Dr.Khadeja Feeding

Premature infants have greater nutritional needs in the neonatal period than at any other time of their lives.

Proper nutrition in preterm is essential for:

They may receive three different kinds of nutrition

Normal growth.

Resistance to infection.

Long term health.

Optimal neurological and cognitive development.

Coordinated sucking and swallowing develops at 32-34 weeks.

SO..

Providing adequate nutrition to preterm infants is challenging because of several problems.

Total parenteral nutrition (TPN)

Breast milk

Infant formula designed for premature babies

Fortified human milk (FHM)

Human milk is the preferred option for feeding infants but requires fortification to meet the nutritional needs of preterm newborns.

Human milk is important for the optimal growth and development of full-term babies, but it is even more important for babies born prematurely

the colostrum from the mother is important for the continued maturation of the gut

Human milk is preferred for feedings (Colostrum should be used for early feedings).

What and how to feed preterm ?

How and what a premature baby is fed depends on their gestational age and whether there are complications with any part of the gastrointestinal tract.

The most common problem of preterm is

There are three ways to feed premature babies:

Feeding difficulty

But WHY?

Intravenously

Preterm infants often display difficulty establishing oral feeding in the weeks following birth.

These problems include:

Immaturity of bowel function

Inability to suck and swallow

High risk of necrotizing enterocolitis (NEC)

Illnesses that may interfere with adequate enteral feeding (e.g., RDS, patent ductus arteriosus)

Medical interventions that preclude feeding (e.g., umbilical vessel catheters, exchange transfusion, indomethacin therapy).

Through a feeding tube

Directly by mouth

When to start feeding and how?

(Babies who are more than 34 weeks gestation are usually able to suck, unless they are ill)

Breast feed and encourage EXCLUSIVE breast feeding

Allow mothers to breast feed on demand and room-in (Colostrum)

Initiate breast feeding within the first 30 minutes of birth

If the infant is able to suck

If preterm less than 34 weeks

keep NPO first 24 hours

Kangaroo care – having skin-to-skin contact with your baby just before and even during expressing helps to increase milk supply

If the baby is not able to feed

Feeding the Gut (Trophic Feedings)

The infant may be <32 weeks or ill e.g. severe respiratory distress.

• Commence IV maintenance fluids at the appropriate rate

• Keep on IV fluids

• Colostrum will be used for mouth care.

• Place a small amount (0.1- 1 ml q 6 hrs) directly onto oral mucosa in buccal cavity for absorption by mucosa

• Gradually add feeds from Day 2

• Increase the feeds if there is no vomiting, apnea or abdominal distension

• If the baby is unable to tolerate feeds at all, IV fluids can be continued for a maximum of 3 days.

• Feedings over 2 ml in volume will be given by infusion pump over 30 minutes

• Do not automatically/routinely freeze colostrum (if not used within 48 hours, then freeze)

• The provision of small amounts of feedings starting soon after birth aims at preventing atrophy of the gut.

• A number of studies in recent years have demonstrated the general feasibility of this approach as well as beneficial clinical effects, with no recognizable increase in the risk of necrotizing enterocolitis.

• Although we have no formal protocol for the use of trophic feedings, such feedings are being used increasingly and their use is encouraged.

• Colostrum/human milk should be used whenever available. Otherwise, preemie formula should be used.

• Trophic feedings should be initiated at a volume not to exceed 15 ml/kg/d.

• These feedings are traditionally given in small boluses of 1 - 3 ml/kg per feeding.

HOW?

Preterm infant receiving PULSED NTrainer stimulation during gavage feeding in the neonatal intensive care unit, with a nasogastric tube placed through the left nares (not visible); pneumatic stimulus control signals and output through the pacifier nipple are shown in the left panel: (a) voltage-controller gate signal, (b) intraluminal pressure (inside) the nipple, and (c) mechanical displacement at the nipple cylinder wall (Photo courtesy of Innara Health, Inc., Olathe, Kansas USA

NTrainer Therapy

Therapeutic Patterned Stimulation of NNS for Premature and Newborn Infants

• Pulsed pneumatic oro cutaneous stimulation has been shown to improve nonnutritive sucking (NNS) skills in preterm infants who exhibit delayed or disordered nipple feeding.

• The aims of this study represent the first attempt to combine noninvasive treatment strategies and transcriptomic assessments of high-risk extremely preterm infants (EPI) to improve oral feeding behavior and skills

• PULSED or SHAM (non-pulsing) oro cutaneous intervention simultaneous with tube feedings 3 times per day for 4 weeks, beginning at 30 weeks postconceptional age

• The ongoing National Institutes of Health funded randomized controlled trial is actively recruiting participants. The expected completion date of the study is 2021.

Try to avoid oral aversion

What Is Oral Aversion?

Many common NICU procedures are painful and can cause babies to try to push or turn away from anything that comes near their faces, even a pacifier, bottle, or mom's breast.

NICU procedures that may increase the risk for oral aversions include:

• Intubation and mechanical ventilation
• Frequent suctioning
• Long-term use of NG or OG tubes
• Inappropriate oral feedings in the NICU

Babies who exhibit oral aversion (the reluctance, avoidance, or fear of eating, drinking, or accepting sensation in or around the mouth) refuse to eat or experience significant distress during feeding, causing them to receive inadequate nutrition.

Signs of oral aversion include:

• Appearing hungry but refusing to eat.

• Fussing or crying when preparations are made for feeding time such as when placed in a feeding position or when presenting a bottle.

• Clamping his or her mouth shut and turning his or her head away from the breast or bottle.

• Taking a small amount of breast or bottle milk and then pulling away.

• Feeding only while drowsy or asleep.

• Consuming less milk or food than expected for age.

• Displaying poor growth.

Risk of oral aversion

Other feeding problems:

1- GER

2- Feeding intolerance

3- NEC

• Oral aversion can be very frustrating for parents, caregivers, and the babies themselves.

• There are many psychosocial and medical complications of feeding difficulties, including:

• Infant and parental distress
• Parental lack of confidence
• Social isolation
• Impaired parent/infant bonding
• Poor growth
• Compromised development