Weight Growth Velocity and Postnatal Growth Failure in Infants 501 to 1500 Grams: 2000-2013

Social-Emotional Functioning and Dietary Intake among Children Born with a Very Low Birth Weight

Very low birth weight infants (VLBW, <1500g) are at elevated risk of neurodevelopmental disorders, later obesity and cardiometabolic disease; if and how neurodevelopmental disorders impact chronic disease risk is poorly understood. The most common neurodevelopmental disorders experienced by VLBW children are those of social-emotional functioning. We compared dietary patterns and body composition between VLBW children with poor vs. typical social-emotional functioning using linear mixed models adjusted for sex, gestational age, cognitive impairment, parental education and BMI. VLBW children (n=158) attending the Donor Milk for Improved Neurodevelopmental Outcomes trial 5.5-year follow-up participated. Poor social-emotional functioning was based on standardized parent-rated questionnaires and/or parent-reported physician diagnosis of autism spectrum or attention-deficit/hyperactivity disorders. Most children had diets categorized as 'needs improvement' (67%) or 'poor' (27%) and 29% of children exhibited poor social-emotional functioning. Poor social-emotional functioning was positively associated with 100% fruit juice (β=0.3 cup equivalents/day; 95% CI 0.1, 0.5) and energy intake (β=118.1 kcals/day; 95% CI 0.9, 235.2). Children with poor social-emotional functioning were more likely to have a limited food repertoire (p=0.02), but less likely to exceed dietary fat recommendations (p=0.04). No differences in overall diet quality or body composition were observed. Diet counselling and research are essential to improving the nutrition of VLBW children to mitigate chronic disease risk. Novelty: • Overall diet quality and body composition did not differ between VLBW children with poor vs. typical social-emotional functioning. • Most had diets "needing improvement" or "poor" according to the HEI 2010. • Diet counselling may help mitigate chronic disease risk in this vulnerable population.

Understanding the Preterm Human Heart: What do We Know So Far?

Globally, preterm birth affects more than one in every 10 live births. Although the short‐term cardiopulmonary complications of prematurity are well known, long‐term health effects are only now becoming apparent. Indeed, preterm birth has been associated with elevated cardiovascular morbidity and mortality in adulthood. Experimental animal models and observational human studies point toward changes in heart morphology and function from birth to adulthood in people born preterm that may contribute to known long‐term risks. Moreover, recent data support the notion of a heterogeneous cardiac phenotype of prematurity, which is likely driven by various maternal, early, and late life factors. This review aims to describe the early fetal‐to‐neonatal transition in preterm birth, the different structural and functional changes of the preterm human heart across developmental stages, as well as potential factors contributing to the cardiac phenotype of prematurity.

Quality Initiative to Reduce Extrauterine Growth Restriction in Very Low Birth Weight Infants

BACKGROUND

We report a statewide quality improvement initiative aimed to decrease the incidence of extrauterine growth restriction among very low birth weight infants cared for in Tennessee NICUs.

METHODS

The cohort consisted of infants born appropriate for gestational age between May 2016 and December 2018 from 9 NICUs across Tennessee. The infants were 23 to 32 weeks gestation and 500 to 1499 g birth weight. The process measures were the hours of life (HOL) when parenteral protein and intravenous lipid emulsion were initiated, the number of days to first enteral feeding, and attainment of full enteral caloric intake (110-130 kcal/kg per day). The primary outcome was extrauterine growth restriction, defined as weight <10th percentile for weight at 36 weeks postmenstrual age. Statistical process control charts and the Shewhart control rules were used to find special cause variation.

RESULTS

Although special cause variation was not indicated in the primary outcome measure, it was indicated for the reduction in specific process measures: HOL when parenteral protein was initiated, HOL when intravenous lipid emulsion was initiated, and the number of days to attainment of full enteral caloric intake (among the hospitals considered regional perinatal centers).

CONCLUSIONS

A statewide quality improvement initiative led to earlier initiation of parenteral and enteral nutrition and improved awareness of the importance of postnatal nutrition.

An Interdisciplinary Approach to Reducing NEC While Optimizing Growth: A 20-Year Journey

BACKGROUND

Necrotizing enterocolitis (NEC) and postnatal growth restriction are significant clinical dilemmas that contribute to short- and long-term morbidities for the most premature infants.

PURPOSE

After a rise in NEC rates in a regional neonatal intensive care unit (NICU), improvement practices were implemented by an interdisciplinary quality improvement (QI) work group whose focus was initially on nutrition and growth. QI work was refocused to address both NEC and growth concurrently.

METHODS

Through various QI initiatives and with evolving understanding of NEC and nutrition, the work group identified and implemented multiple practices changes over 2-decade time span. A standardized tool was used to review each case of NEC and outcomes were continually tracked to guide QI initiatives.

LOCAL FINDINGS

Focused QI work contributed to a significant reduction in NEC rates from 16.2% in 2007 to 0% in 2018 for inborn infants. Exclusive human milk diet was a critical part of the success. Postnatal growth outcomes initially declined after initial NEC improvement work. Improvement work that focused jointly on NEC and nutrition resulted in improved growth outcomes without impacting NEC.

IMPLICATIONS FOR PRACTICE

Use of historical perspective along with evolving scientific understanding can guide local improvement initiatives. Work must continue to optimize lactation during NICU hospitalization. More research is needed to determine impact of care practices on gastrointestinal inflammation including medication osmolality, probiotics, and noninvasive respiratory support.

Feeding Strategies in Preterm Very Low Birth-Weight Infants: State-of-the-Science Review

BACKGROUND

Providing enteral feeds to preterm very low birth-weight (VLBW) infants is critical to optimize nutrition, enhance growth, and reduce complications. Protocols guiding feeding practices can improve outcomes, but significant variation exists between institutions, which may limit their utility. To be most effective, protocols should be based on the best available evidence.

PURPOSE

To examine the state of the science on several key components of feeding protocols for VLBW infants.

SEARCH STRATEGY

The authors searched PubMed, CINAHL, and EMBASE databases for terms related to feeding VLBW infants less than 32 weeks' gestational age, including initiation of feedings, rate of feeding advancement, timing of human milk (HM) fortification, and feeding during blood transfusions, when diagnosed with a patent ductus arteriosus (PDA) and during medical treatment of PDA closure.

RESULTS

Initiation of feeds within the first 3 days of life and advancement by 30 mL/kg/d may decrease time to attain full feeds without increasing complications. Insufficient evidence guides optimal timing of HM fortification, as well as feeding infants undergoing blood transfusions, infants diagnosed with a PDA, and infants receiving medical treatment of PDA closure.

IMPLICATIONS FOR PRACTICE

Integration of existing research regarding feeding initiation and advancement into feeding protocols may improve outcomes. Infants at highest risk of feeding-related complications may benefit from a personalized feeding approach.

IMPLICATIONS FOR RESEARCH

Additional research is needed to provide evidence concerning the optimal timing of HM fortification and feeding strategies for infants undergoing blood transfusions and those diagnosed with a PDA or receiving medical treatment of PDA closure to incorporate into evidence-based feeding protocols.

Using Nature to Nurture: Breast Milk Analysis and Fortification to Improve Growth and Neurodevelopmental Outcomes in Preterm Infants

Premature infants are born prior to a critical window of rapid placental nutrient transfer and fetal growth-particularly brain development-that occurs during the third trimester of pregnancy. Subsequently, a large proportion of preterm neonates experience extrauterine growth failure and associated neurodevelopmental impairments. Human milk (maternal or donor breast milk) is the recommended source of enteral nutrition for preterm infants, but requires additional fortification of macronutrient, micronutrient, and energy content to meet the nutritional demands of the preterm infant in attempts at replicating in utero nutrient accretion and growth rates. Traditional standardized fortification practices that add a fixed amount of multicomponent fortifier based on assumed breast milk composition do not take into account the considerable variations in breast milk content or individual neonatal metabolism. Emerging methods of individualized fortification-including targeted and adjusted fortification-show promise in improving postnatal growth and neurodevelopmental outcomes in preterm infants.

Energy Expenditure, Protein Oxidation and Body Composition in a Cohort of Very Low Birth Weight Infants

The nutritional management of preterm infants is a critical point of care, especially because of the increased risk of developing extrauterine growth restriction (EUGR), which is associated with worsened health outcomes. Energy requirements in preterm infants are simply estimated, so the measurement of resting energy expenditure (REE) should be a key point in the nutritional evaluation of preterm infants. Although predictive formulae are available, it is well known that they are imprecise. The aim of our study was the evaluation of REE and protein oxidation (Ox) in very low birth weight infants (VLBWI) and the association with the mode of feeding and with body composition at term corrected age. Methods: Indirect calorimetry and body composition were performed at term corrected age in stable very low birth weight infants. Urinary nitrogen was measured in spot urine samples to calculate Ox. Infants were categorized as prevalent human milk (HMF) or prevalent formula diet (PFF). Results: Fifty VLBWI (HMF: 23, PFF: 27) were evaluated at 36.48 ± 0.85 post-conceptional weeks. No significant differences were found in basic characteristics or nutritional intake in the groups at birth and at the assessment. No differences were found in the REE of HMF vs. PFF (59.69 ± 9.8 kcal/kg/day vs. 59.27 ± 13.15 kcal/kg/day, respectively). We found statistical differences in the protein-Ox of HMF vs. PFF (1.7 ± 0.92 g/kg/day vs. 2.8 ± 1.65 g/kg/day, respectively, p < 0.01), and HMF infants had a higher fat-free mass (kg) than PFF infants (2.05 ± 0.26 kg vs. 1.82 ± 0.35 kg, respectively, p < 0.01), measured with air displacement plethysmography. Conclusion: REE is similar in infants with a prevalent human milk diet and in infants fed with formula. The HMF infants showed a lower oxidation rate of proteins for energy purposes and a better quality of growth. A greater amount of protein in HMF is probably used for anabolism and fat-free mass deposition. Further studies are needed to confirm our hypothesis.

