Infant NutritionInfant Nutrition

Jennifer Levy, MDJennifer Levy, MD

Children’s Hospital of OaklandChildren’s Hospital of Oakland

OverviewOverview

• Fetal Energy Expenditure & SourcesFetal Energy Expenditure & Sources• Neonatal Energy Expenditure & Neonatal Energy Expenditure &

RequirementsRequirements• ProteinsProteins• FatsFats• CarbohydratesCarbohydrates• VitaminsVitamins• Human MilkHuman Milk• FormulasFormulas• Parenteral NutritionParenteral Nutrition

Fetal EnergyFetal Energy

• Estimated Fetal Energy Expediture = 35 to 55 Estimated Fetal Energy Expediture = 35 to 55 kcal/kg/daykcal/kg/day

• Energy SourcesEnergy Sources

1. Maternal glucose (2/3)1. Maternal glucose (2/3)

2. Placental lactate (1/4)2. Placental lactate (1/4)

3. Maternal amino acids3. Maternal amino acids

Neonatal EnergyNeonatal Energy

Form of EnergyForm of Energy Caloric ExpenditureCaloric Expenditure

Resting Metabolic Rate*Resting Metabolic Rate* 50 kcal/kg/day50 kcal/kg/dayActivityActivity 15 kcal/kg/day15 kcal/kg/dayCold StressCold Stress 10 kcal/kg/day10 kcal/kg/dayNutrition ProcessingNutrition Processing 50 kcal/kg/day50 kcal/kg/day

TotalTotal 120 kcal/kg/day120 kcal/kg/day

ProteinsProteins

Milk SourceMilk Source Whey-to-Casein RatioWhey-to-Casein Ratio

ColostrumColostrum 80:2080:20

Mature MilkMature Milk 55:4555:45

FormulaFormula 20:8020:80

Preterm FormulaPreterm Formula 60:4060:40

FatsFats

• Placental transfer of essential and Placental transfer of essential and non-essential fatty acidsnon-essential fatty acids

• Fat stores are formed by lipogenesis Fat stores are formed by lipogenesis from glucosefrom glucose

• Most poorly digested macronutrientMost poorly digested macronutrient

FatsFats

Types of Fatty AcidsTypes of Fatty Acids• Stearic, Oleic, and Palmitic are commonStearic, Oleic, and Palmitic are common

• Linoleic and Linolenic are the most Linoleic and Linolenic are the most commoncommon

• Long-chain polyunsaturated (LCPUFA)Long-chain polyunsaturated (LCPUFA)

• Short and Medium Chain Triglycerides Short and Medium Chain Triglycerides (MCT)(MCT)

CarbohydratesCarbohydrates

LactoseLactose

• Enhances absorption of calcium and Enhances absorption of calcium and magnesiummagnesium

• Promotes intestinal growth of Promotes intestinal growth of lactobacillilactobacilli

VitaminsVitamins

Water Soluble VitaminsWater Soluble Vitamins

• Vitamin B Complex and Vitamin CVitamin B Complex and Vitamin C

• Generally not formed from Generally not formed from precursorsprecursors

• Daily intake requiredDaily intake required

• No accumulation (except Vitamin BNo accumulation (except Vitamin B1212))

• Cross placenta by active transportCross placenta by active transport

VitaminsVitamins

Fat-soluble vitaminsFat-soluble vitamins

• Vitamins A, D, E, KVitamins A, D, E, K

• Synthesized from precursorsSynthesized from precursors

• Daily intake not usually requiredDaily intake not usually required

• Not easily excreted and can Not easily excreted and can accumulateaccumulate

• Placental transfer by simple or Placental transfer by simple or facilitated diffusionfacilitated diffusion

