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Bala FE, McGrattan KE, Valentine CJ, Jadcherla SR. A Narrative Review of Strategies to Optimize Nutrition, Feeding, and Growth among Preterm-born Infants: Implications for Practice. Adv Nutr 2024:100305. [PMID: 39313071 DOI: 10.1016/j.advnut.2024.100305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 09/11/2024] [Accepted: 09/12/2024] [Indexed: 09/25/2024] Open
Abstract
Preterm birth is the leading cause of neonatal and under-five mortality globally, and healthcare-related burden and nutrition-related morbidities are unsustainable, particularly among resource-limited regions. Additionally, preterm infants are susceptible to multiple adverse outcomes including growth faltering, sub-optimal neurodevelopment, and multi-systemic morbidities. Maturation, healing, repair, and restoration to normalcy in preterm-born infants require optimizing nutrition; only then, prognosis, growth, neurodevelopment, and overall quality of life can improve. In this article, we discuss the various evidence-based feeding and nutritional strategies that can be applicable even in resource-limited settings, where resources and infrastructure for advanced neonatal care are limited. This article addressed nutrition, feeding strategies, and growth monitoring in the Neonatal Intensive Care Unit (NICU) and at discharge to optimize nutrition, growth, and development. STATEMENT OF SIGNIFICANCE: Nutritional and growth assessment, as well as optimizing nutrition in preterm-born infants is a significant problem worldwide. We reviewed pertinent recent literature and provided up-to-date information for interdisciplinary teams including dietitians, nurses, feeding therapists, and physicians.
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Affiliation(s)
- Faith E Bala
- The Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, Ohio, USA; Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Katlyn E McGrattan
- Department of Speech Language Hearing Science, University of Minnesota, 164 Pillsbury Drive, SE, Minneapolis, MN, 55455, USA
| | - Christina J Valentine
- Department of Pediatrics, Division of Neonatology, Banner University Medical Center, The University of Arizona, Tucson, AZ 85719, USA
| | - Sudarshan R Jadcherla
- The Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, Ohio, USA; Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA; Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio, USA; Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA.
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Brown LD, Stremming J, Robinson DT. Targeting optimal protein delivery in parenteral and enteral nutrition for preterm infants: a review of randomized, controlled trials. J Perinatol 2024; 44:603-611. [PMID: 38123801 DOI: 10.1038/s41372-023-01847-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/24/2023] [Accepted: 11/29/2023] [Indexed: 12/23/2023]
Abstract
Close attention to nutritional management is essential for optimizing growth and neurodevelopment of the preterm infant. Protein intake and the protein to energy ratio are the main determinants of growth and body composition. Yet large, multi-center, randomized controlled trials are lacking to guide protein delivery for the preterm infant. Until these studies are pursued, smaller trials must be used to inform clinical practice. This review summarizes the randomized controlled trials that have been performed to test the impact of higher vs. lower protein delivery to the preterm infant. We consider the trials that varied protein delivery rates during parenteral and enteral phases of nutrition. Considerable heterogeneity exists across study designs. Still, cumulative evidence from these trials provides a framework for current recommendations for protein intake in the preterm infant.
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Affiliation(s)
- Laura D Brown
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Jane Stremming
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel T Robinson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Miller AN, Curtiss J, Kielt MJ. Nutritional Needs of the Infant with Bronchopulmonary Dysplasia. Neoreviews 2024; 25:e12-e24. [PMID: 38161180 DOI: 10.1542/neo.25-1-e12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Growth failure is a common problem in infants with established bronchopulmonary dysplasia (BPD). Suboptimal growth for infants with BPD is associated with unfavorable respiratory and neurodevelopmental outcomes; however, high-quality evidence to support best nutritional practices are limited for this vulnerable patient population. Consequently, there exists a wide variation in the provision of nutritional care and monitoring of growth for infants with BPD. Other neonatal populations at risk for growth failure, such as infants with congenital heart disease, have demonstrated improved growth outcomes with the creation and compliance of clinical protocols to guide nutritional management. Developing clinical protocols to guide nutritional management for infants with BPD may similarly improve long-term outcomes. Given the absence of high-quality trials to guide nutritional practice in infants with BPD, the best available evidence of systematic reviews and clinical recommendations can be applied to optimize growth and decrease variation in the care of these infants.
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Affiliation(s)
- Audrey N Miller
- Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital and Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Jennifer Curtiss
- Department of Clinical Nutrition and Lactation, Nationwide Children's Hospital, Columbus, OH
| | - Matthew J Kielt
- Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital and Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
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Curtiss J, Griffiths P, Stephenson KG, Puthoff TD, Ahlsson F, Bapat R, Lendrum-Gatten B, Lindamood K, Lumbaca L, Mehling M, Peck LH, Stonestreet BS, Susey K, Susi M, Zhang H, Lynch S. The Optimal State Scoring Tool: guidance for interdisciplinary care of infants with severe bronchopulmonary dysplasia and its relation to linear growth. J Perinatol 2023; 43:1301-1307. [PMID: 37185366 DOI: 10.1038/s41372-023-01680-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/20/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE Infants with severe bronchopulmonary dysplasia (sBPD) have complex medical courses. We developed the clinician-rated Optimal State Scoring Tool (OSST) that measures factors relevant to clinical improvement of sBPD and investigated preliminary validity using linear growth outcome and OSST scores in sBPD patients. METHODS Tool development process and pilot findings are provided for 13 patients evaluated longitudinally. OSST scores, length measurements, and steroid dependency values were obtained. Changes in OSST scores and lengths were examined using linear mixed-effect models. RESULTS OSST scores were significantly correlated with linear growth (95% CI 0.36, 0.57). The steroid-dependent group showed significantly slower rate of linear growth (95% CI 0.74, 1.05) and slower rate of increase in OSST scores (95% CI 0.99, 2.13) compared to the non-steroid-dependent group, with the OSST showing the largest effect size. CONCLUSION Pilot data reflect promising evidence for OSST construct validity in monitoring clinical outcomes in sBPD patients.
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Affiliation(s)
- Jennifer Curtiss
- Department of Clinical Nutrition & Lactation, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Pamela Griffiths
- Department of Neonatology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Kevin G Stephenson
- Department of Psychology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Teresa D Puthoff
- Department of Pharmacy Services, Nationwide Children's Hospital, Columbus, OH, USA
| | - Fredrik Ahlsson
- Department of Women's and Children's Health, Uppsala Universitet, Uppsala, Sweden
| | - Roopali Bapat
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | | | | | - Leah Lumbaca
- Department of Neonatal Therapy, Nationwide Children's Hospital, Columbus, OH, USA
| | - Margaret Mehling
- Department of Psychology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Lauren H Peck
- Department of Pharmacy Services, Nationwide Children's Hospital, Columbus, OH, USA
| | - Barbara S Stonestreet
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Providence, RI, USA
| | - Kelly Susey
- Department of Neonatal Therapy, Nationwide Children's Hospital, Columbus, OH, USA
| | - Molly Susi
- Department of Neonatal Therapy, Nationwide Children's Hospital, Columbus, OH, USA
| | - Huayan Zhang
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susan Lynch
- Department of Pediatrics, University of North Carolina System, Chapel Hill, NC, USA
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Cuestas E, Hillman M, Galetto S, Gaido MI, Sobh V, Damico LT, Rizzotti A. Inflammation induces stunting by lowering bone mass via GH/IGF-1 inhibition in very preterm infants. Pediatr Res 2023; 94:1136-1144. [PMID: 36941338 DOI: 10.1038/s41390-023-02559-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/13/2023] [Accepted: 02/22/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Sustained systemic inflammatory response (SIR) was associated with poor postnatal growth in very preterm infants (VPI). We hypothesize that VPI with sustained SIR will exhibit linear growth retardation related to lower bone mass accrual mediated by GH/IGF-1 axis inhibition at term corrected age (CA). METHODS C-reactive protein (CRP), procalcitonin (PCT), growth hormone (GH), insulin-like growth factor 1 (IGF-1), calcium, phosphorus, alkaline phosphatase, anthropometric, nutritional, neonatal and maternal data were collected prospectively in 23 infants <32 weeks gestational age. Body composition using dual-energy X-ray absorptiometry was performed at term CA. Analysis was undertaken with multiple linear regression models. RESULTS At term CA 11 infants with sustained SIR compared with 12 infants without sustained SIR present significantly lower IGF-1, length z-score (LZS), bone mineral content (BMC) and lean mass (LM), and higher GH and fat mass (FM). LZS was associated significantly with PCT, BMC with IGF-1, FM and LM with CRP, GH with bronchopulmonary dysplasia and CRP, and IGF-1 with invasive mechanical ventilation, CRP and PCT. CONCLUSIONS In addition to the known effect on linear growth failure, sustained SIR induces lower bone mass accrual related to higher GH and lower IGF-1 levels in VPI. IMPACT Very preterm infants (VPI) with sustained systemic inflammatory response (SIR) compared with VPI without SIR present stunting, lower bone mass, higher GH and lower IGF-1 levels at term corrected age. SIR may help to explain the influence of non-nutritional factors on growth and body composition in VPI. SIR induces postnatal stunting related to lower bone mass accrual via GH/IGF-1 axis inhibition in VPI. VPI with SIR need special attention to minimize inflammatory stress, which could result in improved postnatal growth. Research on inflammatory-endocrine interactions involved in the pathophysiology of postnatal stunting is needed as a basis for new interventional approaches.
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Affiliation(s)
- Eduardo Cuestas
- Department of Pediatrics and Neonatology, Hospital Privado Universitario de Córdoba, Instituto Universitario de Ciencias Biomédicas de Córdoba, Córdoba, Argentina.
| | - Macarena Hillman
- Department of Pediatrics and Neonatology, Hospital Privado Universitario de Córdoba, Instituto Universitario de Ciencias Biomédicas de Córdoba, Córdoba, Argentina
| | - Silvia Galetto
- Department of Pediatrics and Neonatology, Hospital Privado Universitario de Córdoba, Instituto Universitario de Ciencias Biomédicas de Córdoba, Córdoba, Argentina
| | - María Isabel Gaido
- Department of Clinical Biochemistry, Hospital Privado Universitario de Córdoba, Instituto Universitario de Ciencias Biomédicas de Córdoba, Córdoba, Argentina
| | - Viviana Sobh
- Department of Radiology, Instituto Conci-Carpinella, Córdoba, Argentina
| | | | - Alina Rizzotti
- Department of Pediatrics and Neonatology, Hospital Privado Universitario de Córdoba, Instituto Universitario de Ciencias Biomédicas de Córdoba, Córdoba, Argentina
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Lygerou I, Ilia S, Briassoulis P, Manousaki A, Koropouli M, Hatzidaki E, Briassoulis G. The Impact of Estimated Energy and Protein Balances on Extrauterine Growth in Preterm Infants. Nutrients 2023; 15:3556. [PMID: 37630744 PMCID: PMC10458304 DOI: 10.3390/nu15163556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Nutritional support of preterm infants remains a field of debate in the literature and clinical practice varies significantly. Adequate nutrition should promote growth and aim for optimal later neurodevelopment. However, it is often impaired by prematurity-associated morbidity and the physiologic immaturity of preterm infants. This study assessed the impact of energy and macronutrient provision on growth velocity and outcome and explored differences attributed to the heterogeneity of the preterm population. METHODS We retrospectively collected clinical and nutritional data from neonates hospitalized in two separate Neonatal Intensive Care Units (NICUs). Estimated energy and protein balance were calculated based on the ESPGHAN guidelines and their association with the growth outcome was explored. Growth assessment was based on somatometry Delta (Δ) z-scores at discharge. RESULTS In total, 174 neonates were included in the study. By day 14, most preterm infants were exclusively enterally fed, whereas there were infants in the <28 and 28-31+6 subgroups fed exclusively parenterally. Energy balance was positive for all gestational age (GA) subgroups except for those born <28 weeks. Protein balance was consistently positive for extremely premature but negative for late preterms. Cumulative substrates provisions were strong predictors of a positive energy or protein balance in the <34 weeks GA preterms on days 14 (ROC analyses, p < 0.001) and 7 (p < 0.05). A higher GA (p = 0.013) and enteral nutrition (p = 0.005) were additional predictors of a positive energy balance. All GA subgroups had a negative Δ z-score of weight at discharge. In the <34 GA subcohorts, a positive protein balance on day 14 (p = 0.009) and a short time to regain birth weight (exp(B) 3.1 (p = 0.004)) were independently associated with a positive Δ z-score of weight at discharge. CONCLUSIONS Early achievement of a positive energy and protein balance, based on the ESPGHAN guidelines, is crucial to ensure optimal postnatal growth and prevent extrauterine growth restriction, a relatively common occurrence in preterm infants.
