TECHNIQUES Nutritional Management of Infants With
Bronchopulmonary Dysplasia KRISTIN J. REIMERS, RD, LD; SUSAN J. KENNETH A. LOMBARD, MD
CARLSON, MMSC, RD, LD, CNSD;
AND
University of Iowa Hospitals and Clinics, Iowa City
ABSTRACT: The nutritional needs of the child with bronchopulmonary dysplasia (BPD) vary significantly from those of a healthy child. To address the many special aspects of the nutritional care of the child with BPD, a nutrition management protocol was established at the University of Iowa Hospitals and Clinics. This protocol discusses caloric requirements; selection of enteral feedings; electrolyte, vitamin, and mineral supplements; growth, oral feeding advancement, and monitoring of nutritional status. Although many of the guidelines are supported by research, some are based on clinical practice. Many questions remain to be answered about the optimal nutrition therapy for these infants. One goal of this protocol is to stimulate discussion and research that will lead to a better understanding of the nutritional requirements of the BPD population.
striction, instability of pulmonary medical condition, and high energy requirements make the delivery of adequate nutrition a challenging part of managing the infant with BPD. In an attempt to improve the nutritional care for infants with BPD, the following nutritional management protocol has been developed for use at the University of Iowa Hospitals and Clinics (UIHC) nurseries and BPD unit. The protocol highlights the special considerations of nutrient provision and monitoring that occur in this patient population. The purpose of this protocol is to provide a clinical tool that may be useful but will likely continue to evolve as more is learned about the nutritional needs of this type of
patient. ENERGY NEEDS
Bronchopulmonary dysplasia (BPD) in preterm infants was first described as a distinct clinical syndrome in 1967 by Northway et al.’ The high ventilator pressure settings and high oxygen concentrations required to ventilate the immature lung with hyaline membrane disease cause progressive clinical, radiographic, and pathologic changes. These changes may result in long-term oxygen dependency with or without ventilator dependency. Nutrition is important for all preterm infants, but the need for adequate nutrition for the growth and recovery of infants with BPD is especially important because the repair of damaged
lung parenchyma occurs very slowly and the growth of new lung tissue offers the best chance for improved pulmonary function.2-6 Medically indicated fluid re-
Address for reprints: Susan J. Carlson, RD, Dietary Department, Iowa City, IA 52242.
University of Iowa Hospitals and Clinics,
requirements of infants in the of initial, stages BPD can be 20 to 40% greater than those of age-matched healthy infants. Energy needs range from 120 to 150 kcal/kg . d-’ but may be even higher in some severely affected infants or in infants with accompanying problems, such as cardiac anomalies.’ Weinstein and Oh hypothesized that this increase in energy expenditure is the result of the increased cost of breathing.’ In our experience, energy requirements above 150 kcal/kg . d-1 are rare and are often associated with malabsorption. Energy needs will decrease as pulmonary function improves. In addition, as the child approaches 6 months’ corrected age, the percentage of total energy needs that are used for growth declines. In healthy infants, this decline is offset by the energy required for increasing physical activity. Energy needs therefore remain relatively stable throughout the first year of life. In the child with BPD, however, physical activity may be severely limited and energy needs may be as low as 70 to 80 kcal/kg . d-1. Regardless of the energy estimation, growth-defined as an increase The
typical
energy
acute
127 Downloaded from ncp.sagepub.com at SEATTLE UNIV LIBRARY on June 30, 2015
128
in both weight and length-remains the primary indicator of appropriate provision of nutrients.
Enteral formulas for infants less than 10 kg. In general, healthy preterm infants can be weaned from 24 kcal/oz of premature formula (PF) at approximately 2.0 kg. Because of their increased energy needs, frequent fluid restrictions, and diuretic treatment, which causes urinary loss of calcium, most preterm
infants with BPD benefit from the use of a PF until they reach approximately 3.0 kg. Relatively prolonged use of a PF has the added advantage of containing higher levels of calcium, phosphorus, and some vitamins, thus reducing the need to add supplements individually. If the preterm infant receives human milk instead of PF, additional protein, calories, calcium, phosphorus, and vitamins are needed to avoid deficiencies and to support normal growth. This can be achieved by the addition of a human milk fortifier (See Appendix A for composition). In the infant with BPD, the use of the fortified breast milk would also need to be prolonged. When infants with BPD exceed 3.0 kg, the daily vitamin intake from PF exceeds recommended allowances, so a change to term formula (TF) is appropriate. Unlike the healthy preterm infant, the infant with BPD will often continue to require a more calorically dense formula than the standard 20 kcal/oz TF.
