Neonatal Nutrition Support

During my dietetic internship the Neonatal Intensive Care Unit (NICU) was of most interest. The health of women, infants, and children is at the forefront of my mind, and served as the topic of nearly all of my undergraduate research.

​Recently, I have had the generous opportunity to shadow our Registered Dietitian in the NICU, and I could not be more thrilled! As a clinical dietitian, I find acute care to be especially gratifying work, which is only magnified by the opportunity to provide excellent care to our smallest patients.

​As an intern my experience was in a Level II facility, therefore shadowing in the Level III NICU has been a step up in my acute care experience and training with the pediatric population. The American Academy of Pediatrics (AAP) defines neonatal levels of care as (1):
​

• Level I - basic care
• Level II - specialty care
• Level III - sub-specialty care

Registered Dietitians are essential in following the feeding transitions of very preterm and extremely premature infants in the NICU. Infant feeding transitions from birth to 1 month set the foundation for achieving feeding transitions through childhood. ​Successful feedings during childhood influences healthy eating patterns throughout life. (2)

​Feeding transitions are defined as "periods of time in which infants move from one type of feeding to another." The actual age of achieving milestones varies infant to infant, but feeding transitions build upon one another (2). When infants miss milestones the likelihood of feeding difficulties increases. If infants are spurred to meet milestones before they are developmentally ready, feeding problems may also occur (2).

There are seven major feeding transitions for term infants (2):​

​Feeding Transition

• Establishing breastfeeding
• Introduction of solids
• Finger foods
• Cups
• Table foods (textures)
• Weaning from breast/bottle
• Rotary chewing

Age of Occurrence

• Birth to 1 month
• 4-7 months
• 6-8 months
• 6-12 months
• 9-12 months
• 12-18 months
• 2 to 3 years

Weeks Gestation

• Extreme prematurity: <26/6
• Very preterm: 27/0 - 32/6
• Premature: 33/0 - 36/6
• Early term: 37/0 - 38/6
• Full term: 39/0 - 40/6
• Late term: 41/0 - 41/6
• Postterm: >42/0

Prematurity is associated with unique nutrition-related issues, therefore feeding transitions are more complex (3). The gastrointestinal tract becomes functional and the sucking reflex develops between 32-34 weeks gestation. Aggressive nutrition therapy, such as parenteral nutrition, should be initiated immediately for very preterm and extremely premature infants. As the GI tract matures and reflexes develop, feeding transitions to nasogastric (NG) feedings and ultimately oral feedings (PO) of mother's breast milk or formula.

Delivery of nutrients into the circulatory system, or parenteral nutrition (PN), is used to maximize nutrient intake once PO or NG feedings are established. Fortifiers and supplements are often used, as unfortified human milk does not contain enough nutrients for infants born prematurely. Adequate calories and protein, as well as several other micronutrients and electrolytes, results in greater short-term weight gain, length gain, and head growth (3).

Shadowing in the NICU has been an exciting experience, and I am learning more with every day. There is no greater satisfaction in acute care nutrition than helping patients and their families get the best start in life. Registered Dietitians monitoring feeding transitions provides a building block for life, and has the potential to promote a healthier future for generations to come.

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References :
1. Levels of Neonatal Care. Pediatrics. 2012;130(3):587-597. doi:10.1542/peds.2012-1999.
2. Milano K. How Infant Feeding Transitions Relate to Feeding Difficulties in Young Children. Pediatric Nutrition - A Building Block for Life. 2016;39(2):1-6.
3. Perkey KG, Mathis MT. Neonatal Nutrition Support. Nutrition Dimension
4. http://www.marchofdimes.org/pregnancy/what-is-full-term.aspx. Accessed February 26, 2017.