Nutrition for Preterm and Beyond

Lekha  Sreedharan

Nutrition for Preterm and BeyondCHAPTER 1

Lekha Sreedharan

PRETERM AND LOW BIRTH WEIGHT INFANTS

Recent advances in the nutritional care for the preterm neonate have led to better survival and improved awareness regarding the importance of nutritional support. In the early weeks of life, when gastrointestinal motility is still not well established, enteral feed tolerance may be difficult and challenging. The growth velocity is higher in preterm than in term babies. Premature infants have high nutritional demands and poor nutrient stores.

Preterm growth charts should be used for these infants. The Fenton preterm growth chart is one of the most commonly used charts.

Prematurity is often discussed with respect to the birth weight and gestational age, as shown in Box 1.

Feeding of Preterm Infants

Adequate nutrition is essential for optimal growth, resistance to infection, optimal neurologic and cognitive development. Providing adequate nutrition to preterm infants is challenging because of several problems. These problems include immaturity of bowel function, inability to suck and swallow, high risk of necrotizing enterocolitis (NEC), other illnesses that may interfere with adequate enteral feeding¹. Flowchart 1 depicts the nutrient requirements for preterm infants.

BOX 1 : Classification of prematurity categorized as per birthweight and gestational age.

Classifications

Maturity by gestational age

Preterm: <37 weeks
Term: 37–42 weeks
Post-term: >42 weeks

Birth weight

Low birth weight (LBW): <2,500 g
Very low birth weight: <1,500 g
Extremely low birth weight: <1,000 g

Birth weight for gestational age

Intrauterine growth retardation: Weight < 3rd percentile
Small for gestational age (SGA): Weight < 10th percentile
Asymmetric SGA: Weight only < 10th percentile
Symmetric SGA: Weight, length, head circumference < 10th percentile
Appropriate for gestational age: Weight 10th–90th percentile
Large for gestational age: Weight > 90th percentile

Parenteral Nutrition

Goals to achieve while starting of parenteral feeding.

The majority of premature infants will start with the initiation of parenteral nutrition which should provide recommended fluid and nutrient estimates until enteral feeds can be established (Table 1).
Parenteral nutrition for premature infants should begin in the first 24–48 hours of 2life, once urine output is established and electrolyte is stable.

Flowchart 1: Nutrient requirements for preterm infants.²

TABLE 1 Parenteral nutrition in premature infants.³

Fluid requirements

Preterm neonate:	>1,500 g:	60–160 mL/kg
	1,000–1,500 g:	70–180 mL/kg
	<1,000 g:	80–180 mL/kg

Vitamins

Vitamin A: 400–1,000 μg/kg/day	Vitamin D: 800–1,000 IU/kg/day
Vitamin C: 11–46 mg/kg/day	Thiamine: 140–300 μg/kg/day
Riboflavin: 200–400 μg/kg/day	Niacin: 380–5,500 μg/kg/day
Vitamin E: 2.8–3.5 IU/kg/day	Vitamin B₁₂: 0.2 μg/kg/day
Pyridoxine: 0.15–0.2 mg/kg/day	Pantothenic acid: 2.5 mg/kg/day
Biotin: 5–8 μg/kg/day	Folic acid: 56 μg/kg/day

Minerals and trace elements

Iron: 200–250 μg/kg/day	Calcium: 60–90 mg/kg/day	Phosphorus: 31–62 mg/kg/day
Magnesium: 2.5–5.0 mg/kg/day	Iodine: 1–10 μg/kg/day	Zinc: 400–450 μg/kg/day
Selenium: 7 μg/kg/day	Copper: 40 μg/kg/day	Manganese: ≤1 μg/kg/day

Additives

Na: 2–4 mEq/kg/day

K: 2–4 mEq/kg/day

Cl: 2–3 mEq/kg/day

Parenteral nutrient intake may be built up over a number of days; glucose and fat tolerance need to be monitored carefully with blood glucose and plasma triglyceride measurements.
Complications associated with use of parenteral nutrition include glucose intolerance, bloodstream infection resulting from central venous catheter-related sepsis, cholestasis and hypertriglyceridemia.
Parenteral nutrition should follow recommended fluid and nutrient estimates.3

Enteral Nutrition

The gestational age of the infant will affect the decision to feed orally or by tube feeding since suck, swallow and breathe coordination do not develop until 32–34 weeks' gestation. Feed advancement is often based on birth weight (Table 2).

