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Growth and nutrition in preterms
Anne Karin Aurvåg og Christine Gørbitz
Kliniske ernæringsfysiologer, BUK, Akershus University Hospital
Optimal nutrition and growth of the preterms:
• AAP 1985 standard for postnatal nutrition;
”the standard for postnatal nutrition in all preterm infants
aimes to duplicate normal in utero growth rates”
• AAP Commitee on Nutrition 1998;
repeated the message
Intrauterin growth
• Fetus weightgain GA 27 – 34 weeks;
16–17 g/kg/d (baby 2 kg – weightgain = 32-34 g/d)
Lenght/headcircumference increases 1 cm/week
• Accumulation of nutrients mainly in third trimester
”….not because growth per se is important, but
rather because poor growth is a marker of
inadequate nutrition, which in turn can impair
cognitive development.”
Ziegler 2001
Postnatal growth failure
% SGA at birth:
33%
% SGA when leaving the hospital/at term: 58%
• Growth and nutrient intake among very-low-birth-weight infants fed fortified human milk
during hospitalisation
Henriksen C et al, Br J Nutr 2009;102:1179-86
Growth failure (<10 p):
2000: 64,5% - 2013: 50,3%
• Weight Growth Velocity and Postnatal Growth Failure in Infants 501 to 1500 g: 2000-2013
Horbar JD et al, Pediatr 2015;136:84-92
Enhanced Feeding and Diminished
Postnatal Growth Failure in VLBW Infants
• Birthweight < 1500 g
• 50 children
• Interventiongroup had more energy, protein, vitamin A and
essential fatty acids
• Interventiongroup better weightgain og less SGA
Moltu S et al JPGN 2014;58(3),344-351.
Early aggressive nutrition
Adequate nutrition from day 1 - growth
• Weightgain and increased HC is directely correlated to
proteinintake.
Arslanoglu S et al, J Perinatol 2006;26:614-21
• Preterms < 1500 g; before day 5 received > 3 g aa/kg/d
weightgain, HC and lenght by 36 weeks GA.
→ better
Poindexter BB et al,J Pediatr 2006;148:300-5
• Preterms fed more aggressively, regain birth weight sooner
→
NEC and sepsis unchanged or reduced + earlier discharge.
Hay WW et al, Curr Pediatr Rep 2013;1(4):1-17
Adequate nutrition from day 1 – cognitive function
• Perinatal growth failure in VLBW resulted in subnormal HC at 8
months. At 8 years:
→ adverse effect on neurodevelopmental outcome
→ increaced hyperactivity
Hack M et al. N Engl J Med 1991;325:231-7
• + 10 kcal/kg/day first week
→
+ 4,6 point MDI at 18 months
+ 1 g protein/kg/day first week → + 8,2 point MDI at 18 months
Stephens B et al, Pediatr 2009;123:1337-43
Human milk composition
per 100ml
Content
Protein, g
Preterm
Term
2,2
1,8
(W. > 10)
1,4
1,0
1,2
0,9
(W. 1)
60
60
66
(W. 1)
(W. 3-4)
Kcal
(W. 3-4)
(W. > 10)
77
66
A systematic rewiew and meta-analysis of the nutrient content of preterm and term breast milk.
Gidrewicz and Fenton, BMC Pediatrics, 2014;14:216.
n=843 preterm mothers and n=2299 term morthers
68
Our analysis…………….
More than 100 samles om mothers milk analysed
at Rikshospitalet, Oslo University Hospital
– Energy:
– Protein:
– Fat:
44-135 kcal/100ml
0,5-2,3 g/100 ml
2,5-11,7 g/100 ml
If the child only gets unfortified donormilk?
Recommended
preterm intake
(ESPGHAN 2010)
15% (150 ml/kg) bankmelk
Energy, kcal/kg/d
110-135
100
Protein, g/kg/d
4-4,5
1,35
Vitamin A
400-1000 ug/kg/d
90 ug
Vitamin D
800-1000 iu/dag
0
Iron
2-3 mg/kg/dag
0,15
Tiamin, mg
0,14-0,30 mg/kg/dag
0,03
Riboflavin, mg
0,2-0,4 mg/kg/dag
0,04
Vitamin C, mg
11-46 mg/kg/d
6
Preterms need fortification/supplementation
of breast milk!
Individual differences:
–what kind of supplement/fortification?
–amount of supplement/fortification?
–tolerance for supplement/fortification
–tolerance for volum
CAKE I
Effekt av intensiv kostintervensjon hos
barn med fødselsvekt 1500-2000 g
Anne Karin Aurvåg og Christine Elisabeth Gørbitz
Kliniske ernæringsfysiologer BUK
Aims
• Growth duplicating intrauterin growth
• Achive more knowledge concering nutrition and growth
from birth to 4 months corrected age (56 weeks GA)
CAKE hypothesis;
Individual nutritional follow-up of children
with birth weight 1500 - 2000 g, improves
growth compared to controls.
Weight, term
Control: 2993 g
Intervention: 3568 g
P < 0.0005
Weight, 4 months corrected age/GA 56 weeks
Control: 6219 g
Intervention: 7042 g
P < 0.01
Lenght, term
Control: 49.2 cm
Intervention: 50.5 cm
P < 0.0005
Lenght, 4 months corrected age/GA 56 weeks
Control: 62.0 cm
Intervention: 63.7 cm
P < 0.05
Head circumference, term
n.s. = Ikke signifikant forskjell mellom gruppene
Head circumference, 4 months corrected age/GA 56 weeks
Control: 41.1 cm
Intervention: 42.2 cm
P < 0.05
CAKE
CAKE II
Starting september 2015
Akershus University Hospital
Stavanger University Hospital
St. Olavs Hospital in Trondheim
University Hospital North Norway in Tromsø
Telemark Hospital in Skien
Intervention by dietetian; at Akershus University Hospital
More knowledge about preterms (1500-2000 g);
growth, nutrition and feeding difficulties