Nutritional recommendations for the late-preterm infant and the preterm infant after hospital discharge

Growth and body composition of infants born moderate-to-late preterm fed a protein- and mineral-enriched postdischarge formula compared with a standard term formula until 6 months corrected age, a randomized controlled trial

BACKGROUND

Infants born moderate-to-late preterm (i.e., 32 wk-35 wk 6 d gestation) are, analogous to those born very preterm, at risk of later obesity, hypertension, and diabetes. Appropriate early life nutrition is key for ensuring optimal growth and body composition, thereby mitigating potential cardiometabolic risks.

OBJECTIVES

We aimed to compare growth and body composition between infants born moderate-to-late preterm fed isocaloric but protein- and mineral-enriched postdischarge formula (PDF) or standard term formula (STF) until 6 mo corrected age (CA; i.e., after term equivalent age [TEA]).

METHODS

After enrollment (≤7 d postpartum), infants received PDF if (fortified) mother's own milk (MOM) was insufficient. At TEA, those receiving >25% of intake as formula were randomized to either continue the same PDF (n = 47) or switch to STF (n = 50); those receiving ≥75% of intake as MOM (n = 60) served as references. At TEA and 6 mo CA, we assessed anthropometry and body composition using both dual-energy x-ray absorptiometry (DXA) and air displacement plethysmography (ADP).

RESULTS

Feeding groups had similar gestational age (median [25th percentile;75th percentile]: 34.3 [33.5; 35.1] wk), birthweight (mean ± standard deviation [SD]: 2175 ± 412 g), anthropometry, and body composition at TEA. At 6 mo CA, infants fed PDF had slightly, but significantly, greater length (67.6 ± 2.5 and 66.9 ± 2.6 cm, P < 0.05) and larger head circumference (43.9 ± 1.3 and 43.4 ± 1.5 cm, P < 0.05) compared to infants fed STF. Also, infants fed PDF had higher lean mass (LM) and bone mineral content estimated by DXA (4772 ± 675 and 4502 ± 741 g; 140 ± 20 and 131 ± 23 g, respectively; P < 0.05). ADP estimates, however, were not statistically different between feeding groups.

CONCLUSIONS

Infants born moderate-to-late preterm demonstrated modest increases in length, head circumference, LM, and bone mineral content when fed PDF compared to STF for 6 mo after TEA. This trial was registered at the International Clinical Trial Registry Platform as NTR5117 and NTR NL4979.

Nutritional intake and growth until two years of age in moderate and late preterms

BACKGROUND AND AIM

Moderate and late preterm infants (MLPTI) (gestational age 32 0/7-36 6/7 weeks), are at risk for suboptimal growth. This study evaluated adherence to nutritional recommendations until 6 months corrected age (CA), growth until 2 years CA, and associations between nutritional intake and growth until 2 years CA.

METHODS

We prospectively collected nutritional intakes from 100 MLPTI during the first week of life and at 6 weeks, 3 months, and 6 months CA. Anthropometry was assessed at birth, discharge, term age, and at 6 weeks, 3 months, 6 months, 1 year, and 2 years CA.

RESULTS

On day 7, <40% reached nutritional recommendations. Thereafter, >80% reached protein recommendations until 6 months of life, but <60% reached energy recommendations. Weight z-scores increased from -0.44 at term-age to 0.59 at 3 months CA, but declined to -0.53 at 2 years CA on the TNO curves. No significant associations were found between nutritional intake and growth until 2 years CA.

CONCLUSION

No associations were demonstrated between nutritional intakes and growth until 2 years CA, despite not reaching recommended intakes. Despite high efforts to optimize growth, MLPTI find their own growth curve in the first 2 years of life.

IMPACT

This research is pioneering in identifying how nutrition influences growth in moderate and late preterm infants (MLPTI) up to 2 years corrected age (CA). MLPTI often do not meet the recommended protein and energy intake in their first week of life, suggesting that current guidelines might be too high. No association was demonstrated between nutritional intake and growth of MLPTI in the first 2 years of life. Initially, MLPTI show an increase in weight z-scores from term age up to 3 months CA but experience a decline in weight z-scores at 2 years CA, according to TNO growth charts.

Human Milk Fortifier After Neonatal Intensive Care Unit Discharge Improves Human Milk Usage Rates for Preterm Infants

BACKGROUND

A common neonatal intensive care unit (NICU) discharge feeding strategy for preterm infants with growth failure who are fed exclusively expressed human milk (EHM) has been to enrich mother's own milk with formula powder or supplement 2-3 feeds per day with formula. However, this strategy displaces human milk from the diet. Our NICU recently adopted the standard practice of adding commercial human milk fortifier (HMF) to human milk feedings after discharge.

OBJECTIVES

We aimed to compare breastfeeding rates and growth using the aforementioned 2 strategies.

METHODS

Preterm infants (<34 wk of gestation at birth) exclusively feeding EHM fortified with HMF at 2 weeks before discharge were included in this retrospective study. The HMF group (n = 92) continued fortifying with HMF at home, whereas the historical comparison group (n = 35) received our previous guidance to enrich or supplement using postdischarge formula.

RESULTS

Rates of human milk exclusivity after discharge decreased significantly less in the HMF group than those in the historical comparison group (to 83% compared with 39% at the first outpatient visit and 27% compared with 6%, respectively, at the second outpatient visit). Rates of any EHM feedings were also significantly higher in the HMF group. Fenton z-scores for weight, length, and head circumference were not significantly different between the groups.

CONCLUSIONS

Continuing EHM fortification with HMF after NICU discharge, rather than enriching or supplementing with postdischarge infant formula, increases rates of feeding EHM for ≥3 mo but does not affect growth.

The Role of the Neonatal Registered Dietitian Nutritionist: Past, Present, and Future

Neonatal registered dietitian nutritionists (RDNs) are critical members of the neonatal intensive care unit (NICU) team due to their unique skillset of growth assessment, nutrition evaluation, and implementation of nutrition best practices. There is a paucity of data on appropriate staffing of neonatal RDNs in NICUs to promote improved patient outcomes. Here, the authors describe current neonatal RDN staffing and responsibilities in the US NICUs.

Taking Care of Preterm Infants: Outpatient Considerations

In recent decades, the number of pre-term infants born each year has been on the rise as mortality rates decline with improvements in technology and medical care. As a result, many preterm infants are successfully discharged from the neonatal intensive care unit (NICU). However, with prematurity comes the increased risk of ongoing health and development needs. Special attention must be given to certain chronic conditions by the outpatient provider, including growth and nutrition; gastroesophageal reflux; immunizations; vision and hearing impairments; chronic lung diseases, including bronchopulmonary dysplasia and pulmonary hypertension; and neurodevelopmental outcomes. This article will detail some of these topics to better inform the primary care provider of appropriate strategies to manage these chronic conditions and sequalae on NICU discharge. [Pediatr Ann. 2023;52(6):e200-e205.].

Effects of relaxation therapy on maternal psychological status and infant growth following late preterm and early-term delivery: a randomized controlled trial

BACKGROUND

Maternal stress is one modifiable variable that could influence mother-infant signaling and negatively affect breastfeeding and infant growth.

