Nicholas Embleton
Professor of Neonatal Medicine with >25 years experience in large NICU. Lead research programmes in neonatal nutrition & work with parents
www.neonatalresearch.net
www.neonatalbutterflyproject.org
Location Newcastle upon Tyne, UK
Activity
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That is probably OK for a larger healthy baby, say 28-32 weeks, but this could be problematic in a 25 week baby as they may not get enough lipid, especially if they do not tolerate full feeds in next 2-3 days. There needs to be a balance between not leaving baby in PN/long line for longer than needed, but at the same time, not depriving a vulnerable baby of...
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I'm sorry if you wanted a simple answer.
To every complex problem, there is a simple answer that is wrong.
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Fortifier is not used routinely post-discharge but some NICUs do use. Whilst it seems 'sensible' to provide fortifier to some babies there are challenges. 1) it is not marketed/available for use in this way 2) babies feeding ad-lib regulate volume intake to achieve caloric (not protein) requirements. All babies regulate on calories, unless they have complex...
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@HilaryLum I'm visiting Auckland to spend couple of days with `Frank Bloomfield & team next week!
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welcome! which country/city are you working in
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great, best of luck with the PhD
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thanks for joining Khalid
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it really does ; and it doesn't take much time or resource to do this well. Healthcare staff have enormous 'power' to make a difference - both good and bad. We need to know that "little things make a difference"
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replying on behalf of Pr. Iacobelli - "Actually, sodium supplements should be started proactively and in a systematic way in babies who are receiving unfortified mother’s milk
When fortification is started, some babies will need extra sodium added to their diet, so it is recommended to regularly check sodium.
If you don't have access to HM and you do use... -
welcome, thanks for joining
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Hi! Where are you based? Vancouver?
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thanks for joining
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Hi Azza!
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@DeborahSueManigo please let me know if you do this- you can contact me via the website or email Nicholas.embleton@ncl.ac.uk
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@GillianBrodie thanks for joining
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Interesting; we now use DBM like you. There is no work on AA formula in this population- as the osmolality is higher and there is no proven benefit I would tend not to use
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@JulieLanigan welcome!!
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Nicholas Embleton replied to Femi Adeniyi
This is complex issue and we tried not to explore in too much detail. But there are excellent reviews which agree with your practice - to use PTH to determine whether extra calcium is needed. It requires expert insights into biochemistry but we felt this was too complex for this course.
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fully agree - early low phosphate is due to higher AA in PN and needs extra PO4 i.v. But we don't explore that in detail in this course which is focused only on enteral nutrition.
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formula fed is easier! I would switch to a PDF as long as I knew there were no other correctable factors. e.g. if on term milk, was extra iron being given? For breastfed it is different because the benefit of continued breastmilk is greater than weight gain. it is possible to use BMF post-discharge and many NICUs do even though BMF is not marketed for out of...
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Good question - we would use DHM until full feeds at least, or maybe first 3-4 weeks in smallest babies and start BMF at around 100-150ml/kg. After that as the baby gets bigger and risk of NEC decreases we would with to PTF. A few parents decline DHM - not many, and it may depend on who spoke to them and what they said. Complex issue. Few parents decline...
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great! ask your maternity and other bereavement teams to make touch with us via the website or email me Nicholas.embleton@ncl.ac.uk
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Definitely! It's the little things that counts. Those 'brief' interactions have a massive impact on the families. Our willingness to express empathy and listen to parents make a big difference. The words we use, or facial expressions change how parents feel. It doesn't require a massive shift, or extra resources, and it's not difficult to do - we all need to...
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@FlorinaIonescu can I ask if you are based in Romania or Europe? and if so can you think of ways in which we can share the resources better? I have a Romanian translation available on the website
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Oh great - tell me, how do you get the butterfly onto their online file please
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agree - we are all affected by these issues but it is important to recognise that it is their grief and story and not ours. Of course as professionals we have stories we will share/tell our friends [anonymously of course] but ultimately we are there for parents and not the other way around
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communication is so important
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tell me more please! You mean flower seeds to plant?? Sounds like a loverly idea
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Nicholas Embleton replied to Emily Stevens
yes, we use the boxes too from 4louis
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Nicholas Embleton replied to Emily Stevens
I'm pleased you've taken so much from the course, and will share with others. Thanks so much for joining. It means a lot to the parents I worked with to know that sharing their painful stories can help others
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thanks for joining - please share with colleagues and help spread the word!
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lovely :)
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great - also you can get resources from Skye High Foundation
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thanks for joining - hope you find it useful - see if you can persuade other staff in the twin clinic to join?
