Energy expenditure, growth, and nutritional therapy in appropriate and small for gestational age preterm infants

Enteral Nutrition in Preterm Infants (2022): A Position Paper From the ESPGHAN Committee on Nutrition and Invited Experts

OBJECTIVES

To review the current literature and develop consensus conclusions and recommendations on nutrient intakes and nutritional practice in preterm infants with birthweight <1800 g.

METHODS

The European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee of Nutrition (CoN) led a process that included CoN members and invited experts. Invited experts with specific expertise were chosen to represent as broad a geographical spread as possible. A list of topics was developed, and individual leads were assigned to topics along with other members, who reviewed the current literature. A single face-to-face meeting was held in February 2020. Provisional conclusions and recommendations were developed between 2020 and 2021, and these were voted on electronically by all members of the working group between 2021 and 2022. Where >90% consensus was not achieved, online discussion meetings were held, along with further voting until agreement was reached.

RESULTS

In general, there is a lack of strong evidence for most nutrients and topics. The summary paper is supported by additional supplementary digital content that provide a fuller explanation of the literature and relevant physiology: introduction and overview; human milk reference data; intakes of water, protein, energy, lipid, carbohydrate, electrolytes, minerals, trace elements, water soluble vitamins, and fat soluble vitamins; feeding mode including mineral enteral feeding, feed advancement, management of gastric residuals, gastric tube placement and bolus or continuous feeding; growth; breastmilk buccal colostrum, donor human milk, and risks of cytomegalovirus infection; hydrolyzed protein and osmolality; supplemental bionutrients; and use of breastmilk fortifier.

CONCLUSIONS

We provide updated ESPGHAN CoN consensus-based conclusions and recommendations on nutrient intakes and nutritional management for preterm infants.

Comparison of growth curves in very low birth weight preterm infants after hospital discharge

Monitoring preterm infants' growth is essential to ensure the best prognosis for their growth and development. We aimed to compare growth curves in very low birth weight preterm infants after hospital discharge. In this retrospective longitudinal study, 178 preterm infants' growth was assessed by z-scores for weight for age and length to age and compared between Fenton and Kim and Intergrowth-21st charts from hospital discharge until 50 weeks postnatal, and between Intergrowth-21st and WHO charts, 50 and 64 weeks postnatal. The Kappa test was used to evaluate the agreement of the number of cases classified above or below the -2 Z-score concerning weight-for-age and length-for-age indicators to each proposed curve. Our results found that the agreement between Fenton and Kim and Intergrowth-21st curves was almost perfect for most of the weeks investigated, except 35-38 (k = 0.79) and 47-50 (k = 0.61) weeks postnatal. When evaluating the agreement between WHO and Intergrowth-21st, it was substantial for most of the weeks investigated, except for 55-58 and 69-64 weeks postnatal, in which the agreement was almost perfect (k = 0.84; k = 0.81, respectively). Furthermore, we observed that Fenton and Kim curve identified 8.4% and WHO, 5.8% more cases of preterm infants below -2 z than Intergrowth-21st.Conclusion: Although the agreement of the curves was substantial to almost perfect, the Fenton and Kim and WHO curve seem to identify more cases of preterm infants compared to the Intergrowth-21st, a finding that deserves more in-depth investigation in clinical practice. What is Known: • The adequate interpretation of postnatal growth depends on the standard growth chart. • Studies comparing the classification of anthropometric indicators of preterm infants between growth curves consider only the period from birth to hospital discharge. What is New: • This is the first study that compares the classification of weight-for-age and length-for-age indicators of VLBW preterm infants between Intergrowth-21st and Fenton and Kim curves until 64 weeks postnatal. • Substantial to almost perfect agreement of length-for-age indicator was found between the two growth curves of preterm infants during outpatient follow-up.