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Affiliation(s)
- Ioanna Lygerou
- Postgraduate Program “Emergency and Intensive Care in Children Adolescents and Young Adults”, School of Medicine, University of Crete, 71003 Heraklion, Greece; (A.M.); (G.B.)
- Department of Neonatology/Neonatal Intensive Care Unit, University Hospital of Heraklion, School of Medicine, University of Crete, 71500 Heraklion, Greece;
| | - Stavroula Ilia
- Postgraduate Program “Emergency and Intensive Care in Children Adolescents and Young Adults”, School of Medicine, University of Crete, 71003 Heraklion, Greece; (A.M.); (G.B.)
- Pediatric Intensive Care Unit, University Hospital, School of Medicine, University of Crete, 71110 Heraklion, Greece;
| | - Panagiotis Briassoulis
- Pediatric Intensive Care Unit, University Hospital, School of Medicine, University of Crete, 71110 Heraklion, Greece;
- Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Anna Manousaki
- Postgraduate Program “Emergency and Intensive Care in Children Adolescents and Young Adults”, School of Medicine, University of Crete, 71003 Heraklion, Greece; (A.M.); (G.B.)
- Neonatal Intensive Care Unit, Venizelio General Hospital, 71409 Heraklion, Greece;
| | - Marina Koropouli
- Neonatal Intensive Care Unit, Venizelio General Hospital, 71409 Heraklion, Greece;
| | - Eleftheria Hatzidaki
- Department of Neonatology/Neonatal Intensive Care Unit, University Hospital of Heraklion, School of Medicine, University of Crete, 71500 Heraklion, Greece;
| | - George Briassoulis
- Postgraduate Program “Emergency and Intensive Care in Children Adolescents and Young Adults”, School of Medicine, University of Crete, 71003 Heraklion, Greece; (A.M.); (G.B.)
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Herodes M, Le N, Anderson LJ, Migula D, Miranda G, Paulsen L, Garcia JM. Metabolic and quality of life effects of growth hormone replacement in patients with TBI and AGHD: A pilot study. Growth Horm IGF Res 2023; 71:101544. [PMID: 37295336 PMCID: PMC10527000 DOI: 10.1016/j.ghir.2023.101544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/25/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Traumatic brain injury (TBI), a common cause of adult growth hormone deficiency (AGHD), affects 20% of Veterans returning from Iraq and Afghanistan (OEF/OIF/OND). Growth hormone replacement therapy (GHRT) improves quality of life (QoL) in AGHD but remains unexplored in this population. This pilot, observational study investigates the feasibility and efficacy of GHRT in AGHD following TBI. DESIGN In this 6-month study of combat Veterans with AGHD and TBI starting GHRT (N = 7), feasibility (completion rate and rhGH adherence) and efficacy (improvements in self-reported QoL) of GHRT were measured (primary outcomes). Secondary outcomes included body composition, physical and cognitive function, psychological and somatic symptoms, physical activity, IGF-1 levels and safety parameters. It was hypothesized that participants would adhere to GHRT and that QoL would significantly improve after six months. RESULTS Five subjects (71%) completed all study visits. All patients administered daily rhGH injections, 6 (86%) of whom consistently administered the clinically-prescribed dose. While QoL demonstrated numeric improvement, this change did not reach statistical significance (p = 0.17). Significant improvements were observed in total lean mass (p = 0.02), latissimus dorsi strength (p = 0.05), verbal learning (Trial 1, p = 0.02; Trial 5, p = 0.03), attention (p = 0.02), short-term memory (p = 0.04), and post-traumatic stress disorder (PTSD) symptoms (p = 0.03). Body weight (p = 0.02) and total fat mass (p = 0.03) increased significantly. CONCLUSION GHRT is a feasible and well-tolerated intervention for U.S. Veterans with TBI-related AGHD. It improved key areas impacted by AGHD and symptoms of PTSD. Larger, placebo-controlled studies testing the efficacy and safety of this intervention in this population are warranted.
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Affiliation(s)
- Megan Herodes
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; Division of Gerontology and Geriatric Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Nancy Le
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Lindsey J Anderson
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Dorota Migula
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Gary Miranda
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; Division of Gerontology and Geriatric Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Lauren Paulsen
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Jose M Garcia
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; Division of Gerontology and Geriatric Medicine, University of Washington School of Medicine, Seattle, WA, USA.
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Schoephoerster J, Roston S, Lunos S, Ramel SE, Anderson J, Georgieff MK, Ingolfsland EC. Identification of clinical factors associated with timing and duration of spontaneous regression of retinopathy of prematurity not requiring treatment. J Perinatol 2023; 43:702-708. [PMID: 36973383 DOI: 10.1038/s41372-023-01649-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 03/01/2023] [Accepted: 03/13/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVE Identify clinical factors that delay or prolong spontaneous regression of retinopathy of prematurity (ROP). STUDY DESIGN Secondary analysis of three prospective studies with 76 infants with ROP not requiring treatment, born ≤30 weeks postmenstrual age (PMA) and ≤1500 grams. Outcomes were PMA at greatest severity of ROP (PMA MSROP), at which regression began, at time of complete vascularization (PMA CV), and regression duration. Pearson's correlation coefficients, t-tests, or analyses of variance were calculated. RESULTS Increased positive bacterial cultures, hyperglycemia, transfusion volume of platelets and red blood cells and severity of ROP were associated with later PMA MSROP. Positive bacterial cultures, maternal chorioamnionitis, and less iron deficiency were associated with later PMA CV and prolonged regression duration. Slower length gain was associated with later PMA CV. P < 0.05 for all. CONCLUSIONS Preterm infants with inflammatory exposures or linear growth impairment may require longer surveillance for ROP resolution and complete vascularization.
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Affiliation(s)
| | - Sydney Roston
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Scott Lunos
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Sara E Ramel
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, USA
| | - Jill Anderson
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, MN, USA
| | - Michael K Georgieff
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, USA
| | - Ellen C Ingolfsland
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, USA.
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9
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Miller AN, Curtiss J, Taylor SN, Backes CH, Kielt MJ. A review and guide to nutritional care of the infant with established bronchopulmonary dysplasia. J Perinatol 2023; 43:402-410. [PMID: 36494567 DOI: 10.1038/s41372-022-01578-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/20/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022]
Abstract
Bronchopulmonary dysplasia (BPD) remains the most common long-term morbidity of premature birth, and the incidence of BPD is not declining despite medical advancements. Infants with BPD are at high risk for postnatal growth failure and are often treated with therapies that suppress growth. Additionally, these infants may display excess weight gain relative to linear growth. Optimal growth and nutrition are needed to promote lung growth and repair, improve long-term pulmonary function, and improve neurodevelopmental outcomes. Linear growth in particular has been associated with favorable outcomes yet can be difficult to achieve in these patients. While there has been a significant clinical and research focus regarding BPD prevention and early preterm nutrition, there is a lack of literature regarding nutritional care of the infant with established BPD. There is even less information regarding how nutritional needs change as BPD evolves from an acute to chronic disease. This article reviews the current literature regarding nutritional challenges, enteral nutrition management, and monitoring for patients with established BPD. Additionally, this article provides a practical framework for interdisciplinary nutritional care based on our clinical experience at the Comprehensive Center for Bronchopulmonary Dysplasia.
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Affiliation(s)
- Audrey N Miller
- Division of Neonatology, Department of Pediatrics, Ohio State University, Nationwide Children's Hospital, Columbus, OH, USA. .,Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Jennifer Curtiss
- Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Clinical Nutrition and Lactation, Nationwide Children's Hospital, Columbus, OH, USA
| | - Sarah N Taylor
- Division of Neonatology, Yale School of Medicine, New Haven, CT, USA
| | - Carl H Backes
- Division of Neonatology, Department of Pediatrics, Ohio State University, Nationwide Children's Hospital, Columbus, OH, USA.,Division of Cardiology, Nationwide Children's Hospital, Columbus, OH, USA.,Center for Perinatal Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
| | - Matthew J Kielt
- Division of Neonatology, Department of Pediatrics, Ohio State University, Nationwide Children's Hospital, Columbus, OH, USA.,Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital, Columbus, OH, USA
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Mathews T, Hayer SS, Dinkel D, Hanish A, Poppert Cordts KM, Rasmussen H, Moore T. Maternal-Child Microbiome and Impact on Growth and Neurodevelopment in Infants and Children: A Scoping Review. Biol Res Nurs 2023:10998004221151179. [PMID: 36607703 DOI: 10.1177/10998004221151179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Pathologic changes in the microbiome (dysbiosis) have been implicated in affecting the growth and neurodevelopment of infants and children. There is evidence to suggest that prenatal and postnatal stressors may be a factor in dysbiosis and there is also a growing body of evidence to suggest that interventions may reduce this negative impact. A scoping review was undertaken to identify association between maternal and/or child microbiome with child growth and neurodevelopment. Additionally, intervention studies such as use of nutritional supplementation and its impact on the microbiome, growth and neurodevelopment were reviewed. METHODS An exhaustive literature search identified 654 relevant citations. After review of abstracts, 557 were eliminated, and 97 remained for full text review. We identified and reported on 42 articles which met inclusion criteria. RESULTS Seven studies examined associations between microbiome and neurodevelopment and 36 studies evaluated anthropometric measurements, most commonly weight, and microbiota relationships. One study evaluated both growth and neurodevelopment and microbiota. Fourteen studies evaluated supplemental nutrients. Preterm, low birth weight (LBW), and very low birth weight (VLBW) infants were most studied. Findings were inconclusive for consistent associations between microbiota and growth and neurodevelopment. Further, there were no consistent conclusive changes with prescribed treatment interventions. DISCUSSION There is a need for high-quality longitudinal studies evaluating repeated developmental assessment measures using consistent microbial analysis techniques to inform conclusions regarding the association between microbiome and infant and child growth and neurodevelopment. Additional intervention studies that may mitigate dysbiosis are warranted.
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Affiliation(s)
- Therese Mathews
- College of Nursing, 12284University of Nebraska Medical Center, Omaha, NE, USA
| | - Shivdeep S Hayer
- Department of Biology, College of Arts and Sciences, 169231University of Nebraska at Omaha, Omaha, NE, USA
| | - Danae Dinkel
- School of Health and Kinesiology, 14720University of Nebraska at Omaha, Omaha, NE, USA
| | - Alyson Hanish
- College of Nursing, 12284University of Nebraska Medical Center, Omaha, NE, USA
| | - Katrina M Poppert Cordts
- College of Medicine, Department of Psychiatry, 12284University of Nebraska Medical Center, Omaha, NE, USA
| | - Heather Rasmussen
- College of Education & Human Sciences, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Tiffany Moore
- College of Nursing, 12284University of Nebraska Medical Center, Omaha, NE, USA
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11
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Itoshima R, Oda A, Ogawa R, Yanagisawa T, Hiroma T, Nakamura T. Neurodevelopment and physical measurements in infants with birthweight of 500 grams or less. Pediatr Int 2023; 65:e15689. [PMID: 37991183 DOI: 10.1111/ped.15689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/13/2023] [Accepted: 09/21/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND In infants born weighing ≤500 g, little has been studied about the association between neurodevelopmental prognosis and growth. This study aimed to evaluate the association between neurodevelopmental impairment (NDI) and z-scores of physical measurements in infants born weighing ≤500 g. METHODS A single-center, retrospective cohort study in a level IV neonatal intensive care unit in Japan. Infants born weighing ≤500 g between 2010 and 2019 were eligible. Z-scores in weight, length/height, and head circumference at birth, due date (or discharge), 6 and 18 months of corrected age, and 3 years of age were compared between infants with and without NDI at 3 years of age. Three infants with severe intraventricular hemorrhage or periventricular leukomalacia were excluded from the comparison analyses. NDI was defined as having a developmental quotient of ≤70, cerebral palsy, visual impairment, or hearing impairment. RESULTS Of 22 eligible infants, the incidence of NDI at 3 years of age was 54.5%. The z-score was significantly smaller in the NDI group (n = 10) than that in the non-NDI group (n = 9) in head circumference at birth (median, -1.94 vs. -0.75; Z = 0.54; p = 0.020), and in height at 18 months of corrected age (median, -2.84 vs. -1.79; Z = 0.58; p = 0.013) and 3 years of age (median, -2.02 vs. -1.21; Z = 0.47; p = 0.046). CONCLUSIONS NDI at 3 years of age was associated with a small head circumference z-score at birth, height at 18 months of corrected age, and height at 3 years of age in infants born weighing ≤500 g.
