Feeding low birth weight babies:

Update on WHO guidelines

Bernadette Daelmans,

Coordinator Policy, Planning and Programmes

Department of Maternal, Newborn, Child and Adolescent Health (MCA)

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Outline
Definition of LBW and effective interventions Principles and process of guideline development Illustration of process with one example: choice of mother's milk versus formula Summary of recommendations:
Choice of milk Supplements When and how to feed Frequency and progression of feeds

Overview of other newborn guidelines

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Definitions
Low Birth Weight infant: infant with birth weight < 2500 gram regardless of gestational age.
Preterm infant: infant born before 37 weeks of gestational age. Small for Gestational Age (SGA) infant: birth weight below the 10th percentile for gestational age, usually a result of IUGR. Preterm and SGA infant

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Major causes of death in children under 5 (2010)

35% of global under-five deaths are associated with undernutrition*

LBW directly or indirectly contribute to 60 80 % of all newborn deaths

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Burden and distribution (2006)

Global prevalence of LBW: 15.5%, e.g., about 20.6 million LBW babies born each year South-Central Asia: 27.1% Asia (other): 5.9% 15.4% Africa: 14.3% LAC: 10% Oceania: 10.5% North America: 7.7% Europe: 6.4%

Source: Optimal feeding of LBW infants: technical review (2006)

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Improved care of LBW infants

Improved childbirth care Antenatal maternal steroids Attention of early warming, drying and resuscitation Extra care at home Appropriate feeding, including additional support for breastfeeding, expressed breast-milk feeding Keeping the infant warm, including skin-to-skin care Early recognition and care-seeking for infections Facility based care for very small infants Appropriate feeding, including I/G expressed BM feeding Thermal care, including Kangaroo mother care Oxygen and continuous positive airway pressure
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Developmental readiness
32 36 weeks: Infants should be able to attach, suck and extend tongue appropriately and begin breastfeeding 35 37 weeks: Full breastfeeding maturation between 35 37 weeks

Demand feeding may be possible for some infants between 32 36 weeks

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Guidelines development: principles

Systematically developed, based on all available evidence Clear, unambiguous recommendations, but stating the quality of evidence on which they are based

Strength of recommendation based on the balance of benefits and risks, values and preferences, and costs
Should take into account the range of circumstances in which they will be used
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Guidelines development: principles

Systematically developed, based on all available evidence Clear, unambiguous recommendations, but stating the quality of evidence on which they are based

Strength of recommendation based on the balance of benefits and risks, values and preferences, and costs
Should take into account the range of circumstances in which they will be used
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Process of guideline development

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1. Establishing WHO Steering Group and 2. Scoping the guidelines: independent Guidelines key questions and critical Development Group 3. Systematic reviews and outcomes synthesis ofquality evidence 4. Grading of evidence using GRADE 5. Formulation of recommendations by GDG: 6. Peer-review and Benefits, Harms, 7. finalization Field testing, values and preferences, implementation and costs

Examples of PICO questions

What should Low Birth Weight Babies be fed?

In LBW infants (P), what is the effect of feeding mother's own milk (I) compared with feeding infant formula (C) on critical outcomes mortality, severe morbidity, neurodevelopment and anthropometric status (O)? In LBW infants who cannot be fed mother's own milk (P), what is the effect of feeding donor human milk (I) compared with feeding infant formula (C) on critical outcomes (O)?

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GRADE tables: mother's milk vs. formula

OUTCOME (No. of studies) Mortality (4 studies) Design Limitations in methods No serious limitations (0) No serious limitations (0) Limitations in outcome measurement (-0.5) Limitations in analysis (-0.5) Precision Consistency Directness Pooled effect size (95% CI) Overall quality OR 0.82 (0.72 to 0.93) LOW OR 0.40 (0.31 to 0.52) MODERATE Mean difference 5.2 points (3.6, 6.8) LOW MD in SD score: Weight: -0.27 (-0.59, 0.05) Length: -0.47 (-0.79, -0.15) VERY LOW

Obs. studies (-1.0)

Some imprecision (-0.5) No imprecision (0) No imprecision (0) Some imprecision (-0.5)

No serious inconsistency (0) No inconsistency (0) No serious inconsistency (0) Single study

Most evidence from developed countries (-0.5) Most evidence from developed countries (-0.5) Most evidence from developed countries (-0.5) Study from developed country setting (-0.5)

Severe infection or NEC (8 studies) Neurodevelopment (6 studies)

Most of the studies obs. (-1.0) All observational studies (-1.0) All observational studies (-1.0)

Anthropometri c status (1 study)

(-1.0)

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Evidence to recommendations: mother's milk vs. formula

Important benefits:
mortality (18% reduction) LOW QUALITY severe infections or necrotizing enterocolitis (60% reduction) MODERATE mental development scores (5.2 points higher) LOW QUALITY

Harms
lower length at 9 months (0.47 cm lower) VERY LOW QUALITY

Policy makers, health care providers and parents in developing country settings are likely to give a high value to the benefits Observed benefits are clearly worth the costs.
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Recommendation

Low birth weight infants, including those with very low birth weight, should be fed mothers own milk Strong recommendation Based on moderate quality evidence of reduced severe morbidity and low quality evidence of reduced mortality and improved neurodevelopment

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Summary of recommendations

LBW and VLBW infants should be fed mother's own breastmilk. If the mother is not able to breastfeed, donor milk should be given LBW should be put to the breast as soon as clinically stable after birth LBW should be exclusively breastfed on demand for 6 months Daily oral Vitamin A or routine zinc supplementation is not recommended for LBW infants who are breast-milk fed