Quality indicators in nutrition therapy and clinical outcomes in a neonatal intensive care unit

ABSTRACT Objective To associate quality indicators in nutritional therapy and pre-determined clinical outcomes in a neonatal unit. Methods A total of 81 premature newborns were monitored regarding the time to initiate nutrition therapy, time to meet energy needs, energy and protein adequacy, cumulative energy deficit, adequacy of the nutritional formula and fasting periods; weight gain, the occurrence of necrotizing enterocolitis, mortality and length of stay in the intensive care unit. The data were analyzed with the Statistical Package for the Social Sciences at 5% significance level. Results The time to start enteral nutrition and the calories infused/kg/day were predictors of length of hospital stay F(2.46)=6.148; p=0.004; R2=0.211; as well as the cumulative energy deficit+birth weight+infused calories/kg/day (F=3.52; p<0.001; R2=0.422); cumulative energy deficit+calories infused/kg/day+fasting time for Enteral Nutrition (F=15.041; p<0.001; R2=0.474) were predictors of weight gain. The time to start enteral nutrition, gestational age and birth weight were inversely associated with the occurrence of necrotizing enterocolitis (β=-0.38; β=-0.198; β=-0.002). Early enteral nutrition predisposed to mortality (β=0.33). Gestational age, birth weight and calories infused/kg/day were inversely related to mortality (β=-0.442; β=-0.004; β=-0.08). Conclusions Considering the associations between indicators and outcomes, routine monitoring of the time to start enteral nutrition, energy adequacy, energy deficit and fasting time is recommended.

Enteral and parenteral nutrition therapy for neonates at a neonatal unit: a longitudinal retrospective study

BACKGROUND

The goals of nutrition therapy include providing adequate growth and development, avoiding a negative energy and nitrogen balance, and preventing complications.

OBJECTIVE

To evaluate the nutrition therapy received by newborns at the neonatal intensive care unit (NICU) of a public maternity hospital in Rio de Janeiro, Brazil.

METHODS

Retrospective longitudinal observational study in which data were collected on newborns admitted to NICU, in Rio de Janeiro, in 2016. The time that elapsed before commencement of parenteral and trophic enteral nutritional, time to reach full enteral nutrition, type of diet at the beginning of trophic enteral nutrition and at discharge from the NICU, and the relationship between birth weight and nutritional therapy were evaluated.

RESULTS

Trophic enteral nutrition began after 24.42 (SD +20.23) hours, on average, and the mean time to reach full enteral nutrition was 10.0 (SD +5.51) days. Newborns with a birth weight below 1500 g had a longer hospital stay (p = .002), longer oxygen therapy (p = .009), a longer time before commencement of enteral feeding (p = .005), and took longer to reach full enteral feeding (p = .010).

CONCLUSIONS

The institutional nutritional therapy practices were consistent with those proposed in the literature, but more support is needed for breastfeeding in this group.

Assessment of Metabolic and Nutritional Imbalance in Mechanically Ventilated Multiple Trauma Patients: From Molecular to Clinical Outcomes

The critically ill polytrauma patient is characterized by a series of metabolic changes induced by inflammation, oxidative stress, sepsis, and primary trauma, as well as associated secondary injuries associated. Metabolic and nutritional dysfunction in the critically ill patient is a complex series of imbalances of biochemical and genetic pathways, as well as the interconnection between them. Therefore, the equation changes in comparison to other critical patients or to healthy individuals, in which cases, mathematical equations can be successfully used to predict the energy requirements. Recent studies have shown that indirect calorimetry is one of the most accurate methods for determining the energy requirements in intubated and mechanically ventilated patients. Current research is oriented towards an individualized therapy depending on the energy consumption (kcal/day) of each patient that also takes into account the clinical dynamics. By using indirect calorimetry, one can measure, in real time, both oxygen consumption and carbon dioxide production. Energy requirements (kcal/day) and the respiratory quotient (RQ) can be determined in real time by integrating these dynamic parameters into electronic algorithms. In this manner, nutritional therapy becomes personalized and caters to the patients’ individual needs, helping patients receive the energy substrates they need at each clinically specific time of treatment.