DR.dr. RINAWATI ROHSISWATMO, SP.

A(K)
INTRA UTERINE GROWTH INTHE LAST
TRIMESTER
Brain Body
BW Weight calcium

375 g 28000 mg
3500 g

BL
50 cm
800 g 75 g 5600 mg
30 cm

Gestational age (weeks) (Klein CJ. J Nutr 2002)

 The highest ratio of weight gain in fetus are at week
26 to 36

Optimal growth for the premature is the growth curve intra

uterine, this requires the nutrients to be digestable and
absorbable.

6th World Congress Perinatal Medicine In Developing Countries, Jakarta, March 9th, 2010
Extrauterine growth restriction in preterm infants:
importance of optimizing nutrition in neonatal
intensive care units
EUGR in preterm infants secondary to suboptimal
nutrition is a major problem in neonatal intensive
care units.
The parenteral route of feeding is essential to
maintain nutritional integrity before successful
transition to the enteral route of feeding is achieved.
Nevertheless, early initiation of enteral feeding in
sub-nutritional trophic quantity is vital for promoting
gut motility and bile secretion, inducing lactase
activity, and reducing sepsis and cholestatic
jaundice.

Croat Med J. 2005 Oct;46(5):737-43.

EXTRA UTERINE GROWTH
RESTRICTION (EUGR)

Growth value 10th percentile of

intrauterine growth expectation based on
postmenstrual age at the time of discharge
to home.
EUGR is associated with adverse
outcomes including chronic lung disease,
increased risk to infection and abnormal
neurodevelopmental outcome.
Pediatrics 2003;111;986
Early or Aggressive Parenteral Nutrition

Aggressive nutrition, defined by studies is the use of

high nutrient dosages, starting in the first hours of life
The use of aggressive PN produces a more rapid
growth and the curves are a reflection of changes in
hospital nutritional management
Early and aggressive nutritional intervention could
improve the growth of VLBW infants at 40 weeks of
postmenstrual age.

Almudena Ribed Snchez, Rosa MRomero Jimnez. Aggressive parenteral nutrition and growth velocity in
preterm infants. 2013
 THE FIRST GOLDEN HOUR
Axilla temperature 36,5C 37,5C
Blood Glucose 50 mg/dl 110 mg/dl
Dekstrose and Amino Acid should have been
given at least in 1 hour

Val Castrodale, MSN, RN, NNP-BC; Shannon Rinehart, RNC-NIC, BSN. The Golden Hour, improving the stabilization of the very low birth-
weight infant. The natinal association of neonatal nurses. 2014.F9-14
The goal of Early Parenteral
Nutrition (EPN)

To provide an intravenous substrate that promotes

protein deposition and increased lean body mass
that approximates fetal growth rate and accretion.

Amitha R . Aroor et al. Early versus Late Parenteral Nutrition in Very Low Birthweight
Neonates. SQU Med J, February 2012, Vol. 12.
Late or Convensional Parenteral
Nutrition (LPN)

LPN babies were started on intravenous dextrose soon

after birth.
Other nutritions started after day 2 of life
All infants in the LPN group had a negative nitrogen
balance during the first 48 hours of life, while those in the
EPN group had a positive balance throughout the
seven- day study period.

Amitha R . Aroor et al. Early versus Late Parenteral Nutrition in Very Low Birthweight Neonates. SQU Med J, February 2012, Vol. 12
Early amino acid

AA administration 2.4 g/kg/day within 2 hours after birth

better outcome compared with slow stepping-up daily
amino acid administration
Te Braake FWJ, et al. J Pediatr 2005;147:457-61.
Poindexter BB. J Pediatr 2005;147:420-1.

Long term study of ELBW with mean birth weight 800 g &
GA 26 wk; given early amino acid infusion showed
significant growth in 36 weeks postmenstrual age.

Poindexter BB, et al. J Pediatr 2006;148:300-5.

10
REGIMEN DAILY TPN IN CIPTO
MANGUNKUSUMO HOSPITAL
Birth Weight <750 g
1 g = 30 ml

Volume PG Lipid GIR N:NPC Dex %

Tipe ml/kg g/kg/day ml/kg/day g/kg/day ml/kg/day

Day 0 PG1 100 2,5 75 1 5 7.1 1:125 11%

Day 1 PG1 110 3 90 2 10 7.5 1:128 11%
Day 2 PG1 115 3 90 3 15 7.5 1:139 11%
Day 3 PG1/PG2 120 3,5 105 3 15 8 1:139 11%
Day 4 PG 2 130 3,5 105 3 15 8.7 1:138 11%
Day 5 PG 2 150 4 120 3 15 10 1:130 11%

Kebutuhan cairan harus memperhatikan kadar natrium dan gula darah serum
Jika GDS > 250 mg/dl pertimbangkan pemberian insulin
Jika GDS 150 250 mg/dl turunkan GIR
 REGIMEN DAILY TPN IN CIPTO
MANGUNKUSUMO HOSPITAL
Birth Weight : 750 1800 g
1 g = 30 ml

Volume PG Lipid GIR N:NPC Dex%

Tipe ml/kg g/kg/day ml/kg/day g/kg/day ml/kg/day

Day 0 PG1
80 2,5 75 1 5 5.7 1:105 11%

Day 1 PG1
90 2,5 75 2 10 6 1:132 11%

Day 2 PG1
105 3 90 3 15 7.1 1:143 11%

Day 3 PG1/PG2
120 3,5 105 3 15 8 1:153 11%

Day 4 PG 2
130 3,5 105 3 15 8.7 1:161 11%

Day 5 PG 2
150 4 120 3 15 10 1:143 11%
 REGIMEN DAILY TPN IN CIPTO
MANGUNKUSUMO HOSPITAL
Birth Weight : 1801 2500 g
1 g = 30 ml