Appendix A Nutrient composition of breast milk fortifiers
*
HMF, human milk fortifier; Mead Johnson, Evansville, IN. Similac Natural Care, Ross Laboratories, Columbus, OH.
In the situation where a standard preterm formula TF cannot provide adequate calories for growth because of fluid restrictions, poor intake, volume intolerance, or high caloric needs, formula may be concentrated to 24 or 27 kcal/oz. Although the risk of excessive renal solute load is low, monitoring of urine specific gravity is indicated. Formula is concentrated as follows: or
If intake remains inadequate, the addition of modular components such as carbohydrate, fat, or both can safely concentrate the formula to 30 kcal/oz or more without increasing renal solute load or osmolality. Fat modulars are available as long-chain triglycerides (LCT) or medium-chain triglycerides (MCT). LCT is available as a fat emulsion providing 4.5 kcal/ mL. MCT is not emulsified and provides 8.3 kcal/mL. The standard supplemental dose is 1.0 mL of LCT or 0.5 mL of MCT/oz of formula. LCT is commonly used, but MCT is indicated only for the infant with documented fat malabsorption. When MCT is used, it must be mixed thoroughly and is best added to formula immediately before a bolus feeding, because it will separate out and adhere to the plastic tubing. In general, the use of added fat may be more desirable than carbohydrate in patients with compromised respiratory status because the metabolism of fat produces proportionally less C02 than the metabolism of carbohydrate.8 Fat also provides more calories per milliliter than does carbohydrate, which may be beneficial in the fluid-restricted patient. Fat should not provide more than 60% of the total calories in a formula, because this may increase the infant’s risk of developing ketosis.’ The addition of fat may slow gastric emptying and increase the possibility of gastroesophageal reflux (GER); hence, it is contraindicated in patients with high gastric residuals and/or signs of GER. Fat modulars should also be avoided in patients with elevated levels of serum triglycerides. Carbohydrate is available as readily digestible glucose polymers. These modulars are available in powder (4 to 5 kcal/g) or liquid (2 kcal/mL) form. A typical supplemental dose is 1 g of powder or 1 to 2 mL of liquid/oz of formula. Added carbohydrate is usually well tolerated, but if added in excess, it may cause loose stools. If carbohydrate is present upon stool testing (reducing substance positive), the added glucose polymers should be eliminated and then reintroduced gradually.
Downloaded from ncp.sagepub.com at SEATTLE UNIV LIBRARY on June 30, 2015
129
Adding both fat and carbohydrate modulars is another option for concentrating formula. This is an advantage in that the distribution of carbohydrate and fat remains appropriate and is better than concentrating the formula if electrolytes need to be restricted. It should be stressed that carbohydrate and fat contribute calories only and decrease the protein, vitamin, and mineral content per 100 kcal. When a formula is being concentrated with modulars, care should be taken so that the protein content of the formula is not diluted to a point where it is inadequate for growth. To ensure adequate protein intake, modulars should generally be added to the 24- or 27-kcal formula and not to the 20-kcal formula. (Refer to Appendix B for the nutrient content and osmolality of formulas commonly used at UIHC). Problems with feeding, such as refusal to eat, tiring while feeding, vomiting, or increased residuals occur frequently in infants with BPD. Possible causes of such feeding difficulties are listed in Table 1. A change in feeding behavior should prompt an evaluation for possible factors precipitating the change.
