Table 4: High risk infants <27 weeks or <1,000g birthweight Haemodynamically unstable on inotropes Previous NEC or high risk for NEC Recent abdominal surgery Growth restricted infants with absent or reversed end diastolic flow
assessing whether the identification of nutrient deficits and/or excesses can be improved. The nutrition phase analysis approach revealed substantial macronutrient and energy deficits during the TN phase. In particular, deficits were identified as maximal during the EN-dominant TN phase (enteral feeds ≥80ml/kg/d). In contrast, the chronological age analysis approach did not reveal a corresponding pattern of deficit occurrence, but rather intakes that approximated or exceeded recommendations. The authors concluded that actual intakes of nutrients, analysed using a nutrition phase approach to evaluating nutrition support, allowed a more infant-driven rather than age-driven application of nutrition recommendations. This approach highlighted nutrient deficits occurring during the transition phase. Overcoming nutrient deficits in this nutrition phase should be prioritised to improve the nutrition management of preterm infants. EXPECTED WEIGHT GAIN
Intrauterine growth rate of approximately 15g/ kg/day is the most commonly used and accepted rate of weight gain for preterm infants, although this can be difficult to achieve.9 However, an accelerated weight gain in preterm infants should be avoided, as this has demonstrated detrimental consequences on longterm health, such as cardiovascular disease.14 When monitoring growth, the UK-WHO Growth Charts should be used. When correcting for gestation, the following guidance is accepted: • Gestation ≥37 weeks - no correction • Gestation 32 to 36+6 correct until age 1 year • Gestation 23 to 31+6 correct until age 2 years When calculating requirements, the actual weight should be used. In cases where the actual weight is lower than the birthweight or their highest dry weight, use the birthweight or highest dry weight.
CHOICE OF FEED
Breast milk Breast milk is the feed of choice for preterm infants, with all of its benefits being well documented. Where fortification is required, expressed breast milk (EBM) should be fortified with a commercial multicomponent breast milk fortifier (BMF) suitable for the preterm infant. As unfortified BMF cannot meet the needs of preterm infants <1.5kg, it can be commenced in stable preterm infants, usually once 150ml/kg/ day EBM is tolerated. Fortification should then continue until the infant is thriving. In cases where a supplementary preterm formula is given in addition to EBM and BMF, then the BMF should be stopped once 50% of requirements are given as formula, to prevent an excess of protein. It is important to carefully consider when to use a BMF in high risk preterm infants. Table 4 lists high risk infants. PRETERM FORMULA
Preterm infants who are not able to receive breast milk and are <2kg and <35 weeks, should be placed onto a preterm formula. There are three preterm formula milks available in the UK: • SMA PRO Gold Prem 1 (partially hydrolysed formula) • Nutriprem 1 low birth weight (whole protein formula) • Hydrolysed Nutriprem (extensively hydrolysed formula) Additional vitamin and mineral supplements are not required if the infant is on 150ml/kg/day of a preterm formula. These formulas should be continued until the infant is thriving, reaching 2.0-2.5kg and/ or discharged. Depending on growth achieved, www.NHDmag.com November 2017 - Issue 129
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