Nicholas Embleton

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

  • Human newborns are the FATTEST ANIMAL ON THE PLANET. Most mammals are around 3% fat (other primates for examples) but humans are 10-15% at term. This provides energy for the first few days whilst lactation is established. The primary function of colostrum is therefore IMMUNE/INFECTION PREVENTION and the composition/function is similar to amniotic fluid. Most...

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  • thanks for sharing Joan. Yes, I met a mum who had triplets but one died, and she explained how exhausting it was to keep having to tell the story as everyone assumed she had twins

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  • there is still reluctance to use early fortification although this is common in some countries especially US and parts of Europe. But there are very few good RCTs @RuthThomson Remember, if you concern about early fortification is that it increases the risk of NEC (no data this is true, but it is often stated) then to show early fortification is safe i.e. does...

  • everyone on the NICU has a responsibility to focus on nutrition. But neonatology often attracts people fascinated with machines and MRI and USS and blood tests, forgetting that none of that makes the baby better! Nutrition involving milk in a syringe with a tube does not seem very "sexy" compared to all that machinery. But it makes the biggest difference.

  • Oh @JosephAldricGaspar. Of course Alan Lucas is the 'Godfather' of neonatal nutrition and we all have huge respect for him, his studies and insights. But .... that does not mean I always agree with his interpretation of studies, and I do not believe there are data to show that fortification of MOM means you lose the longterm benefits. Which study do you mean?

  • The body composition data is fascinating but as you say @carolineking there is no data showing that excess adiposity is due to 'nutrition' - more likely due to stress. Insufficient protein leads to insufficient lean mass accretion which is a risk for later adverse metabolism. I am less interested in some extra adipose tissue (it doesn't seem to track into...

  • agree; we need more evidence. The data linking fortification to NEC are very weak or non-existent. That doesn't mean there is zero risk, but at present there is no good data to suggest you should not fortify. Poor growth is associated with worse outcomes. "One brain for life"

  • yes, so very difficult (impossible) to meet protein needs in very preterm infant

  • thanks @ThavindraRukshaniDelpagodaGamage where are you working?

    I see, Sri Lanka! Welcome!

  • great! All the best

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  • thanks for joining @AnaO'Reilly-Marshall :)

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  • we have done some studies looking at post-discharge nutrition but mainly effect of macronutrients on growth and body composition rather than breast milk. @RuthThomson

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  • thanks for completing - pleased you enjoyed it

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  • What determines fat content of breastmilk?

    - Fat content of human milk is relatively constant as it is synthesised in the breast.
    - Fat content during a feed is determined by the fullness of the breast. Fat content increases gradually as the breast becomes emptier, as fat globules are “forced” out of the breast by successive milk ejections.
    - A longer...

  • thanks for sharing @JoyOjonileAgagwu

  • thanks Joy

  • risks and benefits of faster/slower growth in IUGR infants may differ from what is 'optimal' in non-growth restricted. We don't know. I would work hard to avoid further loss of centiles in an IUGR infant, and would allow 'slow' catch up, but I would also be concerned about promoting rapid upward centile crossing even in a preterm IUGR infant. Conclusion: we...

  • There is some evidence that you can affect fatty acid profiles e.g. by increasing maternal n3 intakes ; same forVitamin D (and probably Vitamin A but I don't know the data). You can probably influence EPA levels for same reasons - I don't know. But I don't think you can increase overall fat concentration (assuming the mother is nutritionally replete), and you...

  • Great! "Nutrition is more than nutrients"

  • I don't think it is necessary, unless you had very unusual biochemistry. You will find many mothers in high-risk groups for Vitamin D deficiency - dark skin, dietary, medical conditions, obesity, pre-eclampsia etc. - so you can estimate (depending on your local population) that maybe 20-40% of your mothers have low/sub-optimal Vitamin D, and that many of your...

  • I would always maximise intake of MOM - amount of MOM is the key factor determining later outcomes (NOT weight gain). So in the case of 'slow growth' I would never replace MOM with formula just to be able to promote weight gain. In most cases, breast milk fortifier will provide sufficient additional nutrients.

  • thanks for joining - hopefully your IMG posting will be useful. Perhaps you can share this course with colleagues from where you first trained to help widen dissemination

  • It would be great to hear from you if you use the ABCDE tool

  • thanks for joining. It would be great if you can use networks in Indonesia to share this course more widely!

  • What is GEG please?

  • thanks for joining @AnaPatriciaMartínezGonzalez - pleased it was useful - please share it with your colleagues, and national networks. We are keen to maintain free access so we can enable high quality learning across the world!

  • 36 learners from Guatemala!! @AndreaCastillo

  • Hi @BeckiHolbrooke thanks for joining - give my regards to the team!

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  • There have been questions about orally feeding babies who still require CPAP or HiFlow. We generally haven't done this, and would always ask for Speech Therapy assessment. However, historically we have fed some infants on CPAP. Interested to know whether anyone still feeds on non-invasive respiratory support?

    Dumpa V, Kamity R, Ferrara L, Akerman M, Hanna...

  • Good question. It's not clear but I suspect most will use Holder. I looked at this reference again but couldn't find the detail you wanted

    Bonet M, Durox M, Blondel B, Boileau P, Pierrat V, Zeitlin J. Management of mother's own milk for very preterm infants in tertiary-level neonatal units in the Ile-de-France region in France. Breastfeed Med. 2014...

  • You can 'estimate' theoretically but I do not think it makes a difference clinically. The osmolality changes over time - if you leave MOM + BMF the osmolality increases over the first 1-2 hours as enzymes in MOM digest the CHO and fats. Also, the contributors to osmoles (CHO, AA, vitamins etc.) are absorbed at different parts of the GI tract. So the osmolality...

