5
Newborns Who Need Special Nutritional Care

Adequate nutrition is a cornerstone of the care of newborns and older infants with serious health problems or disabilities. Such infants present many challenges to the health team members responsible for their nutritional care. They may have difficulties with feeding per se, or they may have physiologic problems that call for specialized nutrition support to achieve their nutritional goals, including appropriate growth and development, while avoiding potential complications associated with feeding. This chapter has four objectives: (1) to provide information about high-risk neonates and the challenges they present, (2) to describe briefly the variety of feeding methods used for these infants, (3) to summarize the complex monitoring required, and (4) to discuss nutrition service delivery for this population.

BACKGROUND

Conditions That Often Require Special Nutritional Care

Many newborn infants require hospitalization for extended periods because of problems associated with preterm birth (gestational age at birth, ≤37 weeks), low birth weight (LBW; <2,500 g), or very low birth weight (VLBW; <1,500 g). The rates of LBW and VLBW among infants born in



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Nutrition Services in Perinatal Care 5 Newborns Who Need Special Nutritional Care Adequate nutrition is a cornerstone of the care of newborns and older infants with serious health problems or disabilities. Such infants present many challenges to the health team members responsible for their nutritional care. They may have difficulties with feeding per se, or they may have physiologic problems that call for specialized nutrition support to achieve their nutritional goals, including appropriate growth and development, while avoiding potential complications associated with feeding. This chapter has four objectives: (1) to provide information about high-risk neonates and the challenges they present, (2) to describe briefly the variety of feeding methods used for these infants, (3) to summarize the complex monitoring required, and (4) to discuss nutrition service delivery for this population. BACKGROUND Conditions That Often Require Special Nutritional Care Many newborn infants require hospitalization for extended periods because of problems associated with preterm birth (gestational age at birth, ≤37 weeks), low birth weight (LBW; <2,500 g), or very low birth weight (VLBW; <1,500 g). The rates of LBW and VLBW among infants born in

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Nutrition Services in Perinatal Care CHART 5-1 Examples of Conditions That Require Special Nutrition Management of the Neonate • Prematurity (≤37 weeks' gestational age)a • Very low birth weight (less than 1,500 g)a • Low birth weight (less than 2,500 g)a • Congenital anomalies of the gastrointestinal, renal, hepatic, cardiovascular, and central nervous systems • Oral-facial anomalies, e.g., cleft palate • Some congenital syndromes and genetic disorders, e.g., cystic fibrosis and Down syndrome • Inborn errors of metabolism, e.g., phenylketonuria (PKU), galactosemia, or maple sugar urine disease (MSUD) • Necrotizing enterocolitis • Excessive or intractable diarrhea or vomiting • Respiratory distress or apnea • Chronic lung disease (bronchopulmonary dysplasia) • Maternal diabetes mellitus • Drug withdrawal • Sepsis, peritonitis, meningitis • Perinatal hypoxia a The complexity of the nutritional concerns increases with decreasing length of gestation and birth weight. the United States are high compared with the rates in other industrialized countries. These rates are especially high among disadvantaged groups; for example, LBW and VLBW rates for African-Americans were 12.7% and 2.7%, respectively, in 1987.1 The use of illegal drugs, especially cocaine, contributes to the problem of low birth weight2 and is associated with decreased head circumference.3 Although a majority of the infants who require intensive care are born preterm or very small, others are full-term infants with serious congenital birth defects or with any of a large number of other conditions that require special nutritional management (see Chart 5-1). The wide range of problems and the differences among infants make it essential to set individualized nutrition goals for each child. Challenges That Confront Clinicians Establishing goals for compromised neonates is often a complex process. 4,5 Nutritional goals for these infants may be substantially different from those for healthy full-term infants because they must be adjusted for

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Nutrition Services in Perinatal Care gestational age, postnatal age, medical condition, and route of feeding. Technical problems, such as intravenous access in small infants, inability to maintain nutrient solubility, and drug-nutrient interactions may further complicate nutritional support. It is inappropriate and sometimes hazardous simply to apply approaches used for adults to the care of neonates.6 Estimating Nutrient Requirements Estimating the nutrient requirements of neonates with special needs is a challenge. Providing too little or too much of even a single nutrient may prevent or retard growth or result in serious physiologic problems. Recommended Dietary Allowances (RDAs)7 are of limited usefulness for estimating the nutrient needs of neonates. (RDAs are defined as the levels of intake of essential nutrients that, on the basis of scientific knowledge, are judged by the Food and Nutrition Board to be adequate to meet the known nutrient needs of practically all healthy persons.) For young infants, the RDAs are based on a weight of 6 kg, with only one RDA per nutrient spanning the first 6 months after birth. Thus, they are not intended to describe the individual nutrient needs of healthy newborn infants, nor are they intended for infants who are stressed by illness or surgery, whose activity is affected by a disability, or who were born at early gestational ages. Infants with bronchopulmonary dysplasia, a chronic respiratory disease common in premature infants, illustrate one kind of change in requirements that may result from illness: such infants may expend as much as 25% more energy than normal infants.8 In part because published information on desirable intakes is incomplete, considerable judgment is required in deciding on appropriate amounts of certain nutrients for neonates—especially amounts of protein;9 vitamins A,10 D, and E; and calcium, phosphate,11,12 and iron.13 This uncertainty, in turn, increases the importance of frequent, individualized monitoring to determine whether adjustments in intake are needed. Such monitoring is essential to maintain an individualized, patient-centered care plan. Adapting to Changing Needs A second challenge relates to rapid changes in the infant's needs—only some of which are related to growth. For example, VLBW infants may experience wide variations in energy metabolism and may demonstrate rapid changes in their needs for water, solutes, or both.14 Rapid changes