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Affiliation(s)
- Ryo Itoshima
- Division of Neonatology, Nagano Children's Hospital, Azumino, Japan
- Life Science Research Center, Nagano Children's Hospital, Azumino, Japan
- Department of Clinical Medicine, University of Turku, Turku, Finland
| | - Arata Oda
- Division of Neonatology, Nagano Children's Hospital, Azumino, Japan
- Life Science Research Center, Nagano Children's Hospital, Azumino, Japan
| | - Ryo Ogawa
- Division of Neonatology, Nagano Children's Hospital, Azumino, Japan
- Life Science Research Center, Nagano Children's Hospital, Azumino, Japan
| | | | - Takehiko Hiroma
- Division of Neonatology, Nagano Children's Hospital, Azumino, Japan
- Life Science Research Center, Nagano Children's Hospital, Azumino, Japan
| | - Tomohiko Nakamura
- Division of Neonatology, Nagano Children's Hospital, Azumino, Japan
- Life Science Research Center, Nagano Children's Hospital, Azumino, Japan
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12
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Hofi L, Flidel-Rimon O, Hershkovich–Shporen C, Zaharoni H, Birk R. Differences in growth patterns and catch up growth of small for gestational age preterm infants fed on fortified mother's own milk versus preterm formula. Br J Nutr 2022; 129:1-24. [PMID: 35748057 PMCID: PMC10197085 DOI: 10.1017/s0007114522000599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 02/13/2022] [Accepted: 02/18/2022] [Indexed: 11/06/2022]
Abstract
Small for gestational age (SGA) is typically defined as birthweight < 10th percentile for age. Limited data are available regarding the growth of SGA preterm infants in relation to feeding type. We aimed to study SGA preterm infants fed fortified mother's own milk (MOM) or preterm formula (PF) on growth patterns and catch-up growth at discharge and two-years corrected age (CA). Our retrospective cohort study included data from medical records and follow-up questionnaires about SGA preterm infants born at <37 weeks fed on MOM (n=40) and PF (n=40). Weight, length/height and head circumference (HC) were collected at birth, discharge and at two years CA, and Δ z-scores were calculated.The MOM group had significantly larger negative change in weight and length z-scores between birth and discharge, and smaller positive change in HC z-score (-0.47 (±0.41) v. -0.25 (±0.36), P= 0.01; -0.63 (±0.75) v. -0.27 (±0.75), P= 0.03; 0.13 (±0.67) v. 0.41 (±0.55), P= 0.04, respectively). Almost half the MOM fed infants experienced poor length growth by discharge compared to 22% of PF fed infants (P=0.03). By two years CA, both groups had similar positive change in weight and HC z-scores, but MOM fed infants had a slower increase in height z-score (0.64 (±1.30) v. 1.33 (±1.33), P=0.02), and only 40% had achieved catch-up height compared with 68% of the PF group (P=0.02).Our study indicates that fortified MOM fed SGA preterm infants may need extra nutritional support in the first two years of life to achieve height growth potential.
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Affiliation(s)
- Lilach Hofi
- Department of Nutritional Sciences, School of Health Sciences, Ariel University, Ariel, Israel
- Department of Neonatology, Kaplan Medical Center, Rehovot, Hebrew University, Jerusalem, Israel
- Department of Clinical Nutrition, Kaplan Medical Center, Rehovot, Hebrew University, Jerusalem, Israel
| | - Orna Flidel-Rimon
- Department of Neonatology, Kaplan Medical Center, Rehovot, Hebrew University, Jerusalem, Israel
| | | | - Hilla Zaharoni
- Department of Clinical Nutrition, Kaplan Medical Center, Rehovot, Hebrew University, Jerusalem, Israel
| | - Ruth Birk
- Department of Nutritional Sciences, School of Health Sciences, Ariel University, Ariel, Israel
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13
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Buck CO, Montgomery AM. Long-Term Impact of Early Nutritional Management. Clin Perinatol 2022; 49:461-474. [PMID: 35659097 DOI: 10.1016/j.clp.2022.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Catherine O Buck
- Department of Pediatrics, Yale School of Medicine, PO Box 208064, 333 Cedar Street, New Haven, CT 06520, USA.
| | - Angela M Montgomery
- Department of Pediatrics, Yale School of Medicine, PO Box 208064, 333 Cedar Street, New Haven, CT 06520, USA. https://twitter.com/amontgom09
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14
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Intestinal Inflammation is Significantly Associated With Length Faltering in Preterm Infants at Neonatal Intensive Care Unit Discharge. J Pediatr Gastroenterol Nutr 2022; 74:837-844. [PMID: 35442225 PMCID: PMC9296612 DOI: 10.1097/mpg.0000000000003455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE The aim of the study was to assess intestinal inflammatory measures, urinary intestinal fatty acid-binding protein (IFABP), and fecal calprotectin (FC) by gestational age (GA) and postmenstrual age (PMA) and determine the association between intestinal inflammation and growth in preterm infants from birth to hospital discharge. We hypothesized that intestinal inflammation is associated with adverse growth in preterm infants. METHODS We assayed repeated measures of IFABP and FC in 72 hospitalized preterm infants (<34 weeks' gestation). We calculated weight and length z scores at birth and discharge using the Fenton growth reference. Associations between mean IFABP or FC, growth z scores at discharge, and growth faltering (weight or length z score difference <-0.8 from birth to discharge) were assessed using mixed linear and logistic regression models, adjusted for intrafamilial correlation and potential confounders: GA, sex, birth z score, race/ethnicity, and maternal age. RESULTS Mean IFABP was greater among infants born at earlier GA and decreased with increasing PMA. Mean FC did not vary by GA or PMA. Higher mean IFABP and FC were associated with lower discharge growth z scores and greater likelihood of growth faltering significant only for mean IFABP and discharge length z score (β = -0.353, 95% confidence interval [CI]: -0.704 to -0.002) and mean IFABP and length faltering (odds ratio [OR] 1.99, P = 0.018). CONCLUSIONS Intestinal inflammation, measured by IFABP, was associated with lower length z scores and length faltering at discharge. Interventions to prevent intestinal inflammation may improve linear growth among preterm infants.
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15
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Implementation of a Nutrition Care Bundle and Improved Weight Gain of Extremely Preterm Infants to 36 Weeks Postmenstrual Age. J Pediatr 2022; 241:42-47.e2. [PMID: 34687694 DOI: 10.1016/j.jpeds.2021.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/28/2021] [Accepted: 10/15/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the effect of a nutrition care bundle in improving growth in premature infants during neonatal hospitalization. STUDY DESIGN This study was a retrospective analysis of prospectively collected data for 584 surviving infants with birth weight ≤1000 g and gestational age 24-29 weeks admitted to a single-center neonatal intensive care unit between July 3, 2005, and June 6, 2016. Participants were divided into 3 discrete epochs based on evolving nutrition practices during the study period: epoch 1, baseline, open-bay setting; epoch 2, improved lactation staffing, introduction of high-protein formula, single-family room setting; epoch 3, complete nutrition care bundle. Infants in each epoch were evaluated for the primary outcome of change in weight z-score between postnatal day 7 and 36 weeks postmenstrual age (PMA) or discharge if sooner. Univariate and multivariable regression analyses were conducted to evaluate the effect of clinical variables on outcome. RESULTS Significant increases in weight z-score between day of life 7 and 36 weeks PMA were observed across the 3 epochs, which accounted for 31% (P < .0001) of the variance. Variables that were positive predictors of weight z-score change included birth weight z-score, cesarean delivery, and later epochs of nutritional support. Variables that were negative predictors of weight change included gestational age, postnatal steroids, and days on parenteral nutrition. CONCLUSIONS Implementation of a nutrition care bundle was associated with improved weight gain in extremely low birth weight infants.
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16
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Belfort MB, Ramel SE, Martin CR, Fichorova R, Kuban KCK, Heeren T, Fry RC, O’Shea TM. Systemic Inflammation in the First 2 Weeks after Birth as a Determinant of Physical Growth Outcomes in Hospitalized Infants with Extremely Low Gestational Age. J Pediatr 2022; 240:37-43.e1. [PMID: 34508750 PMCID: PMC8712377 DOI: 10.1016/j.jpeds.2021.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 08/31/2021] [Accepted: 09/03/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To examine associations of systemic inflammation with growth outcomes at neonatal intensive care unit discharge or transfer among infants with extremely low gestational ages. STUDY DESIGN We studied 850 infants at born at 23-27 weeks of gestation. We defined inflammatory protein elevation as the highest quartile of C-reactive protein (CRP), Interleukin (IL)-6, tumor necrosis factor-∝, or IL-8 on postnatal days 1, 7, and 14. We compared z-scores of weight, length, and head circumference at neonatal intensive care unit discharge or transfer between infants with vs without inflammatory protein elevation, adjusting in linear regression for birth size z-score, sex, gestational age, diet, comorbidities, medications, and length of hospitalization. RESULTS The mean gestational age was 25 weeks (range, 23-27 weeks) and birth weight z-score 0.14 (range, -2.73 to 3.28). Infants with a high CRP on day 7 had lower weights at discharge or transfer (-0.17 z-score; 95% CI, -0.27 to -0.06) than infants without CRP elevation, with similar results on day 14. Infants with CRP elevation on day 14 were also shorter (-0.21 length z-scores; 95% CI, -0.38 to -0.04), and had smaller head circumferences (-0.18 z-scores; 95% CI, -0.33 to -0.04) at discharge or transfer. IL-6 elevation on day 14 was associated with lower weight (-0.12; 95% CI, -0.22 to -0.02); IL-6 elevation on day 7 was associated with shorter length (-0.27; 95% CI, -0.43 to -0.12). Tumor necrosis factor-∝ and IL-8 elevation on day 14 were associated with a lower weight at discharge or transfer. CONCLUSIONS Postnatal systemic inflammation may contribute to impaired nutrient accretion during a critical period in development in infants with extremely low gestational ages.
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Affiliation(s)
- Mandy B. Belfort
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Sara E. Ramel
- University of Minnesota School of Medicine, Minneapolis, MN
| | - Camilia R. Martin
- Harvard Medical School, Boston, MA,Beth Israel Deaconess Medical Center, Boston, MA
| | - Raina Fichorova
- Harvard Medical School, Boston, MA,Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, MA
| | | | | | - Rebecca C. Fry
- Department of Environmental Sciences and Engineering, University of North Carolina School of Medicine, Chapel Hill, NC
| | - T. Michael O’Shea
- Division of Neonatal-Perinatal Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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17
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An Interdisciplinary Approach to Reducing NEC While Optimizing Growth: A 20-Year Journey. Adv Neonatal Care 2021; 21:433-442. [PMID: 34510070 DOI: 10.1097/anc.0000000000000929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
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.
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18
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Protein Enrichment of Donor Breast Milk and Impact on Growth in Very Low Birth Weight Infants. Nutrients 2021; 13:nu13082869. [PMID: 34445027 PMCID: PMC8401419 DOI: 10.3390/nu13082869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 11/27/2022] Open
Abstract
Protein content is often inadequate in donor breast milk (DBM), resulting in poor growth. The use of protein-enriched target-pooled DBM (DBM+) has not been examined. We compared three cohorts of very low birth weight (VLBW) infants, born ≤ 1500 g: DBM cohort receiving > 1-week target-pooled DBM (20 kcal/oz), MBM cohort receiving ≤ 1-week DBM, and DBM+ cohort receiving > 1-week DBM+. Infants followed a standardized feeding regimen with additional fortification per clinical discretion. Growth velocities and z-scores were calculated for the first 4 weeks (n = 69 for DBM, 71 for MBM, 70 for DBM+) and at 36 weeks post-menstrual age (n = 58, 64, 59, respectively). In total, 60.8% MBM infants received fortification >24 kcal/oz in the first 30 days vs. 78.3% DBM and 77.1% DBM+. Adjusting for SGA, length velocity was greater with DBM+ than DBM in week 1. Average weight velocity and z-score change were improved with MBM compared to DBM and DBM+, but length z-score decreased similarly across all groups. Incidences of NEC and feeding intolerance were unchanged between eras. Thus, baseline protein enrichment appears safe in stable VLBW infants. Weight gain is greatest with MBM. Linear growth comparable to MBM is achievable with DBM+, though the overall length trajectory remains suboptimal.