OBJECTIVES

This study aimed to test the hypothesis that relaxation therapy would reduce maternal stress and improve infant growth, behavior, and breastfeeding outcomes after late preterm (LP) and early-term (ET) delivery.

METHODS

A single-blind randomized controlled trial was conducted in healthy Chinese primiparous mother-infant pairs after LP or ET delivery (34⁺⁰-37⁺⁶ gestation weeks). Mothers were randomly assigned to the intervention group (IG, listening to relaxation meditation at least once a day) or control group (CG, normal care). Primary outcomes-changes in maternal stress (perceived stress scale), anxiety (Beck Anxiety Inventory), and infant weight and length standard deviation score-were assessed at 1 wk and 8 wks postpartum. Secondary outcomes-breast milk energy and macronutrient composition, maternal breastfeeding attitudes, infant behaviors (3-d diary), and 24-hour milk intake-were assessed at 8 wks.

RESULTS

In total, 96 mother-infant pairs were recruited. There was a significantly greater reduction in maternal perceived stress (Perceived Stress Scale score) (mean difference [MD] = 2.65; 95% CI: 0.8, 4.5) and significantly greater infant weight standard deviation score gain (MD = 0.51; 95% CI: 0.2, 0.9) from 1 wk to 8 wks in the IG than those in the CG. Exploratory analyses showed a significant interaction between intervention and sex, with greater effects on weight gain in female infants. Mothers of female infants used the intervention more frequently with significantly higher milk energy observed at 8 wks.

CONCLUSIONS

The relaxation meditation tape is a simple, effective practical tool that could easily be used in clinical settings to support breastfeeding mothers after LP and ET delivery. The findings need confirmation in larger groups and in other populations.

Clinical Phenotypes of Malnutrition in Young Children: Differential Nutritional Correction

This review article summarizes current data on malnutrition etiology and pathogenesis in infants. Topical requirements for revealing this condition, its diagnosis and severity assessment via centile metrics are presented. The characteristics of the most common clinical phenotypes of postnatal growth insufficiency in infants (premature infants with different degree of maturation, including patients with bronchopulmonary dysplasia) are described. Differential approaches for malnutrition nutritional correction in these children are presented. The final section of the article describes special nutritional needs for children with congenital heart defects in terms of hemodynamic disorders nature and severity. Modern nutritional strategies for preparation of these patients to surgery and for their postoperative period are presented. The use of high-calorie/high-protein product for malnutrition correction in the most vulnerable patients with described in this review phenotypes is worth noticing.

Growth of late preterm infants fed nutrient-enriched formula to 120 days corrected age-A randomized controlled trial

Objectives

We aimed to compare the effects of nutrient-enriched formula with standard term formula on rate of body weight gain of late preterm infants appropriately grown for gestational age.

Study design

A multi-center, randomized, controlled trial. Late preterm infants (34-37 weeks' gestation), with weight appropriate for gestational age (AGA), were randomized to nutrient enriched formula (NEF) with increased calories (22 kcal/30 ml) from protein, added bovine milk fat globule membrane, vitamin D and butyrate or standard term formula 20 kcal/30 ml (STF). Breastfed term infants were enrolled as an observational reference group (BFR). Primary outcome was rate of body weight gain from enrollment to 120 days corrected age (d/CA). Planned sample size was 100 infants per group. Secondary outcomes included body composition, weight, head circumference and length gain, and medically confirmed adverse events to 365 d/CA.

Results

The trial was terminated early due to recruitment challenges and sample size was substantially reduced. 40 infants were randomized to NEF (n = 22) and STF (n = 18). 39 infants were enrolled in the BFR group. At 120 d/CA there was no evidence of a difference in weight gain between randomized groups (mean difference 1.77 g/day, 95% CI, -1.63 to 5.18, P = 0.31). Secondary outcomes showed a significant reduction in risk of infectious illness in the NEF group at 120 d/CA [relative risk 0.37 (95% CI, 0.16-0.85), P = 0.02].

Conclusion

We saw no difference in rate of body weight gain between AGA late preterm infants fed NEF compared to STF. Results should be interpreted with caution due to small sample size.

Clinical Trial Registration

The Australia New Zealand Clinical Trials Registry (ACTRN 12618000092291). "mailto:maria.makrides@sahmri.com" maria.makrides@sahmri.com.

Le suivi de l'extrême prématuré après le congé des soins intensifs néonatals

La survie des extrêmes prématurés (moins de 28 semaines d'âge gestationnel) s'est améliorée au fil du temps. Bon nombre s'en sortent bien et ont une bonne qualité de vie. Ils demeurent toutefois vulnérables à des problèmes de santé, y compris des difficultés neurosensorielles et neurodéveloppementales, que les médecins de première ligne, les pédiatres et les cliniques spécialisées doivent surveiller. Le présent document de principes passe en revue les conséquences médicales et neurodéveloppementales potentielles pour les extrêmes prématurés dans les deux ans suivant leur congé et fournit des stratégies de counseling, de dépistage précoce et d'intervention. Parce qu'ils sont tous liés à l'extrême prématurité, la dysplasie bronchopulmonaire ou les troubles respiratoires, les problèmes d'alimentation et de croissance, le développement neurosensoriel (vision et audition), la paralysie cérébrale et le trouble du spectre de l'autisme doivent faire rapidement l'objet d'une évaluation. Pour évaluer la croissance et le développement, il faut corriger l'âge chronologique en fonction de l'âge gestationnel jusqu'à 36 mois de vie. Par ailleurs, l'attention au bien-être émotionnel des parents et des proches fait partie intégrante des soins de qualité de l'extrême prématuré.

Follow-up care of the extremely preterm infant after discharge from the neonatal intensive care unit

The survival of babies born extremely preterm (EP, <28 weeks gestation) has improved over time, and many have good outcomes and quality of life. They remain at risk for health issues, including neurosensory and neurodevelopmental difficulties requiring monitoring by primary physicians, paediatricians, and specialty clinics. This statement reviews potential medical and neurodevelopmental consequences for EP infants in the first 2 years after discharge and provides strategies for counselling, early detection, and intervention. EP-related conditions to assess for early include bronchopulmonary dysplasia or respiratory morbidity, feeding and growth concerns, neurosensory development (vision and hearing), cerebral palsy, and autism spectrum disorder. Correction for gestational age should be used for growth and development until 36 months of age. Integral to quality care of the child born EP is attention to the emotional well-being of parents and caregivers.

Effects of higher protein formula with improved fat blend on growth, feeding tolerance and nutritional biomarkers in preterm infants: A double-blind, randomized, controlled clinical trial

BACKGROUND

Preterm formulas containing greater protein:energy ratio are beneficial for non-breastfed infants, since protein is critical for promoting catch-up growth and synthesis of lean body mass. Additionally, formulas containing enriched sn-2 palmitate (sn-2) and reduced medium chain triglycerides (MCTs) may support better feeding tolerance and nutrient utilization.

