3° Congreso Congreso Argent Argent Buenos Buenos Aeres Aeres PN nutrition in VLBW i PN nutrition in VLBW i postnatal growt postnatal growt postnatal growt postnatal growt J Rigo University of Liège, C tino tino de de Neonatologia Neonatologia s 1_3 July 2016 1_3 July 2016 nfants: improvement of nfants: improvement of th using optimal th using optimal th using optimal th using optimal MD PhD CHU de Liège, Belgium
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33°° CongresoCongreso ArgentArgentBuenos Buenos AeresAeres
PN nutrition in VLBW iPN nutrition in VLBW ipostnatal growtpostnatal growtpostnatal growtpostnatal growt
J Rigo University of Liège, Cy g ,
tinotino de de NeonatologiaNeonatologiass 1_3 July 20161_3 July 2016
nfants: improvement of nfants: improvement of th using optimalth using optimalth using optimalth using optimal
MD PhDCHU de Liège, Belgiumg , g
PN Compounded PN Compounded vsvs industrial sol.industrial sol.CVC Central
Venous Catheter
tcPO2tcPCO2
CCore Temperature
Periperal Infusion
Urine Collection
Peripheral Temperature
Mechanical Ventilation
FeedingTube
Cardio Respiratory Monitoring
Arterial Line blood sampl.
g
Non Invasive
pBP monit.
Oxygen
Invasive BP
Oxygen Saturation
Carnielli VP 2003
Growth similar to intrauterine growth; Myth or Reality?
Growth rate ac
70 16
18
20
60
70
ars) 10
12
14
16
t gai
n (g
/kg/
d)40
50
gain
(cm
/yea
2
4
6
8
Wei
ght
20
30
gth/
heig
ht g
Boys
26 28 300
0
10
leng
Girls
0-1 0 1 2 3 4 5 6 7 8 9
Age (y
ccording to age
6
7
ss (k
g)d)
Weight gain Body weight Fat free massProtein
3
4
5
and
fat f
ree
mas
ccre
tion
(g/k
g/d Protein
Fat mass
1
2
3
Bod
y w
eigh
t aP
rote
in a
c
32 34 36 38 40 42 44 46 48 50 52 54 56 58 60
Postmenstrual age (wks)
0
10 11 12 13 14 15 16 17 18 19 20
years)
Postnatal growth restric
100 Length
80
90Weight
Head circumfere
50
60
70
scha
rge
(%)
30
40
50
SGA
at d
is
10
20
023 24 25 26 27 2
Gestati
ction in preterm infants
ence SGA VLBW infants at discharge• 91% in USA (Fanaroff 2007)
• 57% in Shanghai (Shan 2008)
• 57% in Japan (Sakurai 2008)
• 58% in Norway (Henriksen 2009)
28 29 30 31 32 33 34ional age (weeks)
Clarck 2003
Failure to Achieve Nutritional GoalNutritional Deficits
Energy Intake andCumulative Energy Deficit
Postnatal Age (weeks)
*
N=105 preterm infants ≤34 weeks GA and a birth weight ≤17Energy goal = 120 kcal/kg/d
Postnatal Age (weeks)
Embleton NE, et al. Pediatrics. 2001;107:270-273.
Actual recommendations: EnerProt
s Produces
Protein Intake andCumulative Protein Deficit
Postnatal Age (weeks)
*
750 g
Postnatal Age (weeks)
Protein goal = 3 g/kg/d
6
rgy goal = 120 kcal/kg/dein goal = ± 4.0 g/kg/d
Early Growth and Lo
GrowthGrowth similarsimilar to to intrauterineintrauterine gg
Early Growth and Lo
80
50
60
70
30
40
50
0
10
20
0Quartile1 (12,0±2,1)
Quartile 2 (15,6±0,8)
RA. Ehrenkr
Ex Neur Normal (%) Déficit neurod
ng Term Development
growthgrowth; ; MythMyth or Realityor Reality?
ng Term Development
Quartile 3 (17,8±0,8)
Quartile 4 (21,2±2,0)
ranz & al Pediatrics 2006
dev (%) Rehosp (%) taille<p10 (%)
IntraIntra‐‐uterinuterin growthgrowth; ; MM
First week protein and energy intd l t l tdevelopmental outco
Day 1 : 0.4 g AA /kg*day and 31 kCal/kg*
Day 7 : 2.9 g AA /kg*day and 81 kCal/kg*
+8.2
+1
MythMyth or Realityor Reality?
takes associated with 18-months i ELBW i f tome in ELBW infants
*day
*day Stephens BE, 2009
+4 6+4.6+10
Nutritional approach foNutritional approach fo
Growth similar to intra‐uter
Did we need mineral’s and efirst dayy
Potential side effect of earlyof protein overload?
or the VLBW infantsor the VLBW infants
in growth: Myth or Reality?
electrolyte’s supplies from the
y high AA intake. Is there a risk
9
Growth similar to intrauterine
Is it possible to reduce post natalIs it possible to reduce post natalgrowth restriction in ELBW and VLBW infants?