Human Milk Fortifier

The nutritional composition of expressed breast milk (EBM) can be insufficient to meet the requirement of preterm babies. Human milk fortifier (HMF) can be added to EBM. HMF contains protein, fat, carbohydrate, sodium, calcium, phosphorus, zinc and vitamins.

Discharge Planning

Very low birth weight or small for gestational age infants at birth are at risk. Infants with a history of poor feeding skills, who were on long-term parenteral nutrition, or who have had a complicated medical course or nutritional deficits are also at risk and should have routine follow-up visits after discharge.

The infant should be fed orally, but in certain medical conditions cases, tube feeding may be initiated, based on the medical condition and parental readiness.

Human milk fortifiers are not recommended for home use because of their high concentration of protein and minerals. Infants not on breast milk should be on preterm transition formulas for home. These feed formulations can be started close to time of discharge. Preterm formulas provide a higher concentration of protein, vitamins and minerals than term infant formulas.

TABLE 2 Enteral nutrition: feeding advancement and goals.^2,3

Energy 110–130 kcal/kg/day 150–160 kcal/kg (in bronchopulmonary dysplasia, small for gestational age infants)
Protein 3.0–4.0 gm/kg/day
Calcium: 120–140 mg/kg/day Phosphorus: 60–90 mg/kg/day
Multivitamin Preterm infants receiving breast milk exclusively should receive multivitamin supplementation
Birth weight (g)	Initial volume (mL/kg/day)	Volume increase (mL/kg/day)
<800	10	10–20
800–1,000	10–20	10–20
1,001–1,250	20	20–30
1,251–1,500	30	30
1,501–1,800	30–40	30–40
1,801–2,500	40	40–50
>2,500	50	504

NUTRITION CARE OF THE PEDIATRIC PATIENT

Introduction

Covering over a span of 18 years, childhood is one of the most intense stages in a person's lifetime. The time covered by childhood in one's life is vast that can be categorized into different phases of life such as infancy, preschool and early school-going phase, later childhood years and adolescence. With the global estimates of malnutrition skyrocketing (22% of children under the age of 5 in the world are stunted and 6.7% of children under the age of 5 are wasted) and India not faring any better (34.7% and 17.3% of children in India are stunted and wasted, respectively) as of 2020, it is essential that due importance be given to pediatric nutrition.^4,5

Growth and development during childhood is significant and adequate nutrition is essential for every child's survival. With malnutrition so prevalent in our country, it is important that a clear distinction be made between growth and development.

Figure 1 shows the difference between growth and development, where the former is quantitative, the latter is both quantitative and qualitative.

A severe deviation from normal growth and development is what causes malnutrition in children. Although malnutrition is commonly associated with undernutrition the term also includes overnutrition and micronutrient deficiencies.

During infancy, rapid gains in weight and length are normal. However, persistence of rapid weight gains while going into adolescence is a predictor of progression to obesity. This reinforces effective pediatric nutrition support, by providing accurate assessment of nutritional status and ensuring appropriate nutrients are provided to optimize growth.

A poorly balanced diet can impact several important developmental milestones in children.

Weight Velocity

The age-dependent changes in velocity that characterize postnatal growth can be shown using weight velocity charts. The weight velocity charts can be accessed from the WHO website.

Some important developmental milestones while measuring the weight velocity are given in Figure 2.

According to the child growth standards set by the World Health Organization (WHO), the velocity standards for weight are presented in Table 3.

Fig. 1: Difference between growth and development.

Fig. 2: Developmental milestones while measuring weight velocity.

TABLE 3 Weight velocity standards as per WHO.

Age group	Increments
Birth to 12 months	1 month increment
Birth to 24 months	2 to 6 month increment
Birth to 60 days	Depends on birth weight

Fig. 3: Nutrition care process and its components.