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Nutrition Services in Perinatal Care in medical status may be accompanied by further changes in nutrient needs. These changes call for increased monitoring to determine the appropriateness of nutritional therapy. Physical and Physiologic Limitations A third challenge relates to the infant's physical limitations, especially in gastrointestinal function. Premature, sick, and handicapped infants may be unable to handle feedings by mouth or tube, or they may be able to tolerate only special infant formulas. Innovations in nutrient delivery, along with improved formulations, have been responsible for much progress in neonatal nutrition. For example, parenteral nutrition has been life saving for many infants who are unable to tolerate enteral feedings (see, e.g., Goulet and colleagues15). However, this feeding method is accompanied by increased risk of such conditions as hyperglycemia, hyperlipidemia, and life-threatening infections, and the possibility of mechanical catheter complications. Continuous tube feedings have helped many infants; however, tube feeding exposes the infant to other risks—for example, gastrointestinal perforation and aspiration. A further concern is either toxicity or metabolic complications, which may result from excessive or unbalanced intakes of such nutrients as water, protein, calcium, and trace elements (e.g., zinc), and possibly from aluminum.16 Effects of Medical Therapies on Nutrition A fourth challenge is presented by the effects of medical therapies on the infant's nutrient needs and tolerance to feeding. The use of some drugs (e.g., diuretics) may cause mineral losses; dialysis affects the need for fluids and for certain other nutrients; hypertonic medications may lead to vomiting, diarrhea, and, in some cases, necrotizing enterocolitis; methods of delivering oxygen support may limit enteral feeding options; and infant warmers for LBW babies increase fluid requirements. Long-term parenteral nutrition has been associated with cholestasis. Successful interventions require a well-trained, highly skilled team of personnel. They also necessitate close observation and frequent monitoring of both biochemical and anthropometric parameters and of feeding tolerance.

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Nutrition Services in Perinatal Care The Nutritional Care Plan An individualized nutritional care plan is needed for each infant requiring specialized nutritional care. Participants in such planning should include the parent(s) and other persons they designate as key providers of support, as well as the traditional health care team. If there is a language barrier, a skilled interpreter is needed to help with communication. The care plan should address the infant's feedings (what is to be fed, how it is to be fed, and how often), the methods to be used to monitor the infant's progress, the kinds of education and other forms of support that the parents will need to participate actively in the nutritional care of their child, and referrals to appropriate caregivers and agencies. In addition, the plan should make certain that all routine newborn laboratory screening tests (eg., for PKU) are performed and that the results are followed up. Support for the parents may involve the use of community resources, such as early intervention programs, as well as inpatient and outpatient services. Home visits by nurses or other trained health care workers would help in tailoring the plan of care and the teaching strategies to the needs and resources of the family, as well as to the specific home environment. Parents of preterm or developmentally delayed infants need assistance to develop realistic expectations for the infant's growth and development. 17 For example, adjustments are made for the young gestational age of preterm infants when anticipating developmental milestones that relate to feeding (such as the development of coordinated tongue movements or of sucking and swallowing). FEEDING METHODS There are two general approaches to the feeding of small, sick, or handicapped newborn infants: enteral feeding and parenteral feeding. Enteral feeding makes use of the gastrointestinal tract; it may involve feeding by mouth or by feeding tube. Parenteral feeding involves supplying nutrients through peripherally or centrally placed intravenous catheters. Parenteral feeding is undertaken only when it is impossible to provide adequate nutrition enterally. In many cases, infants are supported initially with parenteral feedings and then are adapted gradually to enteral feedings. Each enteral and parenteral method has specific indications, contraindications, requirements, and complications.18–20 This section describes these methods and feedings briefly, indicates key decisions, and illustrates the complexity of nutritional management of high-risk neonates.

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Nutrition Services in Perinatal Care Enteral Feedings Human Milk For many infants who require specialized nutritional care, human milk is preferred as the major source of nutrients. Depending on the condition of the infant, human milk may be fed by breastfeeding, bottle, tube, or a combination of these methods. Although milk from the mothers of preterm infants tends to be higher in protein than milk obtained from mothers of full-term infants, it does not provide sufficient quantities of protein or of other nutrients to meet the increased requirements of growing VLBW infants, of infants who are small for gestational age, and of infants experiencing certain other kinds of stress. In such cases, expressed mother's milk or milk from a human milk banka can be fortified with commercial human milk fortifiers or other sources of nutrients.21–23 Fortified mother's milk provides the infant with a wide array of protective substances that are not present in formula.24,25 Lucas and Cole26 present evidence from a large, randomized trial that feeding human milk may help prevent necrotizing enterocolitis. Mothers who are taking certain drugs, who are critically ill themselves, or who have certain infectious diseases may be unable to provide adequate or safe milk. For example, the Centers for Disease Control 27 and Guidelines for Perinatal Care28 have advised against breastfeeding by U.S. mothers who test positive for the human immunodeficiency virus (HIV). More commonly, practical barriers (such as long travel times between home and the neonatal intensive care unit and the difficulty of maintaining a milk supply without being able to nurse the baby) make it unrealistic for the mother to provide her milk for the infant. If the mother chooses to provide her milk, she will need assistance in learning to pump her breasts or to express her milk manually; she will also need a private place to do so in the hospital (and at the worksite, if applicable) and information about how to store the milk properly to prevent contamination and the breakdown of nutrients. For short-term storage (≤48 hours), expressed human milk should be refrigerated; for longer storage, it should be frozen immediately. The mother who visits the hospital infrequently may send her frozen milk to the hospital between visits. In the United States and Canada, there are few milk banks (eight in 1991). Milk from these banks differs in composition from that produced by individual mothers of premature infants, but it has been a satisfactory a   An organized unit that pools, pasteurizes, stores, and distributes human milk.

