1. Nutritional Support of
the VLBW Infant
Dr Varsha Atul Shah

2. Objectives
Following self-study of the slide presentation and reading of the
Nutritional
Support of the Very Low Birth Weight (VLBW) Infant Toolkit, the
participant
will have/be able to:
 Recognize that nutrition during critical periods in early life may
permanently affect the structure and/or function of the infant’s
organs and tissues;
 Identify three physiological goals of VLBW infant nutrition
management;
 List suggested best practices for the major aspects of infant
nutrition promotion, including parenteral nutrition, establishing
enteral nutrition, human milk/breastfeeding, transition to oral
feeding and discharge planning;
 Recognize that new research has only reinforced prior best
practices;
 Demonstrate knowledge and skills necessary to establish and
support breastfeeding.

3. Gold Standard of Growth for
VLBW Infants
 To approximate the in utero growth of a
normal fetus of the same post-conceptional
age.
– Body weight
– Body composition
 AAP Committee on Nutrition: Nutritional needs of
low birth weight infants. Pediatrics 1985;75:976
 AAP Committee on Nutrition: Nutritional needs of the
preterm infant, in Kleinman RE (ed): Pediatric
Nutrition Handbook, ed 5, Elk Grove Village, IL,
AAP, 2004, p 23-54.

4. Unique Nutritional Aspects of
the VLBW Infant
 Higher organ:muscle mass ratio
 Higher rate of protein synthesis and
turnover
 Greater oxygen consumption during
growth
 Higher energy cost due to
transepidermal water loss
 Higher rate of fat deposition
 Prone to hyperglycemia

5. Unique Nutritional Aspects of
VLBW infants - Brain Growth
Brain Growth over 8 weeks:
 At 28 wks 100% Increase
 At term 40% Increase
 At 3 mo 25% Increase

6. Preventing Feeding-Related
Morbidities in VLBW Infants
 Necrotizing enterocolitis
 Osteoporosis
 Vitamin and mineral deficiencies
 Feeding intolerance
 Prolonged TPN and related cholestasis
 Prolonged hospitalization
 Lack of full physical and intellectual
potential

7. Optimizing Long Term
Outcome
Nutritional Programming:
Nutrition during critical periods in
early life may permanently affect
the structure and/or function of
organs or tissues.
Alan Lucas, 1990

8. Early Diet Influences Long-
term Health and Disease
Breastfeeding leads to reduction in
diastolic blood pressure in later years of
3.2 mmHg,
a greater impact that seen by other
public health measures including:
– Weight loss (-2.8 mmHg)
– Alcohol reduction (-2.1 mmHg)
– Salt restriction (-1.3)
– Exercise (-0.2 mmHg)

9. Early Diet Influences Long-
term Health and Disease
Adverse effects of growth acceleration in
humans include:
– Obesity
– Elevated blood pressure
– Insulin resistance and diabetes
– IGF-1 concentrations
– Cardiovascular mortality

10. Nutritional Care/Outcomes in VLBW
Infants - Potential Improvements
 Human milk
 “Early” TPN
– Prevent protein deficit
– Prevent EFA deficiency
 GI priming/MEN/Trophic feeds
– Prevent GI atrophy effects
– Faster realization of full enteral feeds
 Fortification/Supplementation
– Starting earlier
– Continuing longer

11. Benefits of Human Milk -
Reduced Infections
 Otitis media – with a reduction in the
frequency and duration of ear infections in
breastmilk versus formula fed newborns
 Respiratory tract illnesses including
respiratory synctial virus infection
 Gastrointestinal illness
 Urinary tract infections
 Infant botulism

12. Benefits of Human Milk -
Reductions in Chronic Diseases
 Obesity
 Allergies/atopy
 Type 1 juvenile onset diabetes
 Crohn’s disease
 Lymphoma

13. Benefits of Human Milk
for Preterm Infants
 Host Defense
 Gastrointestinal Development
 Special Nutrition
 Neurodevelopmental Outcome
 Physically & Psychologically Healthier
Mother

14. Immunoglobulins : 90% IgA and sIgA
 More IgA in preterm milk
 Concentration decreases over time
 IgA found in stool of breastfed infants
unchanged: lines intestine to protect
 Increased urinary excretion of IgA with
breastmilk

