For Healthcare Professionals only

  1. Home
  2. Case Study
  3. Nutritional Management In 20-day Old Infant Suffering With Recurrent Atelec..
Nutritional Management In 20-day Old Infant Suffering With Recurrent Atelectasis Due To Respiratory Distress
By - Dr. Deepa Hariharan
Consulting Neonatologist, MBBS, A.B. (Paeds) USA, A.B (Neo) USA, FAAP HOD, Dept. of Neonatology, Sooriya Hospital, Chennai
Introduction:

Acute respiratory distress syndrome manifests as rapidly progressive dyspnea, tachypnea, and hypoxemia.1 It is considered as one of the most common causes of atelectasis.2 The presence of long-term atelectasis can induce secondary infection or worsen the original infection, causing bronchial damage and inflammatory secretion retention, leading to bronchiectasis or emphysema as time passes.3

Malnutrition is prevalent in critically ill infants with acute respiratory distress syndrome.4 One out of every two children in the pediatric intensive care unit will develop malnutrition or have worsening of baseline malnutrition and present with specific micronutrient deficiencies.5 Malnutrition adversely affects lung function by diminishing respiratory muscle strength, altering ventilatory capacity, and impairing immune function.6 Therefore, Nutrition should be considered a primary rather than supportive therapy for pediatric acute respiratory distress syndrome.5

Precise nutritional therapies, which are titrated and targeted to preservation of intestinal barrier function, prevention of intestinal dysbiosis, preservation of lean body mass, and blunting of the systemic inflammatory response, offer great potential for improving outcomes of pediatric acute respiratory distress syndrome.5

Here, we present a case of a 20-day old infant suffering with recurrent atelectasis due to respiratory distress and not thriving well.

Patient Profile:

A 20-day old female infant presented with chief compliant of recurrent atelectasis and was showing faltering growth. Her weight was 2.8 kg.

Relevant Medical History:

Infant was born at term with antenatal diagnosis of situs inversus totalis. Her birth weight was 3.2 kg. She developed respiratory distress along with cyanosis within an hour after birth and therefore ventilated.

On diagnosis, dextrocardia and pulmonary hypertension were reported. She was treated with inotropes and nitric oxide. Although pulmonary hypertension improved by day 4, infant was dependent on ventilator for > 3 weeks. Infant began retaining tenacious secretions and developed atelectasis.

Relevant Feeding History:

Child was on partial parenteral nutrition and expressed breastmilk 20 ml/kg/day. Infant had lost 400 g of weight by day 20 and therefore started on 100 ml/kg/day of expressed breastmilk along with term formula and continued partial parenteral nutrition to provide 100 kcal/kg/day. Feed volume couldn’t increase further due to gastroesophageal reflux disease (GERD).

Investigations:

Computed tomography (CT) angiogram of chest, flexible bronchoscopy, sepsis screen and serum immunoreactive trypsin for cystic fibrosis were ordered.

Diagnosis:

Sepsis screen and serum immunoreactive trypsin test came out negative. CT angiogram of chest revealed normal vasculature.

Flexible bronchoscopy showed pigtail trachea and pooling of secretions in many small airways suggestive of Kartagener syndrome.

Infants’ weight was less than that for 3rd percentiles on WHO growth chart.

Infant was diagnosed to be suffering from faltering growth due to recurrent atelectasis.

Management:

Since infant was suffering from recurrent atelectasis; she was unable to wean off from the ventilator. She was in the catabolic state. There was increased caloric requirement due to tachypnea. Airway defects were causing oral motor swallowing problems.

Aim of the nutritional management was to achieve significant weight gain. In addition to weight gain, conservative management was also required to reduce the effect of tracheal bronchus and airway anomalies to counter increased work of breathing.

The recommend caloric intake was 125 kcal/kg/day. Infant therefore started on energy and nutrient dense formula (ENDF) 100 ml/kg/day (100 kcal/kg/day) from day 23 in addition to breast feeding. Total 4 to 6 feeds were given per day. The amount was gradually increased to 120 kcal/kg/day. Pantoprazole was given to prevent any symptoms of GERD. By day 40, infant gained 500 g of weight making her weight 3.3 kg with improvement in atelectasis. By day 50, she was extubated to CPAP and her weight was 3.6 kg. Infant was discharged from hospital by day 60 and her weight was 3.9 kg.