  • I don't think there's enough data probably. Other educators might know more. But becuase early milk is such low volume, I do not think it is easy to get samples for analysis purely for research, so perhaps very little is really known about colostrum composition in very preterm. But I don't think knowing the "average" composition for gestation really helps....

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  • thanks for joining. Thunder Bay must be cold

  • :) yes indeed!

  • great; nice to meet you; thanks for joining

  • I dropped a few babies off there when I was fellow and doing transports at BCCH a 'few' years ago. Perhaps you can get your Neos interested in doing the course. There's always hope the physicians might take an interest in nutrition ..... @KailaJabs

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  • There’s a pdf download in one of the last steps in week 4

  • I agree @PaolaCarrascal Many physicians have 'strong opinions' based on very little evidence but based on "experience". I am not sure that experience is always as valuable as they liked to imagine. You can have a lot of experience doing the wrong thing! Our job (as neonatologists thinking about nutrition) is to gently challenge our colleagues. Ask them to...

  • completely agree. it also makes the job much more fun

  • thanks. Can you share with others how much Vit A,D,E you get in Abidec 0.6 and Dalivit 0.3 please? Also, if they are fully fortified MOM+BMF how much extra vitamin do you give then?

  • we don't pasteurise MOM either (UK) but it is more common in France - the background rate of CMV and local experience of CMV transmission mean the risk/benefit ratio differs between countries.

  • sorry, I'm not sure I understand the question. But the impact of human versus cow milk fortifier on the microbiome is quite small

  • how much Abidec do you give, and when do you start?

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  • thanks

    "In our center, routine measurement of gastric residue is not performed if the patient is clinically stable, only in those who have signs/symptoms of abdominal alarm, and in the presence of clinically significant gastric residue (significant volume and green color). 2 feedings are suspended and starting the third feeding is evaluated in the volume of...

  • please you enjoyed it - keep going!

  • agree! I much prefer the idea of just using MOM for first 24-48 hours. We need to think more widely about TEAM - sometimes the midwives on delivery suite are not "tuned in" to the baby and could be more supportive with messaging about buccal colostrum.

  • Oral aversion in preterm infants as they approach 36 weeks + is well described ; I've even seen later onset. But the studies show it is associated with all the usual factors of illness - gestation, ventilation duration, NG duration etc. It is an important issue ("nutrition is more than nutrients") but I am not sure what the alternative is - i.e. you either...

  • Agree - good point that all babies are different and not all need intakes at the upper end of the ranges

    I've thought about & conducted body composition assessment in preterm infants for many years and my conclusions is .... we probably don't need to worry too much about it in clinical practice on the NICU! Current techniques are inconsistent, or lack...

  • Estoy de acuerdo: los protocolos de alimentación estandarizados tienen muchas ventajas. A los padres no les gustan las incoherencias.

    I agree - standardised feeding protocols have many advantages. Parents do not like inconsistencies.

  • Hi, thanks for joining - please share with colleagues across Ireland

  • what about trying out that nutrition tool - just two sides of paper and very easy to complete especially for non-dieticians i.e. medics and nurses!

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  • Welcome - thanks for joining

  • Vielen Dank, dass Sie sich für den Kurs angemeldet haben

  • Good question! Loss of terminal ileum is known risk factor for B12 deficiency but this may not present for months/years. Occasionally B12 has been measured but often not, and most ''complex" infants are followed by paediatric surgery/GI so we (neonates) may not know what really happens. Really interested to hear what other centres do. Do you measure B12 or...

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  • thanks for joining - which hospital /where are you based?

  • Intersting @KailaJabs

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  • I agree @KailaJabs We do not have enough studies to give a precise ratio, and there is some 'flexibility' but in general the more preterm infants need a little more protein than moderate preterm. In practice, we have limited flexibility (only a limited range of fortifiers and formula etc.) and the PER in human milk is 'fixed' - we get what we get! Perhaps in...

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  • thanks for joining @IngridHansenPupp Please share you experience and insights - of course we are all interested in macronutrients, IGF-1 and brain! Share your knowledge!

  • thank you! Please share the course with others in Guatemala. We should all come to visit you!

  • I agree. Furthermore the fat sticks to the inside of the syringe and gastric tube. So bolus is probably better from a nutrient DELIVERY perspective.

    Also, bolus stimulates gall bladder contraction and hormone levels so is more physiological and nutrient DIGESTION is probably better. In utero the fetus swallows from early 2nd trimester, and shows several...

  • Complex and important issue but there is no agreed best approach. We 'learn' about protein requirements - 3rd trimester foetus needs over 2g/kg/day protein. But in-utero that is supplied as amino acids and peptides. Ex-utero, breastmilk mainly provides this as whole protein, but also some free amino acids AA, and peptides. Mammals actually have a requirement...

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  • it will be .....can guarantee that at least :)

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  • regularmente damos cloruro de sodio extra por vía oral

  • hi @MelissaPieters thanks for joining. Wow, you have to learn a lot! we hope you enjoy the course!

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  • Hola! Gracias.

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  • I would wait a week or more; Magnus may have more informed answer! re. sepsis - during acute illness I wouldn't ask the "body" to do more than cope with sepsis so I might stop. Perhaps if just oral antibiotics then there is no concern, but if sick enough for i.v. antibiotics might be worth thinking about stopping for a couple of days? There is evidence that...

  • Certificate for what? @MuhammadFaizan

  • .... a dangerously circuitous argument. Challenge is how we get better evidence. Very few RCTs. I'm sure Kostas is interested in collaborating!

  • see week 4 on fortification @EmmaBarry Many European/US units start fortifier at 40ml/kg/d. However UK/Ireland seems much later/slower based on .... zero evidence

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