NUTRITION 1PRETERI'l

Maint~nance is 50 kcal/kg/dayEach gram of ~eight gain requires 5-6 kcal

Therefore the desired wt gain of 15gm/day requir~~

50 + 75 kcal/kg/day

Fat:te:'l-Resting calories (8MR)

1st day6th day

14th dayIntermittent activityOccasional cold stres.Fecal 105sGrowth allowance

NUTRITION II

I<ccol/kg/day50344250151012

33-40

Fetal to full term biochemical accumulations in weeks

Nitrogen (mg)Sodium (mg)Pe.tassium (mg)Calcium (mg)F'hc.sphorus (mg)Magnes iLlm (mg)1¡-on (mg)

Ce.ppeu- (ugm)Z i ne (ugm)Fat (gm)Watel- (gm)

24 weeks319

2830

11870

3.81.6

582610.5

15.2

30 weeks334

2730

13378

3.81.8

582681.3

15.0

36 weeks350

2430

15186

3.72.0

572603.2

14.7

PRETERMNUTRITION ,111

F.~t :

CBH:

Fluid·:;;:

222

26-28 weeks 3.1 gm/100 kcal Oí 3.75/kg29-31 weeks 2.7 gm/100 kcal Oí 3.5/kg

ranges given are from 2.25 to 3.75but controversy existo

about 6 gm/kg/day

about 11-16 mg/kg/day

54-94 ml/kg/day

NUT¡=;: 1T 1·JN 1'/PRETERM PROTEINS

Protein intake > than 4 gm/kg/day may produce lethargy, acidosisazotemia, and hyperammcnemia.

Premature is unable to metabolize phenylalanine, tyrosine,homogentisic acid, methionine te cysteine and taurine.

Whey-casein ratio formulas 18:82 (cow milk) can increase plasmaphenylalanine and tyresine

Whey-casein ratio of 60:40 <human milk) is safer.

NUTRITION VFRETEPM LIPIDS

40-50% of calories should come as fats, but >60% may produceketosis

Línoleic acid i5 essential at 300 mg/l00 kcalBile salt synthesi5 í5 low, therefore unsaturated FFA bestPanera.tic lipase i5 low, and MCT 1s bestLingual lipase present from 25th week and therefore 60-70%

of f.t hydrolysis OCCUíS in the stomach.BH aids with BM lipase and bile-s.lt esterdse

NUTRITION VIPRETERM CeH

By 28 weeks most dissacharidases are activePancreatic amyla~~ i. low to absent, but salivary amylase is

presentGlucoamyla~e is present in brush borders <for polymers)BM amylase <10-30x serum) suppli&9 430 u/kg/day

Therefores milk amylasQ, s.livary amylase, and gluceamylase~ubstitut. fer low p~ncre.ti~ supplies

NUTRITION VIIPRETERM Gl PHYSIOLOGY

Gastric acid production pre.ent from 28-30 weeksLactose present by 28 weekaPancreatic tryp.in and lip~•• present by 30 week~

Lipolysis started by lingu.l lipase and continued by pancreatic"¡lip~$e, but th. bil. ~cid pool is low.

Pancreatic amylas. 15 low to .bsent

223

NUTRIT';ON 'jI11

Preterm formula vs breast milk vs standard formulas

l<cal/30ml F'rc, tei ii Fat CBH Osmols

Bl-east 2c)-22 1.1 3.8 6.8 273-300Enfamil 20 1.5 3.7 7.0 262-290Similac: se 24 2.2 4.4 8.6 260-300

NUTRITION IXPRETERM SPECIAL REQUIREMENTS

C3avage: <32 weeksinadequata gag reflexpoor suck and swallowROS

by drip

Gastric volumes are 3 rol in an 800 gro baby40 mi in a 4000 gm baby

Therefore, and N-J schedule may be necessary by pump at0.5 to 1.0 ml/hí Oí additional TPN

NUTRITION XPRETERM SCHEDULES

Weight (gms)

1(100-1200

1200-1500

1500-2(100

Age (hrs) Volume (mIs) Time

<24 1-2 q2hr24-48 2-4 q2hl-49-72 3-6 q2hr

>72 4-8 q2hr<12 2-3 q2-3h<24 4-6 q2-3h

24-48 6-9 q2-3h49-72 8-12 q2-3h

>72 10-15 q2-3h<24 5-15 q3-4h

24-48 10-25 q3-4h.>72 20-45 q3-4h

224

NUTRITrCN ~r

TER M BABY

1,000 kcal required to gain 3.5 kg between 0-4 months180,000 kcal required to gain another 3.5 kg between