needs on approximately 60 mL/kg per day. It is difficult to assess fluid needs for the BPD child on chronic diuretics. Routine monitoring of urine specific gravity and serum electrolytes can help determine if fluid intake is sufficient. Fiber is sometimes needed to achieve appropriate stool consistency in the child fed exclusively with formula. One or more feedings per day of fiber-containing formula may be given. These formulas are designed for use in adults and contain relatively high concentrations of protein and electrolytes (especially sodium). An alternate source is a fiber powder, which does not change the nutrient composition when added to formula. It is best administered mixed with formula and given as a bolus through a large-bore feeding tube. The standard supplemental dose is 3 g/d (1 tablespoon), which may be gradually increased on the basis of stool consistency. Table 1. Potential difficulties
causes
of BPD-associated feeding
Enteral formula for infants over 10 kg. For patients with severe BPD, oral feedings are not possible because of ventilatory dependence. In these cases, the child is maintained on tube feedings for an extended period of time. When the infant reaches 10 kg, it is appropriate to change from an infant formula to a 1kcal/mL (30 kcal/oz) formula designed for toddlers and young children. With this change to a more calorically dense formula, the addition of free water may be necessary. This is usually accomplished by following each feeding with water flushes. On the basis of clinical experience, most tube-dependent older infants and toddlers can meet hydration Nutrient content and
*
Appendix B osmolality of commonly used formulas
ML, Microlipid; Sherwood Medical, St. Louis, MO. Polycose, Ross Laboratories.
Downloaded from ncp.sagepub.com at SEATTLE UNIV LIBRARY on June 30, 2015
130 ELECTROLYTE SUPPLEMENTS
The chronic use of diuretics in the child with BPD often makes it necessary to provide electrolyte supplements. In order to simplify feeding and reduce the risk of complications, it is generally preferable to use a formula that limits the number of supplements. Elec-
trolyte supplementation requires frequent monitoring of serum electrolytes. When possible, the addition of only one supplement to a particular feeding may reduce the risk of adverse interaction. When given by gavage, soluble compounds are mixed with the entire feeding. Relatively insoluble compounds are delivered as a small bolus at the midpoint of the feeding. For continuous-drip feedings, calcium supplements (relatively insoluble) are given at the beginning of the feeding to ensure delivery. Electrolyte supplements should be started conservatively (eg, 1 to 1.5 mEq/kg per day) and adjusted in accordance with serum electrolytes. Potassium in the form of potassium chloride is commonly given in conjunction with diuretic therapy. A standard potassium chloride additive (2 mEq/mL) has 2660 mOsm/L and therefore requires dilution in formula. The recommended dilution is 1 mL of potassium chloride mixed with a minimum of 1 oz of a 24kcal formula. Sodium may be required for infants receiving breast milk and chronic diuretic therapy. Sodium chloride is the supplement of choice. Sodium chloride (2 mEq/ ml) has 4000 mOsm/L, and 1 mL should be diluted with a minimum of 1 oz of 24-kcal formula. Chloride, in the form of magnesium chloride, potassium chloride, and/or calcium chloride, may be given
mEq/L). The hypochloremia may be corrected with potassium chloride alone. If adequate amounts of potassium chloride cannot be given because of potassium excess, then magnesium chloride may be a suitable substitute. Magnesium is a renal stone inhibitor and may help reduce the risk of nephrocalcinosis associated with diuretic therapy.l° Magnesium chloride (2 mEq/mL) has 3000 mOsm/L and should be diluted in formula. to correct
significant hypochloremia (400 IU/L), when there is suspicion of increased calcium loss because of diuretic therapy, or when there has been rapid growth in an infant receiving breast milk without calcium or phosphorus supplements. Wrist films obtained every 4 to 6 weeks are the best available method for following the course of rickets and the response to therapy. Biochemical tests. Recommended biochemical tests for monitoring nutrition status in the infant with BPD are listed in Table 4.
1976;89:814-20.