Nutrition Care Process in Pediatrics

A systematic approach to providing high-quality nutrition care to patients is called the Nutrition Care Process (NCP). Nutrition assessment, nutrition diagnosis, nutrition intervention and nutrition monitoring/evaluation are the four main steps in the NCP model. Figure 3, shows the Nutrition care process and its components. This helps us in identifying any possible causes of abnormal nutrition status, collecting any information to develop an appropriate nutrition care plan and to evaluate the effectiveness of the nutrition care plan.⁸

Nutritional Screening

What can be described as a precursor of nutrition assessment, nutrition screening identifies those who are at risk of being malnourished and are susceptible to diseases. The subjective data related to diet and associated lifestyle behavior, information regarding body weight, medical history and other anthropometric data are collected during the screening process. The purpose of a nutritional screening is to provide a snapshot of the dietary factors of interest, define nutritional education goals, guide 6recommendations for dietary supplements and identify the need to refer a patient to a registered dietitian for consultation.

The different aspects of nutrition screening and assessment have been shown in Figure 4.

Tools Used for Nutrition Screening

There are several tools specific to pediatric patients that are commonly used for the process of nutrition screening as shown in Table 4.^9,10

Fig. 4: Different aspects of nutrition screening and assessment.

TABLE 4 Different tools available for nutrition screening and assessment.

S. No.	Screening tool	Tool description or target population
1	Scored Patient-Generated Subjective Global Assessment (PG-SGA)	Useful for oncology and other chronic catabolic condition
2	Pediatric Nutrition Screening Tool (PNST)	Hospitalized pediatric patients
3	Screening Tool Risk on Nutritional Status and Growth (STRONGkids)	Screening tool for risk on nutritional status and growth
4	Pediatric Yorkhill Malnutrition Score (PYMS)	To ensure the early detection of hospitalized children at nutrition risk
5	Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP)	Developed for hospitalized children aged 2–17 years; allows for repeated screening
6	STAMP (Mod) Screening Tool for the Assessment of Malnutrition in Pediatrics-Modified [STAMP (Mod)]	Modified version of STAMP (above) for children in the outpatient setting
7	Electronic Kids Dietary Index (E-Kindex)	For children in the community
8	Integrated Management of Childhood Illness (IMCI)	Designed by WHO to be used by health workers in developing countries
9	Nutrition Risk Screening Tool for Children and Adolescents with Cystic Fibrosis (NRST-CF)	Developed for children with cystic fibrosis in the inpatient or outpatient setting
10	Nutrition Screening Tool for Every Preschooler (NutriSTEP)	A community-based, parent-administered tool for preschool children
11	Nutrition Screening Tool for Every Preschooler-Toddler (NutriSTEP-Toddler)	Modified version of NutriSTEP (above); a community-based, parent-administered tool for toddlers (18–35 months)
12	Pediatric Nutrition Risk Score (PNRS)	Developed for hospitalized children > 1 month of age at risk of acute malnutrition
13	Pediatric Nutrition Screening Tool (PNST)	Developed to improve simplicity of nutrition screening in hospitalized children
14	Pediatric Malnutrition Screening Tool (PMST)	Modified version of STAMP for hospitalized children aged < 2–17 years; screens for both under and overnutrition
15	Nutrition Screening Tool for Childhood Cancer (SCAN)	Developed for children with a cancer diagnosis7

Nutrition Assessment

Nutritional assessment is the systematic process of collecting and interpreting information in order to make decisions about the nature and cause of nutrition-related health issues that affect an individual. It involves the identification and quantification of nutritional deficits. A person's nutritional status reflects the balance between supply and demand and the consequences of any imbalance in their body. This step also includes reassessment for comparing and re-evaluating data from the previous interaction to the next and collection of new data that may lead to new or revised nutrition diagnoses. The ABCD of nutrition assessment includes anthropometry, biochemical, clinical and dietary analysis.

Anthropometry

A quantitative measurement of the muscle, bone and adipose tissue used to assess the composition of the body is called the anthropometric measurement.^11,12

Some of the pediatric anthropometric measurements include:

Height
Weight
Head circumference
Skinfold measurement
Mid-upper arm circumference (MUAC). The grade of malnutrition using MUAC z-score is shown in Table 5.