4-12 month.Therefore, caloric requirements for the full term is:

100-120 kcal/kg/day from 0-10 monthsSO-lOO kcal/kg/day from 10-12 months

Protein is 1.35 to 1.80 gm/kg/day

225

TPN: INDIC~7~O~S

Short bowsl syndromeInflamm.tory bowel dise.seIntractable di_rrhe_ROS-BFDMajor anomalias of the 81 tractChemotherapyMajor trauma or burn~

Prolonged pancreatitisCachextic syndromes

TPN: Contamination Control

Central line placed in ORSilastic catheter securely anchoredInspection of site q.o.d~

Betadíne dressingsSystem used ONLY fo. TPNAIl solutions mixed in laminar hood0.22 u filter used with airtight systgemChest xray to assura SVC placement

TPN: Complications 1

Metabolic acidosis: a) A endogenous H load from ~A catabolismob) renal el shift {tubular disea.e).c) immatura kidney H &~cretion.

d) A HCD3 stool 109S.

Hyperammonemia <>300 ugm/dl): a) exogenous loadb) newborn livere) liver dis.as.

Hyperosmolarity:

Hypoglycemia:

Osteoporosis:

Anemia:

Trace metal def:

Thrombosis

Pulmonary:

226

a) too rapid ~ gluco•• , >1.2gm/kg/hr.~) early sepsis.

TPN: Complications 11

.> too rapid a withdrawal of glucosa

a) inadequate C., P, vit D, Cu

a) inadequate S12, folie .cid, iron, vit E

a) Cu --) anemia, leukopenia, osteomalaciab) Mg --> tetany, hyper-r.flaxiae) Zn --> acrodermatitis, poor wound healingd) Cr --) glucosa intolerance

a) foreign body

.> edema from overlo.db) emboli from air or thrombus

TPN: Complications III

Cholestasis: a) unknown etiologyb) cholelithiasis

Acute polymyopathy: a)fatty acid deficiency?

Fever: a) always a~sume sepsisb) culture from catheter for bacteria both

anerebic and aerebie and for funguse) dIe eatheter if no souree found andTPN Solutionsa General

Proteina Casein hydrolysate-bO% free AAFibrin hydrolys.te-bO% free AACrystalline AA- 100% free AA

CBH: Elemental glueD~e, up to 2~% central,12.5% pel-ipheral

Lipid: Soybean or safflowerEgg yolk phospholipidGlycerin 2.2~%

Water

TPN Solutionsl Lipid

Di 1 10%1.2Y.

54Y.26%

9%8"

LinoleicDleiePalmitic:Linolenic

Caloric value is 1.1 cal/mlDose i5 1 to 4 gm/kg/dayInfuse seperately; heparin to enhanee lipoprotein lipaseMonitor triglycerida ~nd eholesterol leve15Adversa reaetions: dyspnea, cyanosis, flushing, HSM

TPN Solutions: MinaraIs

Na1<MgF'04ClCa2nCl..l

Crt1nl.,Jitamins

2.5 mEq/100 kcal1-2 mEq/l00 kcal0.3 mEq/kg/day2 mM/kg/day <KP04 1 mEq = 0.b8 mM)2.5 mEq/100 kcal4(1)-700 mg/dC";y150-300 ugm/kg/day20-40 ugm/kg/day0.1-0.4 ugm/kg/day2-10 Llgm/kg/dayMVI o<~ B12~ fcollC inactivated by C)

221

TF'N S01~!t101"~S: Vlt¿'~l,~~;_____~~1~m~D 1Df~D~s_~~j~1~~ :n~~~c~D _

A (IU) 230/kg/dayO (IU) 40/kg/dayE (IU) O.7/kg/dayK (mg) O.02/kg/daye (mg> 8.0/kg/dayFolacin (ugm) 14.0/kgldayNiacin (mg) 1.7/kg/dayRiboflavin (mg)O.14/kq/dayThiamin (mg) O.12/kg/dayB6 (mg) O.10/kg/day812 (ugm) O.10/kg/dayPantothenic O.50/kg/day

elC id (mg)8iotin (ugm) 2.0/kg/day

2300/da"'f'400/day7.0/dayO.2/daySO/day140/day17/day1.4/day1.2/day1.0/day1 .O/day5.0/day

