20 | Tiny but Mighty: Nutrition for Premature Babies

Today's chat is extra special because we're diving into the tiny yet mighty world of premature infant nutrition. You know, those little warriors who steal our hearts and ignite our passion for giving them the healthiest start possible.

We've got a rockstar guest in the house – Lauren Seaman, a registered dietitian and preemie mama herself. Together, we're unpacking the nitty-gritty of neonatal nutrition, blending professional wisdom with real-life experiences.

Key Takeaways:

1. Feeding Challenges: Explore the unique challenges premature infants face, such as oral aversions and a higher risk of aspiration. Gain insights into recognizing readiness cues and ensuring safe feeding practices.
2. Premature Formula 101: Uncover the significance of specialized premature formulas like Neosure and Enfacare, designed to support preterm infants' nutritional needs. Get guidance on when and how to transition to regular formulas if needed.
3. Introduction to Solids: Navigate the complexities of introducing solids to preemies, considering their individual developmental milestones. Learn why a combination of purees and baby-led weaning might be beneficial.
4. Common Pitfalls to Avoid: Hear expert advice on steering clear of outdated practices, such as starting solids too early, introducing one food at a time, and weaning too quickly.
5. Understanding Corrected Age: Learn the importance of corrected age in assessing premature infants' developmental readiness for solid foods. Discover how to calculate adjusted age and why it's crucial for tailoring nutritional guidance.

For clinicians and families passionate about providing the best care for premature infants, this episode offers a wealth of knowledge, blending professional expertise with personal experience to create a valuable resource on nutrition in the neonatal journey. I know you'll find something you can walk away with today that will improve the health of your patients! If you have a colleague or friend who struggles with knowing how to discuss nutrition or weight with their patients, and you think they might benefit from my podcast, I would love if you could share this episode with them. My goal is to help as many clinicians as possible realize that nutrition matters and it is possible to educate our patients toward a healthy lifestyle, despite a

Transcript

Colleen: 0:00

Welcome back to the Exam Room Nutrition Podcast. I'm your host, colleen Sloan. I'm a registered dietitian and pediatric PA. Today, we're going to shed some light on the incredible journey of our little warriors, premature infants. I'm sure you're all familiar with the saying tiny but mighty, and today we'll explore how nutrition can make all the difference for these tiny champions.

Colleen: 0:22

Preterm birth, a reality faced by approximately one in 10 infants in the United States, is a topic close to my heart. These little ones born before completing 37 weeks of pregnancy often face numerous challenges as their brains, lungs and livers continue to develop in the final weeks. Tragically, in 2020, preterm birth and low birth weight accounted for about 16% of infant deaths, making this issue more urgent than ever. Today, we are joined by a remarkable registered dietitian, and not just that she's also a preemie mama herself. So her expertise, combined with her personal experience, will provide us with genuine insights and real life tips that will undoubtedly prove invaluable for my pediatricians, neonatologists and any families of preemie babies alike.

Colleen: 1:09

So I'm so excited for this conversation and I'm thrilled to introduce you to Lauren Siemen. She's a University of Pittsburgh graduate and a seasoned registered dietitian with over 12 years of experience following a challenging NICU journey with her own premature daughter, born at 27.4 weeks. Lauren found a new calling, working in a level three NICU. In 2023, she launched her Instagram page at preemienutritionmama, where she combines her personal preemie parenting experiences and her expertise as a NICU pediatric RD to support and guide other preemie moms through the feeding challenges common to preemie's Lauren. I'm so excited that you're here with us today. Preemie nutrition is so near and dear to my heart and you have such a beautiful blending of experience, professionally and personally. So thanks so much for being here. Welcome to the show. Thank you so much for having me, I'm thrilled to be here.

Colleen: 2:00

I love when clinicians combine their own personal experience with their professional training, because I think it's just such a beautiful marriage of the two and you really can provide practical tips that you've probably done, that have succeeded and worked for you, that you didn't just read about in a book. So I love this and I'm so excited to jump into this topic. So I really wanna start where mamas start, and that's in the hospital, especially those days leading up to discharge, because when you're in the hospital for months at a time, you've got nurses and doctors and so many other people. They're helping you, care for them and sometimes doing all the care themselves, depending on how cute your preemie baby was. So let's talk to those moms who are getting ready to be discharged home. Give us the most helpful tips that clinicians can be providing to those moms and dads that would be really helpful in reassuring to them when they are going home.

Lauren: 2:51

So I would say ask questions.

Lauren: 2:53

Often the feeding plan changes leading up to discharge.

Lauren: 2:57

Most of the time, especially if you have a baby that's been on like fortified breast milk feeds, they may be transitioning to a combination of plain breast milk, doing some breastfeeding and then they might transition on to like a combination of some what my NICU calls like booster feeds, where we do a certain number of feeds of high calorie, like preterm discharge formula, and that often changes in the last day or two before discharge.