Confirming malnutrition: Depending on the above measurements, with the help of growth standards/reference charts, several anthropometric indices are made in order to confirm the presence of malnutrition in a person.¹³

TABLE 5 Assessing the grade of malnutrition using MUAC z-score.

MUAC z-score	Grade of malnutrition
1–1.9	Mild malnutrition
2–2.9	Moderate malnutrition
3 or greater	Severe malnutrition

Height-for-age: It compares a child's height/length with a healthy reference child of the same age.
Weight-for-age: It reflects acute and chronic undernutrition.
Weight-for-height: It helps to understand the degree of wasting.
Body mass index (BMI)-for-age: In children, BMI is age and sex specific because the amount of fat varies with age and between boys and girls. This index is specifically used in children above the age of 5.
Z-score/standard: Z-score is a tool used to quantify standard deviations (SDs) from population mean value. Z score is also helpful in quantifying and to track the indicators that are below the 5th or which lie above 95th percentile. (The percentile is the rank position of an individual on a given reference distribution, stated in terms of what percentage of the group the individual equals or exceeds). A z-score of 0 is at the apex of the curve and is the same as a 50th percentile, a z-score of ± 1.0 plots at the 15th or 85th percentiles, respectively and a z-score of ± 2 plots at roughly the 3rd or 97th percentiles.

Growth charts:Growth standards represent the description of physiological growth for children who live under optimal environmental conditions, receiving optimal nutrition, health care and show desirable 8growth characteristics.

Flowchart 2: Measures used in growth charts for different age groups.

The values of weight/height for each age against which we measure the growth of the children are the growth references (Flowchart 2).^14–16

Options in growth charts:

WHO Child Growth Standards/Reference: The curves were created based on data [the Multicentre Growth Reference Study (MGRS)] from selected communities worldwide. These growth charts are recommended by WHO for universal application.
Centers for Disease Control and Prevention (CDC) Growth Curves: These charts describe how certain children grow in a particular place and time.¹⁴
National Centre for Health Statistics (NCHS)/WHO Growth Reference

Biochemical Assessment for Nutritional Deficiencies

Biochemical tests for assessment of nutritional status involve measurement of:

Nutrient, its metabolites or the intermediate products in blood and urine¹⁷
Activity of a vitamin-dependent enzyme in erythrocytes and it is in vitro activation with corresponding coenzyme¹⁷
An accumulated metabolite whose disposal depends on a vitamin or mineral dependent enzyme, with or without preloading with a precursor.¹⁸

These biochemical tests go hand in hand with the dietary information in order to diagnose a deficiency or any other medical condition.

Clinical Assessment

Several nutritional deprivations can easily be detected in most situations. Clinical signs and symptoms of malnutrition, biochemical, anthropometry and dietary evaluation are valuable to detect nutritional deficiency.^17,18

Dietary Assessment/Food/Nutrition-related History

Dietary assessment is the process of evaluating the quantity of either a particular food items/nutrients or of each and every food items/nutrients which a child eats at particular time period with the help of suitable methods.

Key components of a pediatric diet history forms the basis for a good prescription and should always be a thorough process. It is imperative that the case history be taken from the parents and the caregiver. A detailed case history lays the foundation for a better understanding of the challenges faced by the child and the family, social, cultural influences and personal preferences. A 24-hour diet recall 9must include the food along with its quantities as well as the water consumed.¹⁹

Nutrition-focused Physical Finding

The nutrition-focused physical finding (NFPF) is one of the important processes in nutritional assessment.

Nutritional deficiencies can be assessed based on physical signs shown in Table 6.

Feeding Guidelines for Pediatrics Population

Infant feeding: It provides the nutritional, immunological, physiological, health, psychological, social and economic benefits to baby and mother. WHO/UNICEF have emphasized the initial 1,000 days of life to be the critical window period for nutritional intervention. Exclusive breastfeeding should be the gold standard for the initial 6 months of life.

Feeding guidelines for different age groups of children have been given in Table 7.

Energy Needs in Children

There is an extra caloric requirement for the pediatric population as compared to adults due to the rapid growth during the initial years of life. The requirements can also vary depending on the disease conditions the child has.