CONCLUSIONS
The information
represents
an
1981;54:373-7. 9. Fomon SJ. Infant nutrition. Philadelphia: WB Saunders, 1974. 10. Hallson PC, Rose GA. Reduction of the urinary risk factors of urolithiasis with magnesium and tartrate mixture: a new treatment. Br J Urol 1988;61:382-4. 11. Greer FR, Tsang RC. Calcium, phosphorus, magnesium and vitamin D requirements for the preterm infant. In: Tsang RC, ed. Vitamin and mineral requirements in preterm infants. New York: Marcel Dekker, 1985:99-136. 12. Committee on Nutrition, American Academy of Pediatrics. Iron deficiency. In: Forbes GB, ed. Pediatric nutrition handbook. Elk Grove Village, IL: American Academy of Pediatrics; 1985:213-9. 13. Oski FA. Nutrition anemias. In: Walker WA, Watkins JB, eds. Nutrition in pediatrics, basic science and clinical application. Boston: Little, Brown and Co.; 1985:707-26. 14. Nelson S, Rogers R, Ziegler E, et al. Gain in weight and length during early infancy. Early Hum Dev 1989;19:223-39. 15. Roche AF, Guo S, Moore WM. Weight and recumbent length from 1 to 12 months of age: reference data for 1-month increments. Am J Clin Nutr 1989;49:599-607. 16. Dancis, J., O’Connel JR, Holt LE. A grid for recording the weight of premature infants. J Pediatr 1948;33:570-2. 17. Shaffer S, Quimiro C, Anderson J, et al. Postnatal weight changes in low birth weight infants. Pediatrics 1987;79:702-5. 18. Babson SG, Benda GI. Growth graphs for the clinical assessment of infants of varying gestational age. J Pediatr
presented
in this
feeding protocol
attempt to address the many aspects of
nutritional treatment for infants with BPD. Many of the guidelines are supported by sound research, whereas others are based primarily on clinical prac-
19. Hamill PVV, Drizd TA, Johnson CL, et al. Physical growth: National Center for Health Statistics percentiles. Am J Clin
Nutr 1979;32:607-29. 20. Brandt L. Growth dynamics of low birthweight infants with emphasis on the perinatal period. In: Falkner F, Tanner J, eds. Human growth: postnatal growth. New York: Plenum Publishing Corp.; 1979:557-617.
Downloaded from ncp.sagepub.com at SEATTLE UNIV LIBRARY on June 30, 2015
Bronchopulmonary Dysplasia KRISTIN J. REIMERS, RD, LD; SUSAN J. KENNETH A. LOMBARD, MD
CARLSON, MMSC, RD, LD, CNSD;
AND
University of Iowa Hospitals and Clinics, Iowa City
ABSTRACT: The nutritional needs of the child with bronchopulmonary dysplasia (BPD) vary significantly from those of a healthy child. To address the many special aspects of the nutritional care of the child with BPD, a nutrition management protocol was established at the University of Iowa Hospitals and Clinics. This protocol discusses caloric requirements; selection of enteral feedings; electrolyte, vitamin, and mineral supplements; growth, oral feeding advancement, and monitoring of nutritional status. Although many of the guidelines are supported by research, some are based on clinical practice. Many questions remain to be answered about the optimal nutrition therapy for these infants. One goal of this protocol is to stimulate discussion and research that will lead to a better understanding of the nutritional requirements of the BPD population.
striction, instability of pulmonary medical condition, and high energy requirements make the delivery of adequate nutrition a challenging part of managing the infant with BPD. In an attempt to improve the nutritional care for infants with BPD, the following nutritional management protocol has been developed for use at the University of Iowa Hospitals and Clinics (UIHC) nurseries and BPD unit. The protocol highlights the special considerations of nutrient provision and monitoring that occur in this patient population. The purpose of this protocol is to provide a clinical tool that may be useful but will likely continue to evolve as more is learned about the nutritional needs of this type of
patient. ENERGY NEEDS
Bronchopulmonary dysplasia (BPD) in preterm infants was first described as a distinct clinical syndrome in 1967 by Northway et al.’ The high ventilator pressure settings and high oxygen concentrations required to ventilate the immature lung with hyaline membrane disease cause progressive clinical, radiographic, and pathologic changes. These changes may result in long-term oxygen dependency with or without ventilator dependency. Nutrition is important for all preterm infants, but the need for adequate nutrition for the growth and recovery of infants with BPD is especially important because the repair of damaged
lung parenchyma occurs very slowly and the growth of new lung tissue offers the best chance for improved pulmonary function.2-6 Medically indicated fluid re-
Address for reprints: Susan J. Carlson, RD, Dietary Department, Iowa City, IA 52242.