20/day

TPN: Cl~nical monitoring

Pal-ameter First week Follow-up-----------~------------------------------------------------

•

NB

WeightLenght~ HeU/s.g.~glu~ protLytes~ pH, BUN~glu

Ca, Pcee, TP, LFT, Mg,

cl-eat i ni neHemog 1clb i 11GasesAmmonia

228

daily (NB b.í.d.)weeklyq voíddailyq 2 days

weeklyb.i.s.dailyb.i.s.

dailyweekly1-3/day2-3/wkweekly

weeklyb.i.s.

t. i. s

TF:ACE l'1ETALS I

Elements of established nutritional importance

Majer: C, 0, Ca, CIN, Na, P, MgH, K, S,

Fe, Cu, Se, Ni, Si1, Ce, Mn, Va, FZn, Mo, Cr, Sb, Ar

TRACE METALS IIZINC

Absorbtion occurs in duodenum and jejunumAbsorbtien is interfered by phytat~s, Cu, fiber, Ca, vit DConcentrated in bone, muscle, eyes, hair, testes, teeth, liverTotal body zinc is 2 gmCarried bound te albuminExcretion is 65% gut, 35% kidney

**ZINC

TRACE METALS 111

Functions as metalloenzyme in DNA and RNA polymerases,protein synthesis, carbonic anhydrase, alkaline phosphatase

Found in seafood and meat, therefore Vegans at risk60-70% ef 2n ~nd Cu is transfered te fetus during the last 10-12

weeks of gestationNeeds: Prematures 450 ugm/kg

FuIl term 150 ugm/kgAdult 10-15 mg/day

Deficiency: growth retardation, weeping eczemoid, alopecia,depressien, delayed sexual maturation, diarrhea, HSM, poorwound healing, anorexia, hyposmia, cerne.l opacities

TRACE METALS IVCOPPER

30X of dietary copper absorbed in the small bowelTotal body copper is 100 mg9SX carried in ceruloplasmin which binds 8 Cu ~toms

Stored in the liver, with infant 6-8x adult cenc. Falls by 6 mo.Essentíal fClr RBC, bone, and cuproenzyme$ sLlch as cytochrome

oxidase~ ferroxidase, sup&roxidase dismutaseNeeds: lnfants .5-1.0 mg/day

Child 1.0-3.0 mg/dayAdult 2.0-3.0 mg/day

Deficiency: microcytic hypochromic anemia, leuccpenia~

osteopenia, CNS abnormal~tie$, depigmentation.

229

T!=: r:~C,E I..';E T~1L =- '.. )CHROMIUM

Found naturally in most drinking water.Excretad primarily by the kidneysTotal body chromium is 6 mgActs as a insulin co-factor for receptor site.

chrc.mium-nicc.tinic.-3AA acid complex "glucc1sefactor"

Needs: Infants .01-.06 mg/day

FC11~ms a.to 1el~ance

Infants Cb(Ud.(16 mg.'d§yO.2 mg/dayDeficiency: rare~ sean in prolonged TPN without chromium

Geographically, in PEM o~ Jordan, Nigeria, Turkey. Theresults are impaired glucose toleranee and hyperlipidemia

TRACE METALS VIMANGANESE

Concentrated in liver mitochondriaTotal body mangdnese is 20 mgMetalloenzyme for oxidative phosphorylationIn infancy high, lika Cu, falling by 6 monthsTransportad by a B-1-g1obulin transmaganínNeeds: lnfants 0.5-1.0 mg/day

Child 1.0-5.0 mg/dayAdults 2.5-5.0 mg/day

Oeficiency: dermatitis. decreased hair growth,hypocholesterolemia

* SELENIUMTRACE METAL8 VII

Vitamin E eo-factorTotal body stores are 6-10 mgFound in seafood, kidney, liverNeeds: Infants .01-.06 mg/day

Child .02-0.2 mg/dayDeficiency: muscle pain, tenderness, pancreatic degeneration,

hemc.lytic anemia. No confirmad deficiencias however.COBALT NICKLE VANADIUM

812 component ? ?

