Meeting nutrition needs for premature or critically ill patients

The right amount and type of nutrients are vital to premature babies and critically ill patients, such as newborns in the neonatal intensive care unit (NICU) and children in the pediatric intensive care unit (PICU). To help ensure each patient receives the necessary nutrition for their unique needs, many hospitals have developed nutrition programs in their NICUs and PICUs. There are numerous considerations when providing proper nutrition for these patients.

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Nourishment in the NICU

The proper balance of calories, proteins, fats, electrolytes, vitamins, minerals and fluids supports a NICU baby’s growth and development, helps the body’s systems function properly, boosts the immune system, promotes cell growth and provides various other health and healing benefits. While breastmilk produces the most benefits, supplements are often required for NICU babies.

“These supplements provide increased calories, protein intake and minerals for overall growth and bone development,” said Barbara Carr, M.D., a neonatologist and medical director at Pediatrix® Medical Group of Kansas.

In addition, some NICU babies are either too immature or too sick to consume nutrients by mouth at first. Several issues, such as feeding intolerance, gastrointestinal troubles, neurological problems or any number of medical conditions, may also prevent a baby from receiving nutrients by mouth.

When this happens, NICU babies can receive proper nutrients through alternate methods:

• Enteral (feeding tube) — A feeding tube is inserted through the nose or mouth and goes directly into the stomach and food is dripped in.
• Parenteral (intravenously) — An intravenous line (IV) is placed in the hand, foot, scalp or umbilicus (belly button), which carries essential nutrients and fluids to the body until enteral nutrition can be given.

Those who can receive nutrition via mouth may still require supplements to breastmilk or formula, which is why a nutrition program is an indispensable part of a NICU baby’s care.

“Good nutrition impacts nearly every major outcome in the NICU,” said Dr. Carr. “Babies who are better nourished have improved growth, fewer long-term complications and improved performance when they reach school age.”

Nourishment for PICU patients

Infants through young adults are treated in the PICU for various reasons, such as acute respiratory problems, post-surgical needs, serious infections, complications of diabetes and severe injuries or trauma. Like the NICU, early nutrition assessment is critical to patient recovery and outcomes. As with healthy children, PICU patients require proper nutrition, including:

• Carbohydrates — A significant source of energy that builds and repairs tissue.
• Proteins — Build cells, fight infection and carry oxygen.
• Fats — Helps absorb specific vitamins and nutrients.
• Dietary fiber — Stabilizes blood sugar and promotes gastrointestinal health.
• Vitamins and minerals — Strengthen the immune system, promote growth and development, heal wounds and convert food to energy, among numerous other benefits.
• Water — Keeps the body hydrated, lubricates joints, cushions sensitive tissues, regulates body temperature, flushes body waste and provides numerous other benefits.

The difference is that critically ill patients may require more of certain nutrients and less of others, depending on the illness or injury and their specific nutritional needs. Additionally, like NICU patients, they may not be able to consume nutrients through the mouth and may require enteral or parenteral (through IV) nutrients. As with any critically ill or injured patient, nutrition is vital to recovery.

“The PICU sometimes follows patients who present with malnutrition,” said Kristina Deeter, M.D., a pediatric intensivist and specialty medical officer for pediatric critical care medicine at Pediatrix Medical Group. “Following these patients very closely and watching their labs is important because they can develop ‘refeeding syndrome.’”

Refeeding syndrome occurs when a malnourished patient begins to eat food again. The reintroduction of glucose can cause a sudden shift in fluids and electrolytes, which could lead to severe medical complications. Therefore, it is essential to reintroduce foods slowly and gradually increase calories while closely monitoring the patient’s weight, vital signs and shifts in electrolytes and fluids to help prevent refeeding syndrome.  

Nutrition management for premature or critically ill patients

A successful nutrition program requires a task force of multidisciplinary experts who specialize in clinical nutrition, including dietitians, nutritionists and pediatric specialists (e.g., neonatologists and pediatric intensivists), nurses, pharmacists and lactation consultants. The team conducts various activities, such as:

• Performing clinical assessments to help determine a patient’s nutritional status and requirements.
• Developing and implementing nutrition guidelines.
• Identifying and participating in quality-improvement initiatives.
• Establishing lactation and breastfeeding guidelines.
• Managing infection prevention in the handling, storage and delivery of nutritional products.
• Monitoring nutritional status through various means, such as:
  
  • Body weight and height/length.
  • Skinfold thickness to determine body fat mass.
  • Circumference measurements of the arms, legs and torso.
  • Urination and bowel movement frequency.
  • Monitoring metabolic state (to determine if the body breaks down foods and absorbs nutrients properly).

While concerns about malnutrition come to mind when thinking about patients and nutritional needs, overfeeding can prove equally harmful. Using various methods and techniques to monitor the nutritional status of NICU and PICU patients is vital, ensuring neither underfeeding nor overfeeding occurs. Either situation may be detrimental to patient outcomes, which is another reason a nutrition program using a multidisciplinary team approach is a valuable part of the overall patient care and treatment plan.

“Close attention to the nutritional status of the NICU baby is of key importance and a focus of what we do every day,” said Dr. Carr.