Growth patterns and nutritional factors associated with increased head circumference at 18 months in normally developing, low-birth-weight infants

What methods are used to apply positive deviance within healthcare organisations? A systematic review

BACKGROUND

The positive deviance approach focuses on those who demonstrate exceptional performance, despite facing the same constraints as others. 'Positive deviants' are identified and hypotheses about how they succeed are generated. These hypotheses are tested and then disseminated within the wider community. The positive deviance approach is being increasingly applied within healthcare organisations, although limited guidance exists and different methods, of varying quality, are used. This paper systematically reviews healthcare applications of the positive deviance approach to explore how positive deviance is defined, the quality of existing applications and the methods used within them, including the extent to which staff and patients are involved.

METHODS

Peer-reviewed articles, published prior to September 2014, reporting empirical research on the use of the positive deviance approach within healthcare, were identified from seven electronic databases. A previously defined four-stage process for positive deviance in healthcare was used as the basis for data extraction. Quality assessments were conducted using a validated tool, and a narrative synthesis approach was followed.

RESULTS

37 of 818 articles met the inclusion criteria. The positive deviance approach was most frequently applied within North America, in secondary care, and to address healthcare-associated infections. Research predominantly identified positive deviants and generated hypotheses about how they succeeded. The approach and processes followed were poorly defined. Research quality was low, articles lacked detail and comparison groups were rarely included. Applications of positive deviance typically lacked staff and/or patient involvement, and the methods used often required extensive resources.

CONCLUSION

Further research is required to develop high quality yet practical methods which involve staff and patients in all stages of the positive deviance approach. The efficacy and efficiency of positive deviance must be assessed and compared with other quality improvement approaches.

PROSPERO REGISTRATION NUMBER

CRD42014009365.

Early Zinc Supplementation and Enhanced Growth of the Low-Birth Weight Neonate

BACKGROUND:

Nutritional deficits are almost universal in Low-Birth Weight babies. Zinc is essential for normal infant growth and its supplementation assists growth probably through insulin-like growth factor-1.

AIM:

This double-blind randomized-controlled trial aimed at evaluating the role of zinc in catch-up growth of low-birth-weight infants and investigating its proposed mediator.

MATERIAL AND METHODS:

The study was conducted in Ain Shams University Maternity Hospital. Two hundred low-birth-weight neonates were simply randomized to either oral zinc therapy or placebo. Anthropometric measurements were recorded at birth, 3, 6, and 12 months; including weight, recumbent length, head, waist, chest, and mid-upper arm circumferences, and triceps and sub-scapular skin fold thickness.

RESULTS:

We found that initial and 3-months measurements, except weight, were comparable in the 2 groups. All measurements at 6- and 12-months, except sub-scapular skin-fold-thickness, were significantly higher in zinc group than placebo. Catch-up growth, at 12-months, was significant in zinc group and was significantly higher in appropriate-for-gestational-age vs. small-for-gestational-age, in preterm vs. term, and in male vs. female infants. The median 6-months insulin-like growth factor-1 levels were significantly higher in zinc group.

CONCLUSION:

We conclude that early start of oral zinc supplementation in low-birth-weight neonates assists catch-up growth, probably through rise of insulin-like growth factor-1.

Does more protein in the first week of life change outcomes for very low birthweight babies?

BACKGROUND

Following publication of revised recommended nutrient intakes (RNI) for infants <1500 g, our intravenous nutrition (IVN) solutions were reformulated to deliver RNI in a restricted volume to ensure additional non-nutritional fluids did not detract from nutritional intake. An audit was performed to determine whether these changes achieved RNI and influenced growth, clinical or neurodevelopmental outcomes.

METHODS

Two cohorts of 40 infants <1500 g were identified from a prospectively maintained database: babies born before and after reformulation of the IVN solutions. Data on nutritional intakes for the first 30 days of life, growth and clinical outcomes were collected. Neurodevelopmental outcomes at 18 months corrected age (CA) were obtained from a Bayley III assessment. Results are presented as mean ± SD.

RESULTS

The 'after' group received significantly less fluid (105 ± 12 vs. 132 ± 15 mL/kg/day, P < 0.001) but more protein (3.2 ± 0.6 vs. 2.4 ± 0.5 g/kg/day, P < 0.001) in the first week of life. There were no differences in clinical outcome, growth z-scores at 4 weeks of age or neurodevelopmental outcome at 18 months CA between the 'before' and 'after' infants. Enteral protein intake in the first 2 weeks of life was positively associated with neurodevelopmental outcome (cognitive score r(2) = 0.13 P= 0.03, motor score r(2) = 0.27 P= 0.001).

