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Common Disorders andCommon Disorders andManagement in NewbornManagement in Newborn

YunYun CaoCao

ChildrenChildren s Hospital ofs Hospital of FudanFudan UniversityUniversityShanghai, ChinaShanghai, China

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Respiratory DisordersRespiratory Disorders

Apnea of Apnea of prematurityprematurity (AOP)(AOP) Respiratory distress syndrome (RDS)Respiratory distress syndrome (RDS) TransientTransient TachypneaTachypnea of the Newbornof the Newborn

(TTN)(TTN)

MeconiumMeconium aspiration syndrome (MAS)aspiration syndrome (MAS) Chronic lung disease (CLD)Chronic lung disease (CLD)

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Apnea of Preterm Infant Apnea of Preterm Infant

Apnea Apnea Cessation of breathingCessation of breathing

Pathologic ApneaPathologic Apnea Respiratory pauses > 20Respiratory pauses > 20 secssecs any pause accompanied byany pause accompanied by bradycardiabradycardia oror

significantsignificant desaturationdesaturation

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Periodic BreathingPeriodic Breathing

A type of central apnea A type of central apnea Brief pauses in breathing ofBrief pauses in breathing of 1010 Repeat itself for several cyclesRepeat itself for several cycles Significant immaturity of respiratorySignificant immaturity of respiratory

control and a variant of apneacontrol and a variant of apnea

Many preterm infants demonstrateMany preterm infants demonstrate 2020 --30% of total sleep time30% of total sleep time A normal A normal maturativematurative processprocess

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EpidemiologyEpidemiology

Most prevalent in premature infantsMost prevalent in premature infantsprior to 36 weeksprior to 36 weeks gestationgestation

5959 -- 78% of all preterm infants78% of all preterm infants with increasing gestational agewith increasing gestational age > 50% of infants 50% of infants

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Majority of AOP resolve by 37 weeksMajority of AOP resolve by 37 weeks postconceptionalpostconceptional ageage

Persists longer withPersists longer with GAGA

Most infants reach respiratory maturityMost infants reach respiratory maturityby 42by 42 -- 44 weeks CGA44 weeks CGA

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TreatmentsTreatments

StimulationStimulation CPAPCPAP IntubationIntubation Medication:Medication:

CaffeineCaffeineMethylxanthinesMethylxanthines

TheophyllineTheophyllineDoxapramDoxapram

OxygenOxygen

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Application Application

Apnea and Apnea and bradycardiabradycardia is a commonis a commonproblemproblem Adverse Adverse neurodevelopmentalneurodevelopmental outcomeoutcome

may result from more frequent andmay result from more frequent andsignificantsignificant desaturations/bradycardiasdesaturations/bradycardias

Long term effects on infant is less clearLong term effects on infant is less clearand under investigationand under investigation

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Respiratory Distress SyndromeRespiratory Distress Syndrome

Primary cause of respiratory disorders andPrimary cause of respiratory disorders anddeaths in the newborndeaths in the newborn Most frequently occurs in premature infantsMost frequently occurs in premature infants

15% of all low birth weight infants (

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RDSRDS Incidence higher & more severe in:Incidence higher & more severe in:

MalesMales Asphyxia Asphyxia Maternal DiabetesMaternal Diabetes

Second born twinSecond born twin Familial predispositionFamilial predisposition Maternal hypotensionMaternal hypotension

C/S without labour C/S without labour Hydrops fetalisHydrops fetalis 3rd Trimester bleeds3rd Trimester bleeds

2626 --28 wks gestation age (50% incidence)28 wks gestation age (50% incidence)

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RDSRDS

Caused by lack of pulmonaryCaused by lack of pulmonarysurfactantsurfactant

Leads to progressive atelectasisLeads to progressive atelectasis Loss of functional residual capacityLoss of functional residual capacity VentilationVentilation -- perfusion imbalanceperfusion imbalance Also called Also called Hyaline MembraneHyaline Membrane

DiseaseDisease

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Pulmonary SurfactantPulmonary Surfactant Complex material containing different lipidsComplex material containing different lipids

and proteinsand proteins

Produced in Type II GranularProduced in Type II Granular PneumocytesPneumocytes ininthe alveoli and secreted into the air surfacethe alveoli and secreted into the air surface

Decreases surface tension and establishesDecreases surface tension and establishesstable respiratory interface and lung volumestable respiratory interface and lung volume

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Surfactant DeficiencySurfactant Deficiency

Surfactant production starts only inSurfactant production starts only inlate pregnancylate pregnancy