15. Incidence of Necrotizing
Enterocolitis by Type of Feed
Necrotizing
Enterocolitis
Type of feed Incidence
Proportion
EBM 1.2 %
3/253
EBM + PTF 2.5 %
11/437
PTF 7.2 %
17/236

16. GI Benefits of Human Milk for
the Preterm Infant
 Gastrointestinal development
– Reduces intestinal permeability faster
– Induces lactase activity
– Multiple factors to stimulate growth,
motility and maturation of the intestine
– Human milk empties from the stomach
faster than artificial milks
– Less residuals and faster realization of
full enteral feedings

17. Factors in Breastmilk That May
Promote GI Maturation
 Epidermal growth  Thyroxine
factors  Nucleotides
 Nerve growth  Taurine
factors
 Glutamine
 Somatomedin-C
 Lactose
 Insulin-like
growth factors
 Amino sugars
 Insulin
 Cytokines
Groer & Walker. Advances in
 Cortisol Pediatrics 1996; 43:335-358

18. Time Needed to Attain Full Enteral
Feeds in 95% of VLBW Infants
Type of feed Number of days
Expressed breastmilk 20
Standard formula 45
Preterm formula 48
Lucas & Cole. Lancet 1990;336:1519

19. Benefits of Human Milk
for the VLBW Infant
 Special nutritional needs
– Different quantity and quality of
proteins
– Fats: Cholesterol, DHA, ARA
– Carbohydrates designed for human
infants
– Lower osmolality/renal solute load
– Other factors: e.g. erythropoietin,
EGF

20. Human Milk and Retinopathy of
Prematurity in VLBW Infants
 145 VLBW (<1500gm) Jan 1992-Feb 1993
 Incidence of ROP
– Human Milk 37.3% p<0.005
– Formula 63.8%
 Incidence of ROP at discharge
– Human Milk 22.3% p<0.0007
– Formula 53.4%
 Multiple Regression Analysis:
– feeding correlated with ROP incidence and severity
– dose response relationship
– even small vol. (<20%) of human milk protective
Hylander et al. J Perinatol 2001; 21:356-362

21. General
Principles

22. Poor growth during antenatal or postnatal life is
associated with increased risk to long-term
health.
 Significant growth restriction occurs during the
in-hospital phase of post-natal growth among
VLBW infants.
 Maximizing volume of feeding and nutrient
fortification has been shown to improve overall
growth.
 Due to high relative growth rate standardizing
the response to poor or suboptimal growth
should improve overall growth.

23. Best Practice #1.1
Establish consistent, comprehensive,
multidisciplinary nutritional
monitoring as an integral component
of improving nutrition outcomes in
the neonatal population.

24. Best Practice #1.2
Establish standards of nutritional
practice based on best evidence or
expert opinion if evidence is lacking.
Track nutritional continuous quality
improvement (CQI) data and use it to
modify and improve current practices
and outcome.

25. Implementation Strategies
 Daily rounds and progress notes should include
a specific place for weight and feeding
adjustment and should address progress toward
daily growth targets.
 Weekly measurement and plotting of weight,
length and head circumference should be done.
 Standardize response to poor or suboptimal
growth.
 Mother’s milk expression and collection should
be encouraged, supported and monitored
routinely.

26. Parenteral Nutrition for
VLBW Infants

27. Sophisticated techniques for providing short and
long-term parenteral nutrition to critically ill
infants have been developed.
 In-utero protein and energy gain is more than 4
gm/kg/day.
 Administration of 3 gm/kg/day of protein
immediately after birth is safe and can reduce
the early protein deficit cumulated within the
first week of life.
 Early administration of at least 1 gm/kg/day pf
intravenous lipids will prevent essential fatty acid
deficiency.

28. Best Practice #2.1
 Parenteral nutrition, including protein and
lipids, should be started within the first 24
hours of life.
 Parenteral nutrition should be increased
rapidly so infants receive adequate amino
acids (3.0-4.0 gm/kg/day) and non-protein
calories (80-100 kcal/kg/day) as quickly as
possible.

29. Best Practice #2.2
 Start parenteral lipids within the first
24 hours of life. Lipids can be started
at doses as high as 2 g/kg/d. Lipids
can be increased to doses as high as
3.0-3.5 g/kg/day over the first few
days of life.