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Nutrition Services in Perinatal Care source of human milk if the milk has been fortified appropriately. Human milk banking is highly regulated because of concerns about HIV and other viruses. Pasteurization of human milk eliminates HIV and other viruses while moderately reducing the milk's health-promoting properties. The publication Guidelines for the Establishment and Operation of a Human Milk Bank29 provides further information. Formulas If the feeding of human milk is not possible or desired, careful attention must be given to the selection of a formula that is appropriate for the newborn's gestational age and health status. Several formulas have been developed to meet the special nutritional needs of growing preterm infants.30 Specialty formulas address specific concerns, including lactose intolerance, increased vitamin and mineral requirements, impaired fat absorption, protein intolerance, and milk allergy. In fact, the choice of a formula for an individual infant with a specific set of needs becomes a technical decision. In view of the complexity of matching needs with formulas, a neonatal intensive care unit should have access to many formulas and additives, and an experienced team should be available to choose or design the optimal formula and vitamin-mineral supplementation regimen and to oversee the management of nutritional care. In rare cases, an apparently healthy infant may have an inborn error of metabolism, such as PKU, that requires the feeding of a formula designed especially for treating the disorder. Treatment involves extended periods of special nutritional management, including close monitoring of the infant's serum phenylalanine values. This management is usually coordinated on an outpatient basis by a regional metabolic center. Parents may need assistance to obtain an adequate supply of the expensive formula. Methods of Enteral Feeding Breastfeeding Premature or sick infants may be completely unable to breastfeed during the first days and weeks after birth. Convalescent infants and infants with handicaps may breastfeed more slowly or less efficiently and tire more easily than healthy full-term infants. Initially, many sick and premature infants may require total or supplemental feedings by gavage or

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Nutrition Services in Perinatal Care intravenous routes to achieve adequate nutrient intake before breastfeeding can be fully established. Therefore, if the mother wants to be able to breastfeed fully when the infant is ready, she must learn to use a breast pump and receive guidance about its regular use; she must also learn to store her milk properly. In addition, she will need timely assistance in mastering techniques that facilitate adequate intake by infants with physical difficulties that complicate feeding, 31,32 and in achieving a pleasant, relaxed environment for expressing milk or for nursing. Bottle Feeding Bottle feeding of premature, sick, and handicapped infants is also more difficult than that of healthy full-term infants. When these infants are able to begin feedings, many have problems with the coordination of sucking, breathing, and swallowing. Careful assessment and intervention by the clinical team may be needed to assist with the oral feeding of both breastfed and bottlefed infants with oralfacial anomalies, those in whom the initiation of oral feeding is delayed for weeks, and postsurgical infants. Scrupulous attention to detail is necessary in the preparation, storage, and handling of infant formulas of any type. These procedures are outlined in the book Preparation of Formula for Infants: Guidelines for Health Care Facilities.33 Tube Feeding Inability to feed adequately either from breast or bottle is likely to be a problem for infants younger than 34 weeks of gestational age. The risk of aspiration may contraindicate oral feeding for infants of any age who have respiratory distress, abdominal distention, or tracheal-esophageal fistula. If the infant's gastrointestinal tract is functioning adequately, one of the following enteral feeding methods may be selected to provide his or her total nutrient intake or to supplement the infant's oral intake. Intermittent gavage feedings, in which a feeding catheter is passed either orally or nasally into the stomach. Continuous nasogastric feedings, which allow the infant to have a continuous infusion of milk or formula into the stomach. Gastrostomy feedings, in which a small opening is made surgically through the abdominal wall into the stomach to allow the direct insertion

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Nutrition Services in Perinatal Care of a feeding tube. Gastrostomy feedings may also be intermittent or continuous, depending on the infant's condition. Transpyloric feeding, in which feedings are provided through an indwelling catheter whose tip has passed through the stomach and pylorus into the small bowel (duodenum or jejunum). A transpyloric tube may be placed through a gastrostomy as needed. The effects of different tube feeding methods are still under investigation (see, e.g., Grant and Denne34 ). Gradual introduction of breastfeeding or bottle feeding for tube-fed infants is encouraged when the infant shows signs of readiness to suckle. At this time, the mother and infant will benefit from additional support in learning the art of feeding the infant with special needs. Supplemental tube feeding will continue until adequate oral intake can be achieved. When the infant is unable to take any nourishment by nursing, it may be advisable to provide oral stimulation through the use of a pacifier or nipple to encourage sucking and the development of oral motor skills. Parenteral Feeding If the gastrointestinal tract cannot be used for feeding or can be used only to a limited extent, parenteral feeding assumes major importance. Although practices vary in different nurseries, many infants are not fed enterally while they are critically ill and so must rely on parenteral nutrition for all nutrients. However, nutritionally insignificant amounts of enteral feedings are sometimes given to stimulate intestinal function and growth and to reduce the likelihood of cholestasis.35,36 The intravenous infusion of amino acids, glucose, vitamins, minerals, trace elements, and fat emulsions requires careful control of the total volume and amounts of nutrients delivered (see, e.g., Greene et al.,37 Hanning and Zlotkin,38 and Heird et al.39 ). At any point in time, complex decisions concerning the appropriate formulation for an infant require the concerted, coordinated efforts of the neonatal team, which comprises the neonatologist, neonatal nurses and nurse-practitioners, a neonatal dietitian, and a pharmacist.40 Information collected through careful monitoring (see the next section) is crucial to the decision-making process. Some infants—including those with congenital gastrointestinal anomalies, major gastrointestinal surgery, or complications related to necrotizing enterocolitis—may require prolonged parenteral nutrition (i.e., longer than 1 month). These infants are sometimes discharged on home parenteral nutrition if their families can successfully manage this complex feeding method.41 Extensive training of parents is required, however, and these