Insufficient amount of surfactantInsufficient amount of surfactant

causes collapse of the alveoli, loss ofcauses collapse of the alveoli, loss oflung volume due to the abnormallylung volume due to the abnormallyhigh surface tensionhigh surface tension

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Normal Alveolar Normal Alveolar RDSRDS

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RDSRDS -- TreatmentsTreatments RDSRDS -- is a self is a self --limiting diseaselimiting disease -- it usuallyit usually

subsides within 72 hourssubsides within 72 hours

Treatments includeTreatments include Antenatal Antenatal steroidssteroids SurfactantSurfactant Oxygen therapyOxygen therapy CPAP / IntubationCPAP / Intubation Maintaining normal acid/base balance, pHMaintaining normal acid/base balance, pH Neutral thermal environmentNeutral thermal environment

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TransientTransient TachypneaTachypnea of theof theNewbornNewborn

Results from slow absorption ofResults from slow absorption oflung fluidlung fluid

C/SC/S Mild respiratory distressMild respiratory distress

Peaks at about 36 hours of lifePeaks at about 36 hours of life Resolve spontaneouslyResolve spontaneously

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MeconiumMeconium Aspiration Syndrome Aspiration Syndrome

1010 --20% of all deliveries have in20% of all deliveries have in uterouteropassage ofpassage of meconiummeconium MeconiumMeconium staining alone is not a goodstaining alone is not a good

marker of asphyxiamarker of asphyxia MeconiumMeconium --stained amniotic fluid (MSAF)stained amniotic fluid (MSAF)

is found all races and socioeconomicis found all races and socioeconomicstrata in humanstrata in human

The thicker the consistency of MSAF,The thicker the consistency of MSAF,the greater the likelihood of MASthe greater the likelihood of MAS

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Diffuse patchyDiffuse patchyinfiltrates throughoutinfiltrates throughoutthe lung fieldsthe lung fields

Air leak syndrome Air leak syndrome

Occurs in 41% of babiesOccurs in 41% of babieswith MASwith MAS

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ToTo Recognize Potential ProblemsRecognize Potential Problems withwithMeconiumMeconium -- Stained FluidStained Fluid

fetal distressfetal distress meconium aspirationmeconium aspiration multisystem hypoxicmultisystem hypoxic --ischemic injuryischemic injury

Effective communication with obstetriciansEffective communication with obstetricians

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To Recognize Predictor Risk Factorsof MAS

post maturity non reassuring fetal heart tracings

oligohydramnios need for suctioning of baby s trachea one minute Apgar score < 4 = neonatal

depression C/S delivery

Prevention

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To Describe the Benefits of EarlyIntrapartum Interventions

attendance at delivery: skilled personnel suctioning mouth & oropharynx

as soon as head delivered as soon as in resuscitation surface keep baby warm

Assessment at delivery A = airwaysB = breathingC = circulation

Apgar scores

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Treatment of MASTreatment of MAS

OxygenOxygen Ventilation (high frequency)Ventilation (high frequency)

Exogenous surfactantExogenous surfactant Inhaled nitric oxideInhaled nitric oxide

ECMOECMO

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Chronic lung disease (CLD)Chronic lung disease (CLD)

Most frequently occurs in very prematureMost frequently occurs in very prematureinfantsinfants Oxygen dependent > 28 days, > 36 wks postOxygen dependent > 28 days, > 36 wks post

conceptionconception Due toDue to -- pulmonary immaturitypulmonary immaturity

SurfactantSurfactant Lung injuryLung injury BarotraumaBarotrauma Inflammation (due to oxygen therapy)Inflammation (due to oxygen therapy) Genetic predispositionGenetic predisposition

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CLDCLD Treatments:Treatments:

Oxygen therapyOxygen therapy Fluid restrictions / diureticsFluid restrictions / diuretics Steroids, broncodilatorsSteroids, broncodilators

Outcome:Outcome:

Death often occurs within the 1st year of lifeDeath often occurs within the 1st year of lifedue to cardiorespiratory failure; sepsis; ordue to cardiorespiratory failure; sepsis; orrespiratory infectionsrespiratory infections

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Jaundice andJaundice and HyperbilirubinemiaHyperbilirubinemia

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JaundiceJaundice Most common NeonatalMost common Neonatal ProblemProblem

Occurs in 50Occurs in 50 --60% of newborns60% of newborns Duration varies byDuration varies by

