Overview
Definition:
Feeding preterm infants involves establishing adequate nutrition to support growth, development, and prevention of complications
Two main approaches exist: volume-driven protocols, which aim for a specific daily intake of milk, and cue-based feeding, which focuses on the infant's readiness and feeding cues.
Epidemiology:
Preterm birth remains a significant challenge, with millions of infants born prematurely each year globally
Neonates <34 weeks gestation often require specialized feeding support due to immature gastrointestinal systems and increased nutritional demands.
Clinical Significance:
Appropriate feeding strategies are critical for preventing feeding intolerance, promoting neurodevelopment, reducing the risk of infections, and optimizing long-term health outcomes in preterm infants
Understanding these protocols is essential for managing high-risk neonates.
Feeding Approaches
Volume Driven Protocols:
These protocols establish a fixed daily milk intake target (e.g., 150-180 ml/kg/day) and a structured feeding schedule (e.g., every 3 hours)
Feeding volumes are advanced incrementally regardless of infant cues, aiming to meet caloric and fluid needs efficiently
This approach can be beneficial for infants requiring consistent intake but may overlook individual infant readiness.
Cue Based Feeding:
This approach prioritizes recognizing and responding to infant feeding cues such as rooting, sucking on fingers, or lip smacking
Feedings are initiated when the infant shows signs of hunger and are terminated when the infant shows signs of satiety (e.g., turning head away, falling asleep)
This method aims to establish a more natural feeding pattern, enhance mother-infant bonding, and potentially reduce overfeeding or underfeeding.
Comparison And Evidence:
While volume-driven protocols offer a structured approach, evidence suggests cue-based feeding may lead to improved feeding tolerance, shorter time to full enteral feeds, and better weight gain in some preterm populations
However, the optimal approach can vary based on gestational age, infant maturity, and clinical condition
Many NICUs adopt a hybrid approach, combining elements of both.
Diagnostic Approach To Feeding Readiness
History Taking:
Assess gestational age, birth weight, presence of medical conditions (e.g., NEC, sepsis), previous feeding attempts and tolerance, and maternal support
Inquire about infant's state of alertness and behavior during potential feeding times.
Physical Examination:
Evaluate for signs of readiness: appropriate tone and alertness, intact gag reflex, ability to sustain rhythmic sucking and swallowing
Assess abdominal distension, bowel sounds, and presence of emesis or stooling patterns.
Assessment Of Cues:
Recognize early cues (rooting, mouthing) and late cues (fidgeting, crying)
Differentiate between hunger cues and comfort-seeking behaviors
Observe for signs of satiety (turning head away, slowing of sucking, falling asleep).
Management Strategies
Nasogastric Or Orogastric Tube Feeding:
Used for infants unable to coordinate sucking, swallowing, and breathing
Continuous or bolus feeds can be administered
Gradual advancement of volume is guided by tolerance.
Oral Or Paladai Feeding:
Initiated when the infant shows signs of readiness
Techniques include paced bottle feeding or using a paladai to facilitate a more controlled intake, minimizing aspiration risk.
Nutritional Requirements:
Preterm infants have higher caloric (110-150 kcal/kg/day) and protein (3-4 g/kg/day) needs
Fortified human milk or specialized preterm formulas are often used
Vitamin and mineral supplementation is crucial.
Advancement Protocols:
Feeding volumes are advanced based on tolerance (absence of emesis, abdominal distension, significant residuals) and infant cues
A common approach is to increase feeds by 10-30 ml/kg/day, but this can be adapted in cue-based feeding.
Enteral Feeding Tolerance:
Monitor for abdominal distension, vomiting, emesis, increased gastric residuals, bloody stools, and abdominal tenderness
Signs of intolerance necessitate a review of the feeding regimen and potential medical intervention.
Nutritional Support And Monitoring
Human Milk Use:
Human milk is the preferred source of nutrition
Mother's own milk should be fortified for preterm infants to meet their high nutrient demands
Donor human milk is an alternative when mother's milk is unavailable.
Formula Selection:
Specialized preterm formulas offer higher caloric density and protein content
Hydrolyzed or elemental formulas may be considered for infants with feeding intolerance or malabsorption.
Monitoring Growth And Intake:
Regular assessment of weight, length, and head circumference is essential
Accurate recording of fluid intake and output, stool frequency, and emesis helps track tolerance and adequacy of nutrition.
Biochemical Monitoring:
Periodic monitoring of electrolytes, glucose, calcium, phosphorus, and liver function tests helps detect and manage metabolic complications
Micronutrient levels may be assessed as needed.
Complications And Prevention
Feeding Intolerance:
Characterized by abdominal distension, vomiting, and feeding cessation
Prevention includes gradual advancement, avoiding overfeeding, and using appropriate feeding techniques.
Necrotizing Enterocolitis Nec:
A serious intestinal inflammatory condition
Risk factors include prematurity, hypoxic events, and rapid advancement of feeds
Conservative feeding management and early recognition are key.
Growth Failure:
Inadequate caloric intake or malabsorption can lead to poor weight gain
Optimizing nutritional composition, considering parenteral nutrition if necessary, and addressing underlying causes are important.
Mineral And Vitamin Deficiencies:
Preterm infants are at risk for deficiencies of calcium, phosphorus, iron, and vitamins
Adequate fortification and supplementation are crucial.
Key Points
Exam Focus:
DNB/NEET SS often tests the understanding of the physiological immaturity of preterm infants and how it impacts feeding
Differentiating between cue-based and volume-driven protocols, and recognizing signs of feeding intolerance are critical.
Clinical Pearls:
Always assess infant readiness before initiating or advancing feeds
Individualize the feeding plan based on gestational age, clinical status, and tolerance
Early recognition and management of feeding intolerance can prevent serious complications like NEC.
Common Mistakes:
Over-reliance on strict volume targets without assessing infant cues can lead to feeding intolerance
Failure to fortify human milk for preterm infants leads to suboptimal growth
Delayed recognition of feeding intolerance or NEC.
Nutritional Targets:
Caloric needs: 110-150 kcal/kg/day
Protein: 3-4 g/kg/day
Fluid: 120-180 ml/kg/day depending on maturity and clinical status.