Advances in nutrition of the newborn infant

Effects of Gustatory and Olfactory Stimulation on Feeding Outcomes in Preterm Infants: A Systematic Review and Meta-Analysis

BACKGROUND

Few primary studies have examined the impact of olfactory and gustatory stimulation on premature infants, and variability exists in reported outcomes.

PURPOSE

To explore the effects of olfactory and gustatory stimulation on feeding outcomes in preterm infants.

DATA SOURCES

A literature search was conducted in 4 databases (CENTRAL, PubMed, Embase, CINAHL) from the inception of the databases to May 2024.

STUDY SELECTION

Randomized controlled trials (RCTs) or quasi-RCTs to explore the effects of olfactory and gustatory stimulation on feeding outcomes in preterm infants were included.

DATA EXTRACTION

Two reviewers independently extracted data from the included studies and completed the form designed for data extraction.

RESULTS

Eleven RCTs and quasi-RCTs comprising 1009 preterm infants were included. Meta-analysis found that olfactory and gustatory stimulation significantly shortened the time to reach full oral feeds (days) (mean difference [MD]: -2.52, 95% confidence interval [CI]: -3.88 to -1.16, P = .0003), while they had no significant differences in time to achieve full enteral feeds (days), postmenstrual age (PMA) at the removal of the nasogastric tube (weeks), weight at discharge (grams), weight gain (grams), head circumference at discharge (cm), length at discharge (cm), total duration of parenteral nutrition (days), necrotizing enterocolitis, hospitalization duration (days), PMA at discharge (weeks).

IMPLICATIONS FOR PRACTICE AND RESEARCH

Large sample, multicenter studies are needed to demonstrate the effectiveness of olfactory and gustatory stimulation on feeding outcomes in preterm infants.

Human milk proteins differentiate over the sex of newborns and across stages of lactation

BACKGROUND & AIMS

Human milk (HM) is a complete food that meets the nutritional and energy demands of the newborns. It contains numerous bioactive components, including functional proteins. Variations in HM energy and lipid content have already been reported related to the newborn's sex, but differences between protein profiles are still scarce. This work aimed to identify differences between HM proteins produced by mothers of female and male newborns, in the lactation stages of colostrum and mature milk, and the metabolic pathways involved.

METHODS

A total of 98 HM samples were collected from 39 lactating women and classified according to the newborn's sex, stages of lactation, and three mothers' age groups, and evaluated about protein concentration and one-dimensional electrophoretic profile. Next, to assess samples with the greatest differences, the HM proteins regarding the newborn's sex and the stages of lactation were compared using nano-LC-MS/MS, in 24 HM samples randomly rearranged into four groups: female and male infants, and colostrum and mature milk. Functional classification, metabolic pathways, and protein interaction networks were analyzed by Gene Ontology, KEGG, and STRING, respectively.

RESULTS

The soluble protein content of HM decreased throughout lactation, with differences regarding isolated factors, such as mothers' age group, child's sex and stages of lactation, and also in terms of their interactions. A total of 146 proteins were identified, 42 of which showed different abundances over the sexes of newborns and 53 between the stages of lactation. In general, proteins related to metabolic processes were up-regulated for mothers of male infants and in the mature stage of lactation, while proteins related to defense were up-regulated in mothers of female infants and in the colostrum phase.

CONCLUSION

This study indicated that there are differentiated and specific nutritional and defense needs of newborns, by sex and by lactation phase, which is highly relevant for a more appropriate supply of food to infants receiving HM from donor mothers.

Reducing Procedural Pain and Avoiding Peripheral Intravenous Catheters by Implementing a Feeding Protocol for Late Preterm Infants: A Quality Improvement Project

BACKGROUND

Late preterm births account for a large portion of preterm births, yet the optimal method of nutrition and enteral feeding in this population remains unclear and often involves intravenous (IV) fluids.

PURPOSE

To develop and implement a late preterm feeding protocol in order to decrease the necessity of IV access, decrease the use of starter parenteral nutrition (PN), and reduce the pain endured by an infant in the neonatal intensive care unit.

METHODS

The Plan-Do-Study-Act quality improvement model was utilized as a framework for the implementation of this quality improvement project. A literature review was conducted and subsequently, a feeding protocol was developed and included the more judicious use of starter PN. This protocol was implemented, evaluated, and adopted. A second Plan-Do-Study-Act cycle was completed with the addition of an auto-text reminder incorporated into admission notes in the electronic medical record.

RESULTS

The implementation of the protocol significantly reduced placement of IV access and the use of starter (PN) in late preterm infants without considerable differences in balancing measures. The percentage of infants who received peripheral IV access declined considerably from 70% to 42% ( P = .0017) subsequently, less pain endured by the infants. There was a decrease in the initiation of starter PN from 55% to 7% ( P < .00001).

IMPLICATIONS FOR PRACTICE

Administering enteral feedings on admission to stable, late preterm infants reduced the need for peripheral IV access and thus decreased pain from this procedure.

Nutritional Strategies for Preterm Neonates and Preterm Neonates Undergoing Surgery: New Insights for Practice and Wrong Beliefs to Uproot

The nutrition of preterm infants remains contaminated by wrong beliefs that reflect inexactitudes and perpetuate old practices. In this narrative review, we report current evidence in preterm neonates and in preterm neonates undergoing surgery. Convictions that necrotizing enterocolitis is reduced by the delay in introducing enteral feeding, a slow advancement in enteral feeds, and the systematic control of residual gastric volumes, should be abandoned. On the contrary, these practices prolong the time to reach full enteral feeding. The length of parenteral nutrition should be as short as possible to reduce the infectious risk. Intrauterine growth restriction, hemodynamic and respiratory instability, and patent ductus arteriosus should be considered in advancing enteral feeds, but they must not translate into prolonged fasting, which can be equally dangerous. Clinicians should also keep in