Ethnic groupEthnic group AA/Caucasians AA/Caucasians earlier peak and earlier declineearlier peak and earlier decline Asians/native Americans Asians/native Americans later and higher peak andlater and higher peak and

later declinelater decline Methods of feedingMethods of feeding

BreastBreast bottlebottle

Gestational ageGestational age Maternal healthMaternal health Drug exposureDrug exposure

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Physiologic JaundicePhysiologic Jaundice Classic patternClassic pattern

Rise inRise in bilirubinbilirubin on day 3on day 3 Decline to normal by 10Decline to normal by 10 --12days12days

PhysiologyPhysiology

RBCsRBCs have shortened life spanhave shortened life span Erythrocyte precursors degrade post birthErythrocyte precursors degrade post birth IncreasedIncreased enterohepaticenterohepatic circulationcirculation

Relatively deficient hepatic transportRelatively deficient hepatic transportsystemsystem

Resultant retention ofResultant retention of unconjugatedunconjugated

hyperbilirubinemiahyperbilirubinemia

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Breastfeeding JaundiceBreastfeeding Jaundice

Abnormal Abnormal Early onset exaggeration of physiologicEarly onset exaggeration of physiologic

jaundice jaundice

Result of suboptimal frequency and volumeResult of suboptimal frequency and volumeof feedingof feeding Common to see weight loss and decreasedCommon to see weight loss and decreased

number of stoolsnumber of stools High levels ofHigh levels of bilirubinbilirubin inin meconiummeconium IncreasedIncreased enterohepaticenterohepatic circulationcirculation

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PreventionPrevention

Promote early frequent feedingPromote early frequent feeding Early frequent contactEarly frequent contact Check infant in first few days afterCheck infant in first few days after

discharge home or on day 4discharge home or on day 4 Ask about feeding/urine output Ask about feeding/urine output

WeighWeigh

Educate MothersEducate Mothers

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Signs that your baby is BREASTSigns that your baby is BREAST --FEEDING WELLFEEDING WELL

By 3-4 days of age your baby: Has 4Has 4 --5 wet diapers per day5 wet diapers per day Has 2Has 2 --3 BM per day (3 BM per day ( colour colour progressing toprogressing to

seedy mustard yellow)seedy mustard yellow) Breast feeds at least 8 times per 24 hBreast feeds at least 8 times per 24 h Is content after most feedingsIs content after most feedings

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BreastmilkBreastmilk JaundiceJaundice

NormalNormal

Late onset prolonged physiologicLate onset prolonged physiologic jaundice jaundice

Transitional and mature milk increasesTransitional and mature milk increasesintestinalintestinal bilirubinbilirubin absorptionabsorption Unidentified factor in milk interferesUnidentified factor in milk interferes

with conjugationwith conjugation May persist as long as 3 monthsMay persist as long as 3 months

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Natural HistoryNatural History

0

50

100

150

200

250

300

0 1 2 3 4 5 6 7 8 9 10

BreastFormula

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Pathologic JaundicePathologic Jaundice

Onset in the first 24hrs post birthOnset in the first 24hrs post birth

Rate of increase of 0.5mg/dL/hr Rate of increase of 0.5mg/dL/hr

ConjugatedConjugated hyperbilirubinemiahyperbilirubinemia

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Is Jaundice Pathological?Is Jaundice Pathological? ? If there is an underlying diseaseIf there is an underlying disease

processprocess Bruising/Bruising/ polycythemiapolycythemia ?? Inborn error of metabolismInborn error of metabolism Blood group incompatibilityBlood group incompatibility Infant starving?Infant starving? Infection?Infection?

?If it causes neurological damage?If it causes neurological damage

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Blanching SkinBlanching Skin

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Maternal education: an alternative strategy forensuring safety with early newborn discharge

Chandran L, et al. Journal of Perinatal Education 1997

Discuss withcaller Repeatafter 2 days Call MD now

No concernsat this t ime

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BiliChek BiliChek

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Blood Brain Barrier andBlood Brain Barrier andBilirubinBilirubin EncephalopathyEncephalopathy

Prevents freePrevents free unconjunconj bilirubin from crossingbilirubin from crossing Less effective in premature infantsLess effective in premature infants Less effective in unwell infantsLess effective in unwell infants BilirubinBilirubin encephalopathyencephalopathy

HypotoniaHypotonia High pitched cryHigh pitched cry

SeizuresSeizures Long termLong term sequalaesequalae

Athetoid Athetoid CPCP SensoneuralSensoneural deafnessdeafness

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Necessary LabsNecessary Labs