Poor weight gain and its predictors among preterm neonates admitted at Muhimbili National Hospital in Dar-es-salaam, Tanzania: a prospective cohort study

Background

Preterm delivery is among the major public health problems worldwide and the leading cause of morbidity and mortality among neonates. Postnatal poor weight gain, which can contribute to mortality, can be influenced by feeding practices, medical complications and quality of care that is provided to these high-risk neonates. This study aimed to investigate the proportion and predictors of poor weight gain among preterm neonates at Muhimbili National Hospital (MNH), from September 2018 to February 2019.

Methods

A hospital-based prospective cohort study involving preterm neonates with Gestation age (GA) < 37 weeks receiving care at MNH. Eligible preterm, were consecutively recruited at admission and followed up until discharge, death or end of neonatal period. Poor weight gain was defined as weight gain less than 15 g per kg per day. The risk factors associated with poor weight gain were evaluated. Predictors of poor weight gain were evaluated using a multivariate analysis. Results were considered statistically significant if P -value was < 0.05 and 95% confidence interval (CI) did not include 1.

Results

A total of 227 preterm neonates < 37 weeks GA, with male to female ratio of 1:1.2 were enrolled in the study. The overall proportion of preterm with poor weight gain was 197/227 (86.8%). Proportion of poor weight gain among the early and late preterm babies, were 100/113 (88.5%) and 97/114 (85.1%) respectively. Predictors of poor weight gain were low level of maternal education (AOR = 2.58; 95%Cl: 1.02–6.53), cup feeding as the initial method of feeding (AOR = 8.65; 95%Cl: 1.59–16.24) and delayed initiation of the first feed more than 48 h (AOR = 10.06; 95%Cl: 4.14–24.43). A previous history of preterm delivery was protective against poor weight gain (AOR = 0.33; 95% Cl: 0.11–0.79).

Conclusion and recommendation

Poor weight gain was a significant problem among preterm neonates receiving care at MNH. This can be addressed by emphasizing on early initiation of feed and tube feeding for neonates who are not able to breastfeed. Health education and counselling to mothers focusing on feeding practices as well as close supervision of feeding especially for mothers experiencing difficulties in feeding their preterm will potentially minimize risk of growth failure.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02971-y.

Promoting Human Milk and Breastfeeding for the Very Low Birth Weight Infant

Provision of mother's own milk for hospitalized very low birth weight (VLBW) (≤1500 g) infants in the NICU provides short- and long-term health benefits. Mother's own milk, appropriately fortified, is the optimal nutrition source for VLBW infants. Every mother should receive information about the critical importance of mother's own milk to the health of a VLBW infant. Pasteurized human donor milk is recommended when mother's own milk is not available or sufficient. Neonatal health care providers can support lactation in the NICU and potentially reduce disparities in the provision of mother's own milk by providing institutional supports for early and frequent milk expression and by promoting skin-to-skin contact and direct breastfeeding, when appropriate. Promotion of human milk and breastfeeding for VLBW infants requires multidisciplinary and system-wide adoption of lactation support practices.

Growth failure of very low birth weight infants during the first 3 years: A Korean neonatal network

We aimed to evaluate risk factors for growth failure in very low birth weight (VLBW) infants at 18-24 months of corrected age (follow-up1, FU1) and at 36 months of age (follow-up2, FU2). In this prospective cohort study, a total of 2,943 VLBW infants from the Korean Neonatal Network between 2013 and 2015 finished follow-up at FU1. Growth failure was defined as a z-score below -1.28. Multiple logistic regression was used to analyze risk factors for growth failure after dividing the infants into small for gestational age (SGA) and appropriate for gestational age (AGA) groups. Overall, 18.7% of infants were SGA at birth. Growth failure was present in 60.0% at discharge, 20.3% at FU1, and 35.2% at FU2. Among AGA infants, male sex, growth failure at discharge, periventricular leukomalacia, treatment of retinopathy of prematurity, ventriculoperitoneal shunt status and treatment of rehabilitation after discharge were independent risk factors for growth failure at FU1. Among SGA infants, lower birth weight, pregnancy-induced hypertension, and treatment of rehabilitation after discharge were independent risk factors for growth failure at FU1. Mean weight z-score graphs from birth to 36 month of age revealed significant differences between SGA and non-SGA and between VLBW infants and extremely low birth weight infants. Growth failure remains an issue, and VLBW infants with risk factors should be closely checked for growth and nutrition.

Cognitive and Behavioral Outcomes of School-aged Children Born Extremely Preterm: a Korean Single-center Study with Long-term Follow-up

BACKGROUND

School-aged children born very preterm have been suggested to have worse cognitive and behavioral outcomes than children born full-term. Executive function (EF) is a higher level of cognitive function related to academic achievement. The present study aimed to evaluate the cognitive (including EF) and behavioral outcomes of Korean children born extremely preterm (EP) and to analyze any biological or socioeconomic risk factors for poor cognitive outcomes in this population.

METHODS

A total of 71 infants weighing < 1,000 g at birth or born before 30 weeks of gestation (EP group) who were admitted to the neonatal intensive care unit from 2008 to 2009 were included in this study and compared with 40 term-birth controls. The Korean Wechsler Intelligence Scale for Children-Fourth Edition, Advanced Test of Attention (ATA), Stroop test, Children's Color Trails Test (CCTT), and Wisconsin Card Sorting Test (WCST) were used. Additionally, the Korean Child Behavior Checklist (K-CBCL) and Korean ADHD Rating Scale (K-ARS) were completed. Perinatal and demographic data were collected and analyzed.

RESULTS

The mean full-scale intelligence quotient (FSIQ) score in the EP group was significantly lower than that of the term control group (89.1 ± 18.3 vs. 107.1 ± 12.7; P < 0.001). In the EP group, 26 (37%) children had an FSIQ score below 85, compared to only one child (3%) in the control group. Furthermore, the EP group showed significantly worse EF test results (ATA, Stroop test, CCTT, WCST). Except for the higher social immaturity subscore in the EP group, the K-CBCL and K-ARS scores were not different between the two groups. EP children who received laser treatment for retinopathy of prematurity (ROP) had an 8.8-fold increased risk of a low FSIQ score, and a 1-point increase in the discharge weight Z-score decreased the risk of a low FSIQ score by approximately half in this EP cohort.

CONCLUSION

This is the first Korean study to investigate the cognitive and behavioral outcomes of school-aged children born EP. In the study cohort, EP children exhibited significantly lower FSIQ scores and EF than their full-term peers, and 37% of them had cognitive problems. Nonetheless, except for social immaturity, the behavioral problems were not different in EP children. Severe ROP and low discharge weight Z-score were identified as independent risk factors for low FSIQ score after adjusting for birth weight.

Variation in Neonatal Nutrition Practice and Implications: A Survey of Australia and New Zealand Neonatal Units

Background: Significant global variation exists in neonatal nutrition practice, including in assigned milk composition values, donor milk usage, fortification regimens, probiotic choice and in methods used to calculate and report nutrition and growth outcomes, making it difficult to synthesize data to inform evidence-based, standardized nutritional care that has potential to improve neonatal outcomes. The Australasian Neonatal Dietitians' Network (ANDiN) conducted a survey to determine the degree to which neonatal nutritional care varies across Australia and New Zealand (A&NZ) and to highlight potential implications.

Materials and Methods: A two-part electronic neonatal nutritional survey was emailed to each ANDiN member (n = 50). Part-One was designed to examine individual dietetic practice; Part-Two examined site-specific nutrition policies and practices. Descriptive statistics were used to examine the distribution of responses.

Results: Survey response rate: 88%. Across 24 NICU sites, maximum fluid targets varied (150–180 mL.kg.d⁻¹); macronutrient composition estimates for mothers' own(MOM) and donor (DM) milk varied (Energy (kcal.dL⁻¹) MOM: 65–72; DM 69–72: Protein (g.dL⁻¹): MOM: 1.0–1.5; DM: 0.8–1.3); pasteurized DM or unpasteurized peer-to-peer DM was not available in all units; milk fortification commenced at different rates and volumes; a range of energy values (kcal.g⁻¹) for protein (3.8–4.0), fat (9.0–10.0), and carbohydrate (3.8–4.0) were used to calculate parenteral and enteral intakes; probiotic choice differed; and at least seven different preterm growth charts were employed to monitor growth.

Discussion: Our survey identifies variation in preterm nutrition practice across A&NZ of sufficient magnitude to impact nutrition interventions and neonatal outcomes. This presents an opportunity to use the unique skillset of neonatal dietitians to standardize practice, reduce uncertainty of neonatal care and improve the quality of neonatal research.

Malnutrition, poor post-natal growth, intestinal dysbiosis and the developing lung

In extremely preterm infants, poor post-natal growth, intestinal dysbiosis and bronchopulmonary dysplasia are common, and each is associated with long-term complications. The central hypothesis that this review will address is that these three common conditions are interrelated. Challenges to studying this hypothesis include the understanding that malnutrition and poor post-natal growth are not synonymous and that there is not agreement on what constitutes a normal intestinal microbiota in this evolutionarily new population. If this hypothesis is supported, further study of whether "correcting" intestinal dysbiosis in extremely preterm infants reduces postnatal growth restriction and/or bronchopulmonary dysplasia is indicated.