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Nutrition Services in Perinatal Care families need continuing support by a team experienced in the management of home parenteral nutrition for infants. It is important to recognize that not all families succeed in learning this technique. With growth and maturation of the infant's gastrointestinal tract or improvement in the infant's medical condition, he or she may be weaned gradually from parenteral feedings while enteral feedings are being introduced and advanced. MONITORING Although all newborns should be monitored for the adequacy of nutritional intake, it is especially critical to monitor high-risk neonates frequently and with close attention to detail.42–44 Such monitoring is described briefly below and is summarized in Chart 5-2. Food and Fluid Intake and Output An organized system for summarizing and tracking pertinent nutritional data is essential for adequate monitoring, efficient decision making, and other aspects of nutritional support. This system must be linked with detailed information about the composition of the infant's enteral and parenteral intake. Stave and colleagues45 report on the value of such a system. Most nurseries use a paper flow sheet to provide the required information in an easily accessible form. More recently, computerized systems, such as the one described by Lowe and colleagues,46 are being used to organize data and generate progress notes. Collected data should include the daily volumes (intake) and the protein and energy values of enteral and parenteral fluids. The total fluid intake should be presented in relation to other data, such as the kinds and concentrations of formulas and supplements, the route of feeding of each, the amount fed, any gastric residuals, emesis, urine output, and stool frequency and description. To facilitate review, the data are presented in relation to the infant's weight. Especially close monitoring of nutrient intake is needed when fluid intake must be restricted. Conditions requiring total fluid restriction include congestive heart failure, renal insufficiency, and chronic lung disease (bronchopulmonary dysplasia); limited gastric capacity requires restriction of enteral fluids.

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Nutrition Services in Perinatal Care CHART 5-2 Nutrition-Related Variables That May Need to Be Monitored for Newborns Who Require Special Carea Nutrient intake Energy Protein Fluid Growth variables Weight Length Head circumference Metabolic variables Blood measurements Plasma electrolytes Plasma glucose Triglycerides Blood urea nitrogen Plasma calcium, magnesium, phosphorus Acid-base status Serum protein (quantitative serum protein electrophoresis or albumin) Liver function studies Hemoglobin Urine glucose Prevention and detection of infection Clinical observations (e.g., activity, temperature, abdominal tonicity) White blood cell count and differential Cultures a The extent of monitoring and the frequency with which specific variables are monitored depend on the infant's gestational age, weight, medical condition, and feeding method. For convalescent neonates, the observation of appropriate oral formula intake and adequate rates of gain in weight, length, and head circumference for gestational age provide good evidence of adequate nutrient intake.

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Nutrition Services in Perinatal Care Nutrition services for infants with special needs involve comprehensive nutritional care of the infant, facilitation of the family's participation in decision making and care, training and consultation for other care providers, and evaluation efforts. The elements of these services are summarized in the sections below. Comprehensive Nutritional Care of the Neonate. Care of the neonate includes the initial nutritional assessment; screening for inborn errors of metabolism; developing and implementing comprehensive nutritional care plans (covering activities such as enteral and parenteral feedings, family involvement, and the monitoring of feeding tolerance, nutrient adequacy, and growth); and referrals as needed. Nutritional support should be assessed and the plan of care revised at least twice weekly while the infant is hospitalized and as needed after discharge. Services for and Involvement of the Family. Optimal care of the newborn with special needs includes assisting family members to adjust to the situation and to learn the skills that will enable them to become active participants in the infant's care. Nursery staff can help the family to make such an adjustment and acquire the necessary skills by making the environment of the neonatal intensive care unit more inviting, and giving explanations, and initiating other measures that encourage parents to be with their infants. Among the many factors that contribute to an intimidating environment are a small, cramped space; high and distracting noise levels, especially if alarms sound frequently; and confusing visual stimuli, aggravated by complicated equipment. Good staff attitudes and improved facility design59 may help to overcome these problems. Families may need help to make informed decisions concerning enteral feeding of their newborn. They may also require assistance with techniques of breastfeeding, instructions for safe formula preparation and bottle feeding, demonstrations of oral stimulation, training on how to give tube or parenteral feedings, education and training to monitor the infant's progress, and education and counseling relating to realistic expectations and to the management of feeding problems. Training and Consultation. Because of rapid changes in the field of infant nutrition, an organized in-service education program is invaluable for the health care team within the hospital and in the community. The neonatal health care team needs to be prepared to provide consultation services to facilities that provide less complex care and to train community personnel and family members to give follow-up care throughout the first year of life.