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I am not really involved until they are born, but I would say this is indidivudal. If the parents feel their very early loss e.g. 8-12 weeks represented a 'baby' then i don't see why we shouldn't offer to discuss it. I know a mum who had two embryos re-implanted after 'IVF' and she was unsure whether she was allowed to grieve the early loss - i think the...
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thanks Zoe - yes, please encourage the bereavement team to take the course, and anyone working on the NNU. They can get a free resource pack from the Skye High Foundation with cot cards and print outs
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that's great - i thikn the importance of remembering and using their real names is so important
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Nicholas Embleton replied to Hilary Lum
good question! There are no good data. But treat the baby - not the number. If growth (weight and length) is good, the baby is healthy, getting MOM, you are giving vit D and iron, mum is happy and the biochemistry - Na/PO4 is normal - then maybe a urea of 1-2mmol/L is OK?? We don't know. Many think about giving extra protein if the urea is <<3mmol/L but the...
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agreed - preterm needs LOTS more protein, and more energy (but not as much as protein proportionally)
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Nicholas Embleton replied to Michele Mandis
agree - you need EVERY nutrient to grow. you can give plenty macronutrients but if you don't give enough sodium or phosphate then the effect is wasted!
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I am sure the challenges in your setting are much greater than we face in Europe. I hope the course is useful
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great - welcome
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great - thanks for joining
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great - thanks for doing!
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Protein does go down but .... the protein concentration is absolutely perfect for term infants. Nature is very conservative - there is no wastage - so there isn't any more protein in breast milk because healthy term infants don't need it. But the challenge then is for preterm infants who need much higher intakes of protein.
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Nicholas Embleton replied to Ramin Niazi
I agree!
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Nicholas Embleton replied to Ramin Niazi
I'm pleased you learned so much - thanks for joining
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great - enjoy!
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welcome - it is a great topic and always interesting!
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great, welcome!
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I learned so much from so many people! But one thing really struck me when speaking to a psychologist. ACKNOWLEDGMENT. This has relevance to so many issues - whether it is bereavement, or something else - issues with communication with staff, perhaps when things "don't go to plan" or when health care teams make a 'mistake'. Acknowledging what the parents...
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our nurses suggested this a few years back and I think most parents take the option if it is possible
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planting flowers on the anniversary is a lovely idea - thanks for sharing
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thanks for joining. I haven't corresponded with anyone else in Iran. But if you go to our website www.neonatalbutterflyproject.org we do have downloads with an Arabic translation, but not with Farsi. But you are welcome to translate if you would like. You can email me directly
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thanks for joining - great if you can tell any colleagues about the course.
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great - please share with colleagues if you can
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Nicholas Embleton replied to Casey T
that's great you have taken something away from the course; thanks for joining
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thank for joining - you are right that we must acknowledge the contribution that parents have made, by being able to take part in our research and course development. A big thank you!
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Nicholas Embleton replied to Alghanay Abubaker Alghanay
thanks for joining; I hope you find it useful
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thanks for joining
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Nicholas Embleton replied to Lisa Olsson
I agree!
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thanks for joining
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thanks both for joining
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Generally i wouldn't give less than 50mls/kg/day of PN - less than 1g of AA or lipid. That doesn't mean that 0.5g of AA or lipid is not important, but that PN is expensive and associated with risk. So if you are going to give PN, give at least 50ml. that's my "rule" but others may do differently
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i am sure your experience will make hearing about the other cases in this course quite challenging. If you feel able please share your experiences throughout the course. If you feel appropriate you can tell us the names of your babies. take care
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Thanks for joining
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Show them the results and show them what you are doing so they understand the process; parents can help weigh and length. "You can see his weight dipped down a bit after he was born. that is perfectly normal, he will start putting on weight soon". Involve them in decision making about when to start/stop fortifier and how to give supplements. "we usually stop...
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thanks for joining - please share with others in your team and networks
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thanks for joining - please share with others you know and spread the word
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Welcome to the course, thanks for joining - please share with others on the NICU including your physicians!!
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Hello Canada! Welcome Alanna
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welcome, thanks for joining
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Hi - thanks for joining
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what formula would you use - term, preterm or hydrolyes??
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Nicholas Embleton replied to Paola Carrascal
@MichaelMcGowan thanks - I think Paola is talking about the chronic inflammation that happens as part of the metabolic syndrome, MS. There are cytokines or adipokines released from adipose tissue (of which there is an excess in the MS) which pass to the liver and initiate further release of pro-inflammatory mediators. Inflammation then increases risks of...
