Preterm bebeğin enteral beslenmesine güncel yaklaşım

Preterm doğum gelişmiş ülkelerde perinatal morbidite ve mortalitenin önde gelen nedenidir. Özellikle çok düşük doğum ağırlıklı bebekler olmak üzere son dekatlarda prematüre bebeklerin hayatta kalma oranında önemli bir artış olmuştur.beslenmesinde, aynı gebelik haftasındaki sağlıklı fetusun büyüme hızına benzer bir büyüme hızının sağlaması önerilmektedir. Ne yazık ki, çoğu preterm bebek bu hedefe ulaşabilecek kadar yeterli beslenememektedir. Sonuç olarak preterm bebeklerin term bebeklere göre büyümeleri kısıtlıdır. Bu ekstrauterin büyüme kısıtlılığı özellikle kronik akciğer hastalığı, şiddetli intraventriküler kanama, nekrotizan enterokolit veya geç-başlangıçlı sepsis gelişmiş hasta bebeklerde daha belirgindir. Preterm bebeklerde tercih edilen beslenme yöntemi enteral beslenmedir ve besin kaynağı olarak da anne sütü tercih edilir. Çünkü anne sütü konak savunmasındaki avantajları, içeriği, besin ve sindirim üstünlükleri, gastrointestinal sistem fonksiyonlarına katkısı, nörogelişimsel yararları, anneye getirdiği avantajlar ve nekrotizan enterokolit riskini azaltması nedeniyle ilk tercih sebebidir. Anne sütünde bulunan hormonlar, büyüme faktörleri, antiviral ve antienflamatuar ajanlar sepsis olasılığını azaltır ve sağlıklı bir bağırsak florasının oluşmasına yardımcı olur. Bununla birlikte preterm infantların sağlıklı büyümeleri için anne sütünün protein ve mineraller ile güçlendirilmesi gerekir. Anne sütü ile beslenme imkânının olmadığı ya da çok kısıtlı olduğu durumlarda, donör anne sütü veya inek sütü bazlı formulalar preterm bebekler için kullanılmalıdır. Bu derleme, preterm bebeklerin beslenmesi için güncel yaklaşımları sunmayı amaçlamaktadır.

Current approaches to enteral feeding in preterm infants

Preterm birth is the leading cause of perinatal morbility and mortality in developed countries. In the last few decades, there has been a significant increase in survival rate of preterm infants, especially of very low birth weight infants. Nutrition of preterm infants should result in growth similar to that of normally growing fetuses of the same gestational age. Unfortunately most preterm infants are not fed enough to achieve this objective; as a result, their growth is restricted by term gestation. This extrauterine growth restriction is particularly evident in sick infants with developing chronic lung disease, severe intraventricular haemorrhage, necrotizing enterocolitis, or late-onset sepsis. In preterm infants enteral nutrition is the preferred mode of support while human milk is the preferred source of enteral nutrition. Breastfeeding is often the first choice due to its advantages to host defense, content of nutrients and digestion advantages, contribution to gastrointestinal function, neurodevelopmental benefits, advantages to the mother, and its role in reducing the risk of necrotizing enterocolitis. Hormones, growth factors, antiviral and anti inflammatory agents in mother's milk reduce the possibility of sepsis and help maintain a healthy intestinal flora as well. Howewer, for healthy growth of preterm infants, human milk needs to be supported with proteins and minerals. Human milk requires nutrient support to meet the protein and mineral needs of a healthy growing preterm infant. If feeding preterm infants with human milk is impossible or extremely limited, donor human milk or cow-milk-based formulas for preterm infants must be used. This review aims to provide current approaches to feeding in preterm infants.

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1. American Academy of Pediatrics: Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 1997;100(6):1035-9
2. Schanler RJ, Hurst NM, Lau C. The use of human milk and breastfeeding in premature infants. Clin Perinatol 1999;26(2):379-98, vii.
3. Agostoni C, Buonocore G, Carnielli VP, De Curtis M, Darmaun D, Decsi T, et al; ESPGHAN Committee on Nutrition. Enteral nutrient supply for preterm infants: commentary from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition. J Pediatr Gastroenterol Nutr 2010;50(1):85-91.
