Post-Discharge Nutrition: Is 30 The New 20?
Jae Kim, MD, PhD / March 2018
There is a saying about age today – “50 is the new 30.” Having crossed this threshold a few years back, I’ve spent a bit of time contemplating this.
Yes, there is increased awareness about better nutrition, exercise, and well-being largely due to copious resources on the Internet.
People no longer dress their age anymore, so from behind you often can’t tell a person’s generation based on their style or even physical movements. Anti-aging beauty products are amassing at record rates, including for men. Sophisticated surgical and non-surgical enhancements continue to get better.
However, a few things prevent me from believing this new dictum, and I am not buying it.
First, I really don’t feel thirty. I no longer sleep like I’m thirty, and I don’t recover after strenuous exercise like I’m thirty. This could partly result from being so sleep deprived as a trainee at age thirty that I could sleep standing up. I could also be drinking a bit more coffee for cognitive support. Ibuprofen at times becomes a daily vitamin. The one good thing is that I don’t make the same stupid mistakes that I did at thirty.
In neonatology, I see another period that is wanting a better definition. That is the area of post-discharge nutrition.
Many of our preterm infants get to their time of discharge and look awfully close to what a healthy term infant looks like. Often our inclination is to consider it fine, to launch them onto a nutrition pathway similar to the term infant.
I see quite a few NICUs that discharge preterm graduates home on unsupplemented mother’s milk or term formula. In either of these approaches, infants then are going home on approximately 20 kcal/oz-based feeding or less. Since the caloric density of mother’s milk varies considerably, some infants may be feeding on much less than 20 kcal/oz.
As we promote more and more infants to feed on mother’s milk, the potential to increase their nutritional risk looms. Besides those infants being sent home on unsupplemented breast milk, many are being taken off of supplementation by their primary doctors shortly after discharge due to the complexity of our current strategies, or for convenience.
Nutrition and supplementation data
Post-discharge nutrition is one of the most important deficiencies we have in neonatology, as we have not generated enough data in order to help us clearly define the benefits and harm in this area.
In particular, we lack data on supplementation of mother’s milk feeding. Due to the paucity of data in this area, many different supplementation or fortification options have been used to add supplementation to mother’s milk.
Many of our infants have partial or no mother’s milk available, and for those, post-discharge formula (PDF) at 22 kcal/oz is available. These formulas were specifically designed to provide the nutrient requirements for the graduating preemie when taken as a sole feeding.
Some of our strategies have tried to borrow these post-discharge formulas for mother’s milk supplementation. We add a bit of powdered formula to mother’s milk, or ask that infants drink a few bottles per day. As you can imagine, using fractional feeding with these full formulas is a weak strategy. They will provide a small and numerically limited boost in calories, protein, minerals and vitamins that most infants could compensate by taking in more volume. The evidence for these mild supplementation approaches as beneficial is weak.
Better preterm nutrition for the very low birth weight infant in the hospital started when we recognized that their growth rates were 50-100% greater than that of the term infant. These growth rates made it impossible to achieve the goal of matching in utero growth with plain mother’s milk.
Current fortifiers now provide 20% or more protein than our previous strategies in the past, and are getting us closer to the lofty in utero goals. We now graduate preemies many weeks before their official due date, leaving them still in a nutrition crisis with needs for more protein, minerals, and vitamins.
The post-discharge period appears to be a large, risky cliff that infants fall off of, because we don’t have sufficient data, and there are many challenges to maintaining supplemented nutrition or nutrient enrichment compared to a term infant. Going home on 20 kcal/oz, mother’s milk or term formula may not be the best practice when faced with a large swath of nutritional risks for this group of infants.
What is the best strategy in the meantime while we wait for more clinical data? I continue to believe the mantra that in the absence of enough evidence, standardize your practice!
Practically, there are more chances that infants graduating have incurred a nutritional deficit than not before heading home, and need to be able to catch up on these deficits. Feeding them ad libitum on 20 kcal/oz or less feeding will force many of them to increase their volumes to try and make up the difference – but this can be difficult to achieve for infants with feeding issues such as gastroesophageal reflux or respiratory concerns that may limit fluid intake.
More than likely a standardized strategy that assumes that most infants could benefit from some initial nutrient support seems to make sense. One could also start a strategy with the most vulnerable such as those that are growth restricted either at birth or after birth or who have clearly developed nutrient deficits in the hospital as the target of benefit from a nutrient supplementation approach. The key here though is simply to have an approach.
Is 30 the new 20?
Several years ago we sought out a simpler post-discharge strategy that could assist in nutrient supplementation, be easy for mothers, and promote ultimate full breastfeeding, the holy grail of preterm nutrition that most of us are still struggling with in attaining for our babies. We realized that there were a number of liquid 30 kcal/oz preterm formulas that were designed for in-hospital use for preterm infants.
We found that these formulas could be conveniently converted into mother’s milk supplementation for home, especially since they were meant as direct feedings and therefore did not have high osmolality. They offer a far better boost in mineral and nutrient support than the post-discharge formula options many use these days.
The use of a liquid formula also provides an improved convenience for mothers. The most surprising advantage was that since this 30 kcal/oz supplement could be given as a direct feeding from the bottle (or mixed in with bottled mother’s milk), mothers can continue to practice breastfeeding with less impediment! Providing anywhere from 90–120 mL of 30 kcal/oz formula a day achieves a generous boost in calories, protein, minerals, and vitamins.
Having a commercial formula strategy that actually promotes breastfeeding is quite unique. Our approach has been to sustain this supplementation for at least 12 weeks post-discharge and longer for those with higher risk, such as those that have been growth impaired or with chronic lung disease. Flipping an existing formula product to more adequately cover the nutrient gap our preterm graduates experience while not adding too much to the stress of our mothers may be worthy of consideration.
If your unit has an inconsistent post-discharge nutrition practice, and is supplementing at low levels, or not at all like many places, you might want to consider standardizing your post-discharge nutrition approach.
And don’t forget to consider that “30 may be the new 20″!
About the Author
Jae Kim is an academic neonatologist and pediatric gastroenterologist and nutritionist at UC San Diego Medical Center and Rady Children’s Hospital of San Diego. He has been practicing medicine for over 23 years both in Canada and the USA. He has published numerous journal articles, book chapters, and speaks nationally on a variety of neonatal topics. He is the Director for the Neonatal-Perinatal Medicine Fellowship Program at UC San Diego and the Nutrition Director of an innovative multidisciplinary program to advance premature infant nutrition called SPIN (Supporting Premature Infant Nutrition, spinprogram.ucsd.edu). He is the co-author of the book, Best Medicine: Human Milk in the NICU. Dr. Kim is a clinical consultant with Medela LLC.