METHODS

The objective of this randomized, controlled, double-blinded clinical trial is to evaluate growth, feeding tolerance and nutritional biomarkers of preterm infants with birth weight ≤2000g and gestational age ≤33wks from one neonatal unit in Vietnam receiving experimental formula (EF, n = 80) containing higher protein level of 3.4 g/100 kcal and improved fat blend with enriched sn-2 and modified level of MCTs or isocaloric control formula (CF, n = 80) containing protein level of 2.9 g/100 kcal and standard fat blend. The differences in weight gain (g/d; primary endpoint) from day 1 (D1) of full enteral feeding (FEF) until D21 between groups was evaluated for non-inferiority (margin = -2.5  g/d) and superiority (margin = 0  g/d).

RESULTS

Mean weight gain was 3.09  g/d greater in EF than CF; the lower limit of 95% CI (0.31  g/d) exceeded both non-inferiority and superiority margins. There was no significant difference in length-for-age and head circumference-for-age z-score. By D79, the mean change in weight-for-age z-scores from D1 in EF group (+0.76 SDs) surpassed the criteria for catch-up growth (+0.67 SDs). Infants in the EF group (vs. CF) tended to have softer stools (EF = 3.2 ± 0.59 vs. CF = 3.4 ± 0.58; P = 0.07) based on 5-point scale (1 = watery, 5 = hard). Difference in blood urea nitrogen and biomarkers for bone mineral status (i.e., plasma phosphorus, alkaline phosphatase and urinary calcium/phosphorus ratio) between EF and CF on FEF Day 21 reached statistical significance (P < 0.05) but all mean values stayed within normal clinical ranges for both groups.

CONCLUSION

Preterm formula with greater protein:energy ratio and new fat blend is safe, nutritionally suitable, well-tolerated, and improves catch-up weight gain of preterm infants. Clinical trial registry identifier is NCT03055052 (ClinicalTrials.gov).

The nutritional needs of moderate–late preterm infants

This article discusses the nutritional needs of moderate and late preterm infants (born between 32+0weeks and 36+6weeks' gestation) and makes recommendations for best practice both while these infants are in hospital and when they are discharged into the community. These recommendations were derived following a roundtable meeting of a group comprising two neonatologists, three paediatric dietitians, a health visitor/paediatric nurse and a midwife practitioner. The meeting and medical writing assistance was sponsored by Nutricia. None of the participants accepted honoraria for their contributions to the discussion.

Eating Behaviors, Caregiver Feeding Interactions, and Dietary Patterns of Children Born Preterm: A Systematic Review and Meta-Analysis

Infants born preterm (<37 weeks of gestation) often experience feeding problems during hospitalization. Whether difficulties persist or have long-term sequelae on childhood eating is unclear. We aimed to describe the oromotor eating skills (e.g., chewing/swallowing), eating behaviors (e.g., food neophobia), food parenting practices (e.g., pressure to eat), and dietary patterns of preterm children during late infancy (6-12 mo) and early childhood (>12 mo-7 y) and to determine whether these differed from those of term-born peers. We identified 67 articles (57 unique studies) for inclusion. We used random-effects meta-analysis of proportions to examine the prevalence of oromotor eating skill and eating behavior challenges among preterm children, standard meta-analysis for comparisons with term-born peers, and the Grading of Recommendations, Assessment, Development and Evaluation approach to assess the certainty of evidence. Forty-three percent (95% CI: 24%, 62%) of infants and 25% (95% CI: 17%, 33%) of children born preterm experienced oromotor eating difficulties and 16% (95% CI: 4%, 27%) and 20% (95% CI: 11%, 28%), respectively, exhibited challenging eating behaviors. During late infancy and early childhood, oromotor eating difficulties (OR: 2.86; 95% CI: 1.71, 4.77; I2 = 67.8%) and challenging eating behaviors (OR: 1.52; 95% CI: 1.11, 2.10; I2 = 0.0%) were more common in those born preterm than in those born term: however, the certainty of evidence was very low. Owing to the low number and heterogeneity of studies, we narratively reviewed literature on food parenting and dietary patterns. Mothers of preterm infants appeared to have heightened anxiety while feeding and utilized coercive food parenting practices; their infants reportedly received less human milk, started solid foods earlier, and had poorer diet quality than term-born peers. In conclusion, meta-analyses show preterm children experience frequent oromotor eating difficulties and challenging eating behaviors throughout the early years. Given preterm birth increases risk of later obesity and diet-related chronic disease, research examining the effects of caregiver-child interactions on subsequent diet is warranted. This review was registered at www.crd.york.ac.uk/prospero/ as CRD42020176063.

Developing a Quality Improvement Feeding Program for NICU Patients

Practices in NICUs vary widely, particularly when clinical decisions involve complex tasks and multiple disciplines, which occurs with feeding preterm infants. Neonatal feeding difficulties in preterm infants often lead to prolonged tube feeding and therefore lengthened hospital stays. Education and compliance with evidence-based protocols and guidelines are needed on the initiation of feedings and feeding advancement to transform enteral and oral feeding practices and thus reduce practice variation and improve clinical outcomes.

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

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

Improving long-term health outcomes of preterm infants: how to implement the findings of nutritional intervention studies into daily clinical practice

Preterm-born children are at risk for later neurodevelopmental problems and cardiometabolic diseases; early-life growth restriction and suboptimal neonatal nutrition have been recognized as risk factors. Prevention of these long-term sequelae has been the focus of intervention studies. High supplies of protein and energy during the first weeks of life (i.e., energy > 100 kcal kg-1 day-1 and a protein-to-energy ratio > 3 g/100 kcal) were found to improve both early growth and later neurodevelopmental outcome. Discontinuation of this high-energy diet is advised beyond 32-34 weeks postconceptional age to prevent excess fat mass and possible later cardiometabolic diseases. After discharge, nutrition with a higher protein-to-energy ratio (i.e., > 2.5-3.0 g/100 kcal) may improve growth and body composition in the short term.Conclusion: Preterm infants in their first weeks of life require a high-protein high-energy diet, starting shortly after birth. Subsequent adjustments in nutritional composition, aimed at achieving optimal body composition and minimizing the long-term cardiometabolic risks without jeopardizing the developing brain, should be guided by the growth pattern. The long-term impact of this strategy needs to be studied. What is Known: • Preterm infants are at risk for nutritional deficiencies and extrauterine growth restriction. • Extrauterine growth restriction and suboptimal nutrition are risk factors for neurodevelopmental problems and cardiometabolic disease in later life. What is New: • Postnatally, a shorter duration of high-energy nutrition may prevent excess fat mass accretion and its associated cardiometabolic risks and an early switch to a protein-enriched diet should be considered from 32-34 weeks postconceptional age. • In case of formula feeding, re-evaluate the need for the continuation of a protein-enriched diet, based on the infant's growth pattern.