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19
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Strobel KM, Purdy I, Romero T, Calkins KL. Growth from Birth to 30 months for Infants Born with Congenital Gastrointestinal Anomalies and Disorders. Am J Perinatol 2021; 38:e33-e38. [PMID: 32168528 DOI: 10.1055/s-0040-1705136] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE This study aimed to investigate growth among neonates with gastrointestinal disorders. STUDY DESIGN Inclusion criteria included neonates with gastroschisis, omphalocele, intestinal atresia, tracheoesophageal fistula, Hirschsprung's disease, malabsorption disorders, congenital diaphragmatic hernia, and imperforate anus born between 2010 and 2018. Anthropometrics were collected for the first 30 months, and a subgroup analysis was performed for gastroschisis infants. RESULTS In 61 subjects, 13% developed severe growth failure within the first month. One-, four-, and nine-month weight and length z-scores were less than birth weight in all infants (p < 0.05). In infants with gastroschisis, a similar pattern was observed for weight z-scores only (p < 0.05). From birth to 15 months, head circumference z-score increased over time in all infants (p = 0.001), while in gastroschisis infants, weight, length, and head circumference z-scores increased over time (p < 0.05). CONCLUSION In a cohort of infants with gastrointestinal disorders, growth failure was followed by catch-up growth.
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Affiliation(s)
- Katie M Strobel
- Division of Neonatology and Developmental Biology, Department of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, Mattel Children's Hospital at UCLA, Los Angeles, California
| | - Isabell Purdy
- Division of Neonatology and Developmental Biology, Department of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, Mattel Children's Hospital at UCLA, Los Angeles, California
| | - Tahmineh Romero
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, California
| | - Kara L Calkins
- Division of Neonatology and Developmental Biology, Department of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, Mattel Children's Hospital at UCLA, Los Angeles, California
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20
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Philip SS, Davenport SE, Mannan J, White HO, Lee AF, Rhein LM. Impact of a targeted volume-increase nutrition guideline on growth and body mass index in premature infants: A retrospective review. JPEN J Parenter Enteral Nutr 2021; 46:561-571. [PMID: 34114671 DOI: 10.1002/jpen.2204] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The negative impact of disproportionate growth in premature infants is well documented, but optimal nutrition practices needed to prevent an unhealthy body mass index (BMI) remain unclear. METHODS An evidence-based, volume-increase guideline that advanced feeding volumes from 150-160 to 170-180 ml/kg/day between the postmenstrual age (PMA) of 31 0/7 and 34 0/7 weeks was implemented in October 2017 for infants born at ≤32 0/7 weeks' gestational age. Data were collected on 262 infants' weight and length at birth and at discharge for 20 months before and 21 months after guideline implementation, and retrospective analysis was conducted to determine disproportionate growth by comparing BMIs (in g/cm2 ) at birth and at discharge. Changes in infants' body habitus were determined through bivariate analysis of weight and length z-scores from the Fenton growth curve. RESULTS Implementation of a targeted volume nutrition guideline resulted in fewer infants with growth failure, defined as weight <10th percentile (19.5% vs 11.2%; P = .06) at discharge. Infants who received treatment according to the targeted nutrition guideline had a statistically significant reduction in disproportionately low BMI (8.6% vs 2.5%; P = .0380) and an increase in disproportionately high BMIs (4.3% vs 12.3%; P = .025). There was minor change in the percentage of disproportionately large infants who received the guidelines from birth to discharge (11.5% vs 12.3%). CONCLUSIONS A targeted volume-increase nutrition guideline may prevent growth failure, with some effects on disproportionate growth in preterm infants born at ≤32 0/7 weeks' gestational age.
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Affiliation(s)
- Stephanie S Philip
- Department of Neonatology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Sarah E Davenport
- Department of Neonatology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Javed Mannan
- Department of Neonatology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Heather O White
- Department of Neonatology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Austin F Lee
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA.,Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lawrence M Rhein
- Department of Neonatology, University of Massachusetts Medical School, Worcester, Massachusetts, USA.,Department of Pediatric Pulmonary, University of Massachusetts Medical School, Worcester, Massachusetts
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21
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Strobel KM, Romero T, Kramer K, Fernandez E, Rottkamp C, Uy C, Keller R, Moyer L, Poulain F, Kim JH, DeUgarte DA, Calkins KL. Growth Failure Prevalence in Neonates with Gastroschisis : A Statewide Cohort Study. J Pediatr 2021; 233:112-118.e3. [PMID: 33647253 PMCID: PMC8154735 DOI: 10.1016/j.jpeds.2021.02.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To perform a multicenter study to assess growth failure in hospitalized infants with gastroschisis. STUDY DESIGN This study included neonates with gastroschisis within sites in the University of California Fetal Consortium. The study's primary outcome was growth failure at hospital discharge, defined as a weight or length z score decrease >0.8 from birth. Regression analysis was performed to assess changes in z scores over time. RESULTS Among 125 infants with gastroschisis, the median gestational age was 37 weeks (IQR 35-37). Length of stay was 32 days (23-60); 55% developed weight or length growth failure at discharge (28% had weight growth failure, 42% had length growth failure, and 15% had both weight and length growth failure). Weight and length z scores at 14 days, 30 days, and discharge were less than birth (P < .01 for all). Weight and length z scores declined from birth to 30 days (-0.10 and -0.11 z score units/week, respectively, P < .001). Length growth failure at discharge was associated with weight and length z score changes over time (P < .05 for both). Lower gestational age was associated with weight growth failure (OR 0.70 for each gestational age week, 95% CI 0.55-0.89, P = .004). CONCLUSIONS Growth failure, in particular linear growth failure, is common in infants with gastroschisis. These data suggest the need to improve nutritional management in these infants.
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Affiliation(s)
- Katie M Strobel
- Division of Neonatology and Developmental Biology, Department of Pediatrics, University of California Los Angeles, Los Angeles, CA.
| | - Tahmineh Romero
- Division of General Internal Medicine and Health Services Research, Department of Medicine Statistics Core, University of California Los Angeles, Los Angeles, CA
| | - Katelin Kramer
- Division of Neonatology, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Erika Fernandez
- Division of Neonatology, Department of Pediatrics, University of California San Diego, San Diego, CA
| | - Catherine Rottkamp
- Division of Neonatology, Department of Pediatrics, University of California Davis, Davis, CA
| | - Cherry Uy
- Division of Neonatal/Perinatal Medicine, Department of Pediatrics, University of California Irvine, Irvine, CA
| | - Roberta Keller
- Division of Neonatology, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Laurel Moyer
- Division of Neonatology, Rady Children's Hospital, San Diego, CA
| | - Francis Poulain
- Division of Neonatology, Department of Pediatrics, University of California Davis, Davis, CA
| | - Jae H Kim
- Division of Neonatology, Department of Pediatrics, University of California San Diego, San Diego, CA
| | - Daniel A DeUgarte
- Division of Pediatric Surgery, Department of Surgery, University of California Los Angeles, Los Angeles, CA
| | - Kara L Calkins
- Division of Neonatology and Developmental Biology, Department of Pediatrics, University of California Los Angeles, Los Angeles, CA
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22
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Nagel E, Desjardins C, Earthman C, Ramel S, Demerath E. Weight for length measures may not accurately reflect adiposity in preterm infants born appropriate for gestational age during hospitalisation or after discharge from the neonatal intensive care unit. Pediatr Obes 2021; 16:e12744. [PMID: 33140910 PMCID: PMC8026714 DOI: 10.1111/ijpo.12744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 09/19/2020] [Accepted: 10/05/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Weight/length (W/L) indices are poor surrogates for adiposity in preterm infants born appropriate for gestational age (AGA) at birth, but whether the association subsequently improves is unknown. OBJECTIVE To determine if W/L indices accurately reflect adiposity in premature infants born AGA in later infancy. METHODS Associations between W/L indices and fat mass, fat mass index and percent body fat (%BF) obtained via air displacement plethysmography (ADP) were examined in 260 preterm infants (majority born AGA) at 28 to 63 weeks' postmenstrual age (PMA). Accuracy of W/L indices as indicators of adiposity was assessed by proportion of variance explained (R2 ) and root mean square error from linear regression of adiposity on W/L indices and proportion of infants misclassified by W/L indices. Accuracy was further compared in term vs preterm infants at term-equivalent age. The impact of early vs late preterm status on associations between W/L indices and %BF was also examined. RESULTS BMI and W/L were most strongly associated with %BF but yielded poorly fitting models (maximum R2 = 0.35; 53% misclassification). A significant interaction of W/L indices and early vs late preterm status on %BF revealed that estimation of %BF differs by status. Accuracy of W/L indices was worse in preterm infants at term-equivalent age. CONCLUSIONS W/L indices were not good indicators of adiposity in preterm infants from 28 to 63 weeks' PMA (born AGA) with all categories of W/L indices combined. Future research should examine whether results are similar in preterm infants born with disproportionate W/L or who experience disproportionate growth postnatally.
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Affiliation(s)
- Emily Nagel
- Department of Food Science and Nutrition, University of Minnesota-Twin Cities, Minneapolis, Minnesota,School of Public Health, University of Minnesota-Twin Cities, Minneapolis, Minnesota
| | | | - Carrie Earthman
- Department of Behavioral Health and Nutrition, University of Delaware, Newark, Delaware
| | - Sara Ramel
- Department of Pediatrics, University of Minnesota-Twin Cities, Minneapolis, Minnesota
| | - Ellen Demerath
- School of Public Health, University of Minnesota-Twin Cities, Minneapolis, Minnesota
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23
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Mihatsch W, Dorronsoro Martín I, Barrios-Sabador V, Couce ML, Martos-Moreno GÁ, Argente J, Quero J, Saenz de Pipaon M. Bone Mineral Density, Body Composition, and Metabolic Health of Very Low Birth Weight Infants Fed in Hospital Following Current Macronutrient Recommendations during the First 3 Years of Life. Nutrients 2021; 13:nu13031005. [PMID: 33804764 PMCID: PMC8003951 DOI: 10.3390/nu13031005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/14/2021] [Accepted: 03/17/2021] [Indexed: 12/17/2022] Open
Abstract
The present study longitudinally evaluated growth, bone mineral density, body composition, and metabolic health outcome in very low birth weight (VLBW) infants whose in-hospital target nutrient intake was within recent recommendations. From six months to three years, bone mineral density (dual-energy X-ray absorptiometry, DXA), body composition, and metabolic health outcome were compared with a reference group of term infants. The aim was to test whether in-hospital achieved weight gain until 36 weeks of gestation (light or appropriate for term equivalent age; LTEA or ATEA) predicts later growth, bone mineral density (BMD), abdominal obesity, or metabolic health outcomes such as insulin resistance, relative to term infants, during the first three years of life. Target in-hospital energy and protein intake was not achieved. Growth in weight, length and head circumference, mid arm circumference, adiposity, fat free mass (FFM), and bone mineralization in VLBW infants was less than those in term infants and influenced by nutritional status at discharge. Preterm infants had poorer motor and cognitive outcomes. Post-discharge body composition patterns indicate FFM proportional to height but lower fat mass index in LTEA preterm infants than term infants, with no evidence of increased truncal fat in preterm infants. The hypothesis of early BMD catch-up in VLBW infants after discharge was not supported by the present data. The clinical significance of these findings is unclear. The data may suggest a reduced obesity risk but an increased osteoporosis risk. Since postnatal growth restriction may have permanent negative health effects, LTEA VLBW infants would especially appear to benefit from targeted preventive interventions. Further follow-up of the infants is required.
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Affiliation(s)
- Walter Mihatsch
- Department of Pediatrics, Ulm University and Neu-Ulm University of Applied Sciences, 89231 Neu-Ulm, Germany;
| | - Izaskun Dorronsoro Martín
- Department of Neonatology, Hospital Universitario La Paz, Department of Pediatrics, Universidad Autonoma de Madrid, 28046 Madrid, Spain; (I.D.M.); (J.Q.)
| | - Vicente Barrios-Sabador
- Department of Endocrinology, Hospital Infantil Universitario Niño Jesús, Instituto de Investigación La Princesa, Department of Pediatrics, Universidad Autónoma de Madrid, 28039 Madrid, Spain; (V.B.-S.); (G.Á.M.-M.); (J.A.)
- CIBER Fisiopatología de la obesidad y nutrición (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - María L. Couce
- Neonatology Department, University Clinical Hospital of Santiago de Compostela, IDIS-Health Research Institute of Santiago de Compostela, Universidad de Santiago de Compostela, 15704 Santiago de Compostela, Spain;
| | - Gabriel Á. Martos-Moreno
- Department of Endocrinology, Hospital Infantil Universitario Niño Jesús, Instituto de Investigación La Princesa, Department of Pediatrics, Universidad Autónoma de Madrid, 28039 Madrid, Spain; (V.B.-S.); (G.Á.M.-M.); (J.A.)
