EntralandParenteral Nutrition in Neonates

Abstract

Neonatal nutritionalassessmentis very important inneonateand determines the daily energy and nutrient requirements for optimal growthandwhether these nutritionalgoalsaremet.Inaddition,it includesreadjustmentofnutritionalintakeifthetargetgrowthrateis notmet.

Enteral feeding provides the best solution to the nutritional supportof theneonateswithacute orchronic diseasewhoisunable to maintainadequate growthand developmentwith oralfeedingalone, wherethegutisintactandfunctional(andsometimesevenwhenit is not).A variety ofdiseasestatesmay giverisetoarequirementfor nutritionalsupplementationbytheenteralroute,includingdisordersthat impairintake, gastrointestinal dysfunctionandmalabsorption, hepatobiliarydisease,critical illness,chronicsystem-baseddisorders thatimpairgrowth,andhypermetabolicstates.

Enteral feeding should be used whenever possible enteral nutrition is being initiatedearlierthan in the pastbut greatvariation remainsinenteralfeedingpracticesincluding breastfeeding, bottle feeding, tube feeding,transpyloric andgastrostomyfeeding.

Enteralfeedingmaybeprovidedby nasoenteralorenterostomal approaches dependingonindividualcircumstances,and the choice of formulato be used, whetherpolymericordefined,willdependon the digestiveandabsorptivecapabilities oftheneonateandthe metabolic stressorsinvolvedatthe time of provisionof nutritionalsupport.

Thecomplicationsofenteralfeedingcanlargelybeanticipated andavoidedwithappropriatecareandmonitoring ofthe patient.The nutritionalcare ofthe hospitalized patientmaybetransitioned appropriatelyintothecommunity,tocontinuerehabilitationorlong-

term nutritionalsupport.Trophicorminimalenteralfeedingissafeand welltoleratedadvancedata rate dependent ongestational age,degree of illness,and other clinicalfactors,sominimizingthe potentialadverse effectsof PN.

ParenteralNutritionmay bedefinedasprovisionofnutritionfor metabolicrequirementsand growththrough theparenteralroute.which indicatedinthe neonateswith:-

1-Prematureneonates<30weeksgestationand/or<1000gwhocannot bemaintainedenteraly onfeedings becauseofGITtracthypomotility, lowgastriccapacity,andotheraspectsoftheirprematureity.

2-Premature neonates>30weeks gestation butunlikely toachievefull enteralfeedsbyday5.

3-Severeinterauterinegrowthretardation.

4-Necrotising enterocolitis, sepsis, RDS, malabsorption, neonatal asphyxia,nonfunctionalGITtract.

5-neonates with surgical problems (congenital anomalies, abdominal wall defects, heart diseases, diaphragmatic hernia, and intestinal atresia, mid gut volvulus /malrotation, short bowel syndrome, paralyticileus,meconium ileus,autoimmuneenteropathy,diarrheaor microvillusatrophy.

TPNSolutionsshouldcontain

(1)Proteinascrystallineaminoacids, (2)Fatsaslipids. (3)Carbohydrate asglucose.

(4)Electrolytes: Sodium, potassium, chloride, calcium, and magnesium.

(5)Metals/Traceelements:Zinc,copper,manganese,chromium,and selenium.

(6)VitaminsA,C,D,E,K,thiamine,riboflavin,niacin,pantothenic acid,pyridoxme,biotin,choline,andfolicacid.

TPNcan be deliveredthrough peripheral orcentralvenous lines. The limitingfactor indecidingrouteof deliveryisosmolarity.

Theosmolarity ofTPNsolutionisdependentonthedextrose concentration.A dextroseconcentration greater than 12.5 %requires centralline for administration.

Glucoseadministrationfortermneonatesshouldbeinitiatedat GIR4mg/kg/min.but pretermsshouldbe initiatedatGIR4–8 mg/kg/min.GIRshouldbeadvancedgradually (0.5–1mg/kg/min)daily toamaximumof 13mg/kg/min.

ForolderneonatesGIRisstartedat7mg/kg/mintoatargetof10–

18mg/kg/min.

Carefulattentionandroutine monitoringisrequiredwhen administeringTPN. Frequentassessment of the patientandthemedical nutritiontherapyis necessarytoprovidesafe andcost-effectivePN.

Complicationsduetoparenteralnutritionmay becategorizedinto four groups:

1-Central venous line related, mainly sepsis (incidence 5%) and thromboembolism.

2-Deficiencyorexcessofparenteralnutritioncomponentsnamely, electrolytes,glucose,vitaminsandminerals.

3-Liverabnormalities(incidence7.4–70%)e.g.raisedenzymes, cholestasis.

4-Metabolic bone disease andgrowthimpairment.

TPNmay bestoppedwhentheneonateistolerating≥100cc/kgof enteralfeedings or isreceiving≤25cc/kg/dofPN.Therate ofdextrose administration should be tapered to preventreboundhypoglycemia. Chemstrips should be done every 6 hours. neonates need a slower taperingandrequirecontinuedmonitoringofglucoseafterthesolution hasbeenstopped. Lipidsmaybe stoppedwithouttapering.

Itis importantfor thecliniciantoappreciate thespecificnutrient requirementsassociatedwith variousdisease statesandtheir therapiesfor example,inthe illnewborn.Neonatalillnessessignificantly alterenergy, proteinandmineralmetabolismina disease-specific manners.