Vitamin DeficienciesVitamin Deficiencies

Vitamin BVitamin B1212 and Folate and Folate• Vitamin BVitamin B1212 is synthesized by GI microorganisms is synthesized by GI microorganisms

and is required for folate metabolismand is required for folate metabolism

• Risk of BRisk of B1212 deficiency in breast-fed infants of deficiency in breast-fed infants of vegetarian mothers who do not ingest dairy or vegetarian mothers who do not ingest dairy or eggseggs

• Risk of folic acid deficiency in infants fed Risk of folic acid deficiency in infants fed evaporated or goat’s milkevaporated or goat’s milk

• Megaloblastic anemia and hypersegmented Megaloblastic anemia and hypersegmented neutrophilsneutrophils

Vitamin DeficienciesVitamin Deficiencies

Vitamin D DeficiencyVitamin D Deficiency• Vitamin D regulates the concentration of Vitamin D regulates the concentration of

calcium and phosphorus in the calcium and phosphorus in the bloodstream and bonebloodstream and bone

• Important for bone mineralization and Important for bone mineralization and growthgrowth

• Deficiency results in osteopenia -> ricketsDeficiency results in osteopenia -> rickets

• Hypocalcemia -> tetany, seizuresHypocalcemia -> tetany, seizures

Vitamin DeficienciesVitamin Deficiencies

Vitamin E DeficiencyVitamin E Deficiency• Vitamin E has antioxidant properties and is Vitamin E has antioxidant properties and is

recommended to be taken concurrently recommended to be taken concurrently with iron administration to protect from with iron administration to protect from iron-induced hemolysisiron-induced hemolysis

• Manifests with anemia and reticulocytosisManifests with anemia and reticulocytosis

Vitamin DeficienciesVitamin Deficiencies

Vitamin KVitamin K• Required for carboxylation of prothrombin Required for carboxylation of prothrombin

into the active forminto the active form• Newborns are predisposed:Newborns are predisposed:

- - Initial lack of microorganisms that synthesize Initial lack of microorganisms that synthesize Vitamin KVitamin K

- Immature newborn liver- Immature newborn liver

• Maternal medicationsMaternal medications• Breast fed infantsBreast fed infants• Associated with hemorrhagic disease of Associated with hemorrhagic disease of

the newbornthe newborn

Iron DeficiencyIron Deficiency

• Microcytic anemia Microcytic anemia

• Associated with short term and long Associated with short term and long term neurodevelopmental deficitsterm neurodevelopmental deficits

• Preterm infants more susceptible due Preterm infants more susceptible due to small iron stores at birth, high to small iron stores at birth, high growth velocity, and phlebotomy lossgrowth velocity, and phlebotomy loss

Human MilkHuman Milk

PhysiologyPhysiology

• Prolactin is secreted by maternal Prolactin is secreted by maternal anterior pituitary throughout pregnancyanterior pituitary throughout pregnancy

• At delivery, the decrease in estrogen At delivery, the decrease in estrogen and progesterone leads to increased and progesterone leads to increased milk production and deliverymilk production and delivery

• Milk ejection is mediated by oxytocin Milk ejection is mediated by oxytocin from the posterior pituitaryfrom the posterior pituitary

Human MilkHuman Milk

Immunologic and Antibacterial FactorsImmunologic and Antibacterial Factors

• Secretory IgASecretory IgA

• Protective and bactericidal enzymesProtective and bactericidal enzymes

• Lactobacilli growth is increasedLactobacilli growth is increased

• Colostrum has increased Colostrum has increased lymphocytes, macrophages, and lymphocytes, macrophages, and immunoglobulinsimmunoglobulins

Human MilkHuman Milk

ElectrolytesElectrolytes

• Decreased Na, K, Ca, Ph, Cl, and MgDecreased Na, K, Ca, Ph, Cl, and Mg

ProteinProtein

• As breast milk matures, protein decreasesAs breast milk matures, protein decreases

• Amino acids are lowerAmino acids are lower

FatsFats

• 50% calories50% calories

• Triglycerides are variableTriglycerides are variable

Human MilkHuman Milk

Premature MilkPremature Milk

• Increased proteinIncreased protein

• Increased electrolytesIncreased electrolytes

• Inadequate protein, calcium, Inadequate protein, calcium, phosphorus, and vitamin D for premiesphosphorus, and vitamin D for premies