4. Kültürsay N, Bilgen H, Türkyılmaz C. Türk Neonatoloji Derneği Preterm ve Hasta Term Bebeğin Beslenmesi Rehberi.http://www.neonatology.org.tr/images/stories/f iles/makaleler/2015/premature_rehber_son_son.pdf 20.08.2015
5. Gürsoy T, Yurdakök M. Prematüre bebeklerin beslenmesi. Çocuk Sağlığı ve Hastalıkları Dergisi 2008;51(4):240-51.
6. De Curtis M, Rigo J. The nutrition of preterm infants. Early Hum Dev 2012;88(suppl 1):5-7.
7. Schanler RJ, Shulman RJ, Lau C. Feeding strategies for premature infants: beneficial outcomes of feeding fortified human milk vs preterm formula. Pediatrics 1999;103(6):1150-7.
8. Dinerstein A, Nieto RM, Solana CL, Perez GP, Otheguy LE, Larguia AM. Early and aggressive nutritional strategy (parenteral and enteral) decreases postnatal growth failure in very low birth weight infants. J Perinatol 2006;26(7):436-42.
9. Ehrenkranz RA, Younes N, Lemons JA, Fanaroff AA, Donovan EF, Wright LL, et al. Longitudinal growth of hospitalized very low birth weight infants. Pediatrics 1999;104(2):280-9.
10. Stoll BJ, Hansen NI, Bell EF, Shankaran S, Laptook AR, Walsh MC, et al. Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics 2010;126(3):443-56.
11. Lemons JA, Bauer CR, Oh W, Korones SB, Papile LA, Stoll BJ, et al. Very low birth weight outcomes of the National Institute of Child health and human development neonatal research network, January 1995 through December 1996. NICHD Neonatal Research Network. Pediatrics 2001;107(1):E1.
12. Embleton NE, Pang N, Cooke RJ. Postnatal malnutrition and growth retardation: an inevitable consequence of current recommendations in preterm infants? Pediatrics 2001;107(2):270-3.
13. Collaborative Group for the Nutritional, Growth and Developmental Study on Very Low Birth Weight Infants. [Postnatal growth of very low birth weight infants during hospitalization]. Zhonghua Er Ke Za Zhi 2013;51(1):4-11.
14. Stephens BE, Walden RV, Gargus RA, Tucker R, McKinley L, Mance M. First-week protein and energy intakes are associated with 18-month developmental outcomes in extremely low birth weight infants. Pediatrics 2009;123(5):1337-43.
15. Yu VYH, James B, Hendry P, MacMahon RA. Total parenteral nutrition in very low birthweight infants: a controlled trial. Arch Dis Child 1979;54(9):653-61.
16. Schnabl KL, Van Aerde JE, Thomson AB, Clandinin MT. Necrotizing enterocolitis: a multifactorial disease with no cure. World J Gastroenterol. 2008;14(14):2142-61.
17. Ehrenkranz RA, Das A, Wrage LA, Poindexter BB, Higgins RD, Stoll BJ, et al. Early nutrition mediates the influence of severity of illness on extremely LBW infants. Pediatr Res 2011;69(6):522-9.
18. Ben XM. Nutritional management of newborn infants: practical guidelines. World J Gastroenterol 2008;14(40):6133-9.
19. Groh-Wargo S, Sapsford A. Enteral nutrition support of the preterm infant in the neonatal intensive care unit. Nutr Clin Pract 2009;24(3):363-76.
20. Su BH. Optimizing nutrition in preterm infants. Pediatr Neonatol 2014;55(1):5-13.
21. Morgan J, Young L, McGuire W. Slow advancement of enteral feed volumes to prevent necrotising enterocolitis in very low birth weight infants. Cochrane Database Syst Rev 2014;12:CD001241.
22. Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2012;129(3):827-41.
23. Maggio L, Costa S, Zecca C, Giordano L. Methods of enteral feeding in preterm infants. Early Hum Dev 2012;88(suppl 2):31-3.
24. Quigley MA, Henderson G, Anthony MY, McGuire W. Formula milk versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev 2007;4:CD002971.