Overview of Important Micronutrients Supplementation in Preterm Infants after Discharge: A Call for Consensus

Preterm infants have a lower level of nutrient body stores and immature body systems, resulting in a higher risk of malnutrition. Imbalanced complementary feeding could lead to further risk of nutritional deficits and excesses. However, evidence on their nutritional requirements following hospital discharge is limited. When planning complementary feeding, appropriate micronutrient intake should be considered for their critical role in supporting various body functions. This narrative review summarizes the need for iron, zinc, vitamin D, calcium, phosphate and long-chain polyunsaturated fatty acids (LCPUFAs) supplementation in preterm infants during complementary feeding. Regarding iron and vitamin D, the scientific community is reaching an agreement on supplementation in some categories of prematures. On the contrary, there is still not enough evidence to detail possible recommendations for LCPUFAs, zinc, calcium and phosphorus supplementation. However, these micronutrients are paramount for preterms' health: LCPUFAs can promote retinal and brain development while calcium and phosphorus supplementation is essential to prevent preterms' metabolic bone disease (MBD). Waiting for a consensus on these micronutrients, it is clear how the knowledge of the heterogeneity of the prematures population can help adjust the nutritional planning regarding the growth rate, comorbidities and comprehensive clinical history of the preterm infant.

Associated neonatal and maternal factors of osteopenia of prematurity in low resource setting: A cross-sectional study

Objective

Determining neonatal and maternal factors that are associated with the incidence of OFP.

Methods

This study employed a cross-sectional design, in which the participants were identified for clinical variables (sex, gestational age, birth weight, etc.), neonatal morbidity (sepsis, necrotizing enterocolitis (NEC), etc.), and maternal risk factors (premature rupture of membranes, preeclampsia, etc.). The data were analyzed using Chi-square test, independent t-test, and logistic regression test with p < 0.05.

Results

The birth weight ranged from 800 to 1495 g (1219 ± 225 g), of which 5 newborns (17%) were <1000 g. The gestational age ranged from 27 to 32 weeks, with a mean of 29 ± 1.5 weeks. The signs of OFP were observed in 13 (43%) infants, of which 2 (15%) OFP infants had a birth weight <1000 g. There was significant difference in parenteral nutrition duration (p = 0.018), onset of vitamin D supplementation (p = 0.019), and ALP level (p = 0.012) of infants between the OFP group and the non-OFP group. The variables associated with the incidence of OFP were parenteral nutrition duration >15 days (OR = 5.4; 95% CI 1.120-26.044; p = 0.036), ALP level >500 U/L (OR = 2.889; 95% CI 1.703-4.900; p = 0.014), and PROM (OR = 5.4; 95% CI 1.039-28.533; p = 0.045).

Conclusion

The lack of phosphate intake, prolonged parenteral nutrition, ALP level >500 U/L, onset of vitamin D supplementation, and premature rupture of membranes are associated with the incidence of OFP.

An Observational Cohort Study and Nested Randomized Controlled Trial on Nutrition and Growth Outcomes in Moderate and Late Preterm Infants (FLAMINGO)

Background: Over the past decades, the preterm birth rate has increased, mostly due to a rise in late and moderate preterm (LMPT, 32–36 weeks gestation) births. LMPT birth affects 6–7% of all births in the United Kingdom and is associated with increased morbidity risk after birth in infancy as well as in adulthood. Early life nutrition has a critical role in determining infant growth and development, but there are limited data specifically addressing LMPT infants, which was the rationale for the design of the current study.

Objective: The Feeding Late and Moderate Infants and Growth Outcomes (FLAMINGO) study aims to improve understanding of the longitudinal growth, nutritional needs, and body composition of LMPT infants as well as their microbiome development and neurodevelopment. In addition, having a nested non-inferiority trial enables evaluation of the nutritional adequacy of a concept IMF with large milk phospholipid-coated lipid droplets comprising dairy and vegetable lipids. The primary outcome of this RCT is daily weight gain until 3 months corrected age.

Methods: A total of 250 healthy LMPT infants (32+0–36+6 weeks gestational age) with birth weight 1.25–3.0 kg will be recruited to the cohort, of which 140 infants are anticipated to be enrolled in the RCT. During six visits over the first 2 years of life, anthropometry, body composition (using dual energy X-Ray absorptiometry), feeding behavior, and developmental outcomes will be measured. Saliva and stool samples will be collected for oral and gut microbiota assessment.

Discussion: The FLAMINGO study will improve understanding of the longitudinal growth, body composition development, and feeding characteristics of LMPT infants and gain insights into their microbiome and neurodevelopment.

Study Registration:www.isrctn.com; Identifier ISRCTN15469594.

Investigating the Metabolic Model in Preterm Neonates by Tandem Mass Spectrometry: A Cohort Study

The changes of metabolite profiles in preterm birth have been demonstrated using newborn screening data. However, little is known about the holistic metabolic model in preterm neonates. The aim was to investigate the holistic metabolic model in preterm neonates. All metabolite values were obtained from a cohort data of routine newborn screening. A total of 261 758 newborns were recruited and randomly divided into a training subset and a testing subset. Using the training subset, 949 variates were considered to establish a logistic regression model for identifying preterm birth (<37 weeks) from term birth (≥37 weeks). Sventy-two variates (age at collection, TSH, 17α-OHP, proline, tyrosine, C16:1-OH, C18:2, and 65 ratios) entered into the final metabolic model for identifying preterm birth from term birth. Among the variates entering into the final model of PTB [Leucine+Isoleucine+Proline-OH)/Valine (OR=38.36], (C3DC+C4-OH)/C12 (OR=15.58), Valine/C5 (OR=6.32), [Leucine+isoleucine+Proline-OH)/Ornithine (OR=2.509)], and Proline/C18:1 (OR=2.465) have the top five OR values, and [Leucine+Isoleucine+Proline-OH)/C5 (OR=0.05)], [Leucine+Isoleucine+Proline-OH)/Phenylalanine (OR=0.214)], proline/valine (OR=0.230), C16/C18 (OR=0.259), and Alanine/free carnitine (OR=0.279) have the five lowest OR values. The final metabolic model had a capacity of identifying preterm infants with >80% accuracy in both the training and testing subsets. When identifying neonates ≤32 weeks from those >32 weeks, it had a robust performance with nearly 95% accuracy in both subsets. In summary, we have established an excellent metabolic model in preterm neonates. These findings could provide new insights for more efficient nutrient supplements and etiology of preterm birth.

Association of First-Week Nutrient Intake and Extrauterine Growth Restriction in Moderately Preterm Infants: A Regional Population-Based Study

The purpose of this study was to determine the influence of first-week nutrition intake on neonatal growth in moderate preterm (MP) infants. Data on neonatal morbidity and nutrition intake on day of life 7 (DoL7) were prospectively collected from 735 MP infants (32^0/7-34^6/7 weeks gestational age (GA)). Multivariable regression was used to assess the factors associated with extrauterine growth restriction (EUGR) defined as a decrease of more than 1 standard deviation (SD) in the weight z-score during hospitalization. Mean (SD) gestational age and birth weight were 33.2 (0.8) weeks and 2005 (369) g. The mean change in the weight z-score during hospitalization was -0.64 SD. A total of 138 infants (18.8%) had EUGR. Compared to adequate growth infants, EUGR infants received 15% and 35% lower total energy and protein intake respectively (p < 0.001) at DoL7. At DoL7, each increase of 10 kcal/kg/d and 1 g/kg/d of protein was associated with reduced odds of EUGR with an odds ratio of 0.73 (95% CI, 0.66-0.82; p < 0.001) and 0.54 (0.44-0.67; p < 0.001), respectively. Insufficient energy and protein intakes on DoL7 negatively affected neonatal growth of MP infants. Nutritional support should be optimized from birth onwards to improve neonatal weight growth.