Association between postnatal growth and neurodevelopmental impairment by sex at 2 years of corrected age in a multi-national cohort of very preterm children

BACKGROUND & AIMS

Extra-uterine growth restriction (EUGR) is common among very preterm (VPT) infants and has been associated with impaired neurodevelopment. Some research suggests that adverse effects of EUGR may be more severe in boys. We investigated EUGR and neurodevelopment at 2 years of corrected age (CA) by sex in a VPT birth cohort.

METHODS

Data come from a population-based cohort of children born <32 weeks' gestation from 11 European countries and followed up at 2 years CA. Postnatal growth during the neonatal hospitalization was measured with: (1) birthweight and discharge-weight Z-score differences using Fenton charts (2) weight-gain velocity using Patel's model. Published cut-offs were used to define EUGR as none, moderate or severe. Neurodevelopmental impairment was assessed using a parent-report questionnaire, with standardized questions/instruments on motor function, vision, hearing and non-verbal cognition. We estimated relative risks (RR) adjusting for maternal and neonatal characteristics overall and by sex.

RESULTS

Among 4197 infants, the prevalence of moderate to severe impairment at 2 years CA was 17.7%. Severe EUGR was associated with neurodevelopmental impairment in the overall sample and the interaction with sex was significant. For boys, adjusted RR were 1.57 (95% Confidence Intervals (CI): 1.18-2.09) for Fenton's delta Z-score and 1.50 (95% CI: 1.12-2.01) for Patel's weight-gain velocity, while for girls they were 0.97 (0.76-1.22) and 1.12 (0.90-1.40) respectively.

CONCLUSION

EUGR was associated with poor neurodevelopment at 2 years among VPT boys but not girls. Understanding why boys are more susceptible to the effects of poor growth is needed to develop appropriate healthcare strategies.

IGF-I, Growth, and Body Composition in Preterm Infants up to Term Equivalent Age

Context

There are concerns that a higher fat mass in the early life of preterm infants is associated with adverse cardiometabolic outcomes in young adulthood.

Objective

To investigate the role of IGF-I and growth in determining body composition of preterm infants at term equivalent age.

Methods

An observational study was conducted from August 2015 to August 2018. From birth to term equivalent age, IGF-I levels were measured bi-weekly and growth was assessed weekly. At term equivalent age, body composition was assessed through air displacement plethysmography; 65 infants with a gestational age of 24 to 32 weeks were assessed at term equivalent age, of whom 58 completed body composition measurement. The main outcome measures were fat (free) mass (g) and fat (free) mass percentage at term equivalent age.

Results

In the first month of life, each 0.1 nmol/L per week increase in IGF-I was associated with a 465 g (SE 125 g) increase in fat free mass. A greater increase in weight SDS in the first month of life was associated with a higher fat free mass percentage (B 200.9; 95% CI, 12.1-389.6). A higher head circumference SDS was associated with more fat free mass (r = 0.46; 95% CI, 0.21-0.65). However, a greater increase in weight SDS up to term equivalent age was associated with a lower fat free mass percentage (B -55.7, SE 9.4).

Conclusion

These findings suggest that impaired growth in the first month of life is associated with a less favorable body composition at term equivalent age.

Early Enteral Feeding in Preterm Infants: A Narrative Review of the Nutritional, Metabolic, and Developmental Benefits

Enteral feeding is the preferred method of nutrient provision for preterm infants. Though parenteral nutrition remains an alternative to provide critical nutrition after preterm delivery, the literature suggests that enteral feeding still confers significant nutritional and non-nutritional benefits. Therefore, the purpose of this narrative review is to summarize health and clinical benefits of early enteral feeding within the first month of life in preterm infants. Likewise, this review also proposes methods to improve enteral delivery in clinical care, including a proposal for decision-making of initiation and advancement of enteral feeding. An extensive literature review assessed enteral studies in preterm infants with subsequent outcomes. The findings support the early initiation and advancement of enteral feeding impact preterm infant health by enhancing micronutrient delivery, promoting intestinal development and maturation, stimulating microbiome development, reducing inflammation, and enhancing brain growth and neurodevelopment. Clinicians must consider these short- and long-term implications when caring for preterm infants.

Cumulative impact of multiple evidence based strategies on postnatal growth of extremely-low-birth-weight infants

BACKGROUND

Postnatal growth failure is common in very preterm infants and is associated with worse neurodevelopmental outcome.

OBJECTIVE

To evaluate the cumulative impact of multiple evidence based strategies on the postnatal growth of extremely-low-birth-weight (ELBW) infants.

METHODS

We conducted a prospective observational study. Based on current literature, changes were implemented to provide optimal parenteral and enteral nutrition. Daily intakes of calories, protein, lipids and carbohydrates were calculated. The average growth velocity (GV) was calculated using 2-point exponential model and is reported as grams/kg/day. The length and head circumference gains are reported as centimeters/week.

RESULTS

The mean gestational age and birth weight for 38 ELBW survivors were 27.0 ± 2.1 weeks and 752 ± 147 g respectively. The GV was 13.2 ± 2.2 g/kg/day (range 8.8-17.4) and gains in length and head circumference were 0.88 ± 0.9 (range 0.15-1.42) and 0.71 ± 0.5 (range 0.22-0.96) centimeters/week respectively. Twenty nine (76.3%) infants were small-for-gestational-age (SGA) at discharge and 23 of these (60.5% of all infants) had weight below 3rd percentile. All 11 infants who were SGA at birth were SGA at discharge as well. Of 25 appropriate-for-gestational-age (AGA) infants at birth, 16 (64%) were SGA at discharge. The number of infants with length and head circumference below 10th percentile at birth and discharge were 11 (28.9%) and 29 (76.3%) for length and 20 (52.6%) and 27 (71.1%) for head circumference. Infants with multiple morbidities and more hospital days with no enteral feeds had lower GV.

CONCLUSION

All infants born SGA at birth and majority of ELBW survivors born AGA at birth had weight, length and head circumference below 10th percentile at discharge despite aggressive nutrition supplementation.

Comparative effectiveness of liquid human milk fortifiers: A systematic review and meta-analysis

OBJECTIVE

To determine the effectiveness of liquid human milk fortifiers (HMFs) derived from exclusive HM or hydrolyzed protein on growth, necrotizing enterocolitis (NEC), or late-onset sepsis in North American very low-birth-weight (VLBW) infants compared with powder HMFs (control).

METHODS

Prospective trials published between 2009 and 2020 were systematically reviewed, and meta-analysis was conducted by using a random-effects model.

RESULTS

Five studies were identified for up to 591 participants across 39 centers. Study treatments included whey or casein hydrolysate HMF and exclusive HM HMF. Infants fed whey or casein hydrolysate HMF had growth differences compared with the control. No differences were found across treatments in regard to NEC or sepsis.

CONCLUSION

Very low-quality evidence suggests greater linear growth in VLBW infants fed whey hydrolysate liquid HMF, as well as greater weight gain in those fed casein hydrolysate HMF, compared with the control. Additional prospective, multicenter randomized controlled trials are needed to confirm these estimates because of sparsity of evidence. There is insufficient evidence to support HMF decisions regarding NEC or late-onset sepsis prophylaxis.

Lipid Intake and Neurodevelopment in Preterm Infants

Preterm infants are born before the critical period of lipid accretion and brain development that occurs during the third trimester of pregnancy. Dietary lipids serve as an important source of energy and are involved in complex processes that are essential for normal central nervous system development. In addition to traditional neurodevelopmental testing, novel quantitative magnetic resonance imaging (MRI) techniques are now available to evaluate the impact of nutritional interventions on early preterm brain development. Trials of long-chain polyunsaturated fatty acid supplementation have yielded inconsistent effects on neurodevelopmental outcomes and quantitative MRI findings. Recent studies using quantitative MRI suggest a positive impact of early lipid intake on brain volumes and white matter microstructural organization by term-equivalent age.

"Aggressive" Feeding of Very Preterm Neonates and Body Mass Index at School Age

INTRODUCTION

The effects of "aggressive" neonatal feeding policies of very preterm neonates (VPN) and the risk of metabolic syndrome later in life remain questionable. We aimed to evaluate the effect of our "aggressive" nutrition policies of VPN during hospitalisation on body mass index (BMI) at ages 2 and 8 years.

MATERIALS AND METHODS

Eighty four VPN, who received "aggressive" nutrition during hospitalisation in an effort to minimise postnatal growth restriction (PGR) (group A), and 62 term neonates, as controls (group B), were enrolled in the study. Group A was further divided in four subgroups depending on the type (A1: fortified expressed breast milk and preterm formula; A2: exclusively preterm formula) and quantity of milk received (A3: maximum feeds 180-210 mL/kg/day; A4: maximum feeds 210 and up to 260 mL/kg/day). BMI was calculated at ages 2 and 8 years and plotted on the centile charts.

RESULTS

There was no significant difference in BMI between groups A and B at 2 and 8 years, respectively, in both absolute BMI values and their centile chart distribution. There was no significant difference in BMI at 2 and 8 years either between subgroups A1 and A2 or between subgroups A3 and A4.

CONCLUSIONS

"Aggressive" and individualised feeding policy for VPN did not affect the BMI and obesity rates at ages of 2 and 8 years in our study population. The type and quantity of milk feeds had no impact on their BMI at school age. Further larger studies are needed to confirm our results.

Variation in very preterm extrauterine growth in a European multicountry cohort

OBJECTIVE

Extrauterine growth restriction (EUGR) among very preterm infants is related to poor neurodevelopment, but lack of consensus on EUGR measurement constrains international research. Our aim was to compare EUGR prevalence in a European very preterm cohort using commonly used measures.