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Nutrition Services in Perinatal Care Evaluation. Ongoing evaluation of the nutrition program, including its safety and effectiveness, is essential to ensure high-quality care. At a programmatic level, the organized review of neonatal nutritional support services, with attention to usage, level of staff, and rate of nutrition-related complications, is an important part of quality assurance in a neonatal intensive care unit. Calculation of rates of nutrition-related complications provides an index for comparison with published estimates and may offer insight into the strengths and weaknesses of individual support services. Intermediate Care An intermediate care unit should be staffed and equipped to provide nutritional support for moderately ill infants or certain seriously ill infants who have been transferred out of intensive care because their conditions have stabilized. Often these infants need to feed and grow before discharge. Examples of conditions that require an intermediate level of care are mild respiratory distress syndrome, hyperbilirubinemia, hypoglycemia, medically stable VLBW, and mild infections. In addition, many infants with classical birth defects may be hospitalized in intermediate care units. The services described previously for intensive care should be available in the intermediate care setting. However, because the infants being cared for in intermediate-level units have less complex conditions, the staff ordinarily handles routine decisions concerning nutritional management. In some situations, it is the intermediate care facility that has the major responsibility for teaching the family to assume full care of the infant upon discharge. Follow-up Care in the Community Infants with serious handicaps or other health problems may require specialized nutritional support (including monitoring) to achieve optimal growth and development even after discharge.60 This applies to substantial numbers of premature infants: estimated rates of serious handicapsb for those surviving very low birth weights are 26% for those weighing <800 g at birth, 17% for those weighing 750 to 1,000 g, and 11% for those b   serious handicaps are defined as one or more of the following: severe mental retardation (intelligence or development quotient below 70), cerebral palsy of significant degree, major seizure disorders, or blindness.

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Nutrition Services in Perinatal Care weighing 1,000 to 1,500 g.61 A few seemingly normal infants may be found to have problems requiring specialized nutritional care after discharge. (See the previous subsection ''Formulas.'') The follow-up care that is needed varies with the infant's condition, the family's capabilities, and the kinds of health services to which the family has access. Recommendations for follow-up should consider geographic location, as well as available transportation and other resources. Special early childhood intervention programs may help children who have serious health problems to reach their potential. In many communities, however, neither early intervention programs nor the services of specialized care providers are readily available. In this event, the care plan must match the needs of the infant and family with the available services and providers; it must also ensure that the providers receive appropriate guidance from specialists. Personnel The kinds of personnel necessary to provide neonatal nutrition services depend on the intensity of care required, but a multidisciplinary team is almost always essential. Appropriate staffing for nutrition services in intensive care nurseries includes neonatologists, who have the overall responsibility for the supervision, coordination, and delivery of primary neonatal care; neonatal nurses, who provide much of the direct care of the infant and family; a neonatal dietitian, who has a major role in the nutritional management of the infant; a clinical pharmacist, who deals with technical matters relating to feeding mixtures and supplements; a social worker, who provides much practical support for the family; an occupational therapist; a physical therapist; and a behavioral psychologist. A breastfeeding specialist and a speech and language pathologist (for oral motor evaluation and treatment) are also valuable resources. In intermediate care centers, either the pediatrician or the neonatologist serves as the primary physician. This physician must be familiar with the nutritional limitations imposed by prematurity and birth defects, as well as the methods for dealing with the range of nutritional problems that are commonly encountered in the intermediate care nursery. For neonates with less serious disorders, pediatricians or neonatologists may serve as consultants to family physicians providing primary care to these newborns. Regardless of the severity of the infant's condition, the neonatal nurse generally provides much of the direct care and often assumes the role of primary caregiver. The neonatal nurse is expected to develop great skill in using the many different feeding techniques; in monitoring the infant's

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Nutrition Services in Perinatal Care intake, output, and feeding tolerance; and in interpreting the infant's progress in discussions with the parents. The neonatal dietitian integrates information about the physiologic and biochemical bases for nutrient requirements (including changes by age, rate of growth, illness or surgery, and treatments) with information about the nutrient composition and other characteristics of feedings and feeding methods. The neonatal dietitian ordinarily coordinates, develops, implements, and evaluates an individualized plan for the provision of adequate inpatient nutritional care and facilitates the continuation of appropriate nutritional care following discharge. He or she may also participate in the education of other health care providers and students of the health professions.62 A pharmacist with expertise in the field of parenteral nutrition can make daily adjustments in the composition of parenteral feedings. He or she may also advise the other team members about special characteristics of parenteral feedings, the compatibility and stability of components of feedings, procedures for handling them, and drug-feeding interactions. Additional activities may be to check orders for accuracy and alert the team to new developments in parenteral feeding. Education and Training of Health Care Providers Because of the complexity of the nutritional problems that are encountered in neonatal intensive care and in many intermediate care nurseries, special training in neonatal nutrition is advisable for all health team members. The neonatologist should be a pediatrician who possesses active certification by the subspecialty board on neonatology of the American Board of Pediatrics. He or she should have experience with both short-and long-term implications and sequelae of the care of sick newborns. It is also desirable for the neonatologist to have participated in active clinical and research programs and to have an understanding of experimental design and methods of statistical evaluation of data. Recertification is a method to encourage updating of knowledge and skills. The nurse or nurse-practitioner should meet the qualifications necessary to function successfully in a newborn special care unit. However, he or she should also obtain additional in-service training in neonatal nutrition, feeding techniques and protocols, the system for collecting nutritional data, methods for monitoring nutritional progress, formula selection, and vitamin and mineral supplementation. Attendance at short courses in neonatal nutrition of 2 to 3 days' duration can increase the