Comparison of Types of Breast Milk Fortification at Discharge from the Neonatal Intensive Care Unit and Breast Milk Feeding Rates and Growth at 4 Months Corrected Age

Background: Effects of breast milk (BM) enhancement on long-term BM feeding in preterm infants discharged from the neonatal intensive care unit (NICU) have not been examined previously. This study compares any BM feeding rates at 4 months corrected age (CA) in preterm infants discharged from the NICU on BM enhancement by fortification of expressed BM with infant formula additives (BM-F) versus BM supplemented with infant formula feeds (BM-S). Subjects and Methods: We compared infants born between January 1, 2013, and December 31, 2017, with gestational age <32 weeks or birth weight <1500 g, discharged home on BM-F or BM-S from two NICUs and followed at 4 months CA. Multivariate logistic regression with propensity scoring estimated the adjusted associations between nutrition at discharge and any BM feeding at 4 months CA. Results: Two hundred eighty-five infants were followed at 4 months CA. Infants discharged on BM-F were more likely to have mothers with multiple gestation, private insurance and not Caucasian, initiate feeds of human milk, be discharged from NICU-1, and receive any BM at 4 months CA (p < 0.03). No significant difference in growth parameters <10th percentile at 4 months CA was observed between the two groups. After adjusting for confounding factors, discharge from the NICU on BM-F was significantly associated with BM feeding at 4 months CA (odds ratio: 3.89, 95% confidence interval 1.66-9.14, p = 0.002). Conclusion: In this observational study, preterm infants receiving BM fortified with formula powder additives at discharge from the NICU had better BM feeding outcomes without poor growth at 4 months CA relative to those infants receiving BM supplemented with infant formula feeds.

Association of age of initiation and type of complementary foods with body mass index and weight-for-length at 12 months of age in preterm infants

OBJECTIVE

To assess whether in very preterm infants (1) body mass index (BMI) Z-score and weight-for-length (WtFL) Z-score at 1 year of age and (2) head growth from discharge to 1 year are associated with breastfeeding at discharge and the age of onset and type of complementary foods.

STUDY DESIGN

Observational cohort study.

RESULTS

Infants started on only ready-made complementary (RMC) feedings at ≤26 weeks adjusted age had the highest adjusted BMI Z-score and WtFL Z-score at 1 year of age. Adjusted change in fronto-occipital circumference was highest in infants either discharged on breastmilk or receiving home-made complementary food with/without RMC (HMM) at ≤26 weeks adjusted age.

CONCLUSIONS

Infants started on RMC ≤26 weeks adjusted age had the highest BMI Z-score and WtFL Z-score at 1 year. Head growth from discharge to 1 year was highest in infants either discharged on breastmilk or receiving HMM at ≤26 weeks adjusted age.

Prescribed Protein Intake Does Not Meet Recommended Intake in Moderate- and Late-Preterm Infants: Contribution to Weight Gain and Head Growth

BACKGROUND

The purpose of the study was to evaluate differences between prescribed and recommended protein intake in moderate-preterm (MP) and late-preterm (LP) infants and examine the contribution of the first week's prescribed protein intake to growth until term age.

METHODS

Data on intake and anthropometrics were collected retrospectively in 235 preterm infants admitted to our general hospital's neonatal ward: 60 MP (32^0/7 -33^6/7 weeks' gestational age) and 175 LP (34^0/7 -36^6/7 weeks' gestational age). Differences between prescribed and recommended protein intake during the first postnatal week and z-score change for weight and head circumference (HC) between birth and term age were calculated. Multiple regression was used to evaluate the independent contribution of first week's prescribed protein intake to growth until term age.

RESULTS

At day 7, 58% of MP and 19% of LP infants reached recommended protein intake. At term age, mean z-score change was -0.4 for weight and +0.1 for HC. Mean protein intake (g/kg/d) was associated with z-score change of +0.34 (95% CI, 0.14-0.53; P < .001) for weight and +0.25 (95% CI, 0-0.5; P = .03) for HC. Reaching recommended protein intake at day 7 was only independently associated with weight z-score change (+0.22 [95% CI, 0.04-0.41; P = .002]).

CONCLUSION

First week's prescribed protein intake does not meet recommended intake. Higher protein intakes in the first postnatal week result in increased weight gain and head growth until term age. Desirability and feasibility of increasing the protein intake need careful consideration and further discussion.

Effects of a nutrient-dense formula compared with a post-discharge formula on post-discharge growth of preterm very low birth weight infants with extrauterine growth retardation: a multicentre randomised study in China

BACKGROUND

Post-discharge optimal growth and nutritional intake have beneficial effects for neurodevelopment in preterm very low birth weight infants (VLBWIs) with extrauterine growth retardation (EUGR). The present study aimed to compare the effects of a nutrient-dense formula (NDF) to a post-discharge formula (PDF) on post-discharge growth of preterm VLBWIs with EUGR.

METHODS

Forty-eight preterm VLBWIs with EUGR at discharge were randomised to receive NDF (100 kcal per 100 mL; 2.6 g protein per 100 mL) or PDF (74 kcal per 100 mL; 1.95 g protein per 100 mL) for 1-6 months until body weight reached the 50th percentile on growth charts with corrected age. Volume, nutrient intake, anthropometry and biochemistry data were collected.

RESULTS

Volume intake was lower in the NDF group than the PDF group during the first 2 months of feeding (P = 0.039 and 0.018, respectively).There were no significant differences in volume intake during months 2-6 of feeding. Energy, protein, carbohydrate and fat intake were higher in the NDF group during months 1-6 of feeding. There were no significant differences in weight, length, and head circumference Z-scores during months 1-6 between the two groups. The △length Z-score from discharge to month 6 was significantly higher in the NDF group than the PDF group (P = 0.043). No differences existed between the two groups with respect to biochemistry.

CONCLUSIONS

After discharge, preterm VLBWIs with EUGR fed a NDF gain anthropometric parameter Z-scores similar to those for a PDF within 6 months of follow-up. A NDF leading to gain in length requires further follow-up.