DESIGN

Population-based observational study.

SETTING

19 regions in 11 European countries.

PATIENTS

6792 very preterm infants born before 32 weeks' gestational age (GA) surviving to discharge.

MAIN OUTCOME MEASURES

We investigated two measures based on discharge-weight percentiles with (1) Fenton and (2) Intergrowth (IG) charts and two based on growth velocity (1) birth weight and discharge-weight Z-score differences using Fenton charts and (2) weight-gain velocity using Patel's model. We estimated country-level relative risks of EUGR adjusting for maternal and neonatal characteristics and associations with population differences in healthy newborn size, measured by mean national birth weight at 40 weeks' GA.

RESULTS

About twofold differences in EUGR prevalence were observed between countries for all indicators and these persisted after case-mix adjustment. Discharge weight <10th percentile using Fenton charts varied from 24% (Sweden) to 60% (Portugal) and using IG from 13% (Sweden) to 43% (Portugal), while low weight-gain velocity ranged from 35% (Germany) to 62% (UK). Mean term birth weight strongly correlated with both percentile-based measures (Spearman's rho=-0.90 Fenton, -0.84 IG, p<0.01), but not Patel's weight-gain velocity (rho: -0.38, p=0.25).

CONCLUSIONS

Very preterm infants have a high prevalence of EUGR, with wide variations between countries in Europe. Variability associated with mean term birth weight when using common postnatal growth charts complicates international benchmarking.

Poor postnatal weight growth is a late finding after sepsis in very preterm infants

OBJECTIVE

To characterise the association between sepsis and postnatal weight growth when accounting for the degree of growth restriction present at birth.

DESIGN

Retrospective matched cohort study using data from the Postnatal Growth and Retinopathy of Prematurity study. Participants were born with birth weights of <1500 g or gestational ages of <32 weeks between 2006 and 2011 at 29 neonatal centres in the USA and Canada. Sepsis was defined as a culture-confirmed bacterial or fungal infection of the blood or cerebrospinal fluid before 36 weeks' postmenstrual age (PMA). Growth was assessed as the change in weight z-score between birth and 36 weeks' PMA.

RESULTS

Of 4785 eligible infants, 813 (17%) developed sepsis and 693 (85%) were matched 1:1 to controls. Sepsis was associated with a greater decline in weight z-score (mean difference -0.09, 95% CI -0.14 to -0.03). Postnatal weight growth failure (decline in weight z- score>1) was present in 237 (34%) infants with sepsis and 179 (26%) controls (adjusted OR 1.49, 95% CI 1.12 to 1.97). Longitudinal growth trajectories showed similar initial changes in weight z-scores between infants with and without sepsis. By 3 weeks after sepsis onset, there was a greater decline in weight z-scores relative to birth values in those with sepsis than without sepsis (delta z-score -0.89 vs -0.77; mean difference -0.12, 95% CI -0.18 to -0.05). This significant difference persisted until 36 weeks or discharge.

CONCLUSION

Infants with sepsis had similar early weight growth trajectories as infants without sepsis but developed significant deficits in weight that were not apparent until several weeks after the onset of sepsis.

D3-creatine dilution for the noninvasive measurement of skeletal muscle mass in premature infants

BACKGROUND

The rate of accrual of muscle mass in neonates has not been assessed. We describe the D₃-creatine (D₃Cr) dilution method, a noninvasive assessment of muscle mass in neonates.

METHODS

A total of 76 neonates >26-week-old corrected gestational age were enrolled and measured at 2-week intervals while admitted to a neonatal intensive care unit (NICU). Additional measures at 6 and 12-20 months after initial measurement were obtained if available. An enteral dose of 2 mg D₃Cr in 0.5 mL 20% ²H₂O was used to determine muscle mass and total body water (TBW).

RESULTS

Muscle mass by the D₃Cr method was strongly associated with TBW and body weight (r = 0.9272, p < 0.0001 and r = 0.9435, p < 0.0001 for all time points and r = 0.6661, p < 0.0001 and r = 0.8634, p < 0.0001, respectively, while in the NICU). Change in muscle mass vs. change in body weight, TBW, and length were also strongly correlated.

CONCLUSIONS

The D₃Cr dilution method provides a noninvasive assessment of muscle mass accrual in neonates, which has not been previously possible and may be an important new tool for the evaluation of nutritional status and normal growth patterns.

IMPACT

We describe a noninvasive method for the measurement of skeletal muscle mass neonates. At the present time, there is no direct measurement of muscle mass in infants available. The D₃Cr dilution method is a direct and noninvasive measurement of muscle mass. Using a single enteral dose of D₃Cr in ²H₂O followed by urine and saliva samples, rapid and substantial accrual of muscle mass and TBW is assessed. Assessment of muscle mass accrual in premature infants may be a strong indicator of nutritional status. Change in muscle mass is strongly related to change in weight and TBW.

Targeting human milk fortification to improve very preterm infant growth and brain development: study protocol for Nourish, a single-center randomized, controlled clinical trial

Background

Human milk is recommended for very preterm infants, but its variable macronutrient content may contribute to undernutrition during a critical period in development. We hypothesize that individually targeted human milk fortification is more effective in meeting macronutrient requirements than the current standard of care.

Methods

We designed a single-center randomized, controlled trial enrolling 130 infants born < 31 completed weeks’ gestation. Participants will receive fortified maternal and/or pasteurized donor milk but no formula. For participants in the intervention group, milk will be individually fortified with protein and fat modulars to achieve target levels based on daily point-of-care milk analysis with mid-infrared spectroscopy, in addition to standard fortification. The study diet will continue through 36 weeks’ postmenstrual age (PMA). Clinical staff and parents will be masked to study group. Primary outcomes include: 1) body length and lean body mass by air displacement plethysmography at 36 weeks’ PMA; 2) quantitative magnetic resonance imaging-based measures of brain size and microstructure at term equivalent age; and 3) Bayley-IV scales at 2 years’ corrected age.

Discussion

We expect this trial to provide important data regarding the effectiveness of individually targeted human milk fortification in the neonatal intensive care unit (NICU).

Trial registration

NCT03977259, registered 6 June, 2019.

In-hospital Growth of Very Low Birth Weight Preterm Infants: Comparative Effectiveness of 2 Human Milk Fortifiers

OBJECTIVE

Amidst a high prevalence of prematurity, limited research on the growth of very low birth weight (VLBW) preterm infants and the availability of a reformulated fortifier c(RF), the study aimed to compare in-hospital growth of such infants receiving exclusively human milk fortified with either of 2 different formulations in a tertiary South African hospital.

METHODS

In a prospective comparative effectiveness design, intakes and growth of VLBW infants on the Original Fortifier (OF; 2016-2017) were compared with those receiving RF (2017-2018). Daily intake was calculated using published composition of preterm and mature milk with fortifier (OF: 0.2 g protein, 3.5kcal/g powder; RF: 0.4 g protein, 4.4 kcal/g powder). Change in z scores from start to end of fortification for weight (WFAZ), length (LFAZ), and head circumference (HCFAZ) for age was the primary outcome. Additionally, weight gain velocity (g · kg-1 · day-1) and gain in length and head circumference (HC) (cm/week) were calculated.

RESULTS

Fifty-eight infants (52% girls; gestational age: 30 ± 2 weeks; birth weight: 1215 ± 187 g) received OF for 16 days and 59 infants (56% girls; gestational age: 29 ± 2 weeks; birth weight 1202 ± 167 g) received RF for 15 days. Protein intake of RF (3.7 ± 0.4 g · kg-1 · day-1) was significantly higher (P < 0.001) than of OF (3.4 ± 0.2 g · kg-1 · day-1). Protein-to-energy ratio of RF (2.6 ± 0.2 g/100 kcal) was significantly higher (P < 0.001) than of OF (2.3 ± 0.1 g/100 kcal). In both groups, WFAZ and LFAZ decreased; HCFAZ improved slightly. No significant differences (P > 0.05) were noted between the 2 groups for change in z scores, weight gain velocity, length or HC gain.

CONCLUSIONS

Despite a modest increase in protein intake and protein-to-energy ratio, the growth of VLBW infants on RF was not better than on OF during their hospital stay.

High versus standard volume enteral feeds to promote growth in preterm or low birth weight infants

BACKGROUND

Human milk is the best enteral nutrition for preterm infants. However, human milk, given at standard recommended volumes, is not adequate to meet the protein, energy, and other nutrient requirements of preterm or low birth weight infants. One strategy that may be used to address the potential nutrient deficits is to give a higher volume of enteral feeds. High volume feeds may improve nutrient accretion and growth, and in turn may improve neurodevelopmental outcomes. However, there are concerns that high volume feeds may cause feed intolerance, necrotising enterocolitis, or complications related to fluid overload such as patent ductus arteriosus and chronic lung disease. This is an update of a review published in 2017.

OBJECTIVES

To assess the effect on growth and safety of high versus standard volume enteral feeds in preterm or low birth weight infants. In infants who were fed fortified human milk or preterm formula, high and standard volume feeds were defined as > 180 mL/kg/day and ≤ 180 mL/kg/day, respectively. In infants who were fed unfortified human milk or term formula, high and standard volume feeds were defined as > 200 mL/kg/day and ≤ 200 mL/kg/day, respectively.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search Cochrane Central Register of Controlled Trials (CENTRAL; 2020 Issue 6) in the Cochrane Library; Ovid MEDLINE (1946 to June 2020); Embase (1974 to June 2020); and CINAHL (inception to June 2020); Maternity & Infant Care Database (MIDIRS) (1971 to April 2020); as well as previous reviews, and trial registries.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared high versus standard volume enteral feeds for preterm or low birth weight infants.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and independently extracted data. We analysed treatment effects in individual trials and reported risk ratio (RR) and risk difference for dichotomous data, and mean difference (MD) for continuous data, with respective 95% confidence intervals (CIs). We used the GRADE approach to assess the certainty of evidence. The primary outcomes were weight gain, linear and head growth during hospital stay, and extrauterine growth restriction at discharge.