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Nutrition Services in Perinatal Care nurse's appreciation of the need for careful nutrition monitoring and awareness of the nutrition-related roles of other team members in the neonatal unit. The neonatal dietitian should meet all the requirements for registration of the Council for Dietetic Registration and for licensure (where required); he or she should also have either advanced pediatric training that includes clinical neonatal nutrition or clinical experience in the nutritional care of critically ill newborn infants. Among the key areas for this training or experience are neonatal growth and development; nutritional assessment and monitoring; the influence of medical problems or treatment regimens on feeding; feeding alternatives, including neonatal parenteral nutrition; interactions among nutrients, drugs, and foods; the composition of feedings and supplements; and the education of family members and other care providers. Participation in a 3- to 6-month neonatal nutrition course is desirable for experienced dietitians to develop the special skills needed in the neonatal unit. It is desirable for the pharmacist to have completed an advanced degree or residency training in nutritional support pharmacy practice that meets the standards of the American Society of Hospital Pharmacists. 63 He or she should also obtain additional in-service training in relation to neonates. Short refresher courses are a mechanism for updating knowledge and skills in this rapidly changing field.62,64 Special conferences and courses in neonatal nutrition are valuable for educating clinicians about the scope and complexities of neonatal nutritional care and for developing skills in their respective areas. The science of human lactation and human milk should be included in these educational events. Knowledge Base and Clinical Skills For units that provide either intensive or intermediate neonatal care, the requisite knowledge base and clinical skills are generally similar. However, clinicians who work in an intermediate care unit can be somewhat less familiar with parenteral solutions and certain complex surgical and medical problems because they are likely to encounter less severe problems and only the more common kinds of medical and surgical conditions. The team that provides nutrition services for infants with special nutritional needs and their families must have the knowledge and skills listed in Chapter 4 for basic nutrition services, plus those listed below.

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Nutrition Services in Perinatal Care Knowledge and Understanding Physiologic and biochemical bases of the nutrients required to support the growth of preterm and full-term infants. Relationships of infant development to infant feeding. Effects of complex medical and surgical problems on nutritional needs, on acceptable methods of feeding infants, and on potential complications of nutritional support regimens. Safe storage, handling, mixing, and delivery of human milk and infant formula. Appropriate nutritional therapies for disorders that affect the health or development of infants. Alternative feeding techniques for infants, the nutrient composition of specialized feedings (such as parenteral nutrition solutions and modified formulas), benefits and potential problems associated with the feeding methods, and principles involved in transitional feeding. Assessment Skills Accurately measure length, weight, and head circumference. Identify abnormal patterns of growth and development of preterm and SGA infants and of infants with other health problems. Use appropriate screening, assessment, and monitoring methods to determine the nutritional progress of infants. Assess the family's capacity for participating in infant feeding and stimulation and for implementing a nutritional care plan after the infant's discharge. After discharge, obtain a nutrition history from the care providers that includes information about past and present feeding habits and responses, patterns of elimination, and the social setting associated with feeding. Intervention Skills Manage and evaluate the nutritional care of seriously ill infants. Develop and participate in the implementation of appropriate nutritional care plans that consider the infant's developmental level; medical, surgical, or handicapping conditions; feeding techniques; and the nutrient content of feedings. Involve the family in the nutritional care of the infant during hospitalization.

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Nutrition Services in Perinatal Care Provide nutrition counseling that enables parents or other primary caregivers to meet the nutritional needs of the patient. Function effectively as a multidisciplinary care team, recognizing that the services of many disciplines are essential for comprehensive care. Develop realistic nutritional care plans for meeting the infant's initial needs after discharge from the intensive or intermediate care nursery. Communicate to other professionals and parents the importance of nutrition to growth and health. Assist with case management, including plans for home visitation as needed. Program Management and Evaluation Skills Provide organized nutrition education programs for the health care team in the hospital and in the community. Incorporate new knowledge into nutritional care plans, education programs, and protocols and procedures for the unit. Provide leadership in conducting activities to monitor and improve the quality and efficiency of the nutrition services being offered. Evaluate the results of nutrition-related interventions for use in program planning. SUMMARY Providing appropriate nutritional care for infants with special needs poses major challenges to clinicians and family members. A highly trained, multidisciplinary team is essential to provide the individualized care needed for satisfactory growth, development, and health of the infant when he or she requires intensive care. A team effort is also needed to help plan for appropriate follow-up care by primary care providers and family members during the infant's convalescence. REFERENCES 1. National Center for Health Statistics. 1991. Health, United States, 1990. (PHS) 91–1232. U.S. Department of Health and Human Services, Hyattsville, Md. 2. Petitti, D.B., and C. Coleman. 1990. Cocaine and the risk of low birth weight. Am. J. Public Health 80:25–28. 3 Chasnoff, I.J., D.R. Griffith, C. Freier, and J. Murray. 1992. Cocaine/polydrug use in pregnancy: two-year follow-up. Pediatrics 89:284–289.