Volume PG Lipid GIR N:NPC Dex%

Tipe ml/kg g/kg/day ml/kg/day g/kg/day ml/kg/day

Day 0 PG1 60 1.5 0 1 0 4 0 10%

Day 1 PG1 80 2 60 2 10 5.3 1:151 11%

Day 2 PG1 80 2 60 2 10 5.3 1:151 11%

Day 3 PG1/PG2 100 3 90 2 10 6.8 1:100 11%

Day 4 PG 2 120 3,5 105 3 15 8 1:130 11%

Day 5 PG 2 150 3,5 105 3 15 10 1:153 11%

REGIMEN DAILY TPN IN CIPTO
MANGUNKUSUMO HOSPITAL
Birth Weight : > 2500 g
1 g = 30 ml
Volume PG Lipid GIR N:NPC Dex%
Tipe ml/kg g/kg/day ml/kg/day g/kg/day ml/kg/day

Day 0 PG1 60 0 0 0 0 4 0 10%

Day 1 PG1 80 0 0 0 0 5-6 0 10%

Day 2 PG1 80 2 60 2 10 5.3 1:151 11%

Day 3 PG1/PG2 100 3 90 2 10 6.8 1:120 11%

Day 4 PG 2 120 3 90 3 15 8 1:124 11%

Day 5 PG 2 150 3 90 3 15 10 1:152 11%

 Nama zat PG1 PG2
1 g = 30 ml 1 g = 30 ml

Asam Amino 6% 17 17

Dextrosa 40% 11.2 8.5

KCl 0.3 0.3

Ca Glukonas 10% 1.2 1.2

MgS04 40% 0.3 0.3

NS 3% 0 2.7

Fosfat 1-2,3 mmol/kg/hari 60-90 mgh/kg/hari

Amino Start amino acids within 1-2 hours of
birth with 1.5-3 g/kg/day & increase by 1
Acids g/kg daily to max 4.0 g/kg/day

Start lipids within 24 hrs of birth at 1.0

Lipid g/kg/day & increase by 0.5-1 g/kg daily to
max 3.0 g/kg/day

Initiate GIR 4mg/kg/min & increased

Glucose daily by 1-2 mg/kg/min

Dont stop TPN until enteral feeds are

TPN >90% of requirements
 FEEDING PROTOCOL IN PRETERM

Consensus between Neonatal working group

and Nutrition metabolic working group
Indonesian Pediatric Society regarding
nutrition support for preterm infants.
 Panduan pemberian minum
pada bayi prematur di RSCM
<28 minggu >32 <37 minggu
28 32 minggu ATAU 1000-1500
Usia ATAU < 1000 g ATAU risiko g ATAU risiko sedang ATAU1500-2500 g ATAU risiko
tinggi rendah

Segera setelah lahir STABILISASI STABILISASI STABILISASI

Nutrisi enteral dimulai dalam 24 Nutrisi enteral dimulai segera

jam pertama (hari 0) setelah lahir, 30-60
Hari 0 (0-24 jam) NPO
Berikan ASI 10-20 ml/kg/hari, ml/kg/hari, dibagi dalam 8
dibagi 8-12 kali pemberiana kali pemberian

Trophic feeding dimulai setelah 24 jam (hari 1).

Trophic feeding 10 ml/kg/hari dibagi dalam 4-12
Hari 1 (24-48 jam) kali pemberian, dianjurkan volume kecil 10-15 ml/kg setiap 12 jam, dibagi
frekuensi sering, minimal pemberian per kali dalam 8-12 kali pemberian
adalah 0,5 ml. Trophic feeding harus berupa ASI
segar b,c TARGET FULL FEED
DICAPAI PADA HARI
KE-1

Hari selanjutnya Dinaikkan 10 ml/kg setiap 12 jam, dibagi dalam 8-

12 kali pemberian
Dinaikkan bertahap sampai mencapai
target 150-180 ml/kg/hari.
Target TARGET FULL FEED DICAPAI
Dinaikkan bertahap sampai mencapai Target volume PALING LAMA DALAM 2
150-180 ml/kg/hari untuk kejar tumbuh. MINGGU
TARGET FULL FEED DICAPAI PALING
LAMA DALAM 2 MINGGU
Panduan praktis pemberian minum
pada bayi prematur di RSCM
When to use preterm formula
Breastmilk+ HMF not enough
Weight length and HC less than 25 IHDP Chart

When to use post discharge formula

Weight 1800/2000 gram. Weight, length and HC >
p.25 IHDP chart

When to use standard formula

Z- score -2 s/d + 2 weight for age WHO chart
Z- score -2 s/d + 2 weight for length WHO chart
FENTON CHART
 Usia BB PB (cm)
(gram)
Lahir 3500 50
1 bulan 4700 53
2 bulan 5600 56
3 bulan 6300 59
4 bulan 6800 62

Usia BB PB (cm)
(gram)
Lahir 3500 50
1 bulan 4700 53
2 bulan 5600 56
3 bulan 6300 59
4 bulan 6800 62
TERIMA KASIH