MAIN RESULTS

We included two new RCTs (283 infants) in this update. In total, we included three trials (347 infants) in this updated review. High versus standard volume feeds with fortified human milk or preterm formula Two trials (283 infants) met the inclusion criteria for this comparison. Both were of good methodological quality, except for lack of masking. Both trials were performed in infants born at < 32 weeks' gestation. Meta-analysis of data from both trials showed high volume feeds probably improves weight gain during hospital stay (MD 2.58 g/kg/day, 95% CI 1.41 to 3.76; participants = 271; moderate-certainty evidence). High volume feeds may have little or no effect on linear growth (MD 0.05 cm/week, 95% CI -0.02 to 0.13; participants = 271; low-certainty evidence), head growth (MD 0.02 cm/week, 95% CI -0.04 to 0.09; participants = 271; low-certainty evidence), and extrauterine growth restriction at discharge (RR 0.71, 95% CI 0.50 to 1.02; participants = 271; low-certainty evidence). We are uncertain of the effect of high volume feeds with fortified human milk or preterm formula on the risk of necrotising enterocolitis (RR 0.74, 95% CI 0.12 to 4.51; participants = 283; very-low certainty evidence). High versus standard volume feeds with unfortified human milk or term formula One trial with 64 very low birth weight infants met the inclusion criteria for this comparison. This trial was unmasked but otherwise of good methodological quality. High volume feeds probably improves weight gain during hospital stay (MD 6.2 g/kg/day, 95% CI 2.71 to 9.69; participants = 61; moderate-certainty evidence). The trial did not provide data on linear and head growth, and extrauterine growth restriction at discharge. We are uncertain as to the effect of high volume feeds with unfortified human milk or term formula on the risk of necrotising enterocolitis (RR 1.03, 95% CI 0.07 to 15.78; participants = 61; very low-certainty evidence).

AUTHORS' CONCLUSIONS

High volume feeds (≥ 180 mL/kg/day of fortified human milk or preterm formula, or ≥ 200 mL/kg/day of unfortified human milk or term formula) probably improves weight gain during hospital stay. The available data is inadequate to draw conclusions on the effect of high volume feeds on other growth and clinical outcomes. A large RCT is needed to provide data of sufficient quality and precision to inform policy and practice.

Sex Affects Human Premature Neonates' Blood Metabolome According to Gestational Age, Parenteral Nutrition, and Caffeine Treatment

Prematurity is the leading cause of neonatal deaths and high economic costs; it depends on numerous biological and social factors, and is highly prevalent in males. Several factors can affect the metabolome of premature infants. Accordingly, the aim of the present study was to analyze the role played by gestational age (GA), parenteral nutrition (PN), and caffeine treatment in sex-related differences of blood metabolome of premature neonates through a MS/MS-based targeted metabolomic approach for the detection of amino acids and acylcarnitines in dried blood spots. GA affected the blood metabolome of premature neonates: male and female very premature infants (VPI) diverged in amino acids but not in acylcarnitines, whereas the opposite was observed in moderate or late preterm infants (MLPI). Moreover, an important reduction of metabolites was observed in female VPI fed with PN, suggesting that PN might not satisfy an infant's nutritional needs. Caffeine showed the highest significant impact on metabolite levels of male MLPI. This study proves the presence of a sex-dependent metabolome in premature infants, which is affected by GA and pharmacological treatment (e.g., caffeine). Furthermore, it describes an integrated relationship among several features of physiology and health.

Weight, length, and head circumference at 36 weeks are not predictive of later cognitive impairment in very preterm infants

OBJECTIVE

To assess diagnostic accuracy of 36-week anthropometric weight, length, and head circumference <10th and <3rd percentiles to predict preterm infant cognitive impairment.

STUDY DESIGN

Cohort study of 898 preterm <30-week very-low-birth weight (<1500 g) infants. Anthropometric measures' accuracy to predict cognitive impairment (Bayley-III Cognitive Composite score) <80, 21-months corrected age (CA) and Wechsler Preschool and Primary Scale of Intelligence Quotient (intellectual outcomes) <70, 36-months CA, were determined using receiver operating characteristic (ROC) curves.

RESULT

Thirty-six-week weight, length or head circumference <10th or <3rd percentile did not predict cognitive impairment; areas under ROC curves were <0.6. Sensitivities and specificities for 10th and 3rd percentile cut points were all poor, with most not exceeding 70%, whether the Fenton 2013 or INTERGROWTH 2015 growth charts were used. Brain injury and low maternal education were better predictors of cognitive impairment.

CONCLUSION

Preterm infant 36-week anthropometric measurements are not accurate predictors of cognitive impairment.

The indirect calorimetry in very low birth weight preterm infants: An easier and reliable procedure

OBJECTIVES

Preterm infants are at increased risk of developing extrauterine growth restriction, which is associated with worse health outcomes. The energy needs are not well known, as the measurement of resting energy expenditure (REE) using indirect calorimetry has critical issues when applied to infants. One of the main issues is the time required to obtain reliable data owing to the difficulty in keeping infants quiet during the entire examination. Thus, the aim of this study was to define the minimum duration of calorimetry to obtain reliable data.

METHODS

The volume of oxygen consumption (VO₂) and the volume of carbon dioxide production (VCO₂) were recorded for a mean duration of 90 consecutive minutes. REE was calculated using a neonatal prototype calculator. We extracted data regarding VO₂, VCO₂, and REE at 10(T1), 20(T2), 30(T3), 40(T4), and 50(T5) minutes of steady state and compared these data to those of entire steady state period.

RESULTS

Twenty-six very low birth weight preterm infants were evaluated at 36.58 ± 0.99 wk corrected age. Infants were appropriate for gestational age and clinically stable without comorbidities. There were no significant differences between mean VO₂ and REE at T1 (8.26 ± 1.45 mL/kg to 57.80 ± 10.51 kcal/kg), T2 (8.15 ± 1.41 mL/kg to 56.87 ± 10.05 kcal/kg), T3 (8.04 ± 1.41 mL/kg to 56.32 ± 9.73 kcal/kg), T4 (8.05 ± 1.41 mL/kg to 56.07 ± 10.28 kcal/kg), and T5 (8.06 ± 1.55 mL/kg to 57.17 ± 11.62 kcal/kg), respectively, compared to steady state (8.13 ± 1.33 mL/kg to 56.77 ± 9.34 kcal/kg). The median values of VCO₂ were significantly different only when T1 data were compared with other time slots (7.02 ± 1.02 mL/kg at steady state; 7.26 ± 1.23 mL/kg at T1; 7.13 ± 1.20 mL/kg at T2; 7.02 ± 1.19 mL/kg at T3; 6.85 ± 1.16 mL/kg at T4; 6.91 ± 1.24 mL/kg at T5).

CONCLUSION

Twenty consecutive minutes in steady state condition are sufficient to obtain reliable data on REE in stable, very low birth weight infants.

Discharge Age and Weight for Very Preterm Infants: 2005-2018

BACKGROUND

A complex set of medical, social, and financial factors underlie decisions to discharge very preterm infants. As care practices change, whether postmenstrual age and weight at discharge have changed is unknown.

METHODS

Between 2005 and 2018, 824 US Vermont Oxford Network member hospitals reported 314 811 infants 24 to 29 weeks' gestational age at birth without major congenital abnormalities who survived to discharge from the hospital. Using quantile regression, adjusting for infant characteristics and complexity of hospital course, we estimated differences in median age, weight, and discharge weight z score at discharge stratified by gestational age at birth and by NICU type.

RESULTS

From 2005 to 2018, postmenstrual age at discharge increased an estimated 8 (compatibility interval [CI]: 8 to 9) days for all infants. For infants initially discharged from the hospital, discharge weight increased an estimated 316 (CI: 308 to 324) grams, and median discharge weight z score increased an estimated 0.19 (CI: 0.18 to 0.20) standard units. Increases occurred within all birth gestational ages and across all NICU types. The proportion of infants discharged home from the hospital on human milk increased, and the proportions of infants discharged home from the hospital on oxygen or a cardiorespiratory monitor decreased.

CONCLUSIONS

Gestational age and weight at discharge increased steadily from 2005 to 2018 for survivors 24 to 29 weeks' gestation with undetermined causes, benefits, and costs.

Somatic Growth of Enteral-Only Fed Extremely Low Birth Weight Infants in a Resource-Restricted Setting

AIM

To determine the growth and prevalence of extrauterine growth restriction (EUGR) in extremely low birth weight (ELBW) infants receiving enteral-only nutrition in a resource-restricted (RR) environment.

METHODS

Information on nutritional intake, provided largely from fortified breastmilk, was collected retrospectively for 72 ELBW (<1000 g) infants admitted to Tygerberg Hospital, Cape Town, South Africa over a 1 year period. Anthropometric data for the first 49 postnatal days were compared to gender-specific INTERGROWTH-21st standards.

