Nutrition Services in Perinatal Care Second Edition (1992) / Chapter Skim
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5 Newborns Who Need Special Nutritional Care
5 Newborns Who Need Special Nutritional Care
Pages 67-92
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From page 67... ...
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, S37 weelo;) , low birth weight (LBW; <2,500 g)
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From page 68... ...
~ w ,, .~ '''I '~''O''- ~ ~ 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.i 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~.
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From page 69... ...
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 AD D, and E; and calcium, phosphate, and iron.~3 This uncertainty, in turn, increases the importance of frequent, individualized monitoring to determine whether adjustments in intake are needed.
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From page 70... ...
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 LOW babies increase fluid requirements. Long-term parenteral nutrition has been associated with cholestas~s.
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From page 71... ...
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.
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From page 72... ...
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 bank a can be fortified with commercial human milk fortifiers or other sources of nutrients.2~~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.
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From page 73... ...
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.
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From page 74... ...
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.
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From page 75... ...
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~.
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From page 76... ...
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 adequac y of nutritional intake, it is especially critical to monitor high-risk neonates frequently and with close attention to detail.4244 Such monitoring is described briefly below and is summarized in Chart 5-2.
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From page 77... ...
White blood cell count and differential Cultures aloe 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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From page 78... ...
Gestational duration can also be estimated from physical examination of the infant, using the examinations by Dubowitz and colleagues47 or Ballard and coworkers48 for larger infants of more than 30 weeks' gestational age,49 or using the more recent Ballard examinational for extremely low-birth-weight infants. Reference values are available for normal birth weight, length, and head circumference at different gestational ages (see, e.g., Baboons and the review of growth curves by Sparkss)
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From page 79... ...
Head Circumference Head circumference must also be measured, recorded, and plotted regularly, consistently, and accurately. As with length, increases in head circumference are small relative to potential measurement errors.
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From page 80... ...
NUTRITION SERVICES DELIVERY FOR NEONATES WITH SPECIAL NEEDS AND THEIR FAMILIES Nutrition services for sick or recovering infants are delivered in diverse settings. In neonatal intensive care units and in intermediate care nurseries, skilled help is available.
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From page 81... ...
A neonatal intensive care unit should be staffed and equipped to treat and provide nutritional support for critically ill infants and to facilitate the transition to a lower level of care, either in another hospital unit or at home. Many neonatal intensive care units are engaged in the teaching and training of medical students, interns, residents, nurses, and dietitians.
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From page 82... ...
Comprehensive Nutniional 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)
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From page 83... ...
At a programmatic level, the organized review of neonatal nutritional support sentences, with attention to usage, level of staff, and rate of nutritionrelated 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.
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From page 84... ...
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)
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From page 85... ...
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.
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From page 86... ...
; 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 nutnents, drugs, and foods; the composition of feedings and supplements; and the education of family members and other care providers.
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From page 87... ...
· 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)
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From page 88... ...
· 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.
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From page 89... ...
1988. Improved mineral balance in very low birth weight infants fed fortified human milk.
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From page 90... ...
1988. Pediatric parenteral amino acid mixture in low birth weight infants.
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From page 91... ...
1992. Comprehensive computerized neonatal intensive care unit data system including real-time, computer-generated daily progress notes.
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