CONCLUSION

Although the new IVN regimen achieved intakes closer to RNI, there were no major effects on growth, clinical outcome or neurodevelopmental outcome at 18 months CA. Enteral protein intake in the first two weeks was positively associated with neurodevelopmental outcome, suggesting early enteral protein intake is important for optimal brain function.

Growth and energy and protein intake of preterm newborns in the first year of gestation-corrected age

CONTEXT

There are few longitudinal studies that analyze the growth and nutritional status parameters of children born prematurely.

OBJECTIVE

To evaluate the growth and dietary intake of preterm newborns in the first year of gestation-corrected age.

DESIGN

Prospective clinical study.

SETTING

Tertiary care hospital.

PATIENTS

19 children (7 male) who were born prematurely, with birth weight between 1000 g and 2000 g, which was adequate for the gestational age.

PROCEDURES

At 3, 6, 9 and 12 months of gestation-corrected age, children were evaluated in relation to weight, height and cephalic perimeter, using the National Center for Health Statistics as the standard reference, and the Rozalez-Lopez and Frisancho standards for brachial perimeter and triceps and subscapular skinfolds. The calculated dietary intake was compared to the Recommended Dietary Allowances.

MAIN MEASUREMENTS

The Z score was calculated for the weight/age, height/age and weight/height relationships, and the percentiles of the perimeters and skinfolds were considered. Dietary intake records were made using the 24-hour Dietary Recall and the Food Frequency Intake Questionnaire methods. The Virtual Nutri software was used to calculate energy and protein intake.

RESULTS

The weight/age, height/age and weight/height relationships and the brachial perimeter and triceps skinfold were statistically greater in the first semester in relation to the second. The cephalic perimeter remained above the 50th percentile for the ages studied and there was no difference in the subscapular skinfold between the first and second semesters, remaining below the 50th percentile. The calorie and protein intake, although statistically lower in the first than in the second semester, always remained above the recommended.

CONCLUSIONS

The pace of growth is greater in the first semester than in the second, not reaching the standard expected for full-term newborns, with the exception of the cephalic perimeter, which remains adequate. Calorie/protein intake shows an inverse relationship with growth speed, remaining above the recommended for full-term newborns, although with difficulty in depositing subcutaneous fat, in spite of the high caloric intake.

Postdischarge nutrition for high risk neonates

Despite improvements in neonatal care, many preterm babies suffer growth failure during their hospitalization. This appears to persist through early childhood, and possibly into adolescence. The use of enriched formulas improves the early growth of preterm infants, although most if not all of the benefit seems to be lost by 18 months. This growth benefit seems to be restricted to male infants. The improved growth does not improve developmental outcome. Although there are no direct comparisons of 22 kcal/oz post-discharge formulas and 24 kcal/oz preterm formulas, they are probably equally effective. Exactly which component (or components) of enriched formulas is responsible for this growth advantage is not known. Preliminary studies suggest that it may not be protein. Whether this growth benefit leads to decreased morbidity from cardiovascular disease in later life has not been studied. Further research is urgently needed to assess what nutritional factors can improve catch up growth in high-risk infants and whether this improved growth leads to decreased long-term morbidity.

Enhanced-calorie formulas: considerations and options

The long-term developmental impact of nutrition on the preterm newborn has recently been shown to be of even greater importance than previously recognized. Very immature or ill infants are challenged by the need for a high caloric intake, but are unable to tolerate large fluid volumes. These patients may require enhanced-calorie formulas to achieve the desired growth goals. Formula enhancement has traditionally been performed by uniquely developed recipes of base formula concentration with the addition of powdered formula or single components such as medium-chain triglycerides oil, protein, or polycose. These mixtures have been largely unstudied for bioavailability, long-term outcomes, and tolerance. Deviation from recommended protein, fat, carbohydrate, mineral, and vitamin delivery limits may impair growth or lead to undesirable side effects. The practitioner must have an understanding of when and how to use an enhanced formula and the important monitoring and assessment needs of the patient receiving enhanced-calorie formula.