• Need to supplement with human milk Need to supplement with human milk fortifier (2 packets/ 50ml = 24kcal/30mL)fortifier (2 packets/ 50ml = 24kcal/30mL)

Human MilkHuman Milk

BenefitsBenefits

• Decreased IDDM, IBD, NEC, obesityDecreased IDDM, IBD, NEC, obesity

• Decreased infectionsDecreased infections

• Improved neurodevelopmental outcomeImproved neurodevelopmental outcome

Contraindications (in US)Contraindications (in US)

• InfectionInfection

• GalactosemiaGalactosemia

• DrugsDrugs

Nutritional SupplementsNutritional Supplements

Preterm Full term BM P. Form BM Formula

IRONIRON 2w-2mos2w-2mos Fe FortifiedFe Fortified 6mos6mos Fe Fe FortifiedFortified

(2-4 mg/kg/day)(2-4 mg/kg/day)

VitaminsVitamins HMF (ICN)HMF (ICN) NoneNone Vit DVit D None None(200IU/day)(200IU/day)

Fluoride Fluoride ----------after 6 months-------------------------after 6 months---------------(0.25-0.5 mg/day)(0.25-0.5 mg/day)

FormulasFormulas

Classification by Classification by Carbohydrate Carbohydrate SourceSource

Type of Type of CarbohydratCarbohydratee

FormulaFormula

LactoseLactose Enfamil, Enfamil, Neosure, Neosure, SimilacSimilac

Sucrose Sucrose and and glucose glucose polymerspolymers

Alimentum, Alimentum, Isomil, Isomil, PortagenPortagen

Glucose Glucose polymerspolymers

Enfamil Enfamil Lactofree, Lactofree, Neocate, Neocate, Nutramigen, Nutramigen, PregestimilPregestimil

Premature FormulasPremature Formulas

Similac Special Care and Enfamil Premature Similac Special Care and Enfamil Premature LipilLipil

• 24kcal/30 mL or 20kcal/30mL24kcal/30 mL or 20kcal/30mL

• Reduced lactose (50%) and glucose polymersReduced lactose (50%) and glucose polymers

• 50% MCT, ARA and DHA added50% MCT, ARA and DHA added

• Higher protein contentHigher protein content

• Higher calcium and phosphorus contentHigher calcium and phosphorus content

• Increased caloric densityIncreased caloric density

• Use in infants less than 1800g or 32 weeks GAUse in infants less than 1800g or 32 weeks GA

Premature Discharge Premature Discharge FormulasFormulas

Neosure or Enfacare LipilNeosure or Enfacare Lipil

• 22 kcal/30mL22 kcal/30mL

• Increased protein Increased protein

• Increased calcium and phosphorus Increased calcium and phosphorus contentcontent

• Increased caloric contentIncreased caloric content

• Give until 9 months PCAGive until 9 months PCA

TPNTPN

• Recommend 80-90 kcal/kg/dayRecommend 80-90 kcal/kg/day

• Most calories are provided by lipids Most calories are provided by lipids and glucoseand glucose

• Glucose infusion rate: 6-8mg/kg/minGlucose infusion rate: 6-8mg/kg/min

GIR: GIR: 0.167 x concentration x 0.167 x concentration x raterate

weightweight

TPNTPNCarbohydratesCarbohydrates

• Mostly glucoseMostly glucose

• 1g CHO provides 3.4 kcal1g CHO provides 3.4 kcal

• With increasing glucose concentration, With increasing glucose concentration, increasing osmolarityincreasing osmolarity

• Should provide 55-65% of total kilocaloriesShould provide 55-65% of total kilocalories

• Maximum concentration is 12.5% Maximum concentration is 12.5% peripherallyperipherally

