FEEDING

PRESENTER; VICTOR MUTAI

FACILITATOR; DR. NGETICH, CONSULTANT
PAEDIATRICIAN
 TYPES OF FEEDS

1.Breast milk.
2. Alternative feeds ie cowmilk, formula.
3. Total parenteral feeds.

MODES OF FEEDING
1. Breast feeding.
2. Cup and spoon feeding.
3. NGT.
4. Intravenous.
5. Formular feeding.
 A.BREASTFEEDING

 Exclusive B>F recommended for the 1st 6 months of life.

 Physiology.Lactogen induced colostrum in 2nd trimester,
prolactin stimulated milk production, oxytoxin induced milk
letdown reflex, environmental influences eg stress, illness etc.
 Benefits; mother and infant. Include
 Decreased incidence and severity of infection/chronic dse.
 Improved function of the immune system.
 Improved nutriton and growth.
 Improved cognitive development.
 Maternal health and psychosocial benefits.
 Socioeconomic benefits

 Containdications: HIV, CMV, HSV 1,Drug abuse, galactosemic

infant.
Premature infants
 INTRODUCTION

 Premature infants have greater nutritional needs to achieve

optimal growth in the neonatal period than at any other time of
their life
 reasons for this:
i. Born beginning of the third trimester-> are growth-restricted
D2 decreased intrauterine nutrient deposition
ii. hypotension, hypoxia, acidosis, infection, and surgery
increase metabolic energy requirements and thus nutrient
needs
iii. Impediments to growth-physiologic immaturity of the
gastrointestinal tract including decreased gastrointestinal
motility and reduced intestinal enzyme activity- also steroid
use
Nutritional support
 corrects growth restriction at birth
 achieves appropriate rates of weight gain, which are
almost twice that of a term infant
however aggressive feeding may result in
 feeding intolerance
 NEC
 Toxic effects-excess of some feeds
 Parenteral nutrition

 INDICATIONS
When enteral feeding is:
Impossible, inadequate or hazardous
As a result of:
malformation, disease or immaturity

CONTRAINDICATIONS
• Circulatory instability (hypotension, renal failure)
• Severe acidosis
• Borderline oxygenation
• Fulminating sepsis
• Bleeding diathesis
• Jaundice close to exchange transfusion level
 NUTRITIONAL GOALS

 achieve
i. intrauterine rates of growth
ii. nutrient accretion
How?
by providing sufficient calories and nutrients
 Energy requirements

 Adequate caloric requirements to achieve optimal growth are based upon

i. resting energy expenditure 30 kcal/kg/d

ii. energy requirements for activity 5-70 kcal/kg/d
iii. chronic medical conditions
iv. growth 5 kcal/g

 8 to 63 days of postnatal age, , resting energy expenditure;

o 49 to 60 kcal/kg per day

 Thus;
a) enteral fed premature infants- 140-200kcal/kg per day (
b) infants fed parenterally- 80 to 100 kcal/kg per day (less fecal energy
loss, fewer episodes of cold stress, and somewhat less activity).
 NUTRITIONAL ASSESSMENT

determines the daily energy and nutrient

requirements for optimal growth and whether these
nutritional goals are met
Also includes readjustment of nutritional intake if
the target growth rate is not met
 nutritional status
A. monitored by- daily assessments of fluid,
nutrients, and energy intake
B. evaluated by- rate of growth ( wt., head circum. ,
length)
 Growth parameters

Weight- minimum increment of 15g/kg per day

 Once the infant reaches 2.0 kg- 20 to 30 g/d
Length- minimum increment of 1 cm per week
Head circumference- minimum increment of 1 cm
per week.

