L’alimentation parentérale du prématuré : comment la prescrire pour optimiser la croissance et le développement

Expert consensus on clinical management of metabolic bone disease of prematurity (2021)

Metabolic bone disease of prematurity (MBDP) is a systemic bone disease with a reduction in bone mineral content due to disorder of calcium and phosphorus metabolism. There is still a lack of in-depth research and systematic understanding of MBDP in China, and there are many irregularities in clinical management of this disease. Based on relevant studies in China and overseas, Grading of Recommendations Assessment, Development and Evaluation was used to develop the expert consensus on the clinical management of MBDP, which provides recommendations from the following five aspects: high-risk factors, screening/diagnosis, prevention, treatment, and post-discharge follow-up of MBDP, so as to provide relevant practitioners with recommendations on the clinical management of MBDP to reduce the incidence rate of MBDP and improve its short- and long-term prognosis.

15-Year trends in respiratory care of extremely preterm infants: Contributing factors and consequences on health and growth during hospitalization

OBJECTIVES

To review 15-year trends in respiratory care of extremely preterm infants managed in a tertiary perinatal center; to identify the factors contributing to their evolution; and to determine whether these changes had an impact on infant mortality, severe morbidity, and growth.

METHODS

Retrospective cohort study of infants born at 23 to 26 weeks' gestation between 2003 and 2017. Changes in respiratory care were assessed in three 5-year periods. Logistic regression was used to examine the factors associated with prolonged duration (ie, greater than the median) of invasive mechanical ventilation (IMV), noninvasive ventilation (NIV), and overall respiratory support (ORS), and those associated with adequate weight and head circumference growth.

RESULTS

Of the 396 actively treated neonates, 268 (68%) survived to discharge. Between the first and third periods, IMV duration decreased from 22 (6-37) to 4 (1-14.0) days (P < .001), that of NIV increased from 24 (14-34) to 56 (44-66) days (P < .001), and that of ORS from 50 (34-68) to 63 (52-77) days (P < .001). Study period (2003-2007 vs 2013-2017) was the main factor associated with prolonged IMV (P < .001). Use of high-flow nasal cannula was the main factor associated with prolonged NIV (P = .02) and ORS (P = .02). NIV duration was associated with adequate postnatal weight (P = .003) and head circumference (P = .03) growth. Severe morbidities in survivors, including bronchopulmonary dysplasia, and survival at hospital discharge were comparable across the study periods.

CONCLUSIONS

Respiratory management was characterized by a marked reduction in IMV. NIV withdrawal protocols are necessary to limit ORS duration while respecting postnatal growth requirements.

Impact of introducing a standardized nutrition protocol on very premature infants' growth and morbidity

Background

Inappropriate nutritional intake in premature infants may be responsible for postnatal growth restriction (PGR) and adverse long-term outcomes.

Objective

We evaluated the impact of an updated nutrition protocol on very premature infants’ longitudinal growth and morbidity, and secondly the compliance to this new protocol.

Design

All infants born between 26–32 weeks gestation (GA) were studied retrospectively during two 6-month periods before (group 1) and after (group 2) the introduction of an optimized nutrition protocol, in a longitudinal comparative analysis.

Results

158 infants were included; 72 before and 86 after the introduction of the protocol (Group 1: (mean±SD) birthweight (BW) 1154±276 g, GA 29.0±1.4 weeks; Group 2: BW 1215±332 g, GA 28.9±1.7 weeks). We observed growth improvement in Group 2 more pronounced in males (weight z-score) at D42 (−1.688±0.758 vs. −1.370±0.762, p = 0.045), D49 (−1.696±0.776 vs. −1.370±0.718, p = 0.051), D56 (−1.748±0.855 vs. −1.392±0.737, p = 0.072), D63 (−1.885±0.832 vs. −1.336±0.779 p = 0.016), and D70 (−2.001±0.747 vs. −1.228±0.765 p = 0.004). There was no difference in females or in morbidities between the groups. We observed low compliance to the protocol in both groups: similar energy intake but higher lipid intake in Group 1 and higher protein intake in Group 2.

Conclusion

The quality of nutritional care with a strictly-defined protocol may significantly improve weight gain for very preterm infants. As compliance remained low, an educational reinforcement is needed to prevent PGR.

Clinical trial registration

This retrospective study was registered by ClinicalTrials.gov under number NCT03217045, and by the CNIL (Commission Nationale de l’Informatique et des Libertés) under study number R2015-1 for the Maternity of the CHRU of Nancy.