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Nutrition Services in Perinatal Care 4. Hay, W.W. Jr., 1991. Nutritional needs of the extremely low-birth-weight infant. Semin. Perinatol. 15:482–492. 5. Sparks, J.W. 1984. Human intrauterine growth and nutrient accretion. Semin. Perinatol. 8:74–93. 6. Okken, A. 1991. Nutritional needs of newborn infants in intensive care. Int. J. Technol. Assess. Health Care 7(suppl. 1):94–98. 7. National Research Council. 1989. Recommended Dietary Allowances, 10th ed. Report of the Subcommittee on the Tenth Edition of the RDAs, Food and Nutrition Board, Commission on Life Sciences. National Academy Press, Washington, D.C. 8. Kurzner, S.I., M. Garg, D.B. Bautista, C.W. Sargent, C.M. Bowman, and T.G. Keens. 1988. Growth failure in bronchopulmonary dysplasia: elevated metabolic rates and pulmonary mechanics. J. Pediatr. 112:73–80. 9. Heird, W.C., S. Kashyap, and M.R. Gomez. 1991. Protein intake and energy requirements of the infant. Semin. Perinatol. 15:438–448. 10. Peeples, J.M., S.E. Carlson, S.H. Werkman, and R.J. Cooke. 1991. Vitamin A status of preterm infants during infancy. Am. J. Clin. Nutr. 53:1455–1459. 11. Hillman, L.S. 1990. Nutritional factors affecting mineral homeostasis and mineralization in the term and preterm infant. Pp. 55–92 in D.J. Simmons, ed. Nutrition and Bone Development. Oxford University Press, New York. 12. Koo, W.W., R.C. Tsang, P. Succop, S.K. Krug-Wispe, D. Babcock, and A.E. Oestreich. 1989. Minimal vitamin D and high calcium and phosphorus needs of preterm infants receiving parenteral nutrition. J. Pediatr. Gastroenterol. Nutr. 8:225–233. 13. Dallman, P.R. 1988. Nutritional anemia of infancy: iron, folic acid, and vitamin B12 . Pp. 216–235 in R.C. Tsang and B.L. Nichols, eds. Nutrition During Infancy. Hanley & Belfus, Philadelphia. 14. Baumgart, S. 1990. Water metabolism in the extremely-low-birth-weight infant. Pp. 83–93 in R.M. Cowett and W.W. Hay, Jr., eds. The Micropremie: The Next Frontier. Report of the Ninety-ninth Ross Conference on Pediatric Research. Ross Laboratories, Columbus, Ohio. 15. Goulet, O.J., Y. Revillon, D. Jan, S. De Potter, C. Maurage, S. Lortat-Jacob, H. Martelli, C. Nihoul-Fekete, and C. Ricour. 1991. Neonatal short bowel syndrome. J. Pediatr. 119:18–23. 16. Sedman, A.B., G.L. Klein, R.J. Merritt, N.L. Miller, K.O. Weber, W.L. Gill, H. Anand, and A.C. Alfrey. 1985. Evidence of aluminum loading in infants receiving intravenous therapy. N. Engl. J. Med. 312:1337–1343. 17. Field, T.M., S.M. Widmayer, S. Stringer, and E. Ignatoff. 1980. Teenage, lower–class, black mothers and their preterm infants: an intervention and developmental follow-up . Child Dev. 51:426–436. 18. Cowett, R.M., and W.W. Hay, Jr., eds. 1990. The Micropremie: The Next Frontier. Report of the Ninety-ninth Ross Conference on Pediatric Research. Ross Laboratories, Columbus, Ohio. 19. Hay, W.W., Jr., ed. 1991. Neonatal Nutrition and Metabolism. Mosby Year Book, St. Louis. 20. Klaus, M.H., and A.A. Fanaroff. 1986. Care of the High Risk Neonate, 3rd ed. W.B. Saunders Co., Philadelphia. 21. Greer, F.R., and A. McCormick. 1988. Improved bone mineralization and growth in premature infants fed fortified own mother's milk J. Pediatr. 112:961–969. 22. Polberger, S.K.T., G.A. Fex, I.E. Axelsson, and N.C. Raiha. 1990. Eleven plasma proteins as indicators of protein nutritional status in very low birth weight infants. Pediatrics 86:916–921. 23. Schanler, R.J., and C. Garza. 1988. Improved mineral balance in very low birth weight infants fed fortified human milk. J. Pediatr. 112.452–456.

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Nutrition Services in Perinatal Care 24. Institute of Medicine. 1991. Nutrition During Lactation. Report of the Subcommittee on Nutrition During Lactation, Committee on Nutritional Status During Pregnancy and Lactation, Food and Nutrition Board. National Academy Press, Washington, D.C. 25. Schanler, R.J. 1989. Human milk for preterm infants: nutritional and immune factors. Semin. Perinatol. 13:69–77. 26. Lucas, A., and T.J. Cole. 1990. Breast milk and neonatal necrotizing enterocolitis. Lancet 336:1519–1523. 27. Centers for Disease Control. 1985. Recommendations for assisting in the prevention of perinatal transmission of human T-lymphotropic virus type III/lymphadenopathy-associated virus and acquired immunodeficiency syndrome. Morbid. Mortal. Wkly. Rep. 34:721–732. 28. American Academy of Pediatrics/American College of Obstetricians and Gynecologists. 1992. Guidelines for Perinatal Care, 3rd ed. American Academy of Pediatrics, Elk Grove, III. 29. Human Milk Banking Association of North America; Arnold, L.D.W., and M.R. Tully, eds. 1991. Guidelines for the Establishment and Operation of a Human Milk Bank. Human Milk Banking Association, West Hartford, Conn. 30. Brady, M.S., K.A. Rickard, J.F. Fitzgerald, and J.A. Lemons. 1986. Specialized formulas and feedings for infants with malabsorption or formula intolerance. J. Am. Diet. Assoc. 86:191–200. 31. Lemons, P., M. Stuart, and J.A. Lemons. 1986. Breast-feeding the premature infant. Clin. Perinatol. 13:111–122. 32. Lemons, P. 1983. Breast-feeding the premature newborn. Perinatal Press 7:83–88. 33. American Dietetic Association. 1991. Preparation of Formula for Infants: Guidelines for Health Care Facilities. American Dietetic Association, Chicago. 34. Grant, J., and S.C. Denne. 1991. Effect of intermittent versus continuous enteral feeding on energy expenditure in premature infants. J. Pediatr. 118:928–932. 35. Balistreri, W.F., and K. Bove. 1990. Hepatobiliary consequences of parenteral alimentation. Progr. Liver Dis. 9:567–601. 36. Dunn, L., S. Hulman, J. Weiner, and R. Kliegman. 1988. Beneficial effects of early hypochloric enteral feeding on neonatal gastrointestinal function: preliminary report of a randomized trial. J. Pediatr. 112:622–629. 37. Greene, H.L., K.M. Hambidge, R. Schanler, and R.C. Tsang. 1988. Guidelines for the use of vitamins, trace elements, calcium, magnesium, and phosphorus in infants and children receiving total parenteral nutrition: report of the Subcommittee on Pediatric Parenteral Nutrient Requirements from the Committee on Clinical Practice Issues of The American Society for Clinical Nutrition. Am. J. Clin. Nutr. 48:1324–1342. 38. Hanning, R.M., and S.H. Zlotkin. 1989. Amino acid and protein needs of the neonate: effects of excess and deficiency. Semin. Perinatol. 13:131–141. 39. Heird, W.C., W. Hay, R.A. Helms, M.C. Storm, S. Kashyap, and R.B. Dell. 1988. Pediatric parenteral amino acid mixture in low birth weight infants. Pediatrics 81:41–50. 40. Mayfield, S.R., J. Albrecht, L. Roberts, and C. Lair. 1989. The role of the nutritional support team in neonatal intensive care. Semin. Perinatol. 13:88–96. 41. Yowell-Warman, K., and P. Queen. 1989. Pediatric nutrition in the home. Pp. 142–174 in M. Hermann-Zaidins and R. Touger-Decker, eds. Nutrition Support in Home Health. Aspen Publishers, Inc., Rockville, Md. 42. Anderson, D.M. 1987. Nutrition care for the premature infant. Top. Clin. Nutr. 2:1–9. 43. Georgieff, M.K., and S.R. Sasanow. 1986. Nutritional assessment of the neonate. Clin. Perinatol. 13:73–89. 44. Ziegler, E.E. 1985. Nutritional management of the premature infant. Perinatol. Neonatol. 9:11–15.

