than breast milk, unless
medically indicated.
7. Enable mothers and their infants to remain together and to practice rooming-in 24
hours a day.
8. Support mothers to recognize and respond to their infants’ cues for feeding.
9. Counsel mothers on the use and risks of feeding bottles,and pacifiers.
10. Coordinate discharge so that parents and their infants have timely access to ongoing
support and care.
• Energy requirement by a newborn
– Recommended daily Calorie for newborn is 100 – 135
kcal/kg/day
– The calorie requirement for preterm, EVLBW and SGA
infants is higher ( 120-150Kcal/kg/day)
– When baby is sick – (fever, sepsis, hypoxia) Calorie
requirement increases by 10 – 30Kcal/kg/day
 Protein requirement by newborn
• Generally, Newborn needs more protein per unit of weight
than adult
• Preterm needs more protein per body weight per day than
term newborn
 Compositions of Human milk at different stages

• Colostrum
– The first and yellow milk after delivery
– May last till 1 week
– Is more immunogenic (1st immunization of the newborn)
– Have higher protein & electrolyte content than mature milk
– It has lower quantity, which is adequate for newborn.
• Transitional milk
– Produced after 2nd week.
– Its protein and immunologic content is relatively lower than colostrum
but higher than mature milk
– Better quantity when compared with colostrum
– Color become more whiter than colostrum
• Mature milk
– Produced after transitional milk usually 2 – 3 weeks after
delivery
– The color is whiter, relatively thinner, have higher CHO and fat
content but lower protein and immunologic components than
transitional milk.
– Nevertheless, it is complete and provides all what newborn
needs.
• All components of milk have Foremilk and Hind milk
– Foremilk is the 1st milk coming during each
feeding; it is richer with CHO & Proteins
– Hind milk is the milk coming at the end of each
feeding; it is richer with Fats
 Complementary Feeding
• The timely introduction of complementary foods (solid and
liquid foods other than breast milk or formula, also called
weaning foods ) during infancy is important for nutritional
and developmental reasons.
• The ability of exclusive breastfeeding to meet macronutrient
and micronutrient requirements
becomes limited with increasing age of the infant.
 Parenteral nutrition
• Parenteral nutrition (PN) is intravenous
administration of nutrition, which may include
protein, carbohydrate, fat, minerals and electrolytes,
vitamins and other trace elements for patients who
are unable to take recommended daily nutritional
requirement.
• It is life-saving tool in preterm infants who are unable
to tolerate sufficient enteral feeds to meet their
nutritional needs.
 Indications for PN

• Partially functioning gastrointestinal tract :cannot meet

nutritional requirements after maximizing enteral support
– Burns
– Multi-organ failure
– Malabsorption
– Short bowel syndrome
– Chronic intractable diarrhea
– Congenital small bowel malabsorptive syndromes
(congenital chloride diarrhea, tufting enteropathy, or
microvillus inclusion disease)
 INDICATIONS for PN…….

• Pseudo-obstruction
– Severe malnutrition with hypoproteinemia and
bowel edema
• Nonfunctional gastrointestinal tract
– Paralytic ileus
– Small bowel ischemia
– Necrotizing enterocolitis
– Gastrointestinal surgery
– Gastroschisis, omphalocele, gastrointestinal atresias
 When to start PN
• Infants and children
– PN is indicated for infants and children who are unable to be fed
enterally if nutritional support is expected to be required for seven
days or more.
– Well-nourished children or adolescents tolerate up to seven days
without nutrition support
• Neonates and premature infants
– typically initiated earlier for premature infants and term neonates.
– If it is clear that the infant will not tolerate enteral feeds, then PN
usually should be initiated within the first two days of life.
– These infants have limited nutritional reserves and are able to
tolerate starvation or semistarvation for only one to three days.
 Phases of PN

• Early PN
– Its primary goal is to prevent excessive catabolism by
providing energy and protein.
– Secondary goals include prevention of hypocalcemia.
– In this phase, PN usually contains only dextrose, amino
acids and calcium, but not sodium, potassium, magnesium,
or phosphorus .
 Phases of PN …..

• Full PN
– This phase of PN is intended to meet the entire
nutritional needs of the infant and support normal
rates of growth.
– To do so, it must contain a wide range of essential
nutrients, and sufficient protein and energy to
support growth.
• The transition from early to full PN should be accomplished as
quickly as is tolerated.
• Ideally, the transition occurs within three days of birth,
although this may not be possible if the infant does not
tolerate the glucose or lipid infusion rates required to achieve
the nutrient targets.
• Although energy intakes of 30 to 40 kcal/kg/day and protein
intakes of 1 to 1.5 g/kg/day are probably sufficient to limit
catabolism early in postnatal life, much higher energy intakes
are needed to achieve near-normal rates of growth
 Energy requirements

• Early PN should contain 35 to 45 kcal/kg/day of nonprotein energy

(or 45 to 60 kcal/kg/day of total energy).
• Subsequently, the energy intake should be increased as quickly as
possible.
• Full PN should contain >65 kcal/kg/day of nonprotein energy (or 80
to 90 kcal/kg/day of total energy) to allow normal growth rates.
• This target for energy in PN is approximately 20 percent less than
required for enterally fed infants.
• This is because enteral feeds are incompletely absorbed, and the
processes of gastrointestinal digestion and absorption impose
energy costs that are not present when nutrients are provided
parenterally
 Macronutrient balance 