MOLYBDENUMMetalloenzyme of xanthine oxidase and sulfite oxidaseDeficiency produces headaches, lethargy

FLOURINEAs the flouride salt cariostatic at 1 ppm

230

TRACE METALS VIIIIRON

Absorbed from the small bowel10-30X of dietray iron 1S absorbedBinds to transferin and distributed throughout bodyStored in bone marrow for used by RBe, RE cellsLOSS occurs with gastrectomy, Gl bleeding, malabsorbtion,

binding agents <phosphates, oxalates)Needs: Infants, children, men 10 mg/day

Adolescents and females 18 mg/dayDeficiency: anemia and its pathophysiological consequences

VITAMINS 1

Fat-soluble vitamins are constituted by retinol, ergo-andcholecalciferols, tocopherols, and phyllo-and menaquinonefor A, 02, D3, E, VI, and K2.

AIl are $oluble in lipid and organic solventsDeficiency occurs with decreased intake or fat absorbtionAs opposed to water-soluble vitamins, these can be toxic

* * * * * * * * * * *Water-soluble vitamins are thiamin, riboflavin, niacin,

pyrido~ine, folie acid, cyanobalamin, ascorbic acid,pantothenic acid, biotin, cholina, inositol, carnitine,bioflavanoids

These are ubiquitous in natural foodsDeficien~y cccurs predominantly from malnutritionCholine, inositol, carnitine, bioflavanoids not true vitaminscarnitine~ bioflavanoidsnot ~uber~t~amieBzymaticco-factors.

VITAMINS 11VITAMIN A

Exists a$ carotenes in foods, which are vitamin A precursorsB-carotene in ileum split into retinal by dioxygenase,

then in liver to retlnol by reductase.Absorbtion in small bowel, stored in liver as palmitate es terNeeds: Infant 300 ugm (1 i.u. = 0.3 ugm>

Adoleseent 750 ugmSouree: milk fat, &gg, liver~ earotinoid pigments of plantsOeficiency: (levels <100 ugm/L) thickened bones, 1055 of lung

elasticity, salivary gland and epithelial keratinization,impaired hearing, corneal dryness, nightblindness, urinarycalculi

Toxieity: precocious skeletal growth, irritability, fatigue,increased ICP (pseudotumor eerebri), anoreXla. vomiting,nystagmus. gll,givitis and hypertrophy, H5M, lymphadenopathY~

alkallne phosphatasemia

231

VITAMINS IIrVITAMIN D

Absorbed along with TGC and carried by A2-g1obulin to liverD2 dietary, by UV light converted to 03D3 hydroxylated in liver to 25-DHD3 which is the major

circuldtinq form of O (30 mg/dl)In kidney cenverted to 1~25-DiOH cholecalciferolRegulated by Ca and PTH levelsD is needed to fDrm Ca transport protein in dubdenum~ facilitate

bone resorbtion, and P absorbtionSource: mllk (fortified)~ fish~ liver, sunlightNeeds: 10 ug (400 i.u.)/dayDeficiency: rickets, osteomalaciaToxicity: hypercalcemia, azotemia, poor growth, vomiting~

nephrocalcinosis

VITAMINS IVVITAMIN E

A-Tocopherol (B~G,D haya 1/3 activity of A>Stered in adiposa tissue, transported with B-lipoproteinAbsorbtion requires pancreatic and bile functionsActs as an antioxidant of polyunsaturated fatty acids te

stabilize membranesSource: grains~ oil5, peanuts, soy, milkfat, turnip greensNeeds: Infants 4 mg/day

Adolescents 15 mg/dayDeficiency: hemolytic anemia, peripheral neuropathy. In

prematures: BPD, anemia, edemaTexicity: known inhibitor of vitamin K

* VITAMIN kVITAMINS V

V1 i5 phylloquinone and dietaryK2 is menaquinone and bacterialV3 is phytonadione and syntheticV requires bile for absorbtion, intestinal b~cteria

Transported by B-lipoprotsins to liverRequired fer activation o~'facters II,VII,IX,XSource: cow milk, green leafy vegetables, pork, liverNeeds: Infant 5 ug/day, others unknownDeficiency: hemorrhagic m.nifestation5