- CIBER Fisiopatología de la obesidad y nutrición (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Jesús Argente
- Department of Endocrinology, Hospital Infantil Universitario Niño Jesús, Instituto de Investigación La Princesa, Department of Pediatrics, Universidad Autónoma de Madrid, 28039 Madrid, Spain; (V.B.-S.); (G.Á.M.-M.); (J.A.)
- CIBER Fisiopatología de la obesidad y nutrición (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain
- IMDEA Institute, 28049 Madrid, Spain
| | - José Quero
- Department of Neonatology, Hospital Universitario La Paz, Department of Pediatrics, Universidad Autonoma de Madrid, 28046 Madrid, Spain; (I.D.M.); (J.Q.)
| | - Miguel Saenz de Pipaon
- Department of Neonatology, Hospital Universitario La Paz, Department of Pediatrics, Universidad Autonoma de Madrid, 28046 Madrid, Spain; (I.D.M.); (J.Q.)
- Correspondence:
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Cordova EG, Cherkerzian S, Bell K, Joung KE, Collins CT, Makrides M, Gould J, Anderson PJ, Belfort MB. Association of Poor Postnatal Growth with Neurodevelopmental Impairment in Infancy and Childhood: Comparing the Fetus and the Healthy Preterm Infant References. J Pediatr 2020; 225:37-43.e5. [PMID: 32525038 DOI: 10.1016/j.jpeds.2020.05.063] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 05/24/2020] [Accepted: 05/27/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To compare the classification of preterm postnatal poor growth using healthy preterm vs fetal growth references and to examine associations with neurodevelopmental impairment in infancy and childhood. STUDY DESIGN We included 613 infants born at <33 weeks of gestation. Using the INTERGROWTH-21st (healthy-preterm growth) reference and the Fenton and Olsen (fetal growth) references, we classified poor growth as a decline in z-score from birth to term-equivalent >0.8 SD (weight), >1 SD (head), and >2 SD (length). We used generalized estimating equations to estimate aOR for neurodevelopmental impairment at 18 months and 7 years of corrected age, comparing infants with and without poor growth by each reference, accounting for multiple births and covariates. RESULTS The prevalence of poor growth was higher with INTERGROWTH-21st than with fetal references for all measurements. Agreement was higher between the Fenton and Olsen (fetal) growth references (0.72-0.81) than between INTERGROWTH-21st and fetal references (0.41-0.59). Poor growth by fetal references (but not by INTERGROWTH-21st) was associated with low neurodevelopmental scores in infancy and childhood. Poor weight gain using the Fenton reference was associated with 18-month Mental Developmental Index <85 (aOR 1.6, 95%CI: 1.1, 2.4) whereas poor weight gain by the INTERGROWTH-21st reference was not (aOR 1.0, 95%CI: 0.6, 1.7). Poor linear growth by the Olsen reference, but not INTERGROWTH-21st, was associated with 7-year verbal intelligence quotient <70 (aOR 3.5, 95%CI: 1.1, 12.7). CONCLUSIONS Poor neonatal growth categorized using fetal references showed stronger associations with long term neurodevelopment than poor growth categorized using the INTERGROWTH-21st standards.
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Affiliation(s)
- Erika G Cordova
- Department of Medicine, Boston Children's Hospital, Boston, MA.
| | - Sara Cherkerzian
- Department of Newborn Medicine, Brigham and Women's Hospital. Harvard Medical School, Boston, MA
| | - Katherine Bell
- Department of Newborn Medicine, Brigham and Women's Hospital. Harvard Medical School, Boston, MA
| | - Kyoung Eun Joung
- Division of Neonatology and Newborn Medicine, Department of Pediatrics, Massachusetts General Hospital, Boston, MA
| | - Carmel T Collins
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute and Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Maria Makrides
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute and Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Jacqueline Gould
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute and Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Peter J Anderson
- Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia
| | - Mandy Brown Belfort
- Division of Neonatology and Newborn Medicine, Department of Pediatrics, Massachusetts General Hospital, Boston, MA
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Abstract
Short bowel syndrome (SBS) is a malabsorptive state that may occur either after surgical bowel resection or as the result of congenital bowel anomalies. SBS can incur significant morbidity and mortality including intestinal failure, cholestasis, sepsis, and death. For patients with SBS, management involves a multidisciplinary approach that begins with neonatology, pediatric surgery, nutritionists, pharmacists, and nurses in the NICU and also includes the transition to an intestinal rehabilitation program. The aim of this review is to provide the neonatologist with an overview of the common causes of neonatal SBS, anticipated nutritional deficiencies, complications associated with SBS, and the surgical and medical management of SBS to assist in counseling affected families.
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Affiliation(s)
| | - Melissa E Danko
- Pediatric Surgery, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
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Foote JM, Hanrahan K, Mulder PJ, Nielsen AK, Perkhounkova Y, Hein M, Saeidzadeh S, McCarthy AM. Growth Measurement Practices from a National Survey of Neonatal Nurses. J Pediatr Nurs 2020; 52:10-17. [PMID: 32062375 DOI: 10.1016/j.pedn.2020.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/04/2020] [Accepted: 02/04/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE To describe neonatal nurses' growth measurement practices, attitudes, knowledge, bases of practice knowledge, and barriers and facilitators for changing practice; and to identify differences in practices and knowledge by nursing organization, unit type, education, and experience. DESIGN AND METHODS A cross-sectional online survey of U.S. neonatal nurses was distributed through two neonatal nursing organizations. RESULTS The survey was completed by 301 nurses. Some evidence-based practices (EBPs) were infrequently reported including recording frontal-occipital head circumference (FOC) and length using 0.1 cm increments (17.9% and 17.6%, respectively); measuring FOC, weight, and length more than once before recording (61.9%, 27.2%, and 39.6%, respectively); and for length, using a length board instead of tape measure (19.4%), with a second person assisting (25.1%), with Frankfort plane head positioning (3.3%), and measuring from crown to heels of both feet (19.1%). Most nurses perceived their measurements as accurate or highly accurate (96.7% for FOC, 99.3% for weight, and 87.1% for length). The mean percentage correct on knowledge items was 68.1%. NICU nurses scored slightly better than well-newborn nurses (mean 69.3% correct vs. 65.1% correct, p = .04). Most based measurement practices on clinical practice guidelines (86.6%) and unit policies and procedures (85.9%). Team culture (33.3%) and insufficient resources (32.6%) were the most common barriers to EBP. The support of nurse managers (70.0%) and unit educators (68.5%) were common facilitators. CONCLUSIONS AND IMPLICATIONS Knowledge gaps and practice improvement areas were identified. Results can inform interventions to improve the accuracy and reliability of neonatal growth measurement practices.
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Affiliation(s)
- Jan M Foote
- The University of Iowa College of Nursing, Iowa City, IA, USA; Blank Children's Endocrinology Clinic, Blank Children's Hospital, Des Moines, IA, USA.
| | | | - Pamela J Mulder
- The University of Iowa College of Nursing, Iowa City, IA, USA
| | - Anne K Nielsen
- University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Maria Hein
- The University of Iowa College of Nursing, Iowa City, IA, USA
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Belfort MB, Ramel SE. NICU Diet, Physical Growth and Nutrient Accretion, and Preterm Infant Brain Development. Neoreviews 2020; 20:e385-e396. [PMID: 31261105 DOI: 10.1542/neo.20-7-e385] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Half of very preterm infants experience neurodevelopmental impairments after NICU discharge. These adverse outcomes result in part from abnormal brain development and injury that occur during the NICU hospitalization. Although many factors influence infant brain development, nutritional determinants are of particular interest because they are highly modifiable within clinical care. Physical growth of preterm infants in the NICU continues to lag behind the reference fetus, suggesting reduced nutrient accretion during a critical period for brain development. Nutrient accretion is driven by intake of specific nutrients such as macro- and micronutrients as well as non-nutritional factors such as systemic inflammation. Most often, anthropometric indicators, such as weight, length, and head circumference, are used as proxies for nutrient accretion. A limitation of weight is that it does not differentiate the healthy growth of specific organs and tissues from excess fat accumulation. Body length provides information about skeletal growth, and linear growth stunting predicts neurodevelopmental impairment. Head circumference is only a crude proxy for brain size. More recently, application of new technologies such as air displacement plethysmography and magnetic resonance imaging has allowed the direct estimation of lean tissue accretion and brain growth in the NICU. These newer techniques can facilitate research to improve our understanding of the links among the NICU diet, inflammation, physical growth, and brain development. These new measures may also be relevant within clinical care to identify infants who may benefit from specific interventions to enhance nutrient accretion and brain development.
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Affiliation(s)
- Mandy Brown Belfort
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Sara E Ramel
- Division of Neonatology, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
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Ordóñez-Díaz MD, Pérez-Navero JL, Flores-Rojas K, Olza-Meneses J, Muñoz-Villanueva MC, Aguilera-García CM, Gil-Campos M. Prematurity With Extrauterine Growth Restriction Increases the Risk of Higher Levels of Glucose, Low-Grade of Inflammation and Hypertension in Prepubertal Children. Front Pediatr 2020; 8:180. [PMID: 32373566 PMCID: PMC7186313 DOI: 10.3389/fped.2020.00180] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 03/30/2020] [Indexed: 12/31/2022] Open
Abstract
Introduction: An adipose tissue programming mechanism could be implicated in the extrauterine growth restriction (EUGR) of very preterm infants with morbidity in the cardiometabolic status later in life, as has been reported in intrauterine growth restriction. The aim of this study was to assess whether children with a history of prematurity and EUGR, but also with an adequate growth, showed alterations in the metabolic and inflammatory status. Methods: This was a case-control study. A total of 88 prepubertal children with prematurity antecedents were selected: 38 with EUGR and 50 with an adequate growth pattern (PREM group). They were compared with 123 healthy children born at term. Anthropometry, metabolic parameters, blood pressure (BP), C-reactive protein, hepatocyte growth factor (HGF), interleukin-6 (IL-6), IL-8, monocyte chemotactic protein type 1 (MCP-1), neural growth factor, tumour necrosis factor-alpha (TNF-α) and plasminogen activator inhibitor type-1 were analysed at the prepubertal age. Results: EUGR children exhibited higher BP levels and a higher prevalence of hypertension (46%) compared with both PREM (10%) and control (2.5%) groups. Moreover, there was a positive relationship between BP levels and values for glucose, insulin and HOMA-IR only in children with a EUGR history. The EUGR group showed higher concentrations of most of the cytokines analysed, markedly higher TNF-α, HGF and MCP-1 levels compared with the other two groups. Conclusion: EUGR status leads to cardiometabolic changes and a low-grade inflammatory status in children with a history of prematurity, and that could be related with cardiovascular risk later in life.
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Affiliation(s)
- Maria D Ordóñez-Díaz
- Department of Paediatrics, Maimónides Biomedical Research Institute, Reina Sofía University Hospital, University of Córdoba, Córdoba, Spain
| | - Juan L Pérez-Navero
- Department of Paediatrics, Maimónides Biomedical Research Institute, Reina Sofía University Hospital, University of Córdoba, Córdoba, Spain.,Centre for Biomedical Research on Rare Diseases (CIBERER-ISCIII), Madrid, Spain
| | - Katherine Flores-Rojas
- Unit of Metabolism and Paediatric Research, Maimónides Biomedical Research Institute, Reina Sofia University Hospital, University of Córdoba, Córdoba, Spain
| | - Josune Olza-Meneses
- Laboratory 123, Department of Biochemistry and Molecular Biology II, Centre of Biomedical Research, Institute of Nutrition and Food Technology, University of Granada, Granada, Spain
| | - Maria C Muñoz-Villanueva
- Unit of Methodological Support to Research, Maimónides Biomedical Research Institute, Córdoba, Spain
| | - Concepción M Aguilera-García
- Laboratory 123, Department of Biochemistry and Molecular Biology II, Centre of Biomedical Research, Institute of Nutrition and Food Technology, University of Granada, Granada, Spain
| | - Mercedes Gil-Campos
- Unit of Metabolism and Paediatric Research, Maimónides Biomedical Research Institute, Reina Sofia University Hospital, University of Córdoba, Córdoba, Spain
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Neonatal Intestinal Failure Is Independently Associated With Impaired Cognitive Development Later in Childhood. J Pediatr Gastroenterol Nutr 2020; 70:64-71. [PMID: 31651669 DOI: 10.1097/mpg.0000000000002529] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The impact of pediatric intestinal failure (IF) on neurodevelopment beyond infancy has not been systematically studied. Our aim was to evaluate cognitive and motor impairment and to identify risk factors for adverse outcomes among children with IF. METHODS We conducted a cross-sectional single-center study at the Helsinki University Children's Hospital. Patients with IF with >60 days of parental nutrition (PN) dependency aged between 3 and 16 years (n = 40) were invited to participate. The cognitive and motor skills were evaluated using validated tests: Wechsler Preschool and Primary Scale of Intelligence, 3rd edition, Wechsler Intelligence Scale for Children, 4th edition, and Movement Assessment Battery for Children, 2nd edition. RESULTS All the patients attending the study tests (n = 30, males = 24) were included. Their median age, gestational age, and birth weight was 7.5 (range 3-16) years, 35 (interquartile range [IQR] 28-38) weeks and 2238 (IQR 1040-3288) grams, respectively. Median duration of PN was 13 (IQR 5-37) months and 9 patients were currently on PN. Median intelligence quotient was 78 (IQR 65-91) and 10 (35%) patients had an intelligence quotient under 70 (-2 standard deviation). Significant motor impairment was detected in 10 patients (36%) and milder difficulties in 8 (28%). Adverse cognitive outcome was associated with neonatal short bowel syndrome, number of interventions under general anesthesia, and length of inpatient status, whereas adverse motor outcome was associated with prematurity. CONCLUSION Clinically significant cognitive and motor impairments are alarmingly common among neonatal patients with IF. We recommend early neurodevelopmental follow-up for all children with IF.