ANALYSIS OF THE DIFFERENCES BETWEEN THE PRESCRIBED AND THE ADMINISTERED DIET TO PRETERM INFANTS USING AN ELECTRONIC TOO

ABSTRACT Objective: To create an electronic instrument in order to analyze the adequacy of the preterm infants’ nutritional therapy, checking the difference between the prescribed and the administered diet. Methods: A prospective and observational study on newborns with birthweight ≤1,500g and/or gestational age ≤32 weeks, without congenital malformations. The electronic instrument was developed based on Microsoft Excel 2010 spreadsheets and aimed at automatically calculating body weight gain, calories and macronutrients received daily by each patient from parenteral nutrition, intravenous hydration and enteral feedings. The weekly means of each nutrient were used to compare the prescribed and administered diets. Results: To evaluate the instrument, 60 newborns with a birth weight of 1,289±305 g and a gestational age of 30±2 weeks were included. Of them, 9.6% had restricted growth at birth and 55% at discharge. The median length of stay was 45±17 days. There were significant differences between prescribed and administered diet for all of the macronutrients and for total calories in the first three weeks. The lipid was the macronutrient with the greatest percentage error in the first week of life. Conclusions: The use of a computational routine was important to verify differences between the prescribed and the administered diet. This analysis is necessary to minimize calculation errors and to speed up health providers’ decisions about the nutritional approach, which can contribute to patients’ safety and to good nutritional practice. Very low birth weight infants are extremely vulnerable to nutritional deficiencies and any reduction in macronutrients they receive may be harmful to achieve satisfactory growth.

Nutrition in late preterm infants

Late preterm infants comprise the majority of preterm infants, yet there are few data to support best nutritional practice for these infants. Breastmilk is considered the best choice of enteral feeding for late preterm infants. However, supplementation of breastmilk may be indicated to promote optimal growth. Preterm formulas can be used for supplementation of breastmilk or as a breastmilk substitute but there is little evidence for their use in the late preterm infant. Feeding difficulties are common and some infants require intravenous nutritional support soon after birth. Others require tube feeding until full sucking feeds are established. Future research should focus on whether nutritional support of late preterm babies pending exclusive breastfeeding influences growth, body composition and long-term outcomes of late preterm infants and, if so, how nutritional interventions can optimise these outcomes.

Feeding the Late and Moderately Preterm Infant: A Position Paper of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition

Nutritional guidelines and requirements for late or moderately preterm (LMPT) infants are notably absent, although they represent the largest population of preterm infants. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition (CoN) performed a review of the literature with the aim to provide guidance on how to feed infants born LMPT, and identify gaps in the literature and research priorities.Only limited data from controlled trials are available. Late preterm infants have unique, often unrecognized, vulnerabilities that predispose them to high rates of nutritionally related morbidity and hospital readmissions. They frequently have feeding difficulties that delay hospital discharge, and poorer rates of breastfeeding initiation and duration compared with term infants. This review also identified that moderately preterm infants frequently exhibit postnatal growth restriction.The ESPGHAN CoN strongly endorses breast milk as the preferred method of feeding LMPT infants and also emphasizes that mothers of LMPT infants should receive qualified, extended lactation support, and frequent follow-up. Individualized feeding plans should be promoted. Hospital discharge should be delayed until LMPT infants have a safe discharge plan that takes into account local situation and resources.In the LMPT population, the need for active nutritional support increases with lower gestational ages. There may be a role for enhanced nutritional support including the use of human milk fortifier, enriched formula, parenteral nutrition, and/or additional supplements, depending on factors, such as gestational age, birth weight, and significant comorbidities. Further research is needed to assess the benefits (improved nutrient intakes) versus risks (interruption of breast-feeding) of providing nutrient-enrichment to the LMPT infant.

Growth Benefits of Own Mother's Milk in Preterm Infants Fed Daily Individualized Fortified Human Milk

The influence of types of human milk (HM)—raw own mother’s milk (OMM), pasteurized OMM, and donor milk (DM)—was evaluated for growth in premature infants fed exclusively HM with controlled nutritional intakes using daily individualized HM fortification (IHMF). Growth and nutritional intakes were prospectively collected in preterm infants (<32 weeks) fed IHMF and compared in infants fed predominantly (≥75%) OMM and DM. The influence of HM types (raw OMM, pasteurized OMM, and DM) on growth were also evaluated in the whole population. One-hundred and one preterm infants (birth weight 970 ± 255 g, gestational age 27.8 ± 1.9 weeks) were included. Energy (143 ± 8 vs. 141 ± 6 kcal/kg/day; p = 0.15) and protein intakes (4.17 ± 0.15 vs. 4.15 ± 0.14 g/kg/day; p = 0.51) were similar in both groups. Infants receiving predominantly OMM (n = 37), gained significantly more weight (19.8 ± 2.0 vs. 18.2 ± 2.2 g/kg/day; p = 0.002) and length (1.17 ± 0.26 vs. 0.99 ± 0.36 cm/week; p = 0.020) than those fed predominantly DM (n = 33). Stepwise multivariate analysis (n = 101) suggests that raw OMM was the major determinant of growth, contributing 22.7% of weight gain. Length gain was also related to OMM (raw + pasteurized) intakes, explaining 4.0% of length gain. In conclusion, at daily controlled similar protein and energy intakes, OMM had significant beneficial effects on weight and length versus DM in VLBW infants. This difference could be partially explained by the use of raw OMM.

Are there interventions that improve breastfeeding and the use of breast milk in late preterm infants?

To answer the clinical question 'Among late preterm infants are there any interventions that improve the rates of breastfeeding and the use of breast milk compared with current practice?'. MEDLINE via Ovid, Embase via Ovid, the Maternity and Infant Care Database and the Cochrane Library were searched for relevant articles. Articles were excluded if they did not discuss specific interventions to improve breastfeeding, for example, if they only commented on factors such as age, race and education. Articles were also excluded if they were not specific to the late preterm infant population. A total of 516 articles were found and screened by title and abstract independently by two reviewers. The full text of 17 articles was independently reviewed. The reference lists of these full-text articles were screened, and 14 abstracts were subsequently reviewed. The final analysis included three studies. There is limited high-quality research evidence for interventions to improve breastfeeding in late preterm infants. In the absence of robust academic research, clinical practice should be guided by clinical expertise and involve a multidisciplinary team, including qualified lactation consultants. While it seems reasonable for hospitals to support interventions that improve breastfeeding in term infants, managing late preterm infants as healthy term infants without additional specialist support may result in high breastfeeding failure rates among late preterm infants.

Nutritional policies for late preterm and early term infants - can we do better?

Late preterm (LP) and early term (ET) infants can be considered the "great dissemblers": they resemble healthy full-term infants in appearance, but their immaturity places them at increased risk of poor short- and long-term outcomes. Nutritional requirements are greater than for full-term babies, but there are few good data on the nutritional requirements for LP and ET babies, leading to substantial variation in practice. Recent data indicate that rapid growth may be beneficial for neurocognitive function but not for body composition and later metabolic health. Breastfeeding the LP or ET infant can be challenging, and mothers of these infants may need additional support to breastfeed successfully. Future research should investigate nutritional requirements of LP and ET infants for optimal growth, addressing both short- and long-term outcomes and the potential trade-off between neurocognitive and metabolic benefits.