Growth parameters are charted on specific growth

curves for premature infants
 Biochemical assessment

Measurements are made weekly for two weeks, then

every other week if they remain normal
Bone mineral status- serum calcium, phosphorus,
and alkaline phosphatase activity
Protein status-serum albumin and urea nitrogen
Electrolytes
 hemoglobin and reticulocyte count- anemia
 Recommended daily parenteral and enteral
requirements for premature infants

Component (unit) Parenteral intake, Enteral intake,

unit/kg unit/kg

Water (mL) 150 150

Energy (kcal 80-100 120-130

Protein (g 3.0-3.5 3.5

Fat (g) 1-4 5-7

Carbohydrate (g) 16 12-14

 Minimal enteral feedings ("trophic feeding").

 also called hypocaloric, trophic, trickle feedings, low-volume

enteral substrate, or gastrointestinal priming
 Characterized by a small-volume feeding to supplement
parenteral nutrition.
 Studies focus on use in infants <1500 g
 Benefits
i. improved feeding tolerance
ii. prevention of gastrointestinal atrophy
iii. facilitation of gastrointestinal tract maturation- shorter time
required to attain full enteral feedings
iv. decreased incidences of cholestasis, nosocomial infections,
metabolic bone disease, and decreased hospital stay
 no standard method of minimal enteral feeding, and a wide variety of feeding
techniques and formulas exist
 MOH september 2010 protocol:
A. Well baby- immediate milk feeding; 1st feed 7.5 mls n increase by this amount till
full daily vol. reached
B. Sick baby or < 1500g-
day 1 - 10% D
day 2 – NGT feeds unless baby very unwell
5mls/3hrs - <1.5 kg
7.5mls/3hrs- 1.5-2.0 kgs
10mls/3hrs- >2.0kgs
increase feed by the same amount every day n reduce IVF to keep within the
totla daily vol. until IVF stopped
 Always use EBM for NGT feeds unless CI
 If signs of poor perfusion or fluid overload ask for senior opinion on whether to
give bolus, step-up or step-down daily fluids
 Weight: <1200 g; GA: <30 weeks. Gavage feeding through an orogastric or nasogastric
tube is appropriate.
i. Initial feeding: breast milk or donor breast milk; preterm infant
formulas.

ii. Maintenance feeding: breast milk (with or without human milk fortifier,) or preterm formulas Donor
breast milk should not be used for
maintenance because it does not provide adequate proteins and minerals for long-term growth.

iii. Subsequent feedings

(a) Volume. Bolus feeds, 10-20 mL/kg/day in divided volumes every 2 h. Advance feeds
by 10-20 mL/kg/day. Alternatively, give 0.5-1.0 mL/h continuously and increase by 0.5-1.0 mL every
12-24 h. When 10 mL/h is tolerated, change feedings to every 2 h and advance as tolerated.
(b) Strength. Use expressed breast milk or preterm formula. Once full feedings of 20 cal/
oz are tolerated, consider advancing to 24-cal/oz feedings or adding human milk fortifier to breast
milk.

MTRH- aspirate at every feed and

If full volume of previous feed is aspirated, then feed was not retained
 b. Weight: 1200-1500 g; GA: <32 weeks. Gavage feeding
through a nasogastric tube should be used.
 i. Initial feeding. Give breast milk or preterm formula
every 2-3 h.
 ii. Subsequent feedings
 (a) Volume. Bolus feeds, 10-20 mL/kg/day in divided
volumes, every 3 h. Advance feeds by 10-20 mL/kg/day.
Alternatively, give 2 mL/kg every 2 h, and increase by 1 mL every
12 h up to 20 mL every 2 h. Then change to feedings every 3 h.
 (b) Strength. Use breast milk or preterm formulas. Once
full feedings of 20 cal/oz are tolerated, advance to 24 cal/oz if
desired or add human milk fortifier (22 or 24 cal/oz).
 c. Weight: 1500-2000 g. Use gavage feeding through an
orogastric or nasogastric tube.
 Breast-feeding or bottle-feeding can be attempted if the infant is >1600 g,
>34 weeks' gestation, and
 neurologically intact. Initiation of early nursing is associated with earlier
time to achieve full enteral
 feeds.
 i. Initial feeding. Use expressed breast milk or preterm infant
formulas. For infants >1800
 g (>36 weeks), term infant formulas may be considered (controversial).
 Breast milk or preterm infant formula should be used.
 ii. Subsequent feedings. Give 2.5-5 mL/kg every 3 h, and
advance 10-20 mL/kg/day as
 tolerated
d. Weight: 2000-2500 g; GA: >36 weeks.
Nursing or bottle-feeding should be tried if
the
infant is neurologically intact.
i. Initial feeding. Begin breast milk or term
infant formula.
ii. Subsequent feedings. Give 5 mL/kg every
3-4 h, and advance 10-20 mL/kg/day as
tolerated.
e. Weight: >2500 g. Breast-feed or use a
bottle if the infant is neurologically intact.
i. Initial feeding. Begin breast milk or term infant
formula.
ii. Subsequent feedings. Feed every 3-4 h, and
advance as tolerated. Use 5 mL/kg;
advance 20 mL/kg/day.
Management of feeding intolerance. If feeding is
initiated but not tolerated, a complete
abdominal examination should be performed. Consider
abdominal x-ray studies if the physical
findings are suspicious. If the abdominal evaluation is
normal:
A. Attempt continuous feedings with a nasogastric
or orogastric tube. Check the gastric aspirate
B. Use breast milk preferably or special formula
(eg, Similac PM 60/40 or Pregestimil) because
they may be better tolerated.
 Composition of Breastmilk