RESULTS

Full enteral feeds (150 ml/kg) were reached by Day 10-14 with energy >100 Kcal/kg/day from Day 10, and protein >3.5 mg/kg/day from Day 14, onwards. Growth velocity remained below 15 g/kg/day at Day 49. INTERGROWTH-21st Z-scores decreased from -0.8 ± 1.1 at birth to -2.4 ± 1.5 at Day 49. Adequate weight growth velocity (≥15 g/kg/day) was associated with maternal hypertension, completed antenatal steroids, caesarean section delivery and small for gestational age status.

CONCLUSION

This is the first study to evaluate growth of ELBW infants in a RR setting where enteral-only nutrition, principally from fortified breastmilk, was the primary feeding option. The incidence of EUGR, although high, was similar to the incidence in well-resourced settings, where total parenteral nutrition is routinely provided. Lay summaryExtra-uterine growth restriction (EUGR) is high in extremely low birth weight infants receiving enteral-only nutrition. However, EUGR rates are similar to infants receiving parenteral nutrition. Despite developmental immaturity, it is possible for these infants to achieve fetal growth rates. More aggressive feeding and fortification strategies may be necessary and will need to be balanced against the risk and fear of necrotizing enterocolitis. Enteral-only feeding regimens, especially in resource-restricted environments, should be audited regularly to ensure provision of feeds with the most optimal protein, and protein to energy ratios possible.

IL-6 Predicts Poor Early Post-Natal Growth in Very Low-Birth-Weight Infants in a Low-Middle Income Setting

BACKGROUND

Extra-uterine growth restriction (EUGR) is common in preterms and may be associated with elevated pro-inflammatory cytokines.

OBJECTIVE

Describe postnatal growth in a cohort of very low-birth-weight (VLBW) infants and determine the association of interleukin-6 (IL-6) and tumour necrosis factor alpha (TNF-α) in umbilical cord blood with growth at 40 weeks and 12 months postmenstrual age (PMA).

METHODS

Single-centre, prospective cohort study conducted from 1 June 2017 to 31 January 2019 with follow-up to 31 March 2020. Infants <1500 g at birth were enrolled, cord blood collected for IL-6 and TNF-α assays and postnatal care, including anthropometry, provided to 12 months PMA. Informed consent and ethics approval were obtained.

RESULTS

In total, 279 patients were enrolled; 84 (30.1%) died before 12 months and 91 (32.6%) lost to follow-up. Anthropometry was available for 151 infants at 40 weeks and 105 at 12 months. Z-Scores at 40 weeks for males and females combined were -2.5, -2.1 and -1.2 for weight, length and head circumference. EUGR occurred in 103/113 (91.2%), 98/107 (91.6%) and 70/109 (64.2%) participants for weight, length and head circumference. Elevated IL-6 was associated with restricted weight (56.0 vs. 14.5 pg/ml, p = 0.02) and length (60.4 vs. 7.3 pg/ml, p = 0.01) at 40 weeks. There was no difference in IL-6 at 12 months and no difference in TNF-α at 40 weeks or 12 months.

CONCLUSION

The study reports significant EUGR. Elevated IL-6 was associated with growth restriction at 40 weeks but not 12 months PMA.

Digestive enzyme replacement relieves growth failure in preterm infants with poor exocrine pancreatic function: a retrospective case series

In orally fed preterm infants, poor weight gain may be linked to low fecal pancreatic elastase-1 (FPE-1) activity, indicative of exocrine pancreatic insufficiency. The objective of this study was the retrospective assessment of the effect of exogenous digestive enzyme replacement by gavage in preterm infants with growth failure and low FPE-1 (<200 μg/g). We analyzed weight gain relative to baseline and caloric intake during 14-day periods before and after institution of digestive enzyme replacement containing 6000 U lipase and 240 U protease kg^-1 d^-1. Among 46 of 132 preterm infants < 1250g birth weight surviving to at least 14 days in whom FPE-1 was determined, 38 infants had low FPE-1 (< 200 μg/g), and 33 infants received exogenous digestive enzyme replacement. Average daily weight gain significantly increased from 14.4 [range 2.6-22.4] g kg^-1 d^-1 to 17.4 [8.4-29.0] g kg^-1 d^-1 (P = 0.001), as did weight gain per kcal, from 0.08 [0.02-0.13] g kcal^-1 d^-1 to 0.11 [0.05-0.18] g kcal^-1 d^-1.Conclusion: In preterm infants with signs and symptoms of exocrine pancreatic insufficiency, exogenous digestive enzyme replacement is associated with improved growth. What is Known: • Very preterm infants on full enteral nutrition may display growth failure linked to transient poor exocrine pancreatic function. • Porcine pancreatic enzymes covered with an acid-resistant coating are too large to pass the internal diameter of most gavage tubes used in very preterm infants. What is New: • Administration of a liquid formulation of acid-resistant microbial digestive enzymes in preterm infants with growth failure and low fecal pancreatic elastase-1 values was associated with improved weight gain. • Response to exogenous digestive enzyme replacement was associated with the prior extent of growth failure.

Nutritional practices and growth of preterm infants in two neonatal units in the UK and Malaysia: a prospective exploratory study

OBJECTIVE

To explore differences in nutritional practices and growth outcomes among preterm infants in neonatal units in Malaysia and the UK.

DESIGN

Prospective exploratory study of infants born at <34 weeks gestational age (GA).

SETTING

Two neonatal units, one in Malaysia and one in the UK (May 2019 to March 2020).

METHODS

Data collected from birth until discharge and compared between units.

RESULTS

From 100 infants included, median GA (IQR) was 31 (30-33) and mean±SD birth weight was 1549±444 g. There were more small-for-gestational age infants in Malaysian unit: 12/50 (24%) vs UK: 3/50 (6%), p=0.012 and more morbidities. More Malaysian infants received breast milk (Malaysia: 49 (98%) vs UK: 38 (76%), p=0.001), fortified breast milk (Malaysia: 43 (86%) vs UK: 13 (26%), p<0.001) and exclusive breast milk at discharge (Malaysia: 26 (52%) vs UK: 16 (32%), p=0.043). There was higher parenteral nutrition use among Malaysian infants (40/50 (80%)) vs UK (19/50 (38%)) (p<0.001) with higher protein intake (mean±SD Malaysia: 3.0±0.5 vs UK: 2.7±0.6 g/kg/d, p=0.004) in weeks 1-4 and smaller cumulative protein deficits (mean±SD Malaysia: 11.4±6.1 vs UK: 15.4±8.0 g/kg, p=0.006). There were no significant differences in short-term growth between units and more than half of the infants in both units had ≥1.28 changes in weight-for-age Z-score at discharge (p=0.841).

CONCLUSIONS

An exploratory comparison of practices showed differences in patient characteristics and nutritional practices which impacted growth. Future studies with larger sample sizes and detailed analysis of maternal characteristics and infants' outcomes are needed for improving care of preterm infants in all settings.

Antenatal and neonatal factors contributing to extra uterine growth failure (EUGR) among preterm infants in Boston Birth Cohort (BBC)

OBJECTIVE

Identify antenatal and neonatal factors associated with primary outcome of EUGR.

METHODS

1063 preterm infants from a subset of the BBC were included in this prospective cohort study. Regression analysis was carried out to evaluate associations of EUGR with antenatal factors and neonatal factors.

RESULTS

6.1% of the infants had in-utero growth restriction (IUGR) at birth and 21.7% of infants had EUGR. The adjusted odds ratio for EUGR status were significant for birth weight (OR 0.99, p = 0.00, CI 0.99-0.99), for GA at birth (OR 4.58, p = 0.00, CI 3.25-6.44), for PDA (OR 2.9, p = 0.02, CI 1.17-7.1), for NEC (OR 5.14, p = 0.012, CI 1.44-18.3) and for day of life of reaching full feeds (OR 1.04, p = 0.001, CI 1.01-1.06).

CONCLUSION

This study highlights important factors associated with EUGR. Additional studies are needed to gain further insight.

Extrauterine growth restriction in extremely preterm infants based on the Intergrowth-21st Project Preterm Postnatal Follow-up Study growth charts and the Fenton growth charts

Growth charts are essential for monitoring the postnatal growth of preterm infants. The preterm postnatal follow-up study (PPFS) of the Intergrowth-21st Project provides new growth standards based on a longitudinal study. This study was conducted to investigate the prevalence of extrautrine growth restriction (EUGR) and the associated factors of EUGR in preterm infants, using the PPFS charts and the Fenton charts. Data of 1,356 infants with gestational age (GA) less than 28 weeks from the Korean Neonatal Network were analysed. The prevalence of small for gestational age (SGA) of weight and length was higher with the Intergrowth charts than with the Fenton charts. EUGR in weight and length was more prevalent when using the Fenton charts. Multivariate analysis showed that low GA, high birthweight z score, male, treated patent ductus arteriosus (PDA), necrotizing enterocolitis, intraventricular haemorrhage and duration of parenteral nutrition (PN) were associated with EUGR in weight by the Intergrowth charts. High birthweight z score, treated PDA and PN duration were associated with EUGR defined by the Fenton charts.Conclusion: Compared to the Fenton charts, SGA was more defined and EUGR was less prevalent in extremely low gestational infants, while EUGR defined by the Intergrowth charts categorized infants with adverse clinical courses more elaborately. What is Known: • Preterm infants are at risk of postnatal growth restriction (PGR), although optimal postnatal growth is important for the long-term outcomes. • Growth charts are essential tools to monitor the postnatal growth of preterm infants. What is New: • PGR of weight and length were less defined with the Intergrowth charts than the Fenton charts. • PGR defined by the Intergrowth preterm postnatal follow-up study (PPFS) chart categorized preterm infants with morbidities more elaborately than the Fenton charts.