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In a very small baby <26-28w I leave the lipid going until feeds are 150. So I decrease using a very simple recipe - if on 50 EN then I give 100 PN + 2g lipid. If on 50 PN then I give 1g lipid. That keeps the nutrition roughly balanced and maintains nutrient intake. You could fine-tune this better if you had 24/7 dietetic cover, but we don't!
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Nicholas Embleton replied to Kristina Chmelova
Not sure! Whether the gut needs lactose, or galactose - I do not know. And lactose malabosorption has other adverse effects on fluid loss, and production of gas so I don't think malabsorption is a "good" thing!
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Nicholas Embleton replied to Joseph Aldric Gaspar
@JosephAldricGaspar you are correct! Hyperglycemia due to both peripheral insensitivity to insulin, but also pancreatic 'immaturity' perhaps. Long term protein glycosylation may have long term adverse effects - challenge is that all studies are observational, but these show that hyperglycaemia is associated with worse outcomes. The data around the amount of...
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Hi Erika. Well, this course is focused on EN and we will need to make another course for PN!
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Enteral top is 4g/k/d or is this for PN? For PN it would not be common to give more than 4g as they will develop high TG/XOL but for EN you will often give at least twice that
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Nicholas Embleton replied to Claire Howarth
@KristinaChmelova you know I'd always prefer DHM! But there can be cases where infants are lactose intolerant post NEC and they may take days to upreagulate lactase expression - so I can see there could sometimes be a more temporary role for hydrolysed/low lactose formula if DHM is not tolerated - but I might only use for 2 weeks until feeding re-established...
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Nicholas Embleton replied to Ruth Thomson
It makes sense to me to divide out the "extra osmoles" over the 24 hours if that is possible. Of course, if on fortifier, then you are committed to giving that every feed, but I would if possible avoid lots of sodium and vitamins together
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agree; there is no consistency or agreement @RuthThomson
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great; thanks for joining
@HalimaAl-Siyabi -
Nicholas Embleton replied to Ruth Thomson
there is a large trial NeoGastric that is starting in the UK - you can get more information here https://www.npeu.ox.ac.uk/neogastric
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Nicholas Embleton replied to Moriam Mustapha
@AbdulQaderIsmail see my answers below. Fundamentally, I would not routinely use a hydrolysed product as I do not see clear advantages. If it has an appropriate macronutrient composition for preterm infants, it is fine and 'safe' to use, but I do not really see advantages if I am honest. Also hydrolysed products are much more expensive.
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Nicholas Embleton replied to Kaila Jabs
sorry for delay - I missed this! I would definitely transition if I had used early hydrolysed formula. Fundamentally, the gut is designed to process whole protein, and use gastric acid, enzymes to break this down into peptides that are "naturally occurring". When you use an already-hydrolysed protein formula I would be concerned that the peptides are...
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Nicholas Embleton replied to Moriam Mustapha
@RuthThomson thanks for question - of course we can't really make recommendations about individual products but as you know products like PJ are inadequate from overall macronutrient perspective, as well as inadequate in fat terms as the MCT replacement may not even allow enough LCPUFAs (I haven't done the calculations but I suspect that will be true)....
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Nicholas Embleton replied to Moriam Mustapha
we used to use PJ but we haven't used this for years as the nutrient content is inadequate @MohamedAbouseif
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Nicholas Embleton replied to Ruth Thomson
agree
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thanks for joining
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Ho, thanks for joining
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Hi @EmanueleNicastro thanks for joining
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Hi @HilaryLum thanks for joining
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thanks for joining @OlusolaAkinlonu take a look at a new freee course we are developing for Africa! https://docs.google.com/forms/d/e/1FAIpQLSeRXkYoMVWF8OH6xsYeckBLh_lBJ4qmvuADHNUYB7eCzZv8Cg/viewform
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exactly. Protein high in colostrum - most of this is whey protein and primarily Lactoferrin with anti-infective properties. That is the role of early milk (immunoprotection) not nutrition per se!
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great; thanks for joining
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good to check ; in UK the C&G Nutriprem product doesn't have Fe, but SMA does. I think! Best to check
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welcome - thanks for joining
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Nicholas Embleton replied to Eva Albinsson
urea isn't harmful at these levels. However a high urea is a sign that protein intakes are high enough that some of the protein is being catabolised rather than accreted. Protein takes a lot of processing to turn it from AA to energy in the case it isn't needed. Dietary protein breakdown is metabolically expensive. Also endogenous protein breakdown and...
