10/26/2016 Welcome to the NICU Consortium Agenda October 26, 2106 9:00 am Welcome, Announcements JFK Partners and HCP, a program for Children and Youth with Special Health 9:15 am 'Hot Topics in NICU" Care Needs Dr. Anna Zimmermann • Rocky Mountain Hospital for Children Accessing Children’s Benefits through Health First, Colorado’s Medicaid 10:15 am Break State Plan 10:30 am "GI Concerns After Discharge from the NICU" Mon., Nov 14, 2016 - 9:00-10:30 a.m. Dr. Theodore Stathos JFK Partners website – deadline Nov. 8, 2016 Rocky Mountain Pediatric Gastroenterology 11:30 am Adjourn 11:35 am NICU Consortium Steering Committee – To 12:30 pm Please join us if you would like NICU Outreach and Transition Partnership Update Hot Topics Small Work Groups in Neonatal 1. Outreach to families, family advocates. Family engagement 2. Family empowerment, family advocacy Nutrition 3. Mental health support for families and providers 4. Education and capacity building for the NICU and community 5. Building coordinated systems of care for families 6. Sustainability through data, community collaboration, grants, fundraising If you are interested in working with any of these groups or attending the next meeting but were unable to attend in September, contact Barbara at specialcare@sk-sc.org. • Anna Zimmermann, MD, MPH • Neonatologist, Pediatric Medical Group, RMHC Next Full Meeting: February 2017 – date to be announced Topics Covered Discharge nutrition • Nutritional Concerns after Discharge • Marijuana Protocols 1
10/26/2016 Formula 101 Formula 101 • Standard Term Formulas • Soy Formulas – Enfamil Premium Newborn, Enfamil Premium Infant, – Prosobee, Similac Isomil soy Similac Advance – Used for milk allergy, galactosemia or lactose – General Cow’s milk based, used for standard feeding intolerance – Historically 20kcal/oz. Similac now 19kcal/oz – If infants have milk allergy, will typically also be allergic to soy – WIC Contract is with Enfamil Formula 101 Formula 101 • Renal Formula • Semi-elemental formulas – PM 60/40 – Alimentum, Pregestimil, Nutramigen – Mineral levels approximate the mineral content of human milk – For allergy to intact protein and/or generalized malabsorption – Calcium:Phosphorus ratio and content designed to manage serum – Pregestimil has higher % of MCT oil calcium disorders - both hypercalcemia and hypocalcemia due to • Elemental formula hyperphosphatemia – Neocate, Elecare, PurAmino, Alfamino – Low in Iron – Completely elemental, hypoallergenic formula Nutrient needs Formula 101 • Calories – 100-130 kcal/kg/day • Human Milk Fortifier – Similac and Enfamil products • Protein – Liquid and powder formulations – 2.2 - 4 g/kg/day – Used in the NICU to fortify Maternal and Donor Breast Milk – Gives added calories - 22kcal/oz and 24kcal/oz • Fluid – Gives additional protein, calcium, phosphorus necessary for growth – 130-200 ml/kg/day and bone mineralization in preterm infants • Giving 24kcal/oz formula at 160ml/kg/day provides 120kcal/kg/day 2
10/26/2016 Discharge nutrition Discharge nutrition BM x 5 BM + PDF • Infants in the NICU receive fortified BM + HMF feedings Exclusive BM 22kcal/oz PDF x powder PDF 22kcal/oz 3 to 24kcal/oz • We typically transition infants to premature discharge Protein (g/kg) 1.6 2.3 1.9 3.4 formula when they are bottling 50% of their feedings • Providing 5 feedings/day of breast milk and 3 Calcium (mg/kg) 50 83 64 135 feedings/day of preterm discharge formula – Increases protein, calcium, phosphorus vs. “sprinkling” Phos (mg/kg) 26 46 35 77 formula in every breast milk feeding for fortification Vitamin D 8 94 48 180 (IU/day) – Allows mother to breast feed • Infants on WIC will go home on Enfamil products. Iron (mg/kg) 0.08 0.9 0.5 2.3 BM = Breast milk PDF = Premature Discharge Formula (Enfacare, Neosure) Assuming 2.5kg infant with feeds at 120ml/kg/day weight gain goals How long on Preterm Discharge Formula • Smaller babies born at earlier gestations need Age Goal Weight Gain Preterm Discharge Formula longer (2 months - 1year) Preterm (<2kg) 15-20 g/kg/day • Recommend minimum 2-4 months for most Preterm (>2kg) - term 20-30 g/day corrected preterm infants born <32 weeks. 