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Summary of recommendations
LBW and VLBW who cannot be given breast milk should be fed standard infant formula

LBW infants who can not be breastfed, but can swallow should be fed by cup and spoon (or cup with beak), based on hunger cues, but at least every 3 hours

If breastmilk feeding is not possible after discharge, the infant should continue to receive infant formula until 6 months of age

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Special considerations for VLBW

A VLBW infant who is breast-milk fed should be given the following supplements:
a) b) c) d) Vitamin D (400 i.u. 1000 i.u. per day) until 6 months of age Calcium (120 140 mg/kg/day) for the first months of life Phosphorus (60 90 mg/kg/day) for the first months of life Iron (2 -4 mg/kg/day) from 2 weeks to 6 months of age

A VLBW infant who fails to gain weight despite adequate breast milk feeding should be given human-milk fortifiers, preferably human-based milk If a VLBW infant fed standard formula fails to gain weight, preterm formula should be given.
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Special considerations for VLBW

VLBW infants should be fed 10ml/kg/d of enteral feeds, of preferably expressed breast milk, from the first day of life, with remaining fluid needs met by intravenous fluids If a VLBW infants needs to be given intragastric tube feeding, this should be given as intermittent bolus feeds, by either oral or nasal feeding If a VLBW infant is fed by intragastric tube, feed volumes can be increased by up to 30ml/kg/d with careful monitoring for feed intolerance

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List of recommendations: Choice of milk

1. Low birth weight (LBW) infants, including those with very low birth weight, should be fed mothers own milk
2. LBW infants, including those with very low birth weight, who cannot be fed mother's own milk should be fed donor human milk (recommendation relevant for settings where safe and affordable milk banking facilities are available or can be set-up) 3. LBW infants, including those with very low birth weight, who cannot be fed mother's own milk or donor human milk should be fed standard infant formula (recommendation relevant for resource-limited settings). VLBW infants who cannot be fed mother's own milk or donor human milk should be given preterm infant formula if they fail to gain weight despite adequate feeding with standard infant formula. 4. LBW infants, including those with very low birth weight, who cannot be fed mother's own milk should be fed standard infant formula from the time of discharge until 6 months of age (recommendation relevant for resource-limited settings).
* *

Strong
Strong situational

Weak situational

Weak situational

5. Very Low Birth Weight (VLBW) infants who are fed mothers own milk or donor human milk should not be routinely given bovine-milk based human milk fortifier. VLBW infants who fail to gain weight despite adequate breast milk feeding should be given human milk fortifiers, preferably those that are human-milk based.

Weak situational

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List of recommendations: Supplements

6.** VLBW infants should be given vitamin D supplements at a dose ranging from 400 i.u to 1000 i.u. per day until 6 months of age 7.** VLBW infants who are fed mothers own milk or donor human milk should be given daily calcium (120-140 mg/kg/day) and phosphorus (60-90 mg/kg/day) supplementation during the first months of life Weak Weak

8.** VLBW infants fed mothers own milk or donor human milk should be given 24 mg/kg/day iron supplementation starting at 2 weeks until 6 months of age

Weak

9.

Daily oral vitamin A supplementation for LBW infants who are fed mother's own milk is not recommended at the present time because there is not enough evidence of benefits to support such a recommendation.

Weak

10. Routine zinc supplementation for LBW infants who are fed mother's own milk is not recommended at the present time because there is not enough evidence of benefits to support such a recommendation.

Weak

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List of recommendations: when and how to feed

11. 12.*
*

LBW infants who are able to breastfeed should be put to the breast as soon as possible after birth when they are clinically stable. VLBW infants should be given 10ml/kg/day of enteral feeds, preferably expressed breast milk, starting from the first day of life, with the remaining fluid requirement met by intravenous fluids (recommendation relevant for resource-limited settings). LBW infants should be exclusively breastfed until 6 months of age

Strong Weak situational

13.

Strong

14.

LBW infants who need to be fed by an alternative oral feeding Strong method should be fed by cup (or palladai which is a cup with a beak) situational or spoon. VLBW infants requiring intragastric tube feeding should be given bolus intermittent feeds In VLBW infants who need to be given intragastric tube feeding, the intragastric tube may be placed either by oral or nasal route, depending upon the preferences of health care providers Weak Weak

15.*
*

16.*
*

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List of recommendations: frequency and progression of feeds

17.

LBW infants who are fully or mostly fed by an alternative oral feeding method should be fed based on infants hunger cues, except when the infant remains asleep beyond 3 hours of the last feed (recommendation relevant to settings with adequate number of health care providers)

Weak situational

18.** In VLBW infants who need to be fed by an alternative oral feeding method or given intragastric tube feeds, feed volumes can be increased by up to 30 ml/kg/day with careful monitoring for feed intolerance

Weak

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Implications for programmes

Policies: update national policies, clinical care standards. Make linkages
with other policies such as on KMC

Health worker skills and competencies: update training materials and

design ways for on-going education

Commodities: weighing scales, equipment to support milk expression,

cups and spoons, supplies for intragastric and intravenous feeding, standard and preterm formula, micronutrient supplements, milk banking facilities

Community awareness Service delivery: agree on indicators and monitor quality

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Guidelines updated 2010 - 2013

Care of the newborn immediately after birth Newborn resuscitation Newborn immunization Postnatal care Care of the preterm and low birth weight baby Management of neonatal sepsis Management of neonatal seizures Management of neonatal jaundice Management of necrotizing enterocolitis Care of the HIV-exposed newborn
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Thank you

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WHO: Optimal feeding of