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Bell KA, Matthews LG, Cherkerzian S, Palmer C, Drouin K, Pepin HL, Ellard D, Inder TE, Ramel SE, Belfort MB. Associations of Growth and Body Composition with Brain Size in Preterm Infants. J Pediatr 2019; 214:20-26.e2. [PMID: 31377040 PMCID: PMC9131302 DOI: 10.1016/j.jpeds.2019.06.062] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/08/2019] [Accepted: 06/25/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To assess the association of very preterm infants' brain size at term-equivalent age with physical growth from birth to term and body composition at term. STUDY DESIGN We studied 62 infants born at <33 weeks of gestation. At birth and term, we measured weight and length and calculated body mass index. At term, infants underwent air displacement plethysmography to determine body composition (fat and fat-free mass) and magnetic resonance imaging to quantify brain size (bifrontal diameter, biparietal diameter, transverse cerebellar distance). We estimated associations of physical growth (Z-score change from birth to term) and body composition with brain size, adjusting for potential confounders using generalized estimating equations. RESULTS The median gestational age was 29 weeks (range, 24.0-32.9 weeks). Positive gains in weight and body mass index Z-score were associated with increased brain size. Each additional 100 g of fat-free mass at term was associated with larger bifrontal diameter (0.6 mm; 95% CI, 0.2-1.0 mm), biparietal diameter (0.7 mm; 95% CI, 0.3-1.1 mm), and transverse cerebellar distance (0.3 mm; 95% CI, 0.003-0.5 mm). Associations between fat mass and brain metrics were not statistically significant. CONCLUSIONS Weight and body mass index gain from birth to term, and lean mass-but not fat-at term, were associated with larger brain size. Factors that promote lean mass accrual among preterm infants may also promote brain growth.
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Affiliation(s)
- Katherine A Bell
- Department of Pediatric Newborn Medicine, Brigham & Women's Hospital, Boston, MA.
| | - Lillian G Matthews
- Department of Pediatric Newborn Medicine, Brigham & Women's Hospital, Boston, MA
| | - Sara Cherkerzian
- Department of Pediatric Newborn Medicine, Brigham & Women's Hospital, Boston, MA
| | - Caroline Palmer
- Department of Pediatric Newborn Medicine, Brigham & Women's Hospital, Boston, MA
| | - Kaitlin Drouin
- Department of Pediatric Newborn Medicine, Brigham & Women's Hospital, Boston, MA
| | - Hunter L Pepin
- Department of Nutrition, Brigham & Women's Hospital, Boston, MA
| | - Deirdre Ellard
- Department of Nutrition, Brigham & Women's Hospital, Boston, MA
| | - Terrie E Inder
- Department of Pediatric Newborn Medicine, Brigham & Women's Hospital, Boston, MA
| | - Sara E Ramel
- Division of Neonatology, School of Medicine, University of Minnesota, Minneapolis, MN
| | - Mandy B Belfort
- Department of Pediatric Newborn Medicine, Brigham & Women's Hospital, Boston, MA
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Cuestas E, Aguilera B, Cerutti M, Rizzotti A. Sustained Neonatal Inflammation Is Associated with Poor Growth in Infants Born Very Preterm during the First Year of Life. J Pediatr 2019; 205:91-97. [PMID: 30340934 DOI: 10.1016/j.jpeds.2018.09.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/31/2018] [Accepted: 09/11/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine whether a sustained neonatal systemic inflammatory response was associated with poor postnatal growth among infants born very preterm during the first year of life. STUDY DESIGN We studied prospectively 192 infants born preterm (birth weight ≤1.5 kg and gestational age ≤31 weeks). Weight, length, and head circumference were measured at birth, term, 4, and 12 months of corrected age. Serial C-reactive protein and procalcitonin were measured at 1, 3, 7, 14, and 28 days of age and averaged for each infant. A sustained neonatal systemic inflammatory response was defined as an average C-reactive protein level greater than the median for the group. Analysis was undertaken with linear mixed models. RESULTS Decreases in mean z scores for weight, length, and head circumference were associated with the presence of a sustained neonatal systemic inflammatory response from birth to 12 months of corrected age (β [95% CI] = -0.282 [-0.306 to -0.258]; -1.899 [-2.028,-1.769]; -0.806 [-0.910, to -0.701], P < .001, respectively) in main effect models. This association remained significant after including interaction terms for bronchopulmonary dysplasia, neonatal sepsis, and necrotizing enterocolitis (β [95% CI] = -0.393 [-0.520 to -0.265]; -2.128 [-2.754, -1.503]; -1.102 [-1.604, -0.600]; P < .001; respectively) in interaction models. CONCLUSIONS A sustained neonatal systemic inflammatory response was associated with poor postnatal growth, particularly poor linear growth. Serial C-reactive protein and procalcitonin may be useful markers for identifying infants at risk for postnatal growth failure.
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Affiliation(s)
- Eduardo Cuestas
- Department of Pediatrics and Neonatology, Hospital Privado Universitario de Córdoba, Córdoba, Argentina; Department of Pediatrics, Instituto Universitario de Ciencias Biomédicas de Córdoba, Córdoba, Argentina.
| | - Belén Aguilera
- Department of Pediatrics and Neonatology, Hospital Privado Universitario de Córdoba, Córdoba, Argentina
| | - Manuel Cerutti
- Department of Pediatrics and Neonatology, Hospital Privado Universitario de Córdoba, Córdoba, Argentina
| | - Alina Rizzotti
- Department of Pediatrics and Neonatology, Hospital Privado Universitario de Córdoba, Córdoba, Argentina; Department of Pediatrics, Instituto Universitario de Ciencias Biomédicas de Córdoba, Córdoba, Argentina
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Hickey M, Georgieff M, Ramel S. Neurodevelopmental outcomes following necrotizing enterocolitis. Semin Fetal Neonatal Med 2018; 23:426-432. [PMID: 30145060 DOI: 10.1016/j.siny.2018.08.005] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Necrotizing enterocolitis (NEC), a gastrointestinal emergency predominantly affecting premature infants, is associated with increased risk for poor neurodevelopmental outcomes. NEC often strikes during a period of rapid and dynamic neurologic development when the brain is particularly vulnerable to insults and nutrient deficits. The pathogenesis of neurodevelopmental impairment following NEC is likely multifactorial, with both nutritional and non-nutritional factors at play. Follow-up testing that ensures early detection and intervention for impairments is crucial to optimize neurodevelopmental outcomes following NEC. A multifaceted approach to follow-up after NEC is necessary, with close monitoring of growth, serial developmental assessments, neurologic examinations, hearing and vision testing and neuroimaging. Further research is needed to understand the pathogenesis of neurodevelopmental impairment following NEC, to identify more targeted follow-up tests, and to discover interventions aimed at optimizing neurodevelopmental outcomes following NEC.
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Affiliation(s)
- Marie Hickey
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, USA
| | - Michael Georgieff
- Department of Pediatrics and Center for Neurobehavioral Development, Division of Neonatology, University of Minnesota, Minneapolis, MN, USA
| | - Sara Ramel
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, USA.
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Watanabe Y, Itabashi K, Taki M, Miyazawa T, Nakano Y, Murase M. Body length and occipitofrontal circumference may be good indicators of neurodevelopment in very low birthweight infants - secondary publication. Acta Paediatr 2018; 107:975-980. [PMID: 29385636 DOI: 10.1111/apa.14250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/01/2017] [Accepted: 01/25/2018] [Indexed: 01/29/2023]
Abstract
AIM The aim of this study was to predict the neurological prognosis of very low birthweight (VLBW) infants. We examined the relationship between nutritional status, brain volume measured by magnetic resonance imaging (MRI) and anthropometric measurements of VLBW infants at term-equivalent age (TEA). METHODS We evaluated 27 VLBW infants, born at Showa University Hospital in Japan between April 2012 and August 2013, who underwent brain MRI at TEA. Based on their clinical data, we analysed their protein and energy intake. RESULTS Median values for the 27 VLBW infants were as follows: gestational age, 29.7 weeks; birthweight 1117 g; protein intake 2.7 g/kg/day and energy intake 97.9 kcal/kg/day. At TEA, the standard deviation scores (SDSs) of body weight, body length and the occipitofrontal circumference (OFC) were -0.8, -1.4 and 0.7, respectively. Multiple regression analysis revealed that the SDSs of body length and the OFC at TEA were significant determinants of white matter volume, but that the SDS of body weight at TEA was not. CONCLUSION Our findings suggest that the SDSs of body length and the OFC at TEA may be better indicators than body weight for predicting the development of the central nervous system in VLBW infants receiving nutritional management.
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Affiliation(s)
- Yoshitaka Watanabe
- Department of Pediatrics; Showa University School of Medicine; Tokyo Japan
| | - Kazuo Itabashi
- Department of Pediatrics; Showa University School of Medicine; Tokyo Japan
| | - Motohiro Taki
- Department of Pediatrics; Tokyo Metropolitan Health and Medical Treatment Corporation Ebara Hospital; Tokyo Japan
| | - Tokuo Miyazawa
- Department of Pediatrics; Showa University School of Medicine; Tokyo Japan
| | - Yuya Nakano
- Department of Pediatrics; Showa University School of Medicine; Tokyo Japan
| | - Masahiko Murase
- Department of Pediatrics; Showa University School of Medicine; Tokyo Japan
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Frondas-Chauty A, Simon L, Flamant C, Hanf M, Darmaun D, Rozé JC. Deficit of Fat Free Mass in Very Preterm Infants at Discharge is Associated with Neurological Impairment at Age 2 Years. J Pediatr 2018; 196:301-304. [PMID: 29336797 DOI: 10.1016/j.jpeds.2017.12.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 10/11/2017] [Accepted: 12/06/2017] [Indexed: 01/02/2023]
Abstract
Preterm infants have a deficit of fat-free mass accretion during hospitalization. This study suggests that z score of fat-free mass at discharge is associated with neurologic outcome (P = .003) at 2 years of age, independent of sex, gestational age, and birth weight z score. Interventions to promote quality of growth should be considered.