Children recovering from malnutrition need extra calories to correct their growth deficits. In such cases, energy needs may be calculated based on the 50th percentile of weight and height for the actual age, rather than the present weight. Energy needs can be either measured or calculated based on acceptable equations.²³

Of utmost importance in the recent times has been the intake of protein in children. In vegetarian and vegan diets, achieving nutritional adequacy could pose a challenge. Figure 5 depicts the changing protein needs in children from infancy to adulthood.

Estimated average requirement (EAR): The amount of a nutrient that is estimated to meet the requirement for a specific criterion of adequacy of half of the healthy individuals of a specific age, sex and life stage (Table 8).²⁴

TABLE 6 Assessing nutritional deficiency based on physical signs.²⁸

Physical sign	Nutrient deficiency
General appearance: Edema, muscle wasting, growth failure	Protein, calories
Hair: Dull, dry, thin and sparse easily pluckable, color changes	Protein, calories
Skin: Dry and flaky, follicular hyperkeratosis, dyspigmentation, petechiae, pellagrous dermatitis	Vitamin A, C, B₆, protein, niacin, riboflavin, essential fatty acids
Eyes: Pale and dry membranes, or red and inflamed membranes, Bitot's spots, corneal xerosis (dull and hazy) or scarring, cracking in the corners of eyes	Vitamin A, iron, folate
Lips: Redness and swelling, angular stomatitis	Niacin, riboflavin, vitamin B₆
Tongue: Swelling (glossitis), raw tongue, magenta or purplish in color, smooth tongue, sores	Niacin, riboflavin
Teeth and Gums: May be missing teeth, bad color and visible decay or cavities, spongy, swollen and bleeding gums, recession of gums	Fluoride, vitamin C
Cardiovascular system: Tachycardia, enlarged hearty, abnormal heart rate or rhythm	Potassium, selenium, phosphorus, thiamine
Gastrointestinal (GI) system: Spleen or liver enlargement, GI dysfunction	Protein, calories

TABLE 7 Feeding guidelines for different age groups of children.^20–22

6–9 months	Introduce weaning foods along with breastfeed Start with 1 “single-ingredient” food at a time and wait for 3–5 days before introducing a new diet A vitamin D supplement of 400 IU (10 μg) everyday is recommended to those infants who are being breastfed Solid foods can be fed before or after breast milk, depending on the convenience of the caregiver/parent The diet should be a rainbow diet, consisting of different (as diverse as possible) food groups/components in various combinations Avoid adding sugar and salt to the food
9–12 months	After 9 months, introduce soft consistency Encourage the consumption of whole vegetables and fruit instead of juice A standard 3–5 solid food feedings per day is recommended for infants
12–24 months	Cow milk or pasteurized milk (which are fortified) can be introduced in an open cup by the end of 12 months to toddlers Introduce a variety of foods to acclimatize the toddler to different palates Between 12 and 18 months, the toddler is able to chew fully. The toddler eats most of the same foods as the rest of the family. Emphasize offering a variety of food textures including finger foods The transition from bottle-feeding to an open cup for all fluids should be completed Food should be made into bite size pieces
2–6 years	Children require an adequate amount of balanced variety of foods Ensure that all macronutrients and micronutrients are included in the meals Each meal should provide an adequate amount of protein, carbohydrate and fat Snacks should be planned according to the child's choices in order to distract the child from continuous eating
School-going children	A balanced diet is required and children should not skip meals. Include healthy packed lunches and snacks to high school Disordered eating is prevalent in teenagers as they are inundated with images of an “ideal body” from all sorts of media and struggle to define their own body image during an impressionable phase of their lives Major biological changes in velocity of growth and changing endocrine status occur

Fig. 5: Protein needs in children from infancy to adulthood.(m: month; y: years)

TABLE 8 Estimated average requirement for infants and children.