University of Iowa Hospitals and Clinics,
requirements of infants in the of initial, stages BPD can be 20 to 40% greater than those of age-matched healthy infants. Energy needs range from 120 to 150 kcal/kg . d-’ but may be even higher in some severely affected infants or in infants with accompanying problems, such as cardiac anomalies.’ Weinstein and Oh hypothesized that this increase in energy expenditure is the result of the increased cost of breathing.’ In our experience, energy requirements above 150 kcal/kg . d-1 are rare and are often associated with malabsorption. Energy needs will decrease as pulmonary function improves. In addition, as the child approaches 6 months’ corrected age, the percentage of total energy needs that are used for growth declines. In healthy infants, this decline is offset by the energy required for increasing physical activity. Energy needs therefore remain relatively stable throughout the first year of life. In the child with BPD, however, physical activity may be severely limited and energy needs may be as low as 70 to 80 kcal/kg . d-1. Regardless of the energy estimation, growth-defined as an increase The
typical
energy
acute
127 Downloaded from ncp.sagepub.com at SEATTLE UNIV LIBRARY on June 30, 2015
128
in both weight and length-remains the primary indicator of appropriate provision of nutrients.
Enteral formulas for infants less than 10 kg. In general, healthy preterm infants can be weaned from 24 kcal/oz of premature formula (PF) at approximately 2.0 kg. Because of their increased energy needs, frequent fluid restrictions, and diuretic treatment, which causes urinary loss of calcium, most preterm
infants with BPD benefit from the use of a PF until they reach approximately 3.0 kg. Relatively prolonged use of a PF has the added advantage of containing higher levels of calcium, phosphorus, and some vitamins, thus reducing the need to add supplements individually. If the preterm infant receives human milk instead of PF, additional protein, calories, calcium, phosphorus, and vitamins are needed to avoid deficiencies and to support normal growth. This can be achieved by the addition of a human milk fortifier (See Appendix A for composition). In the infant with BPD, the use of the fortified breast milk would also need to be prolonged. When infants with BPD exceed 3.0 kg, the daily vitamin intake from PF exceeds recommended allowances, so a change to term formula (TF) is appropriate. Unlike the healthy preterm infant, the infant with BPD will often continue to require a more calorically dense formula than the standard 20 kcal/oz TF.
Appendix A Nutrient composition of breast milk fortifiers
*
HMF, human milk fortifier; Mead Johnson, Evansville, IN. Similac Natural Care, Ross Laboratories, Columbus, OH.
In the situation where a standard preterm formula TF cannot provide adequate calories for growth because of fluid restrictions, poor intake, volume intolerance, or high caloric needs, formula may be concentrated to 24 or 27 kcal/oz. Although the risk of excessive renal solute load is low, monitoring of urine specific gravity is indicated. Formula is concentrated as follows: or
If intake remains inadequate, the addition of modular components such as carbohydrate, fat, or both can safely concentrate the formula to 30 kcal/oz or more without increasing renal solute load or osmolality. Fat modulars are available as long-chain triglycerides (LCT) or medium-chain triglycerides (MCT). LCT is available as a fat emulsion providing 4.5 kcal/ mL. MCT is not emulsified and provides 8.3 kcal/mL. The standard supplemental dose is 1.0 mL of LCT or 0.5 mL of MCT/oz of formula. LCT is commonly used, but MCT is indicated only for the infant with documented fat malabsorption. When MCT is used, it must be mixed thoroughly and is best added to formula immediately before a bolus feeding, because it will separate out and adhere to the plastic tubing. In general, the use of added fat may be more desirable than carbohydrate in patients with compromised respiratory status because the metabolism of fat produces proportionally less C02 than the metabolism of carbohydrate.8 Fat also provides more calories per milliliter than does carbohydrate, which may be beneficial in the fluid-restricted patient. Fat should not provide more than 60% of the total calories in a formula, because this may increase the infant’s risk of developing ketosis.’ The addition of fat may slow gastric emptying and increase the possibility of gastroesophageal reflux (GER); hence, it is contraindicated in patients with high gastric residuals and/or signs of GER. Fat modulars should also be avoided in patients with elevated levels of serum triglycerides. Carbohydrate is available as readily digestible glucose polymers. These modulars are available in powder (4 to 5 kcal/g) or liquid (2 kcal/mL) form. A typical supplemental dose is 1 g of powder or 1 to 2 mL of liquid/oz of formula. Added carbohydrate is usually well tolerated, but if added in excess, it may cause loose stools. If carbohydrate is present upon stool testing (reducing substance positive), the added glucose polymers should be eliminated and then reintroduced gradually.