30. Best Practice #2.3
 Discontinue parenteral nutrition,
with removal of central catheters, as
soon as adequate enteral nutrition is
established.

31. Implementation Strategies
 Standardized policies, order sets and TPN
solutions should be used to provide
balanced, maintenance parenteral
nutrition.
 Amino acids (of at least 2 gm/kg/day) and
intravenous lipid administration should be
started within the first 24 hours of life
– Available pre-mixed TPN /TNA (Total Nutrition
Admixture) may simply administration and
mixing issues.

32. Establishing Enteral
Feedings

33. Current research confirms that human milk (with
appropriate fortification for the VLBW infant) is the
standard of care for preterm as well as term infants.
 The objective of feeding during the early days of
life is to stimulate gut maturation, hormone
release and motility.
 Early introduction of feedings shortens the time
to full feeds and discharge and does not
increase the incidence of NEC.
 Benefits of human milk include: key digestive
enzymes, immunologic protective factors,
immunomodulators, anti-inflammatory factors,
anti-oxidants, growth factors, hormones and
other bio-active factors.

34. Best Practice #3.1
 Human milk should be used
whenever possible as the enteral
feeding of choice for VLBW infants.

35. Best Practice #3.2
 Enteral feeds, in the form of trophic
or minimal enteral feeds (also called
GI priming), should be initiated
within 1-2 days after birth, except
when there are clear
contraindications such as a
congenital anomaly precluding
feeding (e.g. omphalocele or
gastroschisis), or evidence of GI
dysfunction associated with hypoxic-
ischemic compromise.

36. Implementation Strategies
 Create a supportive environment to maximize milk
production in the early post-partum period.
 Teach mothers hand expression and collection
techniques to maximize colostrum availability.
 Establish a relationship with a human milk bank and
procedures for obtaining heat-treated donor milk quickly.
 Specific standardized feeding policies should be available
in each NICU.
 Reasons for withholding feedings should be documented
and discussed in rounds.

37. Best Practice #7: Every mother of an infant
admitted to the NICU should be provided with an
appropriate breast pump and the support to use it
effectively.

39. Guidelines for advancing feeds have been shown
to
be associated with more consistent orders and
responses to residuals between physicians, faster
rates of advancement and lower rates of
necrotizing
enterocolitis.

40. Best Practice #3.3
 NICU’s should standardize feeding
management based on best available
evidence.
– NICUs should standardize their definition of
feeding intolerance, with specific reference to
acceptable residual volumes, changes in
abdominal girth and the presence of heme-
positive stools.
– Enteral feeds should usually be given by
intermittent bolus, rather than continuously,
and by gastric, rather than transpyloric
administration.

41. Best Practice # 3.3 continued
– Pumps delivering breastmilk should be
oriented so that the syringe is vertically
upright, and the tubing (smallest caliber
and shortest possible) should be
positioned and cleared to prevent
sequestration of fat.
– Enteral feeds should be advanced until
they are providing adequate nutrition to
sustain optimal growth (2% of body
weight/day). For infants fed human milk
this could mean as much as 170 - 200+
mL/kg/day.

42. Best Practice # 3.4
 VLBW infants fed human milk should be
supplemented with protein, calcium,
phosphorus and micronutrients.
Multinutrient fortifiers may be the most
efficient way to do this when feeding
human milk. Formula fed infants may
also require specific caloric and
micronutrient supplementation.

43. Implementation Strategies
 Each NICU should discuss and agree on a
definition of feeding intolerance.
 Staff should be educated on policies, plans and
practice changes.
 NICU feeding policy should specify modes and
methods of feeding as well as fortification
– Reason for variance should be discussed and
documentation.

44. Human Milk and
Breastfeeding

45. Maximal human milk exposure for the
vulnerable preterm infants during
hospitalization is essential.
 A concerted effort of a multidisciplinary team is
an excellent strategy to improve human milk
exposure along with the development of a
strong unit culture in support of human milk.
 Early milk production is correlated with later
maintenance milk volume and lactation success.
 Human milk is a body substance and therefore
carries risks of transmission of infectious agents.
Safe handling should minimize the risk to the
VLBW infant.

