Excessive weight gain

[Schumz]

Hi Guys 

Is there anything called excessive weight gain in a premature (25+5 weeker) infant who is now 54 days old. Having gone through longterm MV, difficulties in getting extubated, use of steroids etc she is stable on CPAP currently and gaining weight 60-90 grams/day, at 180mls/kg/day of EBM and full strength fortifier. Her growth on chart going like mount everest...Bloods are normal...Creatinine is normal, urea is 8.9 which has crept up a bit. She is auto warning on her diuretics (0.8mg/kg) because of weight gain. Since she is gaining weight so fast, she appears oedematous to some nurses sometimes... but obviously she is not, its just fat as linear growth is yet to happen. 

My question actually is.... is there ever a logic in cutting back their feeds because there is too much weight gain? Having worked in different set ups I have seen clinicians cutting back on milk feeds from 200mls/kg/day to 180 or from 180 to 165 because the baby is gaining lots of weight. 

[rehman_naveed]

Hi Schumz 

i would suggest cut down the feed volume at which infant gain weight around 20-30g/kg/day, you can even cut down TFI to 130ml/kg/day but you need to titrate it gradually. First cut fluids to 150ml/kg/day and then 130

Any added fortifier needs also to be reduced. 

Keep this in mind that chubby babies are not healthy. 

Also diuretics have no evidence in BPD, so I would also discontinue them

thanks

naveed

[Stefan Johansson]

@Schumz great discussion topic!

We titrate nutrients with a computer program (https://www.nutrium.se/) and make individual fortification and breast milk analyses (regardless if donated or mother's own expressed BM), to see how many calories, protein, fat (well, fat energy %), and other nutrients are given per kg.

We aim for every infant to regain its "potential" weight (for example, most ex-ELBW infants start off with a growth failure), so when the anabolism kicks off post-level3-care, some of us get a bad feeling that the baby is growing "like crazy". When the baby really just comes back to its own growth potential.

However, we take some precautions. In practical terms, we reduce fortification if there is accelerated growth, but do not reduce volumes usually. But, nature also helps most of those infants practise breast feeding (or bottle feeding for that sake), with succesive reductions in tube feeds.

So, my brief suggestion in this case would be: continue with 180 ml/kg/d, calculate the nutritional intake and take it from there. If there is too much calories, reduce fat before protein fortification. Don't worry about diuretics and some periph edema, as you know that is mostly a matter of cosmetics (and will go away by itself).

(But, since there are as many opinions around feeding as with PDA therapy - I believe there are several other ways to handle this ) 

[Schumz]

Many thanks Naveed and Stefan... I definitely agree there are several different scopes of thought when handling nutrition. After prolonged periods of slow growth, when these premiees start to grow rapidly it feels a bit uncomfortable, whether to let them grow or do something about it. I also agree about "the role (no role)" of diuretics in  BPD and discontinuing its use when its of no benefit but in other complicated scenarios this may be a point of discussion. 

What I did, while I awaited a response... I calculated her total volume for the most recent weight which came to be=165mls/kg/day while being on volume of 180mls/kg/day and I didn't optimise it according to her recent weight and left her on that volume (165mls/kg/day). She gained another 40g next day with this change. Diuretics have been stopped. 

I tried to run this program Stefan but it didn't seem to work ...may be doesn't like Mac!! Will try at work. It might be something we could use in our unit.

[Stefan Johansson]

@Schumz The Nutrium-progr cannot run unless you have a license (checked by IP-nb, and I think it won't work on Macs, we run it on Windows at work). But I guess there are similar programs (maybe also as freeware?). If the infant has good growth with 165 ml/kg/d, I'd stick to that. Can you get a nb of calories and nutrients /kg/d?

For the program - email prof magnus.domellof@umu.se and ask - he's the man behind Nutrium.

[Schumz]

22 hours ago, Stefan Johansson said:

@Schumz The Nutrium-progr cannot run unless you have a license (checked by IP-nb, and I think it won't work on Macs, we run it on Windows at work). But I guess there are similar programs (maybe also as freeware?). If the infant has good growth with 165 ml/kg/d, I'd stick to that. Can you get a nb of calories and nutrients /kg/d?

For the program - email prof magnus.domellof@umu.se and ask - he's the man behind Nutrium.

Great thanks for that... Ill email and find out more