Senterre T and Rigo J. Acta Paediatrica. 2012;101(2):e64‐70
Role of an early aggressivenutritional programme using anutritional programme using a premixed ready‐to‐use parenterasolutionSenterre T and Rigo J. J Pediatr Gastroenterol Nutr. 2011;53(5):536‐42.
growth; Myth or Reality?
ll
al
Need for a Balanced Parenteral S
Growth similar to intrauterine
in VLBWa) AA & energy intakes:
1. Early “aggressive” nutrition reduimproves early postnatal growth
1 12. AA intake >2.5g kg‐1 d‐1 and eneday induces positive nitrogen ba
3 Appropriate fluid intake 50 to 803. Appropriate fluid intake 50 to 80loss (evaporation, perspiration) and 10% improves electrolyte holife
4. Early AA (prot) and energy intak
Solution from the First Day of Life
growth; Myth or Reality
W Infants
uces cumulative nutritional deficit and h in VLBW infants
1 1rgy intake >40 kcal kg‐1 d‐1 on the first alance and promotes LBM deposition
0 ml kg‐1 d‐1 and the limitation of water0 ml kg 1 d 1 and the limitation of water to limit the weight loss to between 5 omeostasis during the first few days of
kes to reach 4.0 g AA and 120 kcal/kg*d
Growth similar to intrauterine
H id d i k d i
Enteral feeding was initiated on t
How to provide adequate intakes during t
Enteral feeding was initiated on tHM, OMM or banked HM
First 20 ml/kg was not considered/ g
HM Fortification was initiated at 5
Individual fortification were perfo Individual fortification were perfocompensate the low fat contentprotein/kg*d
When HM was not available , VLBP/E ratio 3.3 to 3.6 g/100 kcal
growth; Myth or Reality?
h i i l i d l i i
he first or the second day of age with
the transitional period to enteral nutrition
he first or the second day of age with
d in protein and energy count.p gy
50 ml/kg*d
ormed in some preterm infants toormed in some preterm infants to t of OMM and to provide 4.3 g of
BW infants received a PTF with a high
Significant improvement d
IntraIntra‐‐uterinuterin growthgrowth; ; g f p
Recommendations are meet4,5
Recommendation for Stable Gro ing on Oral N trition1
3
3,5
4
g*d)
Embleton 2001Stephen 2009Martin 2009
Recommendation for Stable Growing on Oral Nutrition1
1 5
2
2,5
3
n in
take
(g/k
g Martin 2009Senterre 2011
0,5
1
1,5
Pro
tein
0day 1 week 1 week 2 week 3 week 4
Senterre T and Rigo J. J Pediatr Gastroenterol Nutr.. 2011;53(5):536‐42. .Senterre T and Rigo J. Acta Paediatrica. 2012;101(2):e64‐70 .
during the first week of life
MythMyth or Realityor Reality?g f f f
t at the end of the first week140
Recommendation for Stable Gro ing on Oral N trition1
100
120
l/kg*
d)
Embleton 2001Stephen 2009
Recommendation for Stable Growing on Oral Nutrition1
allows to reduce initial weight lonitrogen balance and to promotg pthe intra‐uterine growth rate.
2. Early HM fortification <50ml/kg,provide at least 4.3g/kg*d of prouse of preterm formula with higuse of preterm formula with higmaintain an adequate growth rarelative catch up growth before p g f
3. Cumulative nutritional deficit carestriction is not an inevitable ph
the range of the recent guidelinesthe range of the recent guidelines oss, to induce early positive te early weight gain in the range of y g g g f
, adequate HM fortification to otein and 130 kcal/kg*g and the h Prot/energy ratio allow toh Prot/energy ratio allow to ate >17g/kg*d and to obtain a discharge or theoretical term.g
an be abolish and postnatal growth henomena in the ELBW infants.
Nutritional approach foNutritional approach fo
Growth similar to intra‐uter
Did we need mineral’s and efirst dayy
Potential side effect of earlyof protein overload?
or the VLBW infantsor the VLBW infants
in growth: Myth or Reality?
electrolyte’s supplies from the
y high AA intake. Is there a risk
19
l
More aggressive nutrition may inducin VLBW in
Ca & P intakes:Parenteral
• Ca and P supplies are nelife in VLBW infants on P
• In parenteral solution, oclose to 1/1 or slightly<1
• Phosphorus need can bethe Ca intakes provided by
ce a new metabolic syndrome fants
nutrition
ecessary from the first day of PN
optimal molar Ca/P ratio is
e estimated from the AA and y the parenteral solution
Electrolyte’s Homeost
Need for a balanced p
Electrolyte s Homeost
• Extra‐Uterin Adaptation = transitioExtra‐Uterin Adaptation = transitio– Physiological Water loss : extracellular vo– Oliguria during the first 24‐48 hours of li– Weight loss: 5‐10% du BW Term infants, 1
matabolic use of potassium and ph2. Optimal nutrition from birth with h
4.5 g of protein during the first weemetabolic syndrome associating hyand hypokaliemiaand hypokaliemia .
3. Parenteral guidelines need to be reparenteral solution providing adeqparenteral solution providing adeqthe first day of life.
4. In enteral nutrition, the use of PTF requirements for phosphorus and p
5. PTF with a Ca/P ratio of 2 are at risVLBW i fVLBW infants.
6. Ca/P ratio and K guidelines need to
first day of life, improves thefirst day of life, improves the hosphorus available for LBM gain. high AA >2.5g/kg*d increasing to 4‐ek of life could induce a new ypophosphatemia, hypercalcemia,
evised to provide well balanced quate minerals and electrolytes fromquate minerals and electrolytes from
with high P/E ratio increases the potassium.sk to induce hypophosphoremia in
o be revised
What is the Divine feeding reegimen for Preterm Infants?