Lauren: 3:18

So ask questions. Make sure that you feel comfortable with what that feeding regimen looks like. Make sure you understand that, what the calorie level is, what the formula is, because it'll often change from a preterm formula in the hospital that they were on till Neosur and Ficare that few days before they leave, so it's a different name. Make sure that you know how to mix it, that you feel comfortable with that and that you feel really comfortable with just safe formula mixing practices. So boiling water for a minute and letting that cool and doing that until your infant is up to three months corrected just to decrease any risk of any illness from that tap water till their immune system gets a little bit stronger. Also, if it's a breastfeeding mom, I would say really want to make sure that you utilize the lactation consultants in the hospital and feel comfortable that your preemie has a good latch. If you need like nipple shields or if you want to transition off of those, just ask all those questions while you have all that support.

Colleen: 4:14

So as clinicians, we need to make sure that they are really understanding what the formula name is, how to mix and prepare it and the appropriate use of water. Now I want to linger here a little bit with water, because I get this a lot in outpatient clinic is what type of water can we use? There's distilled, there's the bottled, just the spring water, tap water, like you touched on a little bit. Can you just give us a little water 101? Is it OK if they just use straight bottled water or do they need to do something special?

Lauren: 4:42

So bottled water, nursery water, spring water all is not sterile, so all of that would still need to be boiled. So because I think nursery waters want to get questions about a lot, so that one would still need to be boiled. One tip that I used personally that the dietitian that had my position at the time was I had a container that could go through the dishwasher in my high heat setting and I would boil a bunch at a time and then cool it and keep it in the fridge. So I had enough ready to use for a couple of days. To make it a little bit less daunting, I didn't have to boil water every time I needed to make formula.

Colleen: 5:15

Smart. I love that. That's sometimes saving hack right there. Ok, so now let's dive a little bit more into the preemie formula 101. For my clinicians who are listening, If you're in primary care of, maybe even if you're a new graduate, this can be overwhelming a little bit because there seems like there's a lot and it can get a little bit confusing. So first I would like to know why do we even use premature formula?

Lauren: 5:37

So preterm to shrump formula. The two that are on the market are Newshire, which is by Abbott, and Enficar, which is by Meade Johnson. Those are designed for preterm infants. They're, at baseline, higher in calories. So most infant formulas are 20 calories per ounce at base. These ones are 22. They're higher in protein. They're higher in minerals, especially calcium and phosphorus, which are really important for premature infants because being born early, they miss that ability to absorb those minerals from mom during that third trimester. So they're in a higher amount and they're also in a ratio to improve the absorption of them. So that's why, if they can tolerate that formula, that is the go-to one to have in some capacity. We definitely wouldn't have breast milk if mom did all that work to breastfeed and pump. But they may need some and then if mom wasn't able to breastfeed, that's really the go-to formula to start out on.

Colleen: 6:33

And now, how long do these babies need to stay on this premature formula? I know this is a little bit nuanced, but give us some guidelines, especially speaking to the pediatricians who are managing them now that they're at home.

Lauren: 6:45

So I'd say A good baseline is that the earlier they were born and the lower their birth weight, the longer they should stay on it. So you're like less than 750 gram infants should probably stay on it. Told them close to a year, corrected that 750 to 1,000, maybe more like nine months, and then it kind of goes down from there, with the caveat that if they're catching up really quickly and they're plotting uncorrected on the growth curve you could transition them off that sooner.

Colleen: 7:12

And a question about regular formula, the typical infant formulas that are the 20 calories per ounce. Can we fortify those, just in case there is an issue that the baby's not tolerating any of the premature formulas? Is that appropriate thing to do?

Lauren: 7:26

On a case-by-case basis I'd say the most often ones that we'll use are in the case of, like a milk protein allergy. So when maybe used like an elecare or like an elementum or a new tramogen, those ones will be used probably the most often in those situations. They are a little higher in protein and calcium and phosphorus they don't have quite that ratio that I mentioned. So they definitely can be used. Those just infants just especially if they were really low birth weight infant and they had a high risk of, like osteopenia, prematurity. It may be worth maybe checking their labs periodically in the first year to make sure that you know their alkaline phosphatase. Those types of things look okay and they don't need maybe some calcium and phosphorus fortification, other term formulas, maybe like a gentilease or like a sensitive I've seen those used too more rarely In similar situations. They absolutely can be fortified to higher calories as needed, which is great for the weight gain. Just again, we want to check certain lamps, especially if they were a lower birth weight infant.

