Case Report

Neonatal nutrition

by Megan Russek, MS, RD, LD

An 807-gram infant was born at 27 ⁴⁄₇-weeks' gestation by emergency cesarean section to a 32-year-old G2P1Ab0 mother. Birth weight was 10th percentile for dates, and length was the 50th percentile; head circumference was less than 3rd percentile. The initial Apgar scores were 1, 5, and 4 at 1, 5, and 10 minutes of life. Umbilical vascular lines were placed and the infant was intubated; the infant developed bilateral pneumothoraces requiring placement of tube thoracostomies. The baby was then transferred to the Texas Children's Hospital NICU for mechanical ventilation.

Initial intravenous fluids (IVF) consisted of 10% dextrose at 80 mL/kg per day. Prior to 24 hours of life, TPN starter solution (TPN SS) was begun with a mixture of amino acids, dextrose, calcium, magnesium, trace elements, and vitamins. Twenty-four hours later, standard TPN, at 80 mL/kg per day and 5 mL/kg per day of Intralipid® (IL), were started. Standard TPN volume and IL were advanced as fluid and lipid tolerance allowed. The chest tube was removed on day of life (DOL) 5. On DOL 6, 130 mL/kg per day of standard TPN and 20 mL/kg per day of IL were attained.

Following successful extubation to NCPAP, trophic feedings of expressed breast milk (EBM) were initiated at 10 mL/kg per day, advanced to 20 mL/kg per day the following day, and maintained at this volume for 5 days. Feedings were then advanced, as tolerated, by 20 mL/kg per day increments. By DOL 21 the baby was receiving 150 mL/kg per day of EBM + human milk fortifier without TPN or IL. Birth weight was regained by 2 weeks of age.

Discussion

Emphasizing several issues will highlight a baby's nutritional course. Initiating a source of protein on the first day of life (TPN SS) prevents negative nitrogen balance and may improve serum glucose control. After 1 to 2 days of the TPN SS, standard TPN solution is initiated. Our TPN solution provides appropriate amounts of all nutrients based on a volume of 130 mL/kg per day with the addition of IL. IL provides a high-calorie energy source and, with at least 2.5 mL/kg per day of IL, adequate essential fatty acid intake.

Trophic feedings are small-volume feedings (10 to 20 mL/kg per day) that are maintained at this low volume for 5 to 10 days. These feedings are meant to up-regulate intestinal tract growth factors and generally are not considered a source of calories and nutrients. Benefits include achievement of full enteral feedings sooner, increased gastrin and other enteric hormone levels, and a more mature intestinal motor pattern.

(Intralipid is a registered trademark of Riker Laboratories, Inc., Northridge CA.)