A)Colosrum.2-3 days postnatal.High density, low volume

feedd of 20-100mls/day.Less lactose,fat, vit B and C,more
vit A, E, K, prot-,minerals esp. sodium and Zn,
Antibodies.Good for gut development i.e normal flora.
B) Transitional Milk.3-14 days
postpartum.colostrum>mature milk.
C)Mature (hind) milk. As shown below;
Content/ Human Cow Formula
Milk
Content
Water% 87 87 87
Energy 67 66 70
kcal/100ml
Protein(gm)
s 9 34 15
Fat(gm) 38 37 37
CHO(gm) 68 49 70
 B.F in the healthy term infant.

 1.Should nurse soonest after delivery i.e 30 mins and

subsequently on demand(*8-12).
 2.Should nurse on first brest until satisfied and come off
spontaneously B4 2nd side; maximises hindmilk ingestion.
 3.Avoid pacifiers and supplememtal feeds during 1st 2 wks
unless medically indicated.
 4.Deep latching; nipple,alveola(0.5-1cm),surroundin breast.
 5.Check for signs of adequate milk transfer: audible
swallowing, 15-20min sucklin,breast softening, wet diapers
etc.
 6.Follow-up and support group for mother.EBM may be
considered for working mothers or sick infants on NGT.
 B.F in premature/sick infants.

Mothers should initiate and maintain lactation through

expressing milk or use of pumps .(Delayed
lactation).Frequency:8-12 times a day.Store milk in clean
container and freeze.
Put infant on breast as soon as they are stable and at each
visit.
Fortification of breastmilk with HMF(High energy,
prot,vit,minerals).
Followup and continued supplementation until
appropriate weight ie >25oog and tolerating full vol. feeds.
Medications to mother should be given cautiously.
 Determination of feeds.
 Index weight: highest weight achieved.
 Trophic feeds (gut priming feeds) recommended at 10mls/kg/day i.e. for gut maturation.
 Frequency of feeds(minimum) =3 hourly(*8 daily).
 Amount of feeds;

Weight(g) Starter(ml Increment Maximum(

/kg/day) (ml/kg/ ml/kg/day)
day)

>1500 60 20 200
1000-1500 80 20 150
<1000 100 20 150

 Minimum calorific requirements

 120-200kcal/kg/day.
 3cc EBM=2 Kcal.
 Increment of feeds;
 Full term 3mls/feed.
 LBW(1500-2500g) 2ml/feed.
 VLBW(<1500g) 1 ml/feed.
 Determination of days from hour and date of birth till present.
 TPN and EBM considered concurrently if need arises.
 Example

 B.M birth weight 1600g c.w=1700g.

 What amount is needed of EBM on day 6 after admission to achieve
growth?

 N.B –If baby can tolerate less amounts increase as per requirements
till recommended.
 Breastmilk is preferable to alternative feeds and should be
acceptable, feasible, affordable, sustainable and safe.(AFASS)
B.TOTAL PARENTERAL NUTRITION(TPN)

Goal: Provide sufficient calories and aa to prevent

negative energy and electrolyte balance.
Indications:
LBW/VLBW.
Comatose infants.
Acutely ill infants e.g. NEC.
Post operative infants.

Admin: Peripheral or central line.