High Early Parenteral Lipid in Very Preterm Infants: A Randomized-Controlled Trial

OBJECTIVE

To determine whether high early parenteral soybean oil lipid intake in very low birth weight (VLBW) infants in the first week after birth decreases the proportion of weight loss and subsequently the incidence of extrauterine growth restriction (EUGR).

STUDY DESIGN

This was a randomized controlled trial of appropriate for gestational- ge VLBW infants. Lipid intake in the control group started at 0.5-1 g/kg per day and increased daily by 0.5-1 g/kg per day till reaching 3 g/kg per day. The intervention group was started on 2 g/kg per day that increased to 3 g/kg per day the following day.

RESULTS

Of the 176 infants assessed for eligibility, 83 were included in the trial. Infants in the intervention group were started on lipid sooner (13.8 ± 7.8 vs 17.5 ± 7.8 hour; P = .03) and had higher cumulative lipid intake in the first 7 days of age (13.5 ± 4.2 vs 10.9 ± 3.5 g/kg per day; P = .03). Infants in the intervention group had a lower percentage of weight loss (10.4 vs 12.7%; P = .02). The mean triglyceride level was higher in the intervention group (1.91 ± 0.79 vs 1.49 ± 0.54 mmol/L; P = .01), however, hypertriglyceridemia was similar between the 2 groups. The incidence of EUGR was lower in the intervention group (38.6% vs 67.6%; P = .01). Head circumference z score was higher in the intervention group (-1.09 ± 0.96 vs -1.59 ± 0.98; P = .04).

CONCLUSIONS

In VLBW infants, provision of a high early dose of parenteral lipid in the first week of age results in less weight loss and lower incidence of EUGR.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT03594474.

Sex differences in postnatal weight gain trajectories of extremely preterm newborns

OBJECTIVE

Both postnatal growth and sex play a crucial role in long-term outcomes of extremely preterm newborns (EPNs), but the relationship between sex and postnatal growth is not clear. This study aims to assess sex differences in weight trajectories.

STUDY DESIGN

Weight data in the first 200 days of life from 4327 EPNs were used for generalized additive mixed modeling. We considered gestational age and sex as fixed-effects, and included random intercepts and random slopes for postnatal age. We assessed interactions between fixed-effects and postnatal age.

RESULTS

Male EPNs had higher predicted weight trajectories than females. Weight z-score trajectories decreased in both sexes before term-equivalent age comparably, but females showed faster increases afterward. Although weight gain velocity was comparable between both sexes, weight gain velocity in male EPNs was lower compared to the corresponding reference values from the 2013 Fenton growth charts, which explained slower z-score rises.

CONCLUSION

Sex disparity exists in postnatal weight gain trajectories of EPNs after reaching the term-equivalent age.

Extrauterine Growth Restriction in Very Low Birth Weight Infants: Concordance Between Fenton 2013 and INTERGROWTH-21st Growth Charts

Postnatal growth restriction has high prevalence in very low birth weight (VLBW) preterm neonates, and this could affect their long-term prognosis. Nowadays, there is no consensus on how to monitor growth in these neonates. Objective: This study aimed to compare prevalence of intra- and extrauterine growth restriction (IUGR and EUGR) in a sample of VLBW infants according to the Fenton 2013 charts and INTERGROWTH-21st (IW-21) standards and to analyze concordance between both in the different EUGR definitions criteria (cross-sectional, dynamic, and true). Patients and Methods: An observational retrospective study of 635 VLBW preterm was performed. The study was carried out in Central University Hospital of Asturias. Body measurements (weight, length, and head circumference) were collected at birth and at hospital discharge and expressed in z-scores for the two references (Fenton 2010 and IW-21). Kappa concordance was calculated. Results: Kappa concordance between Fenton and IW-21 was 0.887 for IUGR and 0.580 for static EUGR. Prevalence was higher according to Fenton in IUGR (36.5 vs. 35.1%), in static EUGR (73.8 vs. 59.3%), and in dynamic EUGR (44.3 vs. 29.3%). Despite observing low prevalence of EUGR when IW-21 was used to define EUGR, a statistical association between neonatal morbidity and diagnosis of EUGR was observed. Conclusion: The Fenton and IW-21 concordance for IUGR is good. IW-21 is more restrictive than Fenton in EUGR. Patients diagnosed by IW-21 as EUGR are more likely to have neonatal morbidity, especially if we use EUGR dynamic definition. In our study, we cannot conclude that one graph is better than the other.

Effects of standardized feeding protocol on growth velocity and necrotizing enterocolitis in extremely low birth weight infants

OBJECTIVE

To assess the effect of a standardized feeding protocol (SFP) on growth velocity (GV) and necrotizing enterocolitis (NEC) in extremely low birth weight infants.

METHODS

This single-study center retrospectively compared growth, nutritional, and gastrointestinal outcomes in two infant cohorts before (cohort 1; n = 145) and after (cohort 2; n = 69) SFP implementation.

RESULTS

Although weekly GV in the first 4 weeks of life did not differ between the two cohorts, median GV at 36 weeks' post-menstrual age (PMA) was higher in cohort 2 compared with cohort 1 (26.8 g/day [24.7, 28.9] vs 24.9 g/day [22.9, 28.3], p = 0.02). The odds of NEC were lower in cohort 2 by 63% after adjusting for birth weight, small-for-gestational-age, and gender (OR = 0.38, 95% CI 0.142-0.993, p = 0.047).

CONCLUSION

Our SFP was associated with improved GV at 36 weeks' PMA and a lower adjusted rate of NEC.

Early full enteral feeding for preterm or low birth weight infants

BACKGROUND

The introduction and advancement of enteral feeds for preterm or low birth weight infants is often delayed because of concerns that early full enteral feeding will not be well tolerated or may increase the risk of necrotising enterocolitis. Early full enteral feeding, however, might increase nutrient intake and growth rates; accelerate intestinal physiological, metabolic, and microbiomic postnatal transition; and reduce the risk of complications associated with intravascular devices for fluid administration.  OBJECTIVES: To determine how early full enteral feeding, compared with delayed or progressive introduction of enteral feeds, affects growth and adverse events such as necrotising enterocolitis, in preterm or low birth weight infants.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search Cochrane Central Register of Controlled Trials; MEDLINE Ovid, Embase Ovid, Maternity & Infant Care Database Ovid, the Cumulative Index to Nursing and Allied Health Literature, and clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials to October 2020.

SELECTION CRITERIA

Randomised controlled trials that compared early full enteral feeding with delayed or progressive introduction of enteral feeds in preterm or low birth weight infants.

DATA COLLECTION AND ANALYSIS

We used the standard methods of Cochrane Neonatal. Two review authors separately assessed trial eligibility, evaluated trial quality, extracted data, and synthesised effect estimates using risk ratios (RR), risk differences, and mean differences (MD) with 95% confidence intervals (CI). We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included six trials. All were undertaken in the 2010s in neonatal care facilities in India. In total, 526 infants participated. Most were very preterm infants of birth weight between 1000 g and 1500 g. Trials were of good methodological quality, but a potential source of bias was that parents, clinicians, and investigators were not masked. The trials compared early full feeding (60 mL/kg to 80 mL/kg on day one after birth) with minimal enteral feeding (typically 20 mL/kg on day one) supplemented with intravenous fluids. Feed volumes were advanced daily as tolerated by 20 mL/kg to 30 mL/kg body weight to a target steady-state volume of 150 mL/kg to 180 mL/kg/day. All participating infants were fed preferentially with maternal expressed breast milk, with two trials supplementing insufficient volumes with donor breast milk and four supplementing with preterm formula.  Few data were available to assess growth parameters. One trial (64 participants) reported a slower rate of weight gain (median difference -3.0 g/kg/day), and another (180 participants) reported a faster rate of weight gain in the early full enteral feeding group (MD 1.2 g/kg/day). We did not meta-analyse these data (very low-certainty evidence). None of the trials reported rate of head circumference growth. One trial reported that the mean z-score for weight at hospital discharge was higher in the early full enteral feeding group (MD 0.24, 95% CI 0.06 to 0.42; low-certainty evidence). Meta-analyses showed no evidence of an effect on necrotising enterocolitis (RR 0.98, 95% CI 0.38 to 2.54; 6 trials, 522 participants; I² = 51%; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Trials provided insufficient data to determine with any certainty how early full enteral feeding, compared with delayed or progressive introduction of enteral feeds, affects growth in preterm or low birth weight infants. We are uncertain whether early full enteral feeding affects the risk of necrotising enterocolitis because of the risk of bias in the trials (due to lack of masking), inconsistency, and imprecision.

Change in body composition of premature infants from parenteral nutrition discontinuation to term equivalent age

AIM

To compare body composition (BC) of premature infants at parenteral nutrition (PN) suspension and at term equivalent age (TEA).

METHODS

Body weight, fat mass (FM), fat free mass (FFM) and FM as % of body weight were measured in infants born at <32 gestational weeks by air-displacement plethysmography at PN suspension and at TEA in a tertiary level hospital. Z-scores were calculated for BC and anthropometric measurements. Nutritional and clinical data were obtained during hospital stay. BC, weight and length were measured at birth in a sample of infants born at term for comparison.