Downloaded from ncp.sagepub.com at SEATTLE UNIV LIBRARY on June 30, 2015
129
Adding both fat and carbohydrate modulars is another option for concentrating formula. This is an advantage in that the distribution of carbohydrate and fat remains appropriate and is better than concentrating the formula if electrolytes need to be restricted. It should be stressed that carbohydrate and fat contribute calories only and decrease the protein, vitamin, and mineral content per 100 kcal. When a formula is being concentrated with modulars, care should be taken so that the protein content of the formula is not diluted to a point where it is inadequate for growth. To ensure adequate protein intake, modulars should generally be added to the 24- or 27-kcal formula and not to the 20-kcal formula. (Refer to Appendix B for the nutrient content and osmolality of formulas commonly used at UIHC). Problems with feeding, such as refusal to eat, tiring while feeding, vomiting, or increased residuals occur frequently in infants with BPD. Possible causes of such feeding difficulties are listed in Table 1. A change in feeding behavior should prompt an evaluation for possible factors precipitating the change.
needs on approximately 60 mL/kg per day. It is difficult to assess fluid needs for the BPD child on chronic diuretics. Routine monitoring of urine specific gravity and serum electrolytes can help determine if fluid intake is sufficient. Fiber is sometimes needed to achieve appropriate stool consistency in the child fed exclusively with formula. One or more feedings per day of fiber-containing formula may be given. These formulas are designed for use in adults and contain relatively high concentrations of protein and electrolytes (especially sodium). An alternate source is a fiber powder, which does not change the nutrient composition when added to formula. It is best administered mixed with formula and given as a bolus through a large-bore feeding tube. The standard supplemental dose is 3 g/d (1 tablespoon), which may be gradually increased on the basis of stool consistency. Table 1. Potential difficulties
causes
of BPD-associated feeding
Enteral formula for infants over 10 kg. For patients with severe BPD, oral feedings are not possible because of ventilatory dependence. In these cases, the child is maintained on tube feedings for an extended period of time. When the infant reaches 10 kg, it is appropriate to change from an infant formula to a 1kcal/mL (30 kcal/oz) formula designed for toddlers and young children. With this change to a more calorically dense formula, the addition of free water may be necessary. This is usually accomplished by following each feeding with water flushes. On the basis of clinical experience, most tube-dependent older infants and toddlers can meet hydration Nutrient content and
*
Appendix B osmolality of commonly used formulas
ML, Microlipid; Sherwood Medical, St. Louis, MO. Polycose, Ross Laboratories.