Impact of Donor Milk on Short- and Long-Term Growth of Very Low Birth Weight Infants

Mother’s own milk (MOM) reduces the risk of morbidities in very low birth weight (VLBW) infants. When MOM is unavailable, donor breastmilk (DM) is used, with unclear impact on short- and long-term growth. This retrospective analysis compared anthropometric data at six time points from birth to 20–24 months corrected age in VLBW infants who received MOM supplements of preterm formula (n = 160) versus fortified DM (n = 161) during neonatal intensive care unit (NICU) hospitalization. The cohort was 46% female; mean birth weight and gestational age (GA) were 998 g and 27.3 weeks. Multilevel linear growth models assessed changes in growth z-scores short-term (to NICU discharge) and long-term (post-discharge), controlling for amount of DM or formula received in first 28 days of life, NICU length of stay (LOS), birth GA, and sex. Z-scores for weight and length decreased during hospitalization but increased for all parameters including head circumference post-discharge. Short-term growth was positively associated with LOS and birth GA. A higher preterm formula proportion, but not DM proportion, was associated with slower rates of decline in short-term growth trajectories, but feeding type was unrelated to long-term growth. In conclusion, controlling for total human milk fed, DM did not affect short- or long-term growth.

Complementary Feeding Practices in a Cohort of Italian Late Preterm Infants

Limited data are available on complementary feeding in preterm infants, who show increased nutritional needs and are at risk of altered postnatal growth. The aim of this study was to investigate the timing and content of complementary feeding in a cohort of late preterm infants. We conducted a prospective, observational study, including mothers who had given birth to infants admitted to level I or II of care with a gestational age between 34 and 36 weeks. Mothers were contacted at 3, 6 and 12 months after delivery by phone calls and were asked about their infant’s mode of feeding and the timing and schedule of the introduction of different solid foods types. A total of 49 mothers and 57 infants completed the study. The mean postnatal age of the introduction of complementary foods was 5.7 ± 0.7 months. Low energy and/or low protein-dense foods were first introduced in most infants. Fruit as the first type of complementary food in the infant’s diet was associated with a 1.6-month advance in initiating complementary feeding. The present findings provide further insight into complementary feeding practices in late preterm infants and underline the need for specific recommendations addressing this vulnerable population.

Postdischarge Feeding of Very-low-birth-weight Infants: Adherence to Nutrition Guidelines

OBJECTIVES

Infant feeding guidelines are important public health strategies to promote optimal growth, development, and chronic disease prevention, but their effectiveness is contingent upon families' ability to adhere to them. Little is known of adherence to guidelines among nutritionally vulnerable infants, specifically those born very-low-birth-weight (VLBW) (<1500 g). This study investigated whether postdischarge feeding practices for VLBW infants align with current recommendations and explored parental and infant baseline sociodemographics related to these practices.

METHODS

Prospectively collected data from families of 300 VLBW infants participating in a randomized clinical trial (ISRCTN35317141) were used. Baseline demographics were obtained at enrollment and postdischarge feeding practices via monthly telephone questionnaires to 6 months corrected age (CA).

RESULTS

At discharge, 4 and 6 months CA, 72%, 39%, and 29% of infants received any amount of mother's milk, respectively; exclusive breast-feeding rates were 49%, 20%, and 6%, respectively. Among infants receiving mother's milk, rates of vitamin D supplementation were ≥83%. Recommendations for introducing solids between 4 and 6 months CA were followed by 71% of the cohort and for iron supplementation by 58%. Overall, 12% of infants adhered to all aforementioned recommendations. Mothers with university degrees were more likely to provide mother's milk, whereas mothers of Middle Eastern/South Asian ethnicity were less likely to provide mother's milk.

CONCLUSIONS

Low rates of partial and exclusive breast-feeding of VLBW infants to 6 months CA were reported. Overall adherence to iron supplementation was low. Strategies to provide increased support for mothers identified as at-risk should be developed.

Early postnatal growth and neurodevelopment in children born moderately preterm or small for gestational age at term: A systematic review

BACKGROUND

Clinicians' interest in the long-term effects of early postnatal growth (EPG) is growing. There is compelling evidence linking rapid EPG with later cardiovascular risk, but its neurodevelopmental benefits still remain hypothetical in individuals born moderately preterm (MP) or small for gestational at term (SGAT).

METHODS

The objective was to perform a systematic review of the relationship between EPG before age 3 years and neurodevelopmental outcome for individuals born MP (32-36 weeks' gestational age) or SGAT. Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, 3 independent investigators searched for articles published on this topic in the Web of Science, EMBASE and PubMed from database inception to July 1, 2017. A detailed quality scale was used to evaluate articles.

RESULTS

We selected 19 articles relying on 12 distinct study populations; 7 articles from 3 study populations were considered at moderate or high quality. The lack of standardisation of growth analysis methods prevented performing a meta-analysis. Overall, EPG was positively associated with neurodevelopmental outcome, especially Intelligence Quotient (IQ) when available. In this relationship, the first 6 months of life might be a critical period. Analysis of the few articles investigating the shape of the relationships revealed a non-linear association, with a plateau for IQ with higher weight gain, which suggests a possible ceiling effect.

CONCLUSIONS

A positive association was generally found between EPG and neurodevelopmental outcome for individuals born MP or SGAT. Strategies for future epidemiological studies are suggested to improve the characterisation of this relationship.

Nutrition Considerations After NICU Discharge

Preterm infants are at high nutrition risk during neonatal intensive care and well after discharge. Nutrition care should be individualized and provided by a multidisciplinary team including a dietitian. Breast milk, the gold standard for feeding, may not meet the increased needs of preterm infants and may require fortification or supplementation. Decisions regarding formula choice and calorie concentration can also be challenging and require individualization based on growth, intake, and individual need. Developmental milestones should be considered during the initation of complementary food. This article presents new research on allergenic food introduction to guide practitioners during caregiver education. Finally, an evidence-based weaning practice for enteral feeding-dependent patients is provided with suggestions for outpatient applicability. [Pediatr Ann. 2018;47(4):e154-e158.].

[Follow-up protocol for newborns of birthweight less than 1500 g or less than 32 weeks gestation]

The mortality of children with a birthweight of less than 1500g or with a gestational age of less than 32 weeks (<1500<32) has decreased significantly in the last 20 years or so. Given the higher risk of disability in these children, follow-up after hospital discharge is considered essential. In this document, the Follow-Up Group of the Spanish Society of Neonatology, in collaboration with the Spanish Society of Paediatric Primary Care, propose a follow-up protocol specific for the<1500<32, which has as its aim to standardise the activities and evaluations according to good practice criteria.

Breastfeeding Characteristics of Late-Preterm Infants in a Kangaroo Mother Care Unit

OBJECTIVE

To describe the breastfeeding characteristics of late-preterm infants (LPIs) in a kangaroo mother care (KMC) unit.

MATERIALS AND METHODS

In a 20-bed KMC unit, the breastfeeding of 73 purposively-selected LPIs' (mean gestational age: 34.8 weeks) was observed once-off, using the Preterm Infant Breastfeeding Behavior Scale. Participants' mean age was 9.5 days, mean number of days in the unit was 3.1 days, and mean number of days breastfeeding was 7.5 on observation.

