Parenterale voeding bij de neonaat. Dr Femke Maingay-de Groof Kinderarts-neonatoloog Medisch Centrum Alkmaar

Transcriptie

1 Sophia Kinderziekenhuis Children s Hospital Parenterale voeding bij de neonaat Dr Femke Maingay-de Groof Kinderarts-neonatoloog Medisch Centrum Alkmaar

2 Survival by Gestational Age for Live-Born Infants England 1995 Sweden '04-'07

3 Sophia Kinderziekenhuis Drawing by Tom Prentiss. In: Cowan MW The development of the brain. Scientific American 113;

4 Sophia Kinderziekenhuis 25 wk term

5 Govaert et al 24 wk premature, now 12 wks old Term newborn

6 Relationship of IQ and GA n= Kaufman-ABC MPC Mean +SEM Bavarian Study 4.8y 60 EPICure Study 6y adjusted for comparison GCA Gestational age (w) Lagercrantz Acta Paed with permission from Marlow and Wolke

7 Sophia Kinderziekenhuis Goal: To mimick intra-uterine growth and body composition and to obtain a functional outcome comparable to infants born at term

8 Sophia Kinderziekenhuis Early nutrition (first weeksmonths) has a profound impact on later functional outcome

9 IQ after preterm formula or standard formula during the first month of life Lucas et al BMJ 1998

10 In-hospital growth velocity and neurodevelopmental outcome Cohort study, 600 infants with birth weight 501 to 1000g 40 MDI < 70 (P<0.01) 40 PDI < 70 (P<0.001) % 20 % Weight gain quartiles (g/(kg. d)) Weight gain quartiles (g/(kg. d)) % Cerebral palsy (P<0.01) % Neurodevelopmental impairment (P<0.001) Weight gain quartiles (g/(kg. d)) Weight gain quartiles (g/(kg. d)) Ehrenkranz, R.A. Pediat. 2006;117:

11 First week protein and energy intake and neurodevelopmental outcome at 18 months Retrospective study of 124 ELBW infants at 18 months CA AA intake 1 st week: 1.8 ± 0.4 g/(kg. d) Energy intake 1 st week: 60 ± 8 kcal/(kg. d) MDI at 18 months MDI at 18 months First week AA intake (g/(kg. d)) First week energy intake (kcal/(kg. d) Stephens, B.E. Pediat. 2009;123:

12 Protein intake is the major driving force of weight gain in low-birth-weight infants

13 Relationship amino acid intake and retention in first day(s) of life Embleton, ND. Early Hum Dev Dec;83(12): mg N retention ~ 5 g weight gain

14 BUT: - TPN associated with catheter-related infections - complications catheter: thrombosis, sepsis - which children really need TPN????

15 Parenteral feeding : Amino acids Effective growth: - term: protein intake > 2.5 g/kg/d - VLBWI: g/kg/d - ELBWI: g/kg/d Start amino acid suppletion day 1: g/kg/d, increase on day 2 untill g/kg/d Ehrenkranz 2007, Simmer 2007, ESPGHAN 2005

16 Parenteral feeding : Glucose - day 1: term: 4 mg/kg/min: (6 g/kg/d) preterm 5-6 mg/kg/min ( 8-10 g/kg/d) - Glucose 12.5% peripheral - Glucose 20% central

17 Parenteral feeding : Lipids Early lipids: - reverse negative nitrogen balance - protein:lipid ratio for optimal protein synthesis : 1 g protein on kcal - essential n-6 and n-3 fatty acids Advised Fat intake g/kg/d ESPGHAN 2005

18 BUT early LIPIDS can cause: - Hyperbilirubinemia: no data available - Sepsis: no proof ( n = 287) - PPHN: no data available - Lung disease: no proof ( n =216) - Liver disease: no data available - Thrombocytopenia: no data available - NEC: no proof ( n=287) - ROP: no proof ( n= 162)

19 Parenteral feeding :NIPI-2 Very low birth weight infants (birth weight < 1500 g) Control Glucose AA 2.4 g/(kg.d) No lipid Standard AA + lipid Glucose AA 2.4 g/(kg.d) Lipid 2 3 g/(kg.d)

20 Early lipid administration did not affect biochemical or growth outcomes Not effect on bilirubin, triglycerides, cholesterol concentrations Vlaardingerbroek et al., J Ped 2013, in press Hester Vlaardingerbroek et al J Pediatr 2013 in press

21 Parenteral feeding : Lipids day 1? - improvement nitrogen balance in lipids day 1 - no improvement nitrogen balance in high AA compared to AA group - lipids day 1 tolerated well - start 2-3 g/kg/d day 1 Vlaardingerbroek et al., J Ped 2013, in press