46. Best Practice # 4.1
 Educate & advocate for human milk for
NICU infants.
– Obstetric, perinatal, neonatal and pediatric
professionals should have the knowledge, skills
and attitudes necessary to effectively support
the provision of breastmilk to the VLBW infant.
– Mothers and families should be given accurate
information about human milk for VLBW
infants, and their decisions respected.

47. Breastfeeding Resources
 International
– ABM (Academy of Breastfeeding Medicine)
– WHO/UNICEF
– ILCA (International Lactation Consultant Association)
– IBLCE (International Board of Lactation Consultant Examiners)
– Wellstart International
– WABA (World Alliance for Breastfeeding Advocacy)
 National
– AAP (American Academy of Pediatrics)
– ACOG (American College of Obstetricians & Gynecologists)
– AAFP (American Academy of Family Physicians)
– DHHS: Office of Women’s Health/Maternal-Child Health Bureau)
– March of Dimes
– WIC (Women, Infant, Children Supplemental Nutrition Program)/USDA
– NIH (National Institutes of Health)
– CDC (Centers for Disease Control & Prevention)

49. Academy of Breastfeeding Medicine
Academy of Breastfeeding Medicine
www.bfmed.org

50. Best Practice #4.2
 Mothers’ milk supply should be
established and maintained.

51. Best Practice # 4.3
 Human milk should be handled to
ensure safety and maximal
nutritional benefit to the infant.

52. Best Practice # 4.4
 Obstetric, perinatal, and neonatal
professionals should counsel mothers
when breastfeeding may be of
concern or contraindicated.

53. Implementation Strategies
 Hold regular CME, CEU and other inservice activities
related to lactation issues.
 Develop competencies regarding human milk
handling and usage.
 Designate a Director of Lactation as a resource
person.
 Risk factors for insufficient lactation should be
communicated to perinatal and post-partum staff as
well as to perinatal staff of referring facilities.
 Routine and standardized patient education should
begin during pre-pregnancy OB/GYN visits and
continue through pregnancy.
 Remove formula company influences from the
perinatal area.

54. Breastfeeding-Supportive Infant
Environment?

57. Transition to Oral
Feedings

58. Early attachment is beneficial for
milk production and mother-child
bonding.
 Skin-to skin contact may strengthen the
mother-infant dyad and lead to longer
breastfeeding periods over the first two
years of life.
 Non-nutritive breastfeeding can stimulate
milk volume and improve breastfeeding
success rates.

60. Best Practice #5.1
 Infants should be transitioned from
gavage to oral feedings when
physiologically capable, not based on
arbitrary weight or gestational age
criteria.

61. Best Practice # 5.2
 A definitive protocol for transition to
oral feedings of human milk or
formula does not currently exist.
NICU healthcare providers should
make use of safe techniques for
which some evidence exists (skin-to-
skin care, non-nutritive
breastfeeding, test-weighing,
alternate feeding methods) to
effectively facilitate transition to full
oral feeding.

62. Implementation Strategies
 Implement and encourage routine skin-to-
skin time.
 Measure lactation time
 Measure breastfeeding frequency and
breastfeeding status at the time of
discharge.

63. Discharge Planning and
Post-Discharge Nutrition

64. In the weeks prior to discharge from
the NICU an individualized nutritional
plan should be prepared.
 These plans should be coordinated between
the family, neonatology, lactation
consultants, dieticians, nursing staff and if
possible the primary care physician
continuing to provide care following
discharge.
 Post-discharge nutrition, including the need
for special diets, frequency of visits and
monitoring of growth and biochemical
markers is required.
 VLBW infants grow faster and have higher
bone mineral content up to 1 year of age if
provided with additional nutrients including

65. Best Practice #6.1
 Nutritional discharge planning should
be comprehensive, coordinated and
initiated early in the hospital course.
Planning should include appropriate
nutrient fortification and nutritional
follow-up.

66. Best Practice #6.2
 Mothers should be encouraged to
eventually achieve exclusive
breastfeeding after discharge
while ensuring appropriate growth
for the infant.

67. The End
Questions?
Review the CPQCC
Toolkit: Nutritional
Support of the Very
Low Birth Weight
Infant.
Available at:
www.cpqcc.org