RESULTS

Only 13.7% of participants were directly breastfeeding without supplementary naso- or orogastric feeding/cup-feeding and 86.3% received supplementary cup-feeding of expressed breast milk. Most participants did not exhibit obvious rooting (83.5%) and although most latched-on (97.3%), those who did, latched shallowly (93%). The mean longest sucking burst was 18.8 (standard deviation: 10.5) and approximately half the participants swallowed repeatedly (53.4%). The mean breastfeeding session duration was 17.8 minutes, but most participants breastfed for less than 10 minutes (76.7%). No statistically significant differences in breastfeeding characteristics were detected between participants of different chronological ages. A general trend toward more mature behaviors in participants' breastfeeding for more days was present for many breastfeeding characteristics. More infants exhibited the most mature behavior for each breastfeeding characteristic when the environment was quiet, rather than noisy and disturbing, except for depth of latching (quiet: 0%, disturbance: 15.2%).

CONCLUSION

LPIs in this sample presented with subtle breastfeeding difficulties, highlighting their need for breastfeeding support. Further research is required to examine the effect of KMC on breastfeeding in LPIs.

Perspectives and attitudes of pediatricians concerning post-discharge care practice of premature infants

OBJECTIVE

Survival rates of premature infants are at a historical high and increasingly more pediatricians are caring for former premature infants. The goal of this study was to describe the perspectives and attitudes of pediatricians, as well as, the challenges of rendering post-neonatal intensive care unit (NICU) discharge care for premature infants.

METHODS

An anonymous 22-question web-based survey was emailed to pediatricians who are current members of the American Academy of Pediatrics (AAP) and practicing in Kings County, New York.

RESULTS

There were 148 completed surveys with 79% being general pediatricians. Of all respondents, 63% believed that premature infants should have a neonatal high risk follow-up visit within days after discharge and 64% were satisfied with the NICU discharge summary acquisition. While 74% of pediatricians felt comfortable following up with former extremely premature infants, 65% referred to specialists, most often to child development, neurology, and physical and/or occupational therapy. The majority (85%) were more likely to refer premature infants to early intervention. Participating pediatricians varied in their knowledge of immunization and breastfeeding guidelines. Finally, 88% of respondents acknowledged that caregivers of premature infants experience increased stress, with 53% stating that the stress should be addressed.

CONCLUSIONS

Understanding the perceptions and challenges of pediatricians who care for premature infants may help improve post NICU quality of care. Transition to the outpatient setting is a crucial step in the management of premature infants and a focus on improved hand-off procedures between hospital and physicians may prove beneficial. Also, pediatricians must stay abreast of current recommendations for breastfeeding and vaccinations. Furthermore, emphasis should be given to stress reduction and management for caregivers of former premature infants.

Growth after late-preterm birth and adult cognitive, academic, and mental health outcomes

BACKGROUND

Late-preterm birth (at 34^0⁄7-36^6⁄7 wk gestation) increases the risk of early growth faltering, poorer neurocognitive functioning, and lower socio-economic attainment. Among early-preterm individuals, faster early growth benefits neurodevelopment, but it remains unknown whether these benefits extend to late-preterm individuals.

METHODS

In 108 late-preterm individuals, we examined if weight, head, or length growth between birth, 5 and 20 months' corrected age, and 56 mo, predicted grade point average and special education in comprehensive school, or neurocognitive abilities and psychiatric diagnoses/symptoms at 24-26 y of age.

RESULTS

For every 1 SD faster weight and head growth from birth to 5 mo, and head growth from 5 to 20 mo, participants had 0.19-0.41 SD units higher IQ, executive functioning score, and grade point average (95% confidence intervals (CI) 0.002-0.59 SD), and lower odds of special education (odds ratio (OR) = 0.49-0.59, 95% CIs 0.28-0.97), after adjusting for sex, gestational age, follow-up age, and parental education. Faster head growth from 20 to 56 mo was associated with less internalizing problems; otherwise we found no consistent associations with mental health outcomes.

CONCLUSION

Faster growth during the critical early period after late-preterm birth is associated with better adult neurocognitive functioning, but not consistently with mental health outcomes.

The clinical utility of anthropometric measures to assess adiposity in a cohort of prematurely born infants: Correlations with MRI fat quantification

OBJECTIVE

To correlate magnetic resonance imaging (MRI) of body fat in preterm infants at the time of hospital discharge with same-day anthropometric measures, and to assess the clinical utility of body mass index (BMI), waist circumference (WC), and WC/length ratio as indicators of visceral fat.

STUDY DESIGN

MRI performed prior to NICU discharge in 25 infants born preterm at <32 weeks gestation. Total body fat and visceral fat were quantified using a commercial software program. The Pearson correlation coefficient (r, 95% C.I.) was used to describe strength of association between MRI fat and anthropometric measures.

RESULTS

BMI and weight at discharge were strongly correlated with total body fat (r = 0.95 and 0.89 respectively; p < 0.001). Total body fat as a % of body weight was moderately correlated with weight (r = 0.53), WC (r = 0.52), and BMI (r = 0.47). Weight, BMI, and ponderal index all were found to correlate with total visceral fat (r = 0.65, 0.64, 0.55 respectively) but WC did not (r = 0.28). WC/length ratio was not correlated with any MRI fat measurements.

CONCLUSIONS

BMI and weight at discharge both correlate with MRI fat measurements. Our findings do not support the usefulness of measuring WC or WC/length ratio in preterm infants at term-equivalent age.

Recombinant Bile Salt-Stimulated Lipase in Preterm Infant Feeding: A Randomized Phase 3 Study

INTRODUCTION

Feeding strategies are critical for healthy growth in preterm infants. Bile salt-stimulated lipase (BSSL), present in human milk, is important for fat digestion and absorption but is inactivated during pasteurization and absent in formula. This study evaluated if recombinant human BSSL (rhBSSL) improves growth in preterm infants when added to formula or pasteurized breast milk.

PATIENTS AND METHODS

LAIF (Lipase Added to Infant Feeding) was a randomized, double-blind, placebo-controlled phase 3 study in infants born before 32 weeks of gestation. The primary efficacy variable was growth velocity (g/kg/day) during 4 weeks intervention. Follow-up visits were at 3 and 12 months. The study was performed at 54 centers in 10 European countries.

RESULTS

In total 415 patients were randomized (rhBSSL n = 207, placebo n = 208), 410 patients were analyzed (rhBSSL n = 206, placebo n = 204) and 365 patients were followed until 12 months. Overall, there was no significantly improved growth velocity during rhBSSL treatment compared to placebo (16.77 vs. 16.56 g/kg/day, estimated difference 0.21 g/kg/day, 95% CI [-0.40; 0.83]), nor were secondary endpoints met. However, in a predefined subgroup, small for gestational age infants, there was a significant effect on growth in favor of rhBSSL during treatment. The incidence of adverse events was higher in the rhBSSL group during treatment.

CONCLUSIONS

Although this study did not meet its primary endpoint, except in a subgroup of infants small for gestational age, and there was an imbalance in short-term safety, these data provide insights in nutrition, growth and development in preterm infants.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01413581.