22 Parenteral feeding :SMOF/Omegaven - SMOF: Soy (30%), MCT s, olive oil (25%), fish oil(15%) - FISH OIL: - - less phytosterols and more balanced fatty acid profile - - probably better than soy, less pro-inflammatory - respons: less n-6 PUFAs, more n-3 fatty acids (LCPUEA) - - slightly better liver tolerability, reduction in oxidative stress

23 Effect of pure soybean oil emulsions vs other emulsions on sepsis (Vlaardingerbroek et al., Am J Clin Nutr. 2012;96:255-68

24 Conclusion: When to start lipids? Directly following birth seems safe (short term results only)

25 How much lipids should we administer? 2 gram/ (kg.d) seems safe in preterm infants (short term results only)

26 What emulsion should we use? Fish oil containing lipid emulsions: - reduce nosocomial infections in preterm infants - reduce bile acid accumulation and liver damage in preterm piglets Mechanism is most likely through phytosterols

27 When to decrease TPN? - First pass utilization of amino acids vary 15-85% - substantial part of enteral protein intake does not reach systemic circulation - infants with reduced tolerance for enteral feeding are at high risk for developing protein malnutrition

28 When to decrease TPN? - do not decrease untill enteral feeding >75 ml/kg/d - enteral feeding >75 ml/kg/d: decrease TPN 50% - enteral feeding > 130 ml/kg/d: stop TPN

29 TPN: Which one? - 3 components: Protein: Primene, Vaminolact, Aminoplasmal, FreAmine, Aminoven, Novaone Lipids: Intralipid, Lipoven, ClinOleic, Structolipid, Lipofundin,Omegaven, SMOF - All in one: Neomix, Numeta, Alliantiemix, Neoforte mix

30 3 componenten: Voorbeeld protocol Start eiwit op dag 1: 1.0 ml/kg/d ( 2.4 g/kg/d) Start Intralipid dag 2: 0.4 ml/kg/uur (1.4 g/kg/d) Glucose intake: 4-6 mg/kg/min; hogere % voor eiwitintake Verhoog Primene dag 2 naar 1.2 ml/kg/uur (2.9 g/kg/d), en ev naar 1.5 ml/kg/uur indien getolereerd wordt Verhoog intake Intralipid als triglyceriden het toelaten naar 0.7 ml/kg/uur a terme 0.9 ml/kg/uur) Streef naar voldoende calorieёn, eventueel met Glucose 20%

31 Stroomdiagram (par-)enterale voeding Direct post partum(=dag 1): Enterale voeding starten? Nee, niets per os of MEV primene 1,2 ml/kg/hr Glucose zonder toevoegingen ja primene 0.6 ml/kg/hr Glucose zonder toevoegingen 1ste dag post partum (=dag 2): Enterale voeding starten? Nee, niets per os of MEV ja primene 1,2 ml/kg/hr Intralipid 0.4 ml/kg/hr TPV glucose 2de dag post partum (=dag 3): Enterale voeding starten? Nee, niets per os of MEV Ja primene 0.6 ml/kg/hr Intralipid 0.4 ml/kg/hr TPV glucose primene 1,2 ml/kg/hr Intralipid 0.7 ml/kg/hr TPV glucose Nee Na 2de dag post partum: Enterale voeding starten? Met ophogen enterale intake wordt TPV glucose aangepast naar gelang de vocht intake. Bij enterale > 130ml/kg/dg worden primene en intralipid gestaakt.

32 Stroomdiagram 3 componenten Dag 1, indien alleen MEV primene 1,2 ml/kg/hr (3g/kg/d) Glucose zonder toevoegingen Dag 2, indien alleen MEV primene 1,2 ml/kg/hr Intralipid 0.4 ml/kg/hr TPV glucose Dag 3, indien alleen MEV primene 1,2 ml/kg/hr Intralipid 0.7 ml/kg/hr TPV glucose Dag 1, indien start voeding primene 0.6 ml/kg/hr (1,5g/kg/d) Glucose zonder toevoegingen Dag 2, indien start voeding primene 0.6 ml/kg/hr Intralipid 0.4 ml/kg/hr TPV glucose Dag 3, indien start voeding primene 0.6 ml/kg/hr Intralipid 0.7 ml/kg/hr TPV glucose 1. Zodra enterale intake > 130 ml/kg/dg stop primene en intralipid. 2. Bij staken voeding: start primene 1,2 ml/kg/hr. Intralipid in 2 dagen ophogen (0,3-0,6 ml/kg/hr). 3. Minimale glucose-intake moet 4 mg/kg/min zijn (enteraal+parenteraal). 4. Kinderen < 1250 gram komen in aanmerking voor een lijn, zodat zij zeker primene en intralipid maximale hoeveelheid kunnen krijgen met gegarandeerde glucose-intake van min 4 mg/kg/min.