Colleen: 8:23

Awesome and I want to clarify, because we're talking dietitian to dietitian. But for somebody who's listening and is like, what does it mean to fortify formula, can you give us what that means and, simply, how is it done?

Lauren: 8:36

Yes, so every powder formulas can be concentrated to a certain amount of water. So you will just add less water to a certain amount of powder to make it more concentrated. And pretty much any infant formula can be fortified between 20 calories up to 30 calories in more extreme cases, and those just should be done with. You know, whether the guidance of a dietitian or a pediatrician or GI doctor or someone following that's comfortable prescribing something that's appropriate for that infant.

Colleen: 9:07

And I think I know your answer, but I just want to linger here a little bit. While we're on formula and fortifying and putting things in the bottle, what are your thoughts on adding rice cereal to the bottle for premature infants?

Lauren: 9:19

The only case I could see that being appropriate is for thickening purposes, for reflux, and even then I would probably maybe go the route of one of the formulas Actually, the only one that's really on the market now is infamilar, that has rice starch built in, because it just adds unnecessary calories and doesn't really add any nutrition. And then now there's like the whole arsenic content in rice cereal. So I would really really avoid that and just that would be a last case resort for me. But the other caveat is those should not be added to breast milk, because the amylase enzyme that's in breast milk will start to break it down and it won't thicken.

Colleen: 9:55

That was super helpful. So we're going to move on beyond the world of formulas. Now let's talk to our six-month-old premies, maybe that four to six range, or four to nine-month-old infants who we might be considering to start on solids. So educate us on what do we need to look for to know when they're ready to start on solids and then what can we do to help families do this appropriately at home.

Lauren: 10:20

So I really want families to go based on the infant's readiness cues for eating, so they should be starting to sit with minimal support. We want them to be starting to show an interest in food, so what mom, dad, brother, sister are eating. We also want to start seeing them bringing their hands and toys to their mouth and just having that skill of bringing their hands up to mouth and midline. That's often in a premature infant, especially your very premature infants. It's going to be closer to their corrected age. So I would really really urge pediatricians not to recommend that at their actual age and if they are making sure that they are showing those readiness cues, just so that they're setting the infant up for success and to be as safe as possible as they introduce those solids.

Colleen: 11:10

Yeah, that's an excellent piece of advice, because we have to be correcting those ages to make sure that they're meeting the appropriate milestones for safety. And so what are some challenges that premature infants face that might be unique to them when it comes to starting solid foods?

Lauren: 11:25

One of the biggest things is they've had a lot happen to them in their little life, more than most people have done to them medically in their whole lifetime. A lot of things that are in their face. Many have had to be intubated and they can have oral aversions so they may not know what to do with that texture. They may have a stronger gag reflex they tend to be an extension and they may not be able to bring their hands up to their mouth as easily to do more self-feeding. So it may need to be more caregiver led, still following the infant's cues to be wanting and willing, but that can be another big challenge. So definitely, I mean every infant's different, but feeding a preemie definitely is not straightforward.

Colleen: 12:07

Now, do preemies follow the same guidelines as typical term infants would when it comes to starting complementary foods? That's kind of mixed.

Lauren: 12:18

So in general, especially if you would start on the earlier side, maybe in that four months, the recommendations that I've seen published in the neonatal guidelines is to start with purees with them and then, closer to that, six months, maybe starting on the soft table foods. When I've had other people really swear by doing like that more of the baby led weaning approach, I personally with my daughter had to do kind of a combination of purees and some of the baby led weaning, doing like those long strips of food to let herself feed. So that's a tricky thing is there isn't specific guidelines, so that's what we do for preemies.

Colleen: 12:56

So we've walked through post-discharge. We've walked through kind of the first six months or so. Now I'm curious because I love ending each segment with hearing from the expert on what are some of the worst preemie nutrition pieces of advice that you've heard, or maybe that you've received, that we, as clinicians, should absolutely avoid giving to our families.

Lauren: 13:15

So some of the worst advice is by going based on their actual age and really not showing readiness cues to start eating solid foods. So I love my pediatrician she's fantastic but she recommended I start solids when my daughter was six months old three months corrected and she could not sit up to touch them on just a little bit more. We want them to be ready because then you not recognize that they're getting full. So they may eat more than what they should initially and that may look great, but then you're displacing nutrition from that breast milk and formula which really should be the nutrition until they're 12 months corrected. So starting to early has that risk. Then you have the risk if they're not able to swallow it properly, they could aspirate, which could then obviously lead to pneumonia or something serious. So we want to make sure that they can safely swallow. So that is probably my number one.

Lauren: 14:03

So the second thing that I do not care for anymore that's outdated advice is to introduce one food at a time.