RESULTS

Thirty premature infants with birth weight of 1198 ± 270 g and gestational age of 29.8 ± 1.8 weeks were included. At PN suspension, at 32.6 ± 1.6 postconceptional weeks, FFM z-score was similar to FFM z-score measured at TEA, at 39.8 ± 0.7 postconceptional weeks (-1.43 ± 1.27 vs -1.78 ± 1.64, p = 0.26), while FM z-score and %FM z-score at PN suspension were lower than those measured at TEA (FM z-score: 0.23 ± 0.62 versus 2.04 ± 1.00, p < 0.0001 and %FM z-score: 0.66 ± 0.76 versus 2.08 ± 1.07, p < 0.0001). At TEA, weight and length of premature infants were similar to those of term-born infants (3130 ± 340 g vs 3350 ± 340 g; 49.2 ± 2.4 cm vs 50.2 ± 2.5 cm, respectively), but %FM was higher (21.3 ± 4.2% vs 9.2 ± 4.4%, p < 0.001); higher exclusive enteral caloric and protein intakes were associated with a decrease in FM z-scores from PN suspension to TEA.

CONCLUSION

In our sample of premature infants, fat free mass z-score was similar, while fat mass and % fat mass z-scores increased substantially from parenteral nutrition suspension to term-equivalent age. Nutritional intakes during exclusive enteral nutrition did not seem to contribute to such increase.

Clinical and Nutritional Determinants of Extrauterine Growth Restriction Among Very Low Birth Weight Infants

Purpose

To identify the clinical and nutritional factors associated with extrauterine growth restriction (EUGR) among very low birth weight infants (VLBW) in a tertiary hospital in Jordan.

Patients and Methods

We conducted a retrospective analysis of all VLBW infants admitted at King Abdullah University Hospital between July 2015 and June 2020. Clinical factors, nutritional intake, and growth parameters were collected and analyzed. A multilogistic regression model was applied to identify factors associated with EUGR.

Results

Of the 247 VLBW infants included in analysis, 112 (45%) were males, 30 (12%) were below 1000 g, and 72 (29%) were small for gestational age (SGA). EUGR was diagnosed in 198 (80%) at discharge. The rates of EUGR among SGA and non-SGA infants were 97% and 73%, respectively. The EUGR infants had a higher gestational age (30.7 vs 29.8 weeks, p=0.04), a lower birth weight (1209 vs 1300 g, p=0.005), a longer ventilatory support (5.7 vs 2.2 days, p=0.03), a higher incidence of sepsis (23% vs 10%, p=0.05), and a longer hospitalization (46 vs 38 days, p=0.03). With multilogistic regression model, the factors associated with EUGR include small-for-gestational age (AOR 9, 95% C.I. 2, 50), >3-day delay in feeding initiation (AOR 3.8, 95% C.I. 1.2,10), >14-day delay in achieving full feeds (AOR 3.3, 95% C.I. 1.2, 8), <3 g/kg of protein intake on the 8th day (AOR 2.1, 95% C.I. 1.1, 4.1), <100 kcal/kg of total caloric intake on the 15th day (AOR 3.8, 95% C.I. 1.6, 8.9), and occurrence of sepsis (AOR 3, 95% C.I. 1.1, 9).

Conclusion

The rate of EUGR in our unit is high. In addition to being SGA at birth, sepsis and suboptimal protein and caloric intake in the first two weeks of life were significantly associated with this complication. A more aggressive enteral and parenteral nutritional approach is needed to minimize postnatal growth delay.

Sustaining improved nutritional support for very low birthweight infants

Background

Postnatal growth failure (PGF) in very low birthweight (VLBW) infants is a result of factors such as prematurity, acute illness and suboptimal nutritional support. Before this project began, 84% of appropriately grown VLBW infants in our neonatal intensive care unit experienced PGF. The aims of this quality improvement project were to reduce the percentage of infants discharged with PGF to less than 50% within 2 years and to maintain a rate of PGF under 50%.

Methods

All inborn VLBW infants were eligible for this study. Infants with congenital anomalies were excluded. We determined key drivers for optimal nutrition and identified potentially better practices (process measures) based on a review of the literature, which included more rapid initiation of starter total parenteral nutrition (TPN), aggressive use and advancement of regular TPN, and fortification of human milk when the volume of intake reached 80 mL/kg/day. Three Plan-Do-Study-Act (PDSA) cycles were tested.

Results

Time to initiation of starter TPN was significantly reduced from 5.5 hours to under 3 hours. Regular TPN provided the goals for amino acids and lipids at increased frequency after the first two PDSA cycles. The proportion of infants whose milk was fortified at 80 mL/kg/day increased after the third PDSA cycle.

Conclusions

We found a sustained decrease in the percentage of infants discharged with PGF from 84% at baseline to fewer than 50% beginning in 2010–2011 through 2016, with 23.1% of infants experiencing PGF in 2016. We have achieved improved nutritional support for VLBW infants using the model for improvement.

Individualized versus standard diet fortification for growth and development in preterm infants receiving human milk

BACKGROUND

Human milk as compared to formula reduces morbidity in preterm infants but requires fortification to meet their nutritional needs and to reduce the risk of extrauterine growth failure. Standard fortification methods are not individualized to the infant and assume that breast milk is uniform in nutritional content. Strategies for individualizing fortification are available; however it is not known whether these are safe, or if they improve outcomes in preterm infants.

OBJECTIVES

To determine whether individualizing fortification of breast milk feeds in response to infant blood urea nitrogen (adjustable fortification) or to breast milk macronutrient content as measured with a milk analyzer (targeted fortification) reduces mortality and morbidity and promotes growth and development compared to standard, non-individualized fortification for preterm infants receiving human milk at < 37 weeks' gestation or at birth weight < 2500 grams.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 9), in the Cochrane Library; Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), on September 20, 2019. We also searched clinical trials databases and the reference lists of retrieved articles for pertinent randomized controlled trials (RCTs) and quasi-randomized trials.

SELECTION CRITERIA

We considered randomized, quasi-randomized, and cluster-randomized controlled trials of preterm infants fed exclusively breast milk that compared a standard non-individualized fortification strategy to individualized fortification using a targeted or adjustable strategy. We considered studies that examined any use of fortification in eligible infants for a minimum duration of two weeks, initiated at any time during enteral feeding, and providing any regimen of human milk feeding.

DATA COLLECTION AND ANALYSIS

Data were collected using the standard methods of Cochrane Neonatal. Two review authors evaluated the quality of the studies and extracted data. We reported analyses of continuous data using mean differences (MDs), and dichotomous data using risk ratios (RRs). We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

Data were extracted from seven RCTs, resulting in eight publications (521 total participants were enrolled among these studies), with duration of study interventions ranging from two to seven weeks. As compared to standard non-individualized fortification, individualized (targeted or adjustable) fortification of enteral feeds probably increased weight gain during the intervention (typical mean difference [MD] 1.88 g/kg/d, 95% confidence interval [CI] 1.26 to 2.50; 6 studies, 345 participants), may have increased length gain during the intervention (typical MD 0.43 mm/d, 95% CI 0.32 to 0.53; 5 studies, 242 participants), and may have increased head circumference gain during the intervention (typical MD 0.14 mm/d, 95% CI 0.06 to 0.23; 5 studies, 242 participants). Compared to standard non-individualized fortification, targeted fortification probably increased weight gain during the intervention (typical MD 1.87 g/kg/d, 95% CI 1.15 to 2.58; 4 studies, 269 participants) and may have increased length gain during the intervention (typical MD 0.45 mm/d, 95% CI 0.32 to 0.57; 3 studies, 166 participants). Adjustable fortification probably increased weight gain during the intervention (typical MD 2.86 g/kg/d, 95% CI 1.69 to 4.03; 3 studies, 96 participants), probably increased gain in length during the intervention (typical MD 0.54 mm/d, 95% CI 0.38 to 0.7; 3 studies, 96 participants), and increased gain in head circumference during the intervention (typical MD 0.36 mm/d, 95% CI 0.21 to 0.5; 3 studies, 96 participants). We are uncertain whether there are differences between individualized versus standard fortification strategies in the incidence of in-hospital mortality, bronchopulmonary dysplasia, necrotizing enterocolitis, culture-proven late-onset bacterial sepsis, retinopathy of prematurity, osteopenia, length of hospital stay, or post-hospital discharge growth. No study reported severe neurodevelopmental disability as an outcome. One study that was published after our literature search was completed is awaiting classification.

AUTHORS' CONCLUSIONS

We found moderate- to low-certainty evidence suggesting that individualized (either targeted or adjustable) fortification of enteral feeds in very low birth weight infants increases growth velocity of weight, length, and head circumference during the intervention compared with standard non-individualized fortification. Evidence showing important in-hospital and post-discharge clinical outcomes was sparse and of very low certainty, precluding inferences regarding safety or clinical benefits beyond short-term growth.

A comparison of macronutrient-based methods for deriving energy values in human milk

OBJECTIVE

Energy values for human milk are increasingly available clinically, though there are no standards for deriving these values. We compared published calorie methods using a common set of samples.

STUDY DESIGN

Ten human milk samples were measured for gross and digestible macronutrients using laboratory methods. Four calorie conversion factors were used: Atwater general (ATW-GEN); Atwater milk specific (ATW-MILK), human milk specific (HUM-MILK), and combustible conversions (COMBUST). Differences in derived calories were assessed using ANOVA.

RESULTS

There was a significant difference (P < 0.001) in calorie values between methods. Gross macronutrients with COMBUST conversion factors produced the highest calorie values (19.4 ± 1.4 kcal/ounce) whereas digestible macronutrients with HUM-MILK conversion factors produced the lowest calorie values (16.3 ± 1.3 kcal/ounce). Mean difference between these values was 3.1 kcal/ounce (95% CI 2.5, 3.7).

CONCLUSION

Mean calorie difference of 3.1 kcal/ounce is clinically important for preterm infants, suggesting the need for standardization.