Downloaded from ncp.sagepub.com at SEATTLE UNIV LIBRARY on June 30, 2015
130 ELECTROLYTE SUPPLEMENTS
The chronic use of diuretics in the child with BPD often makes it necessary to provide electrolyte supplements. In order to simplify feeding and reduce the risk of complications, it is generally preferable to use a formula that limits the number of supplements. Elec-
trolyte supplementation requires frequent monitoring of serum electrolytes. When possible, the addition of only one supplement to a particular feeding may reduce the risk of adverse interaction. When given by gavage, soluble compounds are mixed with the entire feeding. Relatively insoluble compounds are delivered as a small bolus at the midpoint of the feeding. For continuous-drip feedings, calcium supplements (relatively insoluble) are given at the beginning of the feeding to ensure delivery. Electrolyte supplements should be started conservatively (eg, 1 to 1.5 mEq/kg per day) and adjusted in accordance with serum electrolytes. Potassium in the form of potassium chloride is commonly given in conjunction with diuretic therapy. A standard potassium chloride additive (2 mEq/mL) has 2660 mOsm/L and therefore requires dilution in formula. The recommended dilution is 1 mL of potassium chloride mixed with a minimum of 1 oz of a 24kcal formula. Sodium may be required for infants receiving breast milk and chronic diuretic therapy. Sodium chloride is the supplement of choice. Sodium chloride (2 mEq/ ml) has 4000 mOsm/L, and 1 mL should be diluted with a minimum of 1 oz of 24-kcal formula. Chloride, in the form of magnesium chloride, potassium chloride, and/or calcium chloride, may be given
mEq/L). The hypochloremia may be corrected with potassium chloride alone. If adequate amounts of potassium chloride cannot be given because of potassium excess, then magnesium chloride may be a suitable substitute. Magnesium is a renal stone inhibitor and may help reduce the risk of nephrocalcinosis associated with diuretic therapy.l° Magnesium chloride (2 mEq/mL) has 3000 mOsm/L and should be diluted in formula. to correct
significant hypochloremia (400 IU/L), when there is suspicion of increased calcium loss because of diuretic therapy, or when there has been rapid growth in an infant receiving breast milk without calcium or phosphorus supplements. Wrist films obtained every 4 to 6 weeks are the best available method for following the course of rickets and the response to therapy. Biochemical tests. Recommended biochemical tests for monitoring nutrition status in the infant with BPD are listed in Table 4.
1976;89:814-20.
CONCLUSIONS
The information
represents
an
1981;54:373-7. 9. Fomon SJ. Infant nutrition. Philadelphia: WB Saunders, 1974. 10. Hallson PC, Rose GA. Reduction of the urinary risk factors of urolithiasis with magnesium and tartrate mixture: a new treatment. Br J Urol 1988;61:382-4. 11. Greer FR, Tsang RC. Calcium, phosphorus, magnesium and vitamin D requirements for the preterm infant. In: Tsang RC, ed. Vitamin and mineral requirements in preterm infants. New York: Marcel Dekker, 1985:99-136. 12. Committee on Nutrition, American Academy of Pediatrics. Iron deficiency. In: Forbes GB, ed. Pediatric nutrition handbook. Elk Grove Village, IL: American Academy of Pediatrics; 1985:213-9. 13. Oski FA. Nutrition anemias. In: Walker WA, Watkins JB, eds. Nutrition in pediatrics, basic science and clinical application. Boston: Little, Brown and Co.; 1985:707-26. 14. Nelson S, Rogers R, Ziegler E, et al. Gain in weight and length during early infancy. Early Hum Dev 1989;19:223-39. 15. Roche AF, Guo S, Moore WM. Weight and recumbent length from 1 to 12 months of age: reference data for 1-month increments. Am J Clin Nutr 1989;49:599-607. 16. Dancis, J., O’Connel JR, Holt LE. A grid for recording the weight of premature infants. J Pediatr 1948;33:570-2. 17. Shaffer S, Quimiro C, Anderson J, et al. Postnatal weight changes in low birth weight infants. Pediatrics 1987;79:702-5. 18. Babson SG, Benda GI. Growth graphs for the clinical assessment of infants of varying gestational age. J Pediatr
presented
in this
feeding protocol
attempt to address the many aspects of
nutritional treatment for infants with BPD. Many of the guidelines are supported by sound research, whereas others are based primarily on clinical prac-
19. Hamill PVV, Drizd TA, Johnson CL, et al. Physical growth: National Center for Health Statistics percentiles. Am J Clin
Nutr 1979;32:607-29. 20. Brandt L. Growth dynamics of low birthweight infants with emphasis on the perinatal period. In: Falkner F, Tanner J, eds. Human growth: postnatal growth. New York: Plenum Publishing Corp.; 1979:557-617.
Downloaded from ncp.sagepub.com at SEATTLE UNIV LIBRARY on June 30, 2015