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Nutrition Services in Perinatal Care 45. Stave, V.S., S. Robbins, and A.B. Fletcher. 1979. A comparison of growth rates of premature infants prior to and after close nutritional monitoring. Clin. Proc. Children's Hosp. Natl. Med. Ctr. 35:171–180. 46. Lowe, W.W., T.A. Ciszek, and K.J. Gallaher. 1992. Comprehensive computerized neonatal intensive care unit data system including real-time, computer-generated daily progress notes. Pediatrics 89:62–66. 47. Dubowitz, L.M., V. Dubowitz, and C. Goldberg. 1970. Clinical assessment of gestational age in the newborn infant. J. Pediatr. 77:1–10. 48. Ballard, J.L., K.K. Novak, and M. Driver. 1979. A simplified score for assessment of fetal maturation of newly born infants. J. Pediatr. 95:769–774. 49. Sanders, M., M. Allen, G.R. Alexander, J. Yankowitz, J. Graeber, T.R.B. Johnson, and M.X. Repka. 1991. Gestational age assessment in preterm neonates weighing less than 1500 grams. Pediatrics 88:542–546. 50. Ballard, J.L., J.C. Khoury, K.Wedig, L. Wang, B.L. Eilers-Walsman, and R. Lipp. 1991. New Ballard Score, expanded to include extremely premature infants. J. Pediatr. 119:417–423. 51. Babson, S.G. 1970. Growth of low-birth-weight infants. J. Pediatr. 77:11–18. 52. Kaempf, J.W., C. Bonnabel, and W.W. Hay, Jr. 1989 2nd ed. Neonatal nutrition. Pp. 117–203 in G.B. Merenstein and S.L. Gardner, eds. Handbook of Neonatal Intensive Care. C.V. Mosby, St. Louis. 53. Dancis, J., J.R. O'Connell, and L.E. Holt, Jr. 1948. Grid for recording weight of premature infants. J. Pediatr. 33:570–572. 54. Babson, S.G., and G.I. Benda. 1976. Growth graphs for the clinical assessment of infants of varying gestational age. J. Pediatr. 89:814–820. 55. Gairdner, D., and Pearson, J. 1971. A growth chart for premature and other infants. Arch. Dis. Child. 46:783–787. 56. Lubchenco, L.O., C. Hansman, M. Dressler and E. Boyd. 1963. Intrauterine growth as estimated from live born birth-weight data at 24 to 42 weeks of gestation. Pediatrics 32:793–800. 57. Falkner, F. 1973. Long-term developmental studies: a critique. In Early Development. Research Publication of the Association for Research in Nervous and Mental Disease 51:416–418. 58. Ekblad, H., P. Kero, J. Takala, H. Korvenranta, and I. Valimaki. 1987. Water, sodium and acid-base balance in premature infants: therapeutical aspects. Acta Paediatr. Scand. 76:47–53. 59. Ross Planning Associates. 1988. Perspectives in Perinatal and Pediatric Design. Ross Laboratories, Columbus, Ohio. 60. American Dietetic Association; Kozlowski, B.W., and J.A. Powell. 1989. Position of The American Dietetic Association: nutrition services for children with special health care needs . J. Am. Diet. Assoc. 89:1133–1137. 61. Ehrenhaft, P.M., J.L. Wagner, and R.C. Herdman. 1989. Changing prognosis for very low birth weight infants. Obstet. Gynecol. 74:528–535. 62. Pittard, W.B. III, and D.M. Anderson. 1983. Neonatal nutrition training. J. Am. Diet. Assoc. 83:471–473. 63. Vanderveen, T., and R. Parks. 1981. ASHP supplemental standard and learning objectives for residency training in nutritional support pharmacy practice. Am. J. Hosp. Pharm. 38:1971–1973. 64. Brannon, M.E., and M.C. Egan. 1985. Nutrition in perinatal services: where are we? Perinatol. Neonatol. 9:11–20.

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