25. Hay WW Jr. Strategies for feeding the preterm infant. Neonatology 2008;94(4):245-54.
26. Premji S, Chessell L. Continuous nasogastric milk feeding versus intermittent bolus milk feeding for premature infants less than 1500 grams Cochrane Database Syst Rev 2003;1:CD001819.
27. King C. What's new in enterally feeding the preterm infant? Arch Dis Child Fetal Neonatal Ed 2010;95(4):304- 8.
28. Civardi E, Tzialla C, Garofoli F, Mazzucchelli I, Bollani L, Stronati M. Nutritional needs of premature infants. J Matern Fetal Neonatal Med 2011;24(suppl 1):27-29.
29. Hay WW Jr. Aggressive Nutrition of the Preterm Infant. Curr Pediatr Rep 2013;1(4).
30. Fanaro S. Feeding intolerance in the preterm infant. Early Hum Dev 2013;89 (Suppl 2):13-20.
31. Moore TA, Wilson ME. Feeding intolerance: a concept analysis. Adv Neonatal Care 2011;11(3):149-54.
32. Pinelli J, Symington A. Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants. Cochrane Database Syst Rev 2005;19(4):CD001071
33. Tekgündüz KŞ, Gürol A, Apay SE, Caner I. Effect of abdomen massage for prevention of feeding intolerance in preterm infants. Ital J Pediatr 2014;40:89.
34. Oncel MY, Sari FN, Arayici S, Guzoglu N, Erdeve O, Uras N, et al. Lactobacillus Reuteri for the prevention of necrotising enterocolitis in very low birthweight infants: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2014;99(2):110-5.
35. Shulman RJ. Effect of enteral administration of insulin on intestinal development and feeding tolerance in preterm infants: a pilot study. Arch Dis Child Fetal Neonatal Ed 2002;86(2):131-3.
36. Dhillon AS, Ewer AK. Diagnosis and management of gastro-oesophageal reflux in preterm infants in neonatal intensive care units. Acta Paediatrica 2004;93(1):88-93.
37. Birch JL, Newell SJ. Gastrooesophageal reflux disease in preterm infants: current management and diagnostic dilemmas. Archives of Disease in Childhood 2009;94(5):379-83.
38. Corvaglia L, Martini S, Aceti A, Arcuri S, Rossini R, Faldella G. Nonpharmacological management of gastroesophageal reflux in preterm infants. Biomed Res Int 2013;2013:141967.
39. Malcolm WF, Cotten CM. Metoclopramide, H2 blockers, and proton pump inhibitors: pharmacotherapy for gastroesophageal reflux in neonates. Clin Perinatol 2012;39(1):99-109.
40. Vandenplas Y, Salvatore S, Hauser B. The diagnosis and management of gastro-oesophageal reflux in infants. Early Hum Dev 2005;81(12):1011-24.
41. Lin PW, Stoll BJ. Necrotising enterocolitis. Lancet 2006;368(9543):1271-83.
42. Martin CR, Walker WA. Intestinal immune defences and the inflammatory response in necrotising enterocolitis. Semin Fetal Neonatal Med 2006;11(5):369-77.
43. Gülcan H, Üzüm İ, Aslan S, Yoloğlu S. İnönü üniversitesi yenidoğan yoğun bakım ünitesinde izlenen çok düşük doğum ağırlıklı preterm olgularımızın değerlendirilmesi. İnönü Üniversitesi Tıp Fakültesi Dergisi 2004;11(1):19- 23.
44. Cole CR, Hansen NI, Higgins RD, Ziegler TR, Stoll BJ; Eunice Kennedy Shriver NICHD Neonatal Research Network. Very low birth weight preterm infants with surgical short bowel syndrome: incidence, morbidity and mortality, and growth outcomes at 18 to 22 months. Pediatrics 2008;122(3):573-82.
45. Gutierrez IM, Kang KH, Jaksic T. Neonatal short bowel syndrome. Semin Fetal Neonatal Med 2011;16(3):157- 63.
46. Amin SC, Pappas C, Iyengar H, Maheshwari A. Short bowel syndrome in the NICU. Clin Perinatol 2013;40(1):53-68.