TPNTPN

FatsFats

• 1 g fat provides 9 kcal (20% solution 1 g fat provides 9 kcal (20% solution provides 2 kcal/1 ml)provides 2 kcal/1 ml)

• Should provide 30-50% of total Should provide 30-50% of total caloriescalories

• Limit to 3g/kg/dayLimit to 3g/kg/day

• Monitor serum TG levelsMonitor serum TG levels

TPNTPN

ProteinsProteins• Goal is to prevent negative energy and nitrogen Goal is to prevent negative energy and nitrogen

balancebalance• Required early in life to achieve goalsRequired early in life to achieve goals• 1g of protein provides 4 kcal1g of protein provides 4 kcal• Should provide 7-10% of total caloriesShould provide 7-10% of total caloriesCalcium and PhosphorusCalcium and Phosphorus• Ratio should be 1.3:1 to 1.7:1Ratio should be 1.3:1 to 1.7:1• Risk of bone demineralizationRisk of bone demineralization• Cysteine prevents precipitationCysteine prevents precipitation

Sample TPN for Just Born Sample TPN for Just Born LBW InfantsLBW Infants

Adapted from Nutrition and Gastroenterology Clinical Review Committee, 2002Adapted from Nutrition and Gastroenterology Clinical Review Committee, 2002

ComponentComponent QuantityQuantity

Amino AcidsAmino Acids 2.4g/100mL2.4g/100mL

GlucoseGlucose 5-10g/100mL5-10g/100mL

Calcium gluconateCalcium gluconate 500-650mg/100mL500-650mg/100mL

MVI-PediatricMVI-Pediatric 2mL/kg/day2mL/kg/day

HeparinHeparin 1 U/mL1 U/mL

LipidLipid 5mL/kg/day5mL/kg/day

Monitoring Parenteral Monitoring Parenteral Nutrition Nutrition DailyDaily

• WeightWeight

• Urine for glycosuriaUrine for glycosuria

• Intake and OutputIntake and Output

• Serum electrolytes (initially)Serum electrolytes (initially)

• Serum glucose (advanced dextrose)Serum glucose (advanced dextrose)

• Serum triglycerides (advancing Serum triglycerides (advancing lipids)lipids)

Monitoring Parenteral Monitoring Parenteral Nutrition Nutrition

Weekly Weekly• Serum glucose, electrolytes, Ca, Serum glucose, electrolytes, Ca,

Phos, and MgPhos, and Mg

• Serum albumin and total proteinsSerum albumin and total proteins

• Liver function tests, bilirubin (T & D)Liver function tests, bilirubin (T & D)

• Serum triglyceridesSerum triglycerides

• Complete blood countComplete blood count

TPN Supplements for TPN Supplements for Premature Infants Premature Infants

• Insulin infusionsInsulin infusions

• Vitamin AVitamin A

• Cysteine hydrochlorideCysteine hydrochloride

• CarnitineCarnitine

• GlutamineGlutamine

TPNTPN

ComplicationsComplications

• CholestasisCholestasis

• Metabolic AcidosisMetabolic Acidosis

• HyperglycemiaHyperglycemia

• Metabolic Bone DiseaseMetabolic Bone Disease

• Nosocomial InfectionsNosocomial Infections

• Complications of fatComplications of fat

Early Feeding for Preterm Early Feeding for Preterm and Sick Infantsand Sick Infants

• Begin at day 2-3 if stableBegin at day 2-3 if stable

• Human milk 12-24 mL/kg/dayHuman milk 12-24 mL/kg/day

• Reduced hospital stayReduced hospital stay

• Reduced sepsis and sepsis evaluationsReduced sepsis and sepsis evaluations

• Reduced days to full feedingsReduced days to full feedings

• Increased calcium and phosphorus absorptionIncreased calcium and phosphorus absorption

• No increased incidence of NECNo increased incidence of NEC

• Fewer infants with central venous cathetersFewer infants with central venous catheters