Parenteral nutrition for preterm infants: Issues and strategy

Due to transient gut immaturity, most very preterm infants receive parenteral nutrition (PN) in the first few weeks of life. Yet providing enough protein and energy to sustain optimal growth in such infants remains a challenge. Extrauterine growth restriction is frequently observed in very preterm infants at the time of discharge from hospital, and has been found to be associated with later impaired neurodevelopment. A few recent randomized trials suggest that intensified PN can improve early growth; whether or not such early PN improves long-term neurological outcome is still unclear. Several other questions regarding what is optimal PN for very preterm infants remain unanswered. Amino acid mixtures designed for infants contain large amounts of branched-chain amino acids and taurine, but there is no consensus on the need for some nonessential amino acids such as glutamine, arginine, and cysteine. Whether excess growth in the first few weeks of life, at a time when very preterm infants receive PN, has an imprinting effect, increasing the risk of metabolic or vascular disease at adulthood continues to be debated. Even though uncertainty remains regarding the long-term effect of early PN, it appears reasonable to propose intensified initial PN. The aim of the current position paper is to review the evidence supporting such a strategy with regards to the early phase of nutrition, which is mainly covered by parenteral nutrition. More randomized trials are, however, needed to further support this type of approach and to demonstrate that this strategy improves short- and long-term outcome.

The Influence of Method, Timing of Onset and Duration of Enteral Feeding on the Duration of Hospitalization of Newborn Infants in a Nigerian Special Care Baby Unit

Background:

Feeding practices among high-risk newborn babies have not been extensively studied in the resource-constrained parts of the world.

Aim:

To describe the pattern of milk use among infants in a resource-poor special care baby unit (SCBU) and relate these to the outcome of hospitalization.

Subjects and Methods:

Setting – SCBU of Olabisi Onabanjo University Teaching Hospital, Sagamu. Design – Prospective study of consecutively admitted inborn babies within the first 24 h of life. The data analyzed included the weight and estimated gestational age (EGA) of the babies, the age at the onset of and duration of feeds (breast milk and artificial milk [AM]).

Results:

Out of the 118 infants studied, (78.8%) 93/118 received breast milk and 16.1% (19/118) received AM. The mean age at the commencement of enteral feeding was 3.9 days. The age at the onset of suckling was negatively correlated with the EGA and body weight. The age at the onset and duration of enteral feeding were directly related to the duration of admission.

Conclusion:

More than three-quarter of the infants hospitalized in the unit received breast milk, but commencement was mostly delayed beyond the 3^rd day of life. The duration of admission may be related to the timing of onset and duration of milk use.

Electrolyte and Mineral Homeostasis After Optimizing Early Macronutrient Intakes in VLBW Infants on Parenteral Nutrition

OBJECTIVES

The aim of the present study was to evaluate electrolyte and mineral homeostasis in very-low-birth-weight (VLBW) infants who received high protein and energy intakes with a unique standardized parenteral nutrition solution containing electrolytes and minerals from birth onward.

METHODS

Prospective cohort study in 102 infants with birth weight <1250 g. The evolution of plasma biochemical parameters was described during the first 2 weeks of life.

RESULTS

During the first 3 days of life, mean parenteral intakes were 51 ± 8 kcal · kg · day with 2.7 ± 0.4 g · kg · day of protein, 1.1 ± 0.2 mmol · kg · day of sodium and potassium, and 1.3 ± 0.2 mmol · kg · day of calcium and phosphorus. Afterwards, most nutritional intakes (parenteral and enteral) met growth requirements. No infant developed a hyperkalemia >7 mmol/L, and a hypernatremia >150 mmol/L occurred only in 15.7% of the infants. In contrast, hyponatremia <130 mmol/L and hypokalemia <3 mmol/L occurred in 30.4% and 8.8% of the infants, respectively. The initial neonatal metabolic acidosis rapidly resolved in most infants and only 2.0% developed a base deficit >10 mmol/L after day 3 of life. Early hypocalcemia <1.8 mmol/L occurred in 13.7% of the infants. In contrast, hypophosphatemia <1.6 mmol/L occurred in 37.3% and hypercalcemia >2.8 mmol/L occurred in 12.7% of the infants.

CONCLUSIONS

Increasing early protein and energy intakes in VLBW infants in the first week of life improves electrolyte homeostasis. It also increases the phosphorus requirements with a calcium-to-phosphorus ratio ≤1.0 (mmol/mmol) and the potassium and sodium requirements to avoid the development of a refeeding-like syndrome. These data suggest that the parenteral nutrition guidelines for VLBW infants for the first week of life need to be revised.