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Affiliation(s)
- Anne Frondas-Chauty
- Department of Neonatal Medicine, University Hospital of Nantes, Nantes, France; INRA UMR 1280, Physiologie des Adaptations Nutritionnelles, IMAD, CRNH Ouest, Nantes, France.
| | - Laure Simon
- Department of Neonatal Medicine, University Hospital of Nantes, Nantes, France; INRA UMR 1280, Physiologie des Adaptations Nutritionnelles, IMAD, CRNH Ouest, Nantes, France
| | - Cyril Flamant
- Department of Neonatal Medicine, University Hospital of Nantes, Nantes, France; INRA UMR 1280, Physiologie des Adaptations Nutritionnelles, IMAD, CRNH Ouest, Nantes, France; INSERM CIC 1413, Clinical Investigation Center, Nantes University Hospital, Nantes, France
| | - Matthieu Hanf
- INSERM CIC 1413, Clinical Investigation Center, Nantes University Hospital, Nantes, France; INSERM UMR 1181 Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases (B2PHI), Versailles Saint Quentin University, Villejuif, France
| | - Dominique Darmaun
- INRA UMR 1280, Physiologie des Adaptations Nutritionnelles, IMAD, CRNH Ouest, Nantes, France; Nantes University, IMAD, Nantes, France
| | - Jean-Christophe Rozé
- Department of Neonatal Medicine, University Hospital of Nantes, Nantes, France; INRA UMR 1280, Physiologie des Adaptations Nutritionnelles, IMAD, CRNH Ouest, Nantes, France; INSERM CIC 1413, Clinical Investigation Center, Nantes University Hospital, Nantes, France
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Goldberg DL, Becker PJ, Brigham K, Carlson S, Fleck L, Gollins L, Sandrock M, Fullmer M, Van Poots HA. Identifying Malnutrition in Preterm and Neonatal Populations: Recommended Indicators. J Acad Nutr Diet 2018; 118:1571-1582. [PMID: 29398569 DOI: 10.1016/j.jand.2017.10.006] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Indexed: 01/04/2023]
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Parlapani E, Agakidis C, Karagiozoglou-Lampoudi T. Anthropometry and Body Composition of Preterm Neonates in the Light of Metabolic Programming. J Am Coll Nutr 2018; 37:350-359. [PMID: 29425475 DOI: 10.1080/07315724.2017.1400479] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The improved survival of preterm infants has led to increased interest regarding their health as adults. In the context of metabolic programming, the connection between perinatal and early postnatal nutrition and growth with health in later life has brought to the fore the role of catch-up growth during the first months of preterm infants' lives and its association with body fat and obesity in childhood or puberty. A state-of-the art review was conducted in order to assess the way catch-up is evaluated, in terms of timing and rate. Adequate growth is of major importance for neurodevelopment; however, it may compete with adiposity or metabolic health. Studies based on body composition assessment have given conflicting results as regards the effect of early versus late and rapid versus slow catch-up growth on later health, mainly attributed to the lack of established criteria and definitions. Given that adequate early nutrition is crucial for the neurodevelopment of preterm infants, further studies are needed on the role of catch-up growth in long-term outcome, using generally accepted qualitative and quantitative criteria.
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Affiliation(s)
- Elisavet Parlapani
- a Clinical Nutrition Lab, Nutrition/Dietetics Department , Alexander Technological Educational Institute of Thessaloniki , Thessaloniki , Greece.,b 1st Department of Neonatology and NICU , Faculty of Medicine, Aristotle University of Thessaloniki, Ippokration Hospital , Thessaloniki , Greece
| | - Charalampos Agakidis
- c 1st Department of Pediatrics , Faculty of Medicine, Aristotle University of Thessaloniki, Ippokration Hospital , Thessaloniki , Greece
| | - Thomais Karagiozoglou-Lampoudi
- a Clinical Nutrition Lab, Nutrition/Dietetics Department , Alexander Technological Educational Institute of Thessaloniki , Thessaloniki , Greece
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Morlacchi L, Roggero P, Giannì ML, Bracco B, Porri D, Battiato E, Menis C, Liotto N, Mallardi D, Mosca F. Protein use and weight-gain quality in very-low-birth-weight preterm infants fed human milk or formula. Am J Clin Nutr 2018; 107:195-200. [PMID: 29529139 DOI: 10.1093/ajcn/nqx001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 10/13/2017] [Indexed: 02/05/2023] Open
Abstract
Background Nutritional management of preterm infants aims to approximate the tissue growth and body composition of a fetus of the same postmenstrual age. The adequacy of the quality of protein supply can influence the rate and the relative quality of weight gain. Objective We investigated the protein balance according to feeding regimen and the association between human milk feeding and fat-free mass content at the term-corrected age in very-low-birth-weight preterm infants. Design A prospective observational study was conducted. Inclusion criteria were as follows: healthy infants, gestational age ≤32 wk, birth weight <1500 g, stable clinical conditions, and feeding by mouth with human milk or formula at discharge. Infants were enrolled at hospital discharge. At enrollment, macronutrient intakes and protein balance were determined. Anthropometric measurements and body composition were also assessed. The nutritional composition of human milk was calculated by infrared spectroscopy. The protein balance was determined according to the nitrogen balance standard method. Body composition was assessed by an air-displacement plethysmography system. At the term-corrected age, anthropometry and body composition assessments were repeated. Results Seventeen preterm infants fed fortified human milk and 15 preterm infants fed formula were enrolled. At discharge, despite similar macronutrient intakes, infants fed fortified human milk showed a higher nitrogen balance (expressed as mg · kg-1 · d-1) compared with preterm formula-fed infants (mean ± SD: 488.3 ± 75 compared with 409.8 ± 85 mg · kg-1 · d-1, P = 0.009). At term-corrected age, growth was similar in the 2 groups, whereas fortified human milk-fed infants showed a higher percentage of fat-free mass (85.1% ± 2.8% compared with 80.8% ± 3.2%, P = 0.002). Moreover, at multiple linear regression, fat-free mass content was independently associated with being fed human milk (R2 = 0.93, P < 0.0001). Conclusion Our findings suggest that human milk feeding is associated with early fat-free mass deposition in healthy and stable preterm infants. This trial was registered at www.clinicaltrials.gov as NCT03013374.
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Affiliation(s)
- Laura Morlacchi
- Neonatal Intensive Care Unit, Department of Clinical Science and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan Italy
| | - Paola Roggero
- Neonatal Intensive Care Unit, Department of Clinical Science and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan Italy
| | - Maria Lorella Giannì
- Neonatal Intensive Care Unit, Department of Clinical Science and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan Italy
| | - Beatrice Bracco
- Neonatal Intensive Care Unit, Department of Clinical Science and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan Italy
| | - Debora Porri
- Neonatal Intensive Care Unit, Department of Clinical Science and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan Italy
| | - Enrico Battiato
- Neonatal Intensive Care Unit, Department of Clinical Science and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan Italy
| | - Camilla Menis
- Neonatal Intensive Care Unit, Department of Clinical Science and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan Italy
| | - Nadia Liotto
- Neonatal Intensive Care Unit, Department of Clinical Science and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan Italy
| | - Domenica Mallardi
- Neonatal Intensive Care Unit, Department of Clinical Science and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Department of Clinical Science and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan Italy
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Abdel-Rahman SM, Paul IM, Delmore P, James L, Fearn L, Atz AM, Poindexter BB, Al-Uzri A, Lewandowski A, Harper BL, Smith PB. An anthropometric survey of US pre-term and full-term neonates. Ann Hum Biol 2017; 44:678-686. [PMID: 29037091 PMCID: PMC5794488 DOI: 10.1080/03014460.2017.1392603] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 09/11/2017] [Accepted: 10/04/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Anthropometric data prove valuable for screening and monitoring various medical conditions. In young infants, however, only weight, length and head circumference are represented in publicly accessible databases. AIM To characterise length and circumferential measures in pre-term and full-term infants up to 90 days post-natal. SUBJECTS AND METHODS In eight US medical centres, trained raters recorded humeral, ulnar, femoral, tibial and fibular lengths along with mid-upper arm, mid-thigh, chest, abdominal and neck circumference. Data were pooled by post-menstrual age into 1-week intervals and population curves created using the lambda, mu and sigma (LMS) method. Goodness-of-fit was assessed by examining de-trended quantile-quantile plots, Q statistics and fitted centiles overlaid on empirical centiles. RESULTS In total, 2097 infants were enrolled in this study with a mean ± SD gestational age and post-natal age of 37.1 ± 3.3 weeks and 27.3 ± 25.3 days, respectively. A re-scale option was used to describe all curves. The resultant models reliably characterised anthropometric measures from 33-52 weeks PMA, with less certainty at the extremes (27-55 weeks). CONCLUSION The population curves generated under this investigation expand existing reference data on a comprehensive set of anthropometric traits in infants through the first 90 days post-natal.
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Affiliation(s)
- Susan M. Abdel-Rahman
- Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Department of Pediatrics, Children’s Mercy Hospitals and Clinics, University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
| | - Ian M. Paul
- Pediatrics and Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Paula Delmore
- Divisions of Pulmonology, Respiratory Medicine, and Pediatrics, Wesley Medical Center, Wichita, KS, USA
| | - Laura James
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital Research Institute, Little Rock, AR, USA
| | - Laura Fearn
- Department of Pediatrics, Children’s Memorial Hospital, Chicago, IL, USA
| | - Andrew M. Atz
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Brenda B. Poindexter
- Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Amira Al-Uzri
- Pediatric Nephrology, Oregon Health and Science University, Portland, OR, USA
| | | | - Barrie L. Harper
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - P. Brian Smith
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
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Boguszewski MCDS, Cardoso-Demartini ADA. MANAGEMENT OF ENDOCRINE DISEASE: Growth and growth hormone therapy in short children born preterm. Eur J Endocrinol 2017; 176:R111-R122. [PMID: 27803030 DOI: 10.1530/eje-16-0482] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 10/25/2016] [Accepted: 11/01/2016] [Indexed: 11/08/2022]
Abstract
Approximately 15 million babies are born preterm across the world every year, with less than 37 completed weeks of gestation. Survival rates increased during the last decades with the improvement of neonatal care. With premature birth, babies are deprived of the intense intrauterine growth phase, and postnatal growth failure might occur. Some children born prematurely will remain short at later ages and adult life. The risk of short stature increases if the child is also born small for gestational age. In this review, the effects of being born preterm on childhood growth and adult height and the hormonal abnormalities possibly associated with growth restriction are discussed, followed by a review of current information on growth hormone treatment for those who remain with short stature during infancy and childhood.
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Demerath EW, Johnson W, Davern BA, Anderson CG, Shenberger JS, Misra S, Ramel SE. New body composition reference charts for preterm infants. Am J Clin Nutr 2017; 105:70-77. [PMID: 27806978 DOI: 10.3945/ajcn.116.138248] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 09/27/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The American Academy of Pediatrics (AAP) has recommended that nutritional management of the preterm infant should aim to achieve body composition that replicates the in utero fetus, but intrauterine body composition reference charts for preterm infants are lacking. OBJECTIVE Our objective was to create body composition reference curves for preterm infants that approximate the body composition of the in utero fetus from 30 to 36 wk of gestation. DESIGN A total of 223 ethnically diverse infants born at 30 + 0 to 36 + 6 wk of gestation were enrolled. Inclusion and exclusion criteria were specified so that the sample would represent healthy appropriately growing fetuses (e.g., singleton, birth weight appropriate for their gestational age, and medically stable). Cross-sectional reference values were generated for fat mass (FM), fat-free mass (FFM), and percentage body fat (PBF) by gestational age (GA), with the use of air-displacement plethysmography (ADP) and the lambda-mu-sigma method for percentile estimation. RESULTS GA-specific percentile values and a percentile and z score calculator for FFM, FM, and PBF are presented. These values aligned closely with ADP centile values published for term infants from 36 to 38 wk of gestation. The medians were also similar to the mean values for the reference fetus derived from chemical analysis previously. CONCLUSIONS To our knowledge, these are the first body composition reference charts for total FM and FFM at birth in preterm infants to assist in following AAP guidelines. Future work will test the clinical utility of body composition monitoring for improving nutritional management in this population. This trial was registered at clinicaltrials.gov as NCT02855814.
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Affiliation(s)
- Ellen W Demerath
- Division of Epidemiology and Community Health, School of Public Health, and
| | - William Johnson
- Medical Research Council Human Nutrition Research, Cambridge, United Kingdom
| | - Bridget A Davern
- Division of Neonatology, School of Medicine, University of Minnesota, Minneapolis, MN
| | | | | | - Sonya Misra
- Division of Neonatology, Santa Clara Valley Medical Center, San Jose, CA; and
| | - Sara E Ramel
- Division of Neonatology, School of Medicine, University of Minnesota, Minneapolis, MN
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Regev RH, Arnon S, Litmanovitz I, Bauer-Rusek S, Boyko V, Lerner-Geva L, Reichman B. Association between neonatal morbidities and head growth from birth until discharge in very-low-birthweight infants born preterm: a population-based study. Dev Med Child Neurol 2016; 58:1159-1166. [PMID: 27214124 DOI: 10.1111/dmcn.13153] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2016] [Indexed: 01/09/2023]
Abstract
AIM To evaluate the possible association between major neonatal morbidities and poor head growth from birth to discharge home in very-low-birthweight (VLBW) infants born preterm. METHOD Population-based observational study comprising 12 992 infants (6340 male, 6652 female) of 24 to 32 weeks' gestation, and birthweight ≤1500g. Severe head growth failure (HGF) was defined as a decrease in head circumference z-score >2 z-scores, and moderate HGF as a decrease of 1 to 2 z-scores. Multinomial logistic regression analysis was applied to determine morbidities associated with HGF. RESULTS Severe HGF occurred in 4.5% and moderate HGF in 20.9% of infants. Each unit increase in head circumference z-score at birth was associated with increased odds for severe and moderate HGF (odds ratios [OR] 5.29, 95% confidence intervals [CI] 4.67-6.00, and OR 2.38, 95% CI 2.23-2.54 respectively). Both severe and moderate HGF were associated with respiratory distress syndrome (OR 2.03, 95% CI 1.58-2.62, and OR 1.66, 95% CI 1.48-1.85 respectively); bronchopulmonary dysplasia (OR 3.38, 95% CI 2.33-4.91, and OR 1.87, 95% CI 1.52-2.30 respectively); necrotizing enterocolitis (OR 2.89, 95% CI 2.04-4.09, and OR 1.72, 95% CI 1.38-2.16 respectively), and sepsis (OR 2.06, 95% CI 1.69-2.50, and OR 1.38, 95% CI 1.24-1.53 respectively). INTERPRETATION Major neonatal morbidities were associated with HGF in VLBW infants born preterm. Identification of whether this is a direct effect of these morbidities or mediated through nutritional or growth factors may enable interventions to improve postnatal head growth of infants born preterm.