Lauren: 14:08

So unless it is one of the common allergens, you can introduce multiple foods at a time and that actually does allow you to introduce many more foods, and especially in that timeframe where you want their palate to be exposed to as many foods as possible. The last thing that I would say is to lean too quickly and that's as great as I think baby lead weaning is. I think the name was confusing because you're not, in that first year, really weaning, you are building skills and over time they're solid. Intake from that six months corrected to 12 months should improve and increase as their skill does. The amount of breast milk and formula that they're taking should stay about the same. It may increase in volume and then they may decrease the amount of times that they feed, but that still needs to stay the main source of their nutrition until they're about that 12 months corrected. So we don't want to wean off of those things until that timeframe to make sure that they're getting the most nutrition as possible.

Colleen: 15:02

That's a great point. I love those final tips because if you're not staying up to date on the nutrition guidelines, some of this stuff that we are hearing is outdated and it can be harmful and dangerous to the premature babies. This conversation has been so helpful and I know my pediatricians, neonatologists or even you fellow preemie mamas out there are gonna find it super, super helpful. If you would like to gain more information on feeding a premature baby, I would absolutely recommend that you follow Lauren on Instagram. You can find her at preemie nutrition mama. So if you have any questions for me, I would love to hear from you. You can find me on Instagram at exam room nutrition and we would love to have you back. Lauren, thank you so much for giving me the gift of your time. I can't give this time back to you. I know you're super busy with your own baby at home, so thank you again for being with us.

Lauren: 15:48

Thank you so much. I really enjoyed being able to talk to you and share my passion for nutrition for premature infants.

Colleen: 15:55

All right, guys. Now it's time for my nutrition notes. In this section. I leave you with a nutrition tip, an encouraging quote or an interesting case that I think might add value to your day.

Colleen: 16:05

So I wanted to clarify something just in case you forgot exactly what corrected age or justed age means and how you can figure that out, because we referenced to that a lot in our discussion with Lauren, and I wanted to make sure that you understand what exactly that means and why it's important. So chronological age is the number of days, weeks, months or years from the date of the infant's delivery. Some facilities might actually refer to this as actual age, because it is basically the child's birthday or the date on which that they were born. Corrected age, which is sometimes called adjusted age, will account for the infant's prematurity. It's going to help provide a better understanding of how to interact with the infant and what the expectations are for the developmental milestones. So how do we actually calculate for corrected age for premies? It's actually quite easy. All you need to do is take their chronological age, so the actual age that they are, and subtract it by their weeks of prematurity, and that gives you the adjusted age. So, for example, suppose a six month old infant was born at gestational age of 32 weeks. So that means the child was born eight weeks before the term date of 40 weeks. So remember, full term is 40 weeks. So if they were born at 32 weeks, 40 minus 32 is eight weeks. So that is how premature that infant was. So although that child that you're looking at is six months, chronologically you would actually need to adjust their age. So subtract six months their actual age by two months, which is eight weeks, because they were eight weeks premature. So six months minus two months, they would be four months adjusted age. So why is this important. It's really important to understand this because that six month old infant who was born two months premature is not going to be at the same developmental readiness, especially for feeding, as if it were a full term infant. That infant who was born two months premature is actually at the developmental stages and should be meeting the milestones of a four month old. So they might not be holding their head up steady, they might not have those oral motor functions and skills that we've discussed and that we expect to see in order to prove that they are ready for those solid foods. So it's really, really important that you get this adjusted age and make sure that you are providing appropriate education based on their adjusted age, not their chronological age. That six month old baby, who is actually four months old, might not be ready for solid foods yet. If you need a refresher or a reminder what those developmental stages of readiness are, go ahead and check out a previous podcast that we did called Babies First Foods Best Practices for Starting Solids and we go into those signs to look for in detail. One final thought regarding adjusted age is how long you need to adjust the infant's age for, and most experts recommend adjusting it until around age two years old. Now this can vary depending on your infants. Some babies who are premature by two months might be meeting their chronological age milestones, and that's perfectly fine. So it's really important that you do a very thorough physical exam and ask your parent really good questions.

Colleen: 19:21

I hope you found this episode valuable. I really want you to walk away with at least one thing that you learned here and that you think you know what. I'm going to start doing that, or I'm going to start saying that, and if you have a friend or a colleague who struggles with finding the words to say around nutrition or weight. Could you share this episode with them? Grab the link and shoot them a text? I'd love for them to listen as well. My goal is to help as many clinicians as possible realize that nutrition matters and it is possible to educate our patients toward a healthy lifestyle despite all the barriers we face. Thanks again so much for being here and choosing to listen to my podcast. I'd love to connect from you and hear from you, so find me on Instagram at exam room nutrition. And, as always, guys, let's continue to make our patients healthier, one exam room at a time. I'll see you next time.