0-4 months corrected 23-34 g/day • Would like to see weight at 25%ile and Head Curcumfrence over 10%ile. 4-8 months corrected 10-16 g/day 8-12 months corrected 6-11 g/day vitamin supplementation Managing Poor Growth • All term infants on breast milk need 400 IU Vitamin D until 1 • #1 - Investigate year of age. – How are parents mixing the formula – What is mom’s milk supply like? • All infants on plain or fortified BM need Iron supplementation – How many total ounces/day is the infant receiving until 1 year corrected age (2mg/kg/day) – Other sypmtoms? Rash? Emesis? Excessive crying? • Formula fed infants do not need supplemental Iron • Premature infants on fortified Breast Milk feedings – Continue Multivitamin supplementation as long as infant remains on breast milk feedings 3
10/26/2016 Managing poor growth Post-discharge HMF • If infant is receiving at least 120kcal/kg/day • Just approved by WIC – Consider increasing volume to provide 130kcal/kg/day • May get some help from insurance for private – Consider increasing calories above 22-24kcal/oz. pay patients • Can use formula or canola oil • Providers from hospitals across Colorado • If infant is receiving >130 kcal/kg/day joined forces to create guidelines to – think malabsorption, milk protein allergy or other intolerance standardize use and recommendations to use powder HMF post discharge to fortify breast milk. Post-discharge HMF Post-discharge HMF • Recipes: • Indications: – MOC as adequate Breast Milk supply and one or more of the – 22kcal/oz Human Milk: 1 packet HMF + 50mL breast following: milk (or 2 packets + 100mL) • Birthweight <1500g – 24kcal/oz Human Milk: 1 packet HMF + 25mL • <28 weeks at birth breastmilk (or 2 packets + 50mL) • Alk Phos >600, Serum Phos <6, BUN <10 • Daily Limits -- do not exceed 20 packets per • Radiological evidence of bone demineralization and/or day of HMF fractures • <10% on Fenton Growth curve for CGA at time of discharge Post-discharge HMF Post-discharge HMF • Recommended Labs to be monitored by • Guidelines for when to Stop HMF: Pediatrician – Depends on the nutrition status of the infant – Calcium, Phos, Alk Phos levels at 3-4 weeks post • 12 weeks Post-discharge with normal biochemical labs • Weight >3.6kg with good growth and normal labs discharge and then monthly while infant remains on HMF • Or per RD discretion with agreement with Primary MD – If Ca or Phos levels are elevated (Ca>11.5mg/dL and Phos >8.5mg/dL), suggest decreasing number of packets of HMF per day) 4
10/26/2016 Questions? Marijuana and Breastfeeding Marijuana Marijuana • In Marijuana smoke there are more than 400 • Typically inhaled, but can be ingested (Edibles at showers???) compounds present with THC • Made legal in Colorado about 2 years ago • THC is the agonist of cannabinoid receptors in the • Most common illicit drug used by pregnant women in US – 4.6% report use during 1st trimester nervous system – 1.4% report use during 3rd trimester • These receptors are found in high quantities in the parts – ? Higher rate in CO since legalization of the brain that influence thought, concentration, – Overall prevalence of ever using THC among WIC mothers: 30% memory, pleasure, perception of time and pain and also • Overall prevalence of current THC use among WIC mothers: 6%. cognitive concentration Higher in women <30. THC: THC: Benefits Tetra-hydro-cannabinol • Beneficial for treating MS • Releases Dopamine giving euphoric high – Treats spasticity and muscle contractions – Alleviates tremors • Subtle effects on two opioid receptors giving pain management • Treats Alzheimer’s disease • Anxiolytic and calming effects can lead to • Reduces seizures associated with epilepsy ambivalence • Treatment for anorexia • Decreases nausea and induces appetite • Treatment for HIV/AIDS patients • Enhances our own natural endocannabinoid system • Treats symptoms / side effects of chemotherapy • Improves selective memory 5
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