Maternal ABO andMaternal ABO and RhRh typing andtyping and isoimmuneisoimmune Ab Ab screen/direct Coombsscreen/direct Coombs Neonate ABO andNeonate ABO and RhRh typingtyping BilirubinBilirubin panelpanel includes total and directincludes total and direct

RepeatRepeat bilibili q6q6 --12hrs12hrs Peripheral blood smearPeripheral blood smear hemolysishemolysis ?? CBCCBC anemic?anemic? ConsiderConsider reticulocytereticulocyte countcount Sepsis work up if suspicious for infectionSepsis work up if suspicious for infection

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TreatmentTreatment Consider Phototherapy while waitingConsider Phototherapy while waiting

for investigationsfor investigations OptimizeOptimize enteralenteral intakeintake

Options:Options: ObserveObserve PhototherapyPhototherapy Phototherapy and exchange transfusionPhototherapy and exchange transfusion

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New AAP Guidelines for StartingNew AAP Guidelines for Starting

PhototherapyPhototherapy

050

100

150

200

250

300

350400

0 1 2 3 Days

Term, wellConsider...

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New AAP Guidelines for ExchangeNew AAP Guidelines for Exchange

Transfusion: NoTransfusion: No hemolysishemolysis

0

100

200300

400

500

600

0 1 2 3 Days

Term, wellConsider PTExch if PT fail sExch!

Exchange transfusion + Intensive PTExchange transfusion + Intensive PTExchange only i f PT failsExchange only if PT fails

InvestigateInvestigate

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Guidelines for PT/ExchangeGuidelines for PT/Exchangetransfusion:transfusion: HemolysisHemolysis

0

100

200300

400

500

600

0 1 2 3 Days

Phototh/InvestPT if unwellExch if PT fail sExch!

Exchange transfusion + Intensive PT

Investigate & Rx

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Recommendation Prior to the discharge of every newborn, there should

be a process and protocol in place for assessing therisk for development of significant hyperbilirubinemiain all newborns nurseries

There should be a systematic approach to theassessment of all infants before discharge for thisrisk and program and follow up should be in place ifthe infant develops jaundice

All newborn infants who are visibly jaundiced, near(between 35 37 weeks) and full (>38 weeks) termshould have a bilirubin level determined

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Recommendation,cont.

Infants, although not visibly jaundiced but with two

or more risk factors should have at least onebilirubin level preformed prior to discharge

Serum bilirubin may be done on either capillary or

venous blood sample Infants with severe or prolonged jaundice should

have further investigations including an analysis ofthe conjugated component of the bilirubin

A Transcutaneous Bilirubin measurement may beused if available as a screening device

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Follow Up TSB that needs photo therapy should mandate an

investigation for cause

History, physical examination, lab tests, etc. etc.

ecommend tion

Adequate follow-up should be ensured for all infantswho are jaundiced.

Infants under phototherapy should be investigated

for determination of the cause of jaundice.

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Prolonged JaundiceProlonged Jaundice

Common in breast fed infants; ? 20%Common in breast fed infants; ? 20%

VERY common in premature breast fedVERY common in premature breast fedinfantsinfants .? >30%.? >30%

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Does Prolonged JaundiceDoes Prolonged JaundiceRequire Investigation?Require Investigation?

PathologicalPathological vsvs physiological?physiological? Breast fed?Breast fed?

Feeding well?Feeding well? Thriving?Thriving? TSH screen negative?TSH screen negative?

No investigation needed until 2No investigation needed until 2 --3 weeks3 weeks

l d d

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Prolonged Persistent JaundiceProlonged Persistent Jaundice(>2 weeks) Investigations(>2 weeks) Investigations

PathologicalPathological vsvs physiological?physiological? Breast fed?Breast fed? Feeding well?Feeding well? Thriving?Thriving? TSH screen negative?TSH screen negative?

Blood for split bilirubinCheck urine for wbcs, urobilinogen

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Neonatal InfectionNeonatal Infection

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Global Impact (1)Global Impact (1) Infection associated with 7Infection associated with 7 --54% of early54% of early

neonatal deathneonatal death Infection associated with 30Infection associated with 30 --73% of late73% of late

neonatal deathneonatal death Neonatal sepsis in hospital 5Neonatal sepsis in hospital 5 --6 per 10006 per 1000

livebirthslivebirths Neonatal meningitis 0.7Neonatal meningitis 0.7 1 .0 per 10001 .0 per 1000livebirthslivebirths

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Global Impact (2)Global Impact (2)