	Age group	Energy (kcal)	Fat (g/day)	Ca (mg/day)	Iron (mg/day)	Zinc (mg/day)
Infant	0–6 months	550	-	-	-	-
Infant	6–12 months	670	25	-	2	2.0
Children	1–3 years	1,010	25	400	6	2.5
	4–6 years	1,360	25	450	8	3.7
	7–9 years	1,700	30	500	10	4.9
Boys	10–12 years	2,220	35	650	12	7.0
Girls	10–12 years	2,060	45	650	16	7.1
Boys	13–15 years	2,860	50	800	15	11.9
Girls	13–15 years	2,400	35	800	17	10.7
Boys	16–18 years	3,320	40	850	18	14.7
Girls	16–18 years	2,500	35	850	18	11.8

REFERENCES

Aggett P, Agostoni C, Axelsson I, De Curtis M, Goulet O, Hernell O, et al. Feeding preterm infants after hospital discharge. J Pediatr Gastroenterol Nutr. 2006;42(5):596–603.

McGuire W, Henderson G, Fowlie P. Feeding the preterm infant. BMJ. 2004;329(7476):1227–30.

Koletzko B, Poindexter B, Uauy R. Nutritional Care of Preterm Infants. Basel, Switzerland: Karger; 2014.

UNICEF. Global nutrition report 2020. [online] Available from https://globalnutritionreport.org.

UNICEF. UNICEF data. [online] Available from https://data.unicef.org.

World Health Organization. Weight velocity. [online] Available from https://www.who.int/tools/child-growth-standards/standards/weight-velocity.

De Onis M, Siyam A, Borghi E, Onyango A, Piwoz E, Garza C. Comparison of the World Health Organization growth velocity standards with existing US reference Data. Pediatrics. 2011;128(1):e18–26.

Carpenter A, Mann J, Yanchis D, Campbell A, Bannister L, Vresk L. Implementing a clinical practice change: adopting the nutrition care process. Can J Diet Pract Res. 2019;80(3):127–30.

Academy of Nutrition and Dietetics (Academy). Nutrition screening pediatrics. [online] Available from https://www.andeal.org.

Huysentruyt K, Vandenplas Y, De Schepper J. Screening and assessment tools for pediatric malnutrition. Curr Opin Clin Nutr Metab Care. 2016;19(5):336–40.

University of Cambridge. Paediatric measures for babies and children. MRC Epidemiology Unit. [online] Available from https://www.mrc-epid.cam.ac.uk/take-part/typical-visit/paediatric-measures.

CDC-National Health and Nutrition Examination Survey (NHANES). Anthropometry Procedures Manual. [online] Available from https://www.cdc.gov/nchs/data/nhanes/nhanes_09_10/bodymeasures_09.pdf.

Casadei K, Kiel J. Anthropometric Measurement. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021. [online] Available from https://www.ncbi.nlm.nih.gov/books/NBK537315.

Centers for Disease Control and Prevention (CDC). Growth charts. [online] Available from https://www.cdc.gov/growthcharts/index.htm.

Indian Academy of Pediatrics (IAP). IAP Growth charts. [online] Available from https://iapindia.org/iap-growth-charts.

12 World Health Organization. The WHO child growth standards. [online] Available from https://www.who.int/tools/child-growth-standards/standards.

Sonneville K, Duggan C, Hendricks K. Manual of Pediatric Nutrition, 4th edition. Shelton, Connecticut: People's Medical Publishing House; 2014.

Global Nutrition Report. 2020 Global nutrition report. [online] Available from https://globalnutritionreport.org.

National Institute of Nutrition. Dietary Guidelines for Indian Pediatrics. India: ICMR-NIN; 2020.

Pediatric Nutrition Guidelines (Six Months to Six Years) for Health Professionals. British Columbia; 2016.

Coles J. A Preschool Nutrition Primer for RDs: Pediatric Nutritional Assessment. Ontario; 2008.

Mehta MN, Mehta NJ. Nutrition and Diet for Children: Simplified, 1st edition. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.; 2014.

Energy. J Pediatr Gastroenterol Nutr. 2005;41:S5–11. [online] Available from https://journals.lww.com/jpgn/fulltext/2005/11002/2energy.2.aspx.

Sayyed A. Nutritional requirements for Indians. India: ICMR-NIN; 2020. [online] Available from https://www.metabolichealthdigest.com/nutrient-requirements-for-indians-icmr-nin-2020.

Chapter Notes

Nutrition for Preterm and BeyondCHAPTER 1

BOX 1 : Classification of prematurity categorized as per birthweight and gestational age.