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Nutritionally speaking, does breast milk benefit small-birthweight babies? Lactation consultants tell the mothers of preterm babies that they should be breastfed in the nursery and go home only on breast milk. Can you comment on that?
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Human milk is our first choice, but for babies less than 1500 g, we fortify that milk. A few babies who are only on human milk grow very sluggishly and their head circumferences are below the 10th percentile. You may want to talk to these mothers about offering a feeding or two a day that is enriched with breast milk fortifier, and even using a postdischarge formula a few times a day.
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What about when we have a 1000 g baby and the mother wants to breast-feed? We are giving the baby his or her first breast milk with fortifier in the nursery. Now we are moving from gavage feeding to nipple feeding. The lactation consultants are against giving them anything by bottle, even though I am trying to send the baby home on fortifier. How do I deal with it?
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Negotiate. Show them the grow chart. There are data suggesting that babies whose head circumferences are two standard deviations from the norm have impaired neurocognitive function at 8 years of age. In some subgroups, we would like to get this critical growth period to work in our favor, and enrichment can help to achieve that.
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You referred to the importance of giving enough protein to very premature babies. We all may remember a very strange disease called late-onset metabolic acidosis associated with high protein intake. Has this disease disappeared? How we should monitor babies who may get extra protein, especially if you fortify the milk? Also, how important is zinc in formula?
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I used to diagnose late metabolic acidosis a lot on rounds to impress the residents. You give the baby bicarbonate and he grows the next day, making you look smart. The protein data that are most important involve excessive doses of protein. The newer formulas are more like breast milk. Even though we feed more protein, the aminograms look normal, just like the postprandial breastfed baby. The late metabolic acidosis may be more related to renal immaturity than diet.
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Some of the milk fortifiers are very expensive. We read an article advocating adding NeoSure formula to breast milk, so we do that now. NeoSure (Abbott Laboratories, Abbott Park, Illinois, USA) is not that expensive. Is anyone here using it?
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I see some people nodding. I think in the future, we will see modified human milk from human milk banks that are 22 or 24 calorie, as well as an actual human milk fortifier made from human milk.
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A recent paper in Journal of Pediatrics said that intrauterine growth restriction (IGUR) babies who catch up faster do not do too well. Could you comment on that?
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Those were term IUGR babies and the study looked at some markers when these kids were 8 years old. Those IUGR term babies who grew faster had the marker for metabolic syndrome and that data suggested that it might not be a good strategy for term IUGR babies to have rapid catch up.
When it comes to the preterm baby, we have to balance too rapid growth and theoretic concerns about cardiovascular disease vs neurocognitive outcome. We would err on the side of neurocognitive outcome since there are not a lot of data suggesting cardiovascular risk with rapid growth. There was one paper that used brachial artery dilatation as a marker for atherosclerosis and it was not as good in the premature babies who grew more rapidly, but it was 2 weeks of growth.
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Can you discuss how you caution prenatally and what to handle postnatally. What if you and the family decide not to intervene but the baby is becoming more viable and continues to cry? What decisions do you make in an hour, or two?
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We have probably all faced that. Assuming we have the luxury of time and adequate counseling of the parent, my standard approach is that we are going to make the best judgment possible at each moment. If the baby is really, truly very premature in the delivery room, the only marker we have is the skin. If it is gelatinous-looking skin, most of us would agree resuscitation is not a good idea. I tell families we have to make judgments and re-evaluate in 6, 12, and 24 h. We never declare babies to be nonviable and just quit. We always swaddle babies, even if no treatment is planned. If a decision has to be overridden, we will talk to the mother every few hours and re-evaluate. Unfortunately, the father is not always there. That can leave you with a mother who is not awake. You have to be prepared to be the advocate of the child.
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Could you review your practice of protein intake, particularly the protein enriched intravenous fluids, used in your nursery?
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There is a good body of data suggesting that early amino acids are a very good strategy. We begin something that we call ‘vanilla’ total parenteral nutrition (TPN) as soon as the umbilical venous catheter is inserted. It is a stock solution of 4% amino acids. Our nutritional solution, which only contains amino acids and glucose, is infused literally from the first hours of life with the intention of providing about 2 g per kilogram per day of protein right from the beginning.
The next day, whether it is 6 or 12 h later, we begin TPN, continuing that dose and the initiation of lipid.
The benefits are not only positive nitrogen balance, but a dramatic reduction in non-oliguric hyperkalemia because of increased insulin from providing amino acids. Insulin is dependent on some amino acids for its secretion, so non-oliguric hyperkalemia occurs because of intracellular energy failure.
When a baby does not get amino acids, glucose is not transported into the cell, sodium potassium ATPase downregulates, and potassium leaks out of the cell. Data show that the incidence of hyperglycemia and hyperkalemia falls dramatically in nurseries that use early amino acids.
Nutritionally speaking, does breast milk benefit small-birthweight babies? Lactation consultants tell the mothers of preterm babies that they should be breastfed in the nursery and go home only on breast milk. Can you comment on that?