VITAMINS VI8IDTIN

Water soluble and made by gut bacteriaActs as a co-enzyme te carboxylases of CoASource: liver, egg yolk, peanutNeeds: unknown, but defi~iency treated with 10mg/d3YDeficiency: anorexia, dermatitis, myalqias, hyperesthesia,

50mnolence

*232

qbsorbed in ileum, requires gastric intrlnsic factorTr~ce metal cobalt essential componentActs a coenzyme for RBe maturatioh, CNS met~bolism, and

together with folate contributes to DNA synthesisTransmethylation requires B12

Total stores are 4 mgSource: animal only, me~ts, milk, eggNeeds: 1-2 ugm/dayDeficiency: pernicious anemia~ neurologic deterioration

(posterolater~l columns)~ glossitis

VITAMINS VIIIFOLACIN

AIso called folie acid, pteroylglutamin acidGroup of compounds containing a pteridine ring~ p-aminobenzoic

and glutamic acidsActive form is tetrahydrofolic acid and contributed to the

formation of purines, pyrimidines~ and methylationTotal body pool is 5-10 mgSource; liver~ green vegetables, cereal, orangesNeeds: Infants 50 ugmJday

Adolescents 400 ugm/dayDeficiency: megaloblastic anemia, apathy, irritability

VITAMINS IX

NIACIN

Nicotinic aeid acts as co-enzyme <NAD-NADP)60 mg of tryptophan yields 1 mg nicotinic .cidSource: meat, fish, grains, green vegetable.Needs: 6.6 mg/l000 caloríesDeficiency: pellegra, diarrhea, dementia, apathetic,

anorexia, myalgia

FOLACIN

AIso called folie acid, pteroylglutamin acidGroup of compounds cont~in~ng a pteridine ring~ p-aminobenzoic

and glutamic acid.Active form is tetr~hYdro~olic acid and contributed to the

formatlon of pUrln.~, pyrimidines, and methylationTotal body pool i5 5-10.mgSource: liver, gr••n veg.tables, cereal, orangesNeeds: Infants ~O ug~/day

.. Adolescents 400 ugm/dayDeflClency: megaloblastic anemia, apathy., irritability

233

NIACIN

N' t·· .1 ce, 11"11 e ae l.d C\~ ts as cc'''''''enzyme n'JAD-NADP)

60 mg of tryptophaD y~eld:5' 1 ro ni ·,t· .'Souree: m~at f" " Q '. CQ lnle aCld

, lsh, gralns~ green vegetablNeeds: 6.6 mg/l000 calaries esDeficiency: pellegra, diarrhea~ dementia apath t.

anorexIa, myalgi~ 'e lC~

'JITAMINS X

PANTOTHENIC ACID

Component of co-enzyme ASpecific functions unknownSc,ul-ce.: almost al1 f.c.C'~s

N~.d~: uriknown~ estimated at 5-10 mg/dayDefici~n~y: hypot.nsion~~mus~.leweakneses.

**PYRIDOXINE (86)

VITAMJNS Xl.

Enzymat~cco~ta~tor f9r'~n~bolie and catabolic AA metabólism:espe~i~li~~ ~he transferases.

Source: 1iver~ meats, grains, eorn~ soy~ eggs, avocadoNeeds: Infants 0.2 ~g/d~y"

Adults 2.0 mg/dayDeficieney: glossitis, cheilosis, peripheral neuropath~,

(infants, eonvu1sions>

JI TAMINS X.IlRIBOFLAVIN <B2)

Enzymat ie cafae te.! for any en.:ymes as flavin mancmuc leotide Orflavin adenin~ dinucleotid~. Paít of multiple oxidation­reduction reactions

Source: meats, milk, eggs, graín~

Needs: 0.6 mg/lOOO caloriesDeficiency: P~lC't(;:.plic.biát che} ~o$is, gl'ós.ítis. sebo,,'"haa

VITAMINS )( lI1THIAMIN CBl)

Decarbo;<ylation coenzym¡¡¡o o'" A"'ket'ciacids to .lá~hydes andNAOPH

Adult stÚf";es are 30 mg~ depleted in 10-14 óaysSource: yeast, liver, meats~ milk, grainsNeeds: 0.5 mg/lOOO ealQriesDeficiency: beriberi, neuritis, edema, hoalseness, anorexia,

CHF, malaise, weakness. Infants: irritability, agitated,cCl\ivul s i 0115