• Energy in PN can be provided as carbohydrates (as glucose),

lipids, and protein (as amino acids).
• Each of these components is necessary to achieve growth.
• Glucose – To avoid hypoglycemia and to meet the obligatory
glucose needs of the developing brain, glucose should be
provided at a minimum rate of 5 to 8 mg/kg/minute, starting
immediately after birth (eg, 10% dextrose solution at 100
mL/kg/day).
• As PN is advanced, the glucose component is typically increased
to around 12 to 15 mg/kg/minute, but the target rate may vary
depending on the proportion of energy needs provided by
lipids.
• Lipids – Lipids should provide approximately 30 to 50 percent
of nonprotein energy (similar to human milk), which may help
to optimize protein accretion while limiting the potential
toxicity of excessive lipids.
• PN containing either 29 or 40 percent of nonprotein energy as
fat (equivalent to approximately 2 to 3 g/kg/day of lipid)
resulted in improved protein retention compared with PN
with a lower proportion of fat
• Protein – If sufficient energy cannot be provided due to lipid
or glucose intolerance in the very low birth weight (VLBW)
infant, providing the "target" intake of amino acid/protein will
not achieve normal growth; rather, it will impose a metabolic
burden on the infant as amino acids need to be catabolized.
• Amino acid intakes as low as 1.0 to 1.5 g/kg/day appear
sufficient to prevent overt catabolism, which is associated
negative nitrogen balance and risk of hyperkalemia
• VLBW infants
– For VLBW infants (birth weight 1000 to 1500 g), amino acids are
usually started at 1.5 to 2.5 g/kg/day and then advanced rapidly
to reach a target of 3.5 g/kg/day by the second or third day of
life
• ELBW infants
– For ELBW infants (<1000 g) amino acid intakes (eg,
approximately 2.5 to 3.0 g/kg/day) may be appropriate during
the first week of life.
• Larger infants
– For larger infants (≥1500 g) maximum parenteral protein intake
of 3 g/kg for 1500 to 2000 g and 2.5 g/kg for 2000 to 2500 g.
• Lipids
– Lipids are an important component of PN for preterm infants.
– They are an important source of energy.
– They are also needed to prevent essential fatty acid deficiency,
which can occur within the first week of life, and as early as the
second day.
• Initiation
– typically initiated at 1 to 2 g/kg/day of intravenous lipid emulsion
(ILE)
– ILE can be safely started on the first day of life.
– A minimum infusion of 0.25 g/kg/day is probably sufficient to
prevent essential fatty acid deficiency in the short term
• Calcium and phosphorus needs
– To maximize bone mineralization, high concentrations of
calcium and phosphate are generally recommended in PN
for preterm infants.
– Target intakes are 65 to 100 mg/kg/day of elemental
calcium and 50 to 80 mg/kg/day of phosphorus and can be
achieved in most VLBW infants.
 Trace minerals

• A variety of trace minerals are routinely added to PN for

preterm infants.
• Many of these are probably not important if PN is a short-
term bridge to full enteral nutrition.
• However, they become increasingly important the longer PN
is continued.
• Standard formulations of trace elements include zinc,
copper.
• These are typically added to the PN within the first few days
of life, while the PN is advanced to meet full nutritional
needs
Component Initial amount Target amount

Total energy 45 to 60 kcal/kg/day[1] 80 to 90 kcal/kg/day

Nonprotein energy 35 to 45 kcal/kg/day >65 kcal/kg/day
Amino acid 1.5 to 2.5 g/kg/day[1] 2.5 to 3.5 g/kg/day
OR OR
2 g/kg/day[2] Weight-based dosing:
 Weight <1000 g – 2.5 to 3.5 g/kg/day
 Weight ≥1000 to <1500 g – 3.0 to 3.5
g/kg/day
 Weight ≥1500 to 2000 g – 3 g/kg/day
Lipid 0 to 1 g/kg/day 2 to 3 g/kg/day
Calcium 25 to 40 mg/kg/day 65 to 100 mg/kg/day
OR 30 to 50 mg/kg/day
Phosphorus None 50 to 80 mg/kg/day
Sodium None 69 to 115 mg/kg/day
OR 2 to 4 mEq/kg/day OR 3 to 5 mEq/kg/day
Potassium None 78 to 117 mg/kg/day
OR 2 to 4 mEq/kg/day OR 2 to 3 mEq/kg/day
 ADVERSE EFFECTS OF PARENTERAL NUTRITION

• Infection
• Hyperglycemia 
• Hyperlipidemia
• Cholestatic liver disease
• Calcium/phosphate precipitates
 MICRONUTRIENT SUPPLEMENTATION

• Iron
– recommended for human milk-fed preterm or low-birth-
weight infants who are not receiving iron from another
source
– 2–4 mg/kg per day on discharge and continuing until 6
months of age
– anemia of prematurity starting at 1 mo of age and
continuing until about 1 yr
• Oral zinc
– daily dose of 1–3 mg/kg per day of elemental zinc
– Start at 2 wk to 6mo
– Zinc deficiency is associated with
• dysfunction in epidermal
• gastrointestinal,
• central nervous, immune, skeletal and
• reproductive systems
• Vitamin D supplementation
– Daily dose 400–800 IU may be initiated when
enteral feeds are well established
– 400–1000 IU per day until 6 months of age
• Vitamin A supplementation
– very preterm (< 32 weeks’ gestation) or very-low-
birth-weight (< 1.5 kg) infants
– daily dose of 1000–5000 IU
– Reduces bronchopulmonary dysplasia
• Calcium
– Required by breast-fed preterm infants until their
weight reaches term weight (3 to 3.5 kg)
– Dose 100mg/kg/day
 References
• Nelson textbook of pediatrics,21st edition
• Fanaroff and Martins neonatal- perinatal medicine, 9th
edition
• National NICU guideline, 2021
• Uptodate