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Affiliation(s)
- Rivka H Regev
- Department of Neonatology, Meir Hospital, Sapir Medical Center, Kfar Saba, Israel. .,Sackler Medical School, Tel Aviv University, Tel Aviv, Israel.
| | - Shmuel Arnon
- Department of Neonatology, Meir Hospital, Sapir Medical Center, Kfar Saba, Israel.,Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Ita Litmanovitz
- Department of Neonatology, Meir Hospital, Sapir Medical Center, Kfar Saba, Israel.,Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Sofia Bauer-Rusek
- Department of Neonatology, Meir Hospital, Sapir Medical Center, Kfar Saba, Israel
| | - Valentina Boyko
- Women and Children's Health Research Unit, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel
| | - Liat Lerner-Geva
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel.,Women and Children's Health Research Unit, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel
| | - Brian Reichman
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel.,Women and Children's Health Research Unit, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel
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Guellec I, Lapillonne A, Marret S, Picaud JC, Mitanchez D, Charkaluk ML, Fresson J, Arnaud C, Flamant C, Cambonie G, Kaminski M, Roze JC, Ancel PY. Effect of Intra- and Extrauterine Growth on Long-Term Neurologic Outcomes of Very Preterm Infants. J Pediatr 2016; 175:93-99.e1. [PMID: 27318373 DOI: 10.1016/j.jpeds.2016.05.027] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 03/14/2016] [Accepted: 05/09/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine whether extrauterine growth is associated with neurologic outcomes and if this association varies by prenatal growth profile. STUDY DESIGN For 1493 preterms from the EPIPAGE (Étude Épidémiologique sur les Petits Âges Gestationnels [Epidemiological Study on Small Gestational Ages]) cohort, appropriate for gestational-age (AGA) was defined by birth weight >-2 SD and small for gestational-age (SGA) by birth weight ≤-2 SD. Extra-uterine growth was defined by weight gain or loss between birth and 6 months by z-score change. Growth following-the-curve (FTC) was defined as weight change -1 to +1 SD, catch-down-growth (CD) as weight loss ≥1 SD, and catch-up-growth (CU) as weight gain ≥1 SD. At 5 years, a complete medical examination (n = 1305) and cognitive evaluation with the Kauffman Assessment Battery for Children (n = 1130) were performed. Behavioral difficulties at 5 years and school performance at 8 years were assessed (n = 1095). RESULTS Overall, 42.5% of preterms were AGA-FTC, 20.2% AGA-CD, 17.1% AGA-CU, 5.6% SGA-FTC, and 14.5% SGA-CU. Outcomes did not differ between CU and FTC preterm AGA infants. Risk of cerebral palsy was greater for AGA-CD compared with AGA-FTC (aOR 2.26 [95% CI 1.37-3.72]). As compared with children with SGA-CU, SGA-FTC children showed no significant increased risk of cognitive deficiency (aOR 1.41[0.94-2.12]) or school difficulties (aOR 1.60 [0.84-3.03]). Compared with AGA-FTC, SGA showed increased risk of cognitive deficiency (SGA-FTC aOR 2.19 [1.25-3.84]) and inattention-hyperactivity (SGA-CU aOR 1.65 [1.05-2.60]). CONCLUSION Deficient postnatal growth was associated with poor neurologic outcome for AGA and SGA preterm infants. CU growth does not add additional benefits. Regardless of type of postnatal growth, SGA infants showed behavioral problems and cognitive deficiency.
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Affiliation(s)
- Isabelle Guellec
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France.
| | | | - Stephane Marret
- Rouen University Hospital, Neonatal Medicine, Rouen; Institute of Biomedical Research, University, Inserm Avenir Research Group, IFR 23, Rouen, France
| | - Jean-Charles Picaud
- Department of Neonatology, Human Nutrition Research Center, Hospital E. Herriot, Lyon, France
| | | | - Marie-Laure Charkaluk
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France
| | - Jeanne Fresson
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France; Clinical Epidemiology and Biostatistics Department, CHRU Nancy, Nancy, France
| | | | - Cyril Flamant
- Department of Neonatology, CHU Nantes, Nantes, France
| | - Gilles Cambonie
- Montpellier University Hospital Center, Neonatal and Pediatric Intensive Care Unit, Montpellier, France
| | - Monique Kaminski
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France
| | | | - Pierre-Yves Ancel
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France
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Mena P, Milad M, Vernal P, Escalante MJ. [Nutrition in the preterm hospitalized newborn. Recommendations of the Chilean Neonatology Branch, Chilean Pediatric Society]. ACTA ACUST UNITED AC 2016; 87:305-21. [PMID: 27156140 DOI: 10.1016/j.rchipe.2016.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 03/29/2016] [Indexed: 11/27/2022]
Abstract
Recommendations based on current publications are presented for postnatal preterm nutrition, depending on birth weight: less 1000g, between 1000 and 1500g, and above 1500g, as well for the development periods: adaptation, stabilisation, and growth. A review is also presented on the nutritional management of morbidities that affect or may affect nutrition, such as: osteopenia, bronchopulmonary dysplasia, patent ductus arteriosus, red cell transfusion, and short bowel syndrome.
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Affiliation(s)
- Patricia Mena
- Departamento de Neonatología, Facultad de Medicina, Pontificia Universidad Católica de Chile y Servicio de Recién Nacidos Hospital Dr. Sótero del Río, Santiago, Chile.
| | - Marcela Milad
- Servicio de Neonatología, Clínica Santa María, Santiago, Chile
| | - Patricia Vernal
- Servicio de Recién Nacidos, Hospital San José, Santiago, Chile
| | - M José Escalante
- Departamento de Neonatología, Facultad de Medicina, Pontificia Universidad Católica de Chile y Servicio de Recién Nacidos Hospital Dr. Sótero del Río, Santiago, Chile
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Thompson LM, Peñaloza RA, Stormfields K, Kooistra R, Valencia-Moscoso G, Muslima H, Khan NZ. Validation and adaptation of rapid neurodevelopmental assessment instrument for infants in Guatemala. Child Care Health Dev 2015; 41:1131-9. [PMID: 26250756 PMCID: PMC4715612 DOI: 10.1111/cch.12279] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 06/08/2015] [Accepted: 06/28/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Timely detection of neurodevelopmental impairments in children can prompt referral for critical services that may prevent permanent disability. However, screening of impairments is a significant challenge in low-resource countries. We adapted and validated the rapid neurodevelopmental assessment (RNDA) instrument developed in Bangladesh to assess impairment in nine domains: primitive reflexes, gross and fine motor development, vision, hearing, speech, cognition, behaviour and seizures. METHODS We conducted a cross-sectional study of 77 infants (0-12 months) in rural Guatemala in July 2012 and July 2013. We assessed inter-rater reliability and predictive validity between the 27-item RNDA and the 325-item Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III) and concurrent validity based on chronic malnutrition, a condition associated with neurodevelopmental impairments. For both RNDA and BSID-III, standardized scores below 80 were defined as borderline impairment. RESULTS Children came from rural households (92%), were born to indigenous women of Mayan descent (73%) and had moderate or severe growth stunting (43%). Inter-rater reliability for eight RNDA domains was of moderate to high reliability (weighted κ coefficients, 0.49-0.99). Children screened positive for impairment in fine motor (17%) and gross motor (14%) domains using the RNDA. The RNDA had good concurrent ability; infants who were growth stunted had higher mean levels of impairment in gross motor, speech and cognition domains (all p < 0.001). The RNDA took 20-30 min to complete compared with 45-60 min for BSID-III. CONCLUSIONS Wide-scale implementation of a simple, valid and reliable screening tool like the RNDA by community health workers would facilitate early screening and referral of infants at-risk for neurodevelopmental impairment.
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Affiliation(s)
- Lisa M. Thompson
- Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco
| | - Reneé Asteria Peñaloza
- Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco
| | - Kate Stormfields
- Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco
| | - Rebecca Kooistra
- Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco
| | | | - Humaira Muslima
- Department of Pediatric Neuroscience, Dhaka Shishu (Children’s) Hospital, Dhaka, Bangladesh
| | - Naila Zaman Khan
- Department of Pediatric Neuroscience, Dhaka Shishu (Children’s) Hospital, Dhaka, Bangladesh
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Soto-Méndez MJ, Romero-Abal ME, Aguilera CM, Rico MC, Solomons NW, Schümann K, Gil A. Associations among Inflammatory Biomarkers in the Circulating, Plasmatic, Salivary and Intraluminal Anatomical Compartments in Apparently Healthy Preschool Children from the Western Highlands of Guatemala. PLoS One 2015; 10:e0129158. [PMID: 26075910 PMCID: PMC4468091 DOI: 10.1371/journal.pone.0129158] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 05/05/2015] [Indexed: 12/22/2022] Open
Abstract
Background Undernutrition and inflammation are related in many ways; for instance, non-hygienic environments are associated with both poor growth and immunostimulation in children. Objective To describe any existing interaction among different inflammation biomarkers measured in the distinct anatomical compartments of whole blood, feces, plasma and saliva. Methods In this descriptive, cross-sectional study, samples of whole blood, feces, plasma and saliva were collected on the 8th and last week of observation among 87 attendees (42 girls and 45 boys) of 3 daycare centers offering a common 40-day rotating menu in Guatemala’s Western Highlands. Analyses included white blood cell count (WBC), fecal calprotectin, and plasmatic and salivary cytokines including IL-1B, IL-6, IL-8, IL-10 and TNF-α. Associations were assessed using Spearman rank-order and goodness-of-fit correlations, as indicated, followed by backwards-elimination multiple regression analyses to determine predictor variables for IL-10 in both anatomical compartments. Results Of a total of 66 cross-tabulations in the Spearman hemi-matrix, 22 (33%) were significantly associated. All 10 paired associations among the salivary cytokines had a significant r value, whereas 7 of 10 possible associations among plasma cytokines were significant. Associations across anatomical compartments, however, were rarely significant. IL-10 in both biological fluids were higher than corresponding reference values. When a multiple regression model was run in order to determine independent predictors for IL-10 in each anatomical compartment separately, IL-6, IL-8 and TNF-α emerged as predictors in plasma (r2 = 0.514) and IL-1B, IL-8 and TNF-α remained as independent predictors in saliva (r2 = 0.762). Significant cross-interactions were seen with WBC, but not with fecal calprotectin. Conclusion Interactions ranged from robust within the same anatomical compartment to limited to nil across distinct anatomical compartments. The prominence of the anti-inflammatory cytokine, IL-10, in both plasma and saliva is consistent with its counter-regulatory role facing a broad front of elevated pro-inflammatory cytokines in the same compartment.
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Affiliation(s)
- María José Soto-Méndez
- Center for the Studies of Sensory Impairment, Aging, and Metabolism–CeSSIAM- Guatemala City, Guatemala
- * E-mail:
| | - María Eugenia Romero-Abal
- Center for the Studies of Sensory Impairment, Aging, and Metabolism–CeSSIAM- Guatemala City, Guatemala
| | - Concepción María Aguilera
- Department of Biochemistry and Molecular Biology II, Institute of Nutrition and Food Technology, Center of Biomedical Research, University of Granada, Granada, Spain
| | - María Cruz Rico
- Department of Biochemistry and Molecular Biology II, Institute of Nutrition and Food Technology, Center of Biomedical Research, University of Granada, Granada, Spain
| | - Noel W. Solomons
- Center for the Studies of Sensory Impairment, Aging, and Metabolism–CeSSIAM- Guatemala City, Guatemala
| | - Klaus Schümann
- Molecular Nutrition Unit, ZIEL, Research Center for Nutrition and Food Science, Technische Universität München, Freising, Germany
| | - Angel Gil
- Department of Biochemistry and Molecular Biology II, Institute of Nutrition and Food Technology, Center of Biomedical Research, University of Granada, Granada, Spain
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