Follow-up:

ENDF was continued post dischrge along with breastfeeding and energy dense solids. By 8 months of age, infant’s weight was 6.7 kg and was thriving well. No emergency room visit was observed within last 4 months.

Case Study 7 figure 1

Discussion:

Respiratory distress syndrome is one of the most common causes of atelectasis in the neonatal period. In neonates, pulmonary parenchyma is not yet fully formed, undergoing the remodeling that will finalize the development of the capillaries and alveoli.2 Development of atelectasis is associated with decreased lung compliance, impairment of oxygenation, increased pulmonary vascular resistance, and development of lung injury.7

Nutritional issues are increasingly recognized in the course of respiratory diseases, from primary prevention to advanced disease care.8 Malnutrition is prevalent in critically ill infants with acute respiratory distress syndrome.4 Cumulative deficits of energy, protein and micronutrients not only lead to faltering growth but may also impact clinical and functional outcomes.9,10,11

Adequate nutrition therapy in support of protein, energy, and micronutrient prevents loss of lean body mass, improves protein turnover for production of acute phase and immune proteins, prevents depletion of tissue antioxidant systems which occur with starvation, and is associated with improved 60-day mortality in mechanically ventilated, critically ill infants.5

Therefore, to overcome nutritional issues, energy and nutrient dense formula (ENDF) can be given to critically ill infants. ENDF provides increased intake of all nutrients in a balanced form which can help to promote weight gain and linear growth. It is also safe and well tolerated.12

In the case presented here, infant was suffering from recurrent atelectasis and was unable to gain weight. Infant needed increased caloric intake (125 kcal/kg/day). Increasing feed volume with expressed breast milk and term formula was not possible due to GERD. Infant therefore started on ENDF along with breast feeding which led to significant weight gain. Use of ENDF can be considered as one of the important measures in critically ill infants suffering with recurrent atelectasis.

Key features of ENDF:
  • Highest energy in small volume - 1kcal/1ml
  • 15-14% more vitamin and minerals than standard infant formula
  • Suitable for tube feeding
  • Optimal protein: 2.6g/100 ml
  • Fortified with nucleotides
  • Osmolality within recommended guidelines
Conclusion:

We can conclude that ENDF can help in weight gain in infants with recurrent atelectasis who are not thriving well.

References:-

  1. Saguil A, Fargo M. Acute respiratory distress syndrome: diagnosis and management. Am Fam Physician. 2012 Feb 15;85(4):352-8.

  2. Dominguez MC, Alvares BR. Pulmonary atelectasis in newborns with clinically treatable diseases who are on mechanical ventilation: clinical and radiological aspects. Radiol Bras. 2018 Jan-Feb;51(1):20-25

  3. Liu J., Cao HY. Pulmonary Atelectasis of the Newborn. In: Liu J., Sorantin E., Cao HY. (eds) Neonatal Lung Ultrasonography. Springer, Dordrecht. 2019. Page no. 89-102.

  4. Loi M, Wang J, et al. Nutritional support of critically ill adults and children with acute respiratory distress syndrome: A clinical review. Clinical Nutrition ESPEN. 2017 Jun; e1-e8.

  5. Wilson B, Typpo K. Nutrition: A Primary Therapy in Pediatric Acute Respiratory Distress Syndrome. Front Pediatr. 2016 Oct 13;4:108. eCollection 2016.

  6. Pingleton SK. Enteral nutrition in patients with respiratory disease. Eur Respir J. 1996 Feb;9(2):364-70.

  7. Duggan M, Kavanagh BP. Pulmonary atelectasis: a pathogenic perioperative entity. Anesthesiology. 2005 Apr;102(4):838-54

  8. Schols AM. Nutritional advances in patients with respiratory diseases. Eur Respir Rev. 2015 Mar;24(135):17-22

  9. Mehta NM, Corkins MR, et al. Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr. 2013 Jul;37(4):460-81.

  10. Sullivan PB, Goulet O. Growth faltering: how to catch up? Eur J Clin Nutr. 2010 May;64 Suppl 1:S1.

  11. Mehta NM, Skillman HE, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. Pediatr Crit Care Med. 2017 Jul;18(7):675-715.