Acute respiratory infectionAcute respiratory infection 800,000800,000deaths per annumdeaths per annum

Neonatal tetanusNeonatal tetanus 438,000 per annum,438,000 per annum,

372,000 died372,000 died OmphalitisOmphalitis 22--54 per 1000 livebirths54 per 1000 livebirths

with 0with 0 --15% died15% died DiarrheaDiarrhea responsible for 1responsible for 1 --12% of12% of

neonatal deathsneonatal deaths

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Neonatal SepsisNeonatal Sepsis

Illness with positive blood culture inIllness with positive blood culture infirst 30 days of lifefirst 30 days of life

Early onset sepsisEarly onset sepsis

Late onset sepsisLate onset sepsis

l l f

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Clinical Signs: NonspecificClinical Signs: Nonspecific

HyperthermiaHyperthermia 55%55%

Jaundice 35%Jaundice 35% RespiratoryRespiratory

distressdistress 33%33%

Anorexia 28% Anorexia 28% Vomiting 25%Vomiting 25% Apnea 22% Apnea 22% Abdominal Abdominal

distension 17%distension 17%

HypothermiaHypothermia 15%15%

DiarrheaDiarrhea 11%11% Less frequentLess frequent

LethargyLethargy

Poor feedingPoor feeding Poor perfusionPoor perfusion Bloody stoolsBloody stools

Strategies to Reduce Neonatal Infections

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Antenatal Care Antenatal CareTetanus immunization,Tetanus immunization,

Management of STD, urinary infection, malaria, TBManagement of STD, urinary infection, malaria, TBIdentify pregnancy related maternal diseases andIdentify pregnancy related maternal diseases and

GBS carriersGBS carriers

Intrapartum/delivery care Intrapartum/delivery carePrevent prolonged laborPrevent prolonged laborOptimal management of complications: fever,Optimal management of complications: fever,PROM, puerperal sepsisPROM, puerperal sepsisClean delivery, cutting of cord and optimal cord careClean delivery, cutting of cord and optimal cord care

Breast feeding Breast feedingPromote early and exclusive breast feedingPromote early and exclusive breast feeding


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g

Gender issuesGender issuesPromote gender equalityPromote gender equalityEncourage education of girlsEncourage education of girls

Interventions to decrease incidence of LBW or Interventions to decrease incidence of LBW or prematurity prematurity

Delay childbearing in young adolescentsDelay childbearing in young adolescents

Promote maternal educationPromote maternal educationImprove maternal nutritionImprove maternal nutritionReduce tobacco useReduce tobacco use

Treatment of STD, Malaria treatment andTreatment of STD, Malaria treatment andprophylaxisprophylaxisLimit maternal work load during pregnancyLimit maternal work load during pregnancy

Maternal support to decrease stress/anxietyMaternal support to decrease stress/anxiety

Strategies to Reduce Neonatal InfectionsStrategies to Reduce Neonatal Infections

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Strategies to Reduce Neonatal InfectionsStrategies to Reduce Neonatal Infections

CommunityCommunity -- based intervention based interventionTrain birth attendants to identify problems in the newborn,Train birth attendants to identify problems in the newborn,

refer with serious problemsrefer with serious problemsPromote and support breast feedingPromote and support breast feeding

Maternal education regarding personal and domestic hygiene,Maternal education regarding personal and domestic hygiene,newborn care, and childhood immunizationnewborn care, and childhood immunization

Public health care followPublic health care follow --up after delivery, early diagnosis andup after delivery, early diagnosis andtreatment of newborn infection and mother, immunizationtreatment of newborn infection and mother, immunization

Early identification and improved treatment of neonates Early identification and improved treatment of neonateswith infectionwith infectionIntegrated approach to the sick infantIntegrated approach to the sick infant

Improve newborn care at all levelsImprove newborn care at all levels

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Infection ControlInfection Control

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Most common mode of transmissionMost common mode of transmissionof pathogens is via hands!of pathogens is via hands!

Infections acquired in healthcareInfections acquired in healthcare

Spread of antimicrobial resistanceSpread of antimicrobial resistance

So Why All Concern AboutSo Why All Concern AboutHand Hygiene?Hand Hygiene?

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Hand washing with antimicrobial soapHand washing with antimicrobial soapand water and water

Alcohol Alcohol --based hand rubbased hand rub

Hand HygieneHand Hygiene

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Indications for Hand HygieneIndications for Hand Hygiene

Before:Before: Direct contact with a patient and/or donningDirect contact with a patient and/or donning

glovesgloves

Guideline for Hand Hygiene in HealthGuideline for Hand Hygiene in Health --care Settings.care Settings.MMWR 2002MMWR 2002 ; vol. 51, no. RR; vol. 51, no. RR --16.16.