33 Voorbeeld protocol all-in one: Numeta - All in one - centrale lijn: Numeta G13% (prematuren), osmolariteit 1155 mosmol/l - voor perifeer gebruik: verdunning met water 150 ml, osmolariteit: 770 mosmol/l - nadeel: door verdunning lage eiwit intake - losse primene naast Numeta in eerste dagen

34 GG < 1250 gram Direct post partum (dag 1) : enterale voeding start? NEE (NPO / MEF) Primene 1.0 cc/kg/uur glucose 10% (4 mg/kg/min) Primene 0.6 cc/kg/uur glucose 10% JA 1 e dag post partum (dag 2) : enterale voeding start? NEE JA Primene 0.4 cc/kg/uur + Numeta perifeer Overwegen plaatsen lijn < 24 x 2.5 cc of 8 x 5 24 x 2.5 cc of 8 x 5 Primene 0.4 cc/kg/uur + Numeta perifeer Numeta perifeer 2 e dag post partum (dag 3) : enterale voeding start? enterale voeding goed op te hogen? NEE JA NEE JA Primene 0.4 cc/kg/uur + Numeta perifeer Overweeg plaatsen lijn Primene 0.4 cc/kg/uur + Numeta perifeer Overweeg plaatsen lijn

35 GG g Direct post partum (dag 1) : enterale voeding start? NEE (NPO / MEF) JA Primene 1.0 cc/kg/uur glucose 10% (4 mg/kg/min) Primene 0.6 cc/kg/uur glucose 10% 1 e dag post partum (dag 2) : enterale voeding start? NEE Primene 0.4 cc/kg/uur + Numeta perifeer Indien lijn: Numeta centraal (geen Primene) JA < 24 x 1.0 cc 24 x 1.0 cc Primene 0.4 cc/kg/uur + Numeta perifeer Indien lijn: Numeta centraal (geen Primene) Numeta perifeer of centraal 2 e dag post partum (dag 3) : enterale voeding start? enterale voeding goed op te hogen? NEE JA NEE JA Primene 0.4 cc/kg/uur + Numeta perifeer Indien lijn: Numeta centraal (geen Primene) Primene 0.4 cc/kg/uur + Numeta perifeer Indien lijn: Numeta centraal (geen Primene)

36 GG > 1750 gram Direct post partum (dag 1) : enterale voeding start? NEE (NPO / MEF) Primene 1.0 cc/kg/uur glucose 10% (4 mg/kg/min) Primene 0.6 cc/kg/uur glucose 10% JA 1 e dag post partum (dag 2) : enterale voeding start? NEE JA Primene 0.4 cc/kg/uur + Numeta perifeer < 8 x 5 ml 8 x 5 ml Numeta perifeer geen Numeta 2 e dag post partum (dag 3) : enterale voeding start? enterale voeding goed op te hogen? NEE JA NEE JA Primene 0.4 cc/kg/uur + Numeta perifeer Overweeg plaatsen lijn Numeta perifeer

37 Parenterale voeding (indien geen voeding) Prematuren < 1250 gram Primene Glucose 10% Numeta perifeer Parente aal vocht Direct pp Dag Dag Dag Dag Dag Dag glucose-calcium-mengsel: 48 ml glucose + 2 ml Calcium-Sandoz (bevat 0,009 mmol Ca 2+ / ml).

38 Parenterale voeding (indien geen voeding) Pasgeborenen gram Primene Glucose 10% Numeta perifeer Parente aal vocht Direct pp Dag Dag Dag Dag Dag Dag

39 Parenterale voeding indien geen voeding Pasgeborenen gram Primene Glucose 10% Numeta perifeer Parente aal vocht Direct pp Dag Dag Dag Dag Dag Dag glucose-calcium-mengsel: 48 ml glucose + 2 ml Calcium-Sandoz (bevat 0,009 mmol Ca 2+ / ml).

40 Parenterale voeding( indien geen voeding) Pasgeborenen > 3000 gram Primene Glucose 10% Numeta perifeer Parente aal vocht Direct pp Dag Dag Dag Dag Dag Dag

41 Conclusions Start protein directly after birth at 2.5 g/kg/d, increase to 3-4 g/kg/d Lipids directly after birth seem safe (2 g/kg/d) Decrease TPN when enteral feeds > 75 ml/kg/d, stop > 130 ml/kg/d Parenteral Feeding Protocol: improved nutrition, better outcomes?!?