 Nutritional requirements

A) Carbohydrates.
Administered in the form of 10% dextrose .VLBW infants
are given 5% dextrose due to increased risk of
hyperglycaemia.
Rx commences from day 1.
Calorific value of dextrose is 3.4kcal/day.
Infusion rates;
• TERM 5mg/kg/min.
• Preterm 5-8mg/kg/min.(higher energy needs).

Increments 1-2mg/kg/min daily until ~14mg/kg/min.

Check for signs of glucose intolerance:hyperglycaemia and
sec. glucosuria.
 B)Protein.
 Calorific value of aa is 4kcal/g.
 Infusion recommended at 1g/kg/day (VLBW) or
1.5g/kg/day (LBW/NBW)per day in first 24 hrs.
 Increments at 1g/kg/day till target, 3.5g/kg/day(<1500)
and 3.0g/kg/day(>1500).
 C)LIPID.
 Soybean oil,sunflower oil.
 <1000g=0.5-1.0g/kg/day in first
24-48hrs.max=3.0g/kg/day.
 >1000g=1.0g/kg/day in first 24-48hrs. Max=3.0g/kg/day.
 D)ELECTROLYTES.
 Na 2meq/kg/day.
 K 1meq/kg/day.
 E)VITAMINS.
 A, B, C, D,E, K, Pyridoxine, Biotin, Folate, Niacin, Thiamine, Riboflavin.
 Multivitamins supplements.
 Preterm;
 Vitamin K (i.m) 1mg at birth.
 Vitamin A and D(1000i.u &400 i.u resp. from 2 weeks of age.
 Vitamin E supplements till 37 wks.
 F)MINERALS.
 Imp: Calcium, Phosphorus supplements till 37 wks.
 Fe 2mg/kg/day starting 4-8 wks till 12 months of age.
 Folate 5mg/wk.
 Zn 8-12umol/kg/day.
 N.b. Preterm milk provides adequate amounts of protein, Na, K, Vit and Cu and nearly dequate
amounts of ZN, Fe and Mg.I t’s poor in Ca and Phos.
 G)TRACE ELEMENTS.
 Cu, Mn, Se.
 DETERMINATION OF FEEDS.
Index weight: Highest weight achieved.
Administration of fluids;
Weight Initial Increment Maximum
Therapy(m (ml/day) fluids.
l/kg/day) (ml/kg/day
)
>1500g 60 20 200
1ooo-1500g 80 20 150
<1000 100 20 150
Extra(1.2-1.5)ml/kg of fluid added to babies under
phototherapy.
Electolyte ratios
Nacl(ml/kg) Kcl(ml/kg) Dextrose(ml/
kg)
19 1 (remainder)
 If fluids are given with breast milk(EBM) both used to
calculate total body fluid requirements.
 EXAMPLE 1
 Wt. 1500g,how much fluid is going to be administered on
day 5?How much of Nacl/kcl/dextrose is to be given?
 Start=80ml/kg day 5=(20*4=80mls increment),total=160
bt max is 15oml/kg.
 150*1.5=225mls of fluid.
 Nacl=19*1.5=28.5ml.
 Kcl=1*1.5=1.5ml.
 Dextrose=(remaining)=225-(28.5+ 1.5)=225-30=195ml.
EXAMPLE2
Baby in example 1 is also receiving breast milk 6ml/3
hrs/day.How much Na, K and dextrose does he
need?
Total fluids=225mls.Total milk=48mls in 24hrs.
Electrolyte needed=225-48=177mls.
Na=19*1.5=28.5,k=1*1.5=1.5mls, Dextrose=177-
(28.5+1.5)=147ml.
 Metabolic monitoring

BLOOD: Glucose, elecrolytes, pCo2,pO2,urea,

nitrogen, creatinine, phos., mg, total prot-, albumin,
transaminases(ALT/AST), bilirubin, Tg’s,
Haematocrit.(Above done daily/weekly).
URINE: Specific gravity,total volume.(Daily)
 COMPLICATIONS

Cholestasis.
Metabolic bone disease.
Metabolic abn e.g azotemia, hyperammonemia and
hyperchloremic metabolic acidosis,hyperlipidemia.
Indirect hyperbilirubinemia.
Sepsis.
Chronic lung disease.
Fluid overload and CCF.