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Indications for Hand HygieneIndications for Hand Hygiene After: After:

Contact with a patientContact with a patient s intact skins intact skin Contact with blood, body fluids, excretions,Contact with blood, body fluids, excretions,

secretions nonsecretions non --intact skin, mucousintact skin, mucous

membranes, wound dressings in whichmembranes, wound dressings in whichglove use is indicated.glove use is indicated. Removing glovesRemoving gloves

Removal of any personal protectiveRemoval of any personal protectiveequipmentequipment Contact with environmental surfaces in theContact with environmental surfaces in the

patientpatient s immediate environments immediate environment

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Asphyxia and Neonatal Asphyxia and Neonatal

HypoxicHypoxic --IschemicIschemicEncephalopathyEncephalopathy

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Hypoxia

Perinatal asphyxia, apnea, respiratory failure,

right to left shunt

Ischemia

Heart failure, Shock, maternal hypotension

Causes

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Onset of HIE

Timing of Insults PercentageTiming of Insults Percentage

Antepartum Antepartum 2020IntrapartumIntrapartum 3535

Antepartum Antepartum antepartumantepartum 3535Postnatal 10Postnatal 10

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History of hypoxia or ischemia Clinical features

Neuroimaging Electrodiagnostic techniques

Neuronal biochemistry

Diagnosis

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1. Monitoring of vital signs

NICU, CNS, respiration,cardiovascular,renal, GI, fluid

Management

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2. Maintenance of AdequateVentilation and Perfusion

Respiratory support, blood gas Avoidance of systemic hypotensionor hypertension

Avoidance of hyperviscosity

Management

Management

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3. Maintenance of Adequate Glucose

LevelsNormal level: 3.9-6.6 mmol/L

4. Control of SeizurePhenobarbital

5. Control of Brain swellingPrevention of fluid overloadMannitol

g

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6. Other Therapeutic ApproachesMild hypothemia

7. Follow-up and Rehabilitation

Management

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Feeding Preterm infantsFeeding Preterm infants

Beneficial Effect of Feeding HM toBeneficial Effect of Feeding HM to

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ggPreterm InfantsPreterm Infants

Improved later cognitive developmentImproved later cognitive development

Reduced risk of NEC, infection,Reduced risk of NEC, infection,

atopyatopy

Nutritional programming of laterNutritional programming of latercardiovascular diseasecardiovascular disease

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Breastfeeding Premature InfantsBreastfeeding Premature Infants

SkinSkin --toto --skinskin Maintaining milk supplyMaintaining milk supply NonNon --nutritive sucklingnutritive suckling Initiation of breastfeedingInitiation of breastfeeding

TestTest --weightingweighting Breast vs bottleBreast vs bottle

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Skin to Skin ContactSkin to Skin Contact

Temperature RegulationTemperature Regulation OxygenationOxygenation Control of BreathingControl of Breathing Behavioral StateBehavioral State Rates of InfectionRates of Infection Maternal Milk ProductionMaternal Milk Production Duration of LactationDuration of Lactation

Bioactive Factors in Human MilkBioactive Factors in Human Milk

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With Effects on GI TractWith Effects on GI Tract

Secretory IgASecretory IgA

LactoferrinLactoferrin Cytokines (ILCytokines (IL --10)10) Enzymes (PAFEnzymes (PAF -- acetylhydrolase)acetylhydrolase) Growth factors (EGF)Growth factors (EGF)

NucleotidesNucleotides

Antioxidants Antioxidants Nutrients:Nutrients: Glutamine, TaurineGlutamine, Taurine

Human Milk Fortifier Human Milk Fortifier

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HM provides adequate nutrition for termHM provides adequate nutrition for term

infantsinfants

HM contains insufficient quantities of someHM contains insufficient quantities of somenutrients to satisfy the rapid growth rate ofnutrients to satisfy the rapid growth rate ofpremature infantspremature infants

HM fortifiers provide additional nutrients:HM fortifiers provide additional nutrients:protein, Ca, P, carbohydrates, vitamins, traceprotein, Ca, P, carbohydrates, vitamins, traceelementselements

HM fortifiers have short term benefits onHM fortifiers have short term benefits ongrowth with absence of documented longgrowth with absence of documented longterm benefitsterm benefits

Cochrane review 2004

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