  12. Clarke SE, Evans S, et al. Randomized comparison of a nutrient-dense formula with an energy-supplemented formula for infants with faltering growth. J Hum Nutr Diet. 2007 Aug;20(4):329-39

Important Notice:

The World Health Organization (WHO)* has recommended that pregnant women and new mothers be informed of the benefits and superiority of breast-feeding, in particular, the fact that it provides the best nutrition and protection from illness for babies. Mothers should be given guidance on the preparation for and maintenance of lactation, with special emphasis on the importance of the well-balanced diet both during pregnancy and after delivery. Unnecessary introduction of partial bottle feeding or other foods and drinks should be discouraged since it will have a negative effect on breast-feeding. Similarly mothers should be warned of the difficulty of reversing a decision not to breastfeed. Before advising a mother to use an infant formula, she should be advised of the social and financial implications of her decision. For example, if a baby is exclusively bottle-fed, more than one can (500g) per week will be needed, so the family circumstances and cost should be kept in mind. Mother should be reminded that breast milk is not only the best but also the most economical food for babies. If a decision to use infant formula is taken, it is important to give instruction on correct preparation methods, emphasizing that unboiled water, unsterilized bottles or incorrect dilution can lead to illness.

*See: International Code of Marketing of Breast Milk Substitutes, adopted by the World Health Assembly in Resolution WHA 34.22, May 1981.

Mothers should be explained the following advantages & nutritional superiority of breastfeeding:

  1. Immediately after delivery, breast milk is yellowish and sticky. This milk is called colostrum, which is secreted during the first week of delivery. Colostrum is more nutritious than mature milk because it contains more protein, more anti-infective properties which are of great importance for the infant's defence against dangerous neonatal infections. It also contains higher levels of, Vitamin 'A'.
  2. Breast miIk:
    1. Is, a complete and balanced food and provides all the nutrients needed by the infant (for the first six months of life).
    2. Has anti-infective properties that protect the infants from infection in the early months.
    3. Is always available.
    4. Needs no utensils or water (which might, carry germs) or fuel for its preparation.
  3. Breastfeeding is much cheaper than feeding infant milk substitutes as the cost of the extra food needed by the mother is negligible compared to the cost of feeding infant milk substitutes.
  4. Mothers who breast-feed usually have longer periods of infertility after child birth than non-lactators.

Details of management of breast feeding, as under:

  1. Breast-feeding.
    1. Immediately after delivery enables the contraction of the womb and helps the mother to regain her figure quickly.
    2. Is successful when the infant suckles frequently and the mother wanting to breast-feed is confident in her ability to do so.
  2. In order to promote and support breast-feeding the mother's natural desire to breast feed should always be encouraged by giving, where needed, practical advice and making sure that she has the support of her relatives.
  3. Adequate care for the breast and nipples should be taken during pregnancy.
  4. It is also necessary to put the infant to the breast as soon as possible after delivery.
  5. Let the mother and the infant stay together after the delivery, the mother and her infant should be allowed to stay together (in hospital, this is called "rooming-in").
  6. Give the infant colostrum as it is rich in many nutrients and anti-infective factors protecting the infants from infections during the few days of its birth.
  7. The practice of discarding colostrum and giving sugar water, honey water, butter or other concoctions instead of colostrum should be very strongly discouraged.
  8. Let the infants suckle on demand.
  9. Every effort should be made to breast-feed the infants whenever they cry.
  10. Mother should keep her body and clothes and that of the infant always neat and clean.
    Breast-feeding is the best form of nutrition for babies and provides many benefits to babies and mothers. It is important that, in preparation for and during breast-feeding, you eat a healthy, balanced diet. Combined breast and bottle feeding in the first weeks of life may reduce the supply of your own breast-milk, and reversing the decision not to breast-feed is difficult.
    Always consult your Health-care Professional for advice about feeding your baby. The social and financial implications of using infant formula should be considered. Improper use of an infant formula or inappropriate foods or feeding methods may present a health hazard. If you use infant formula, you should follow manufacturer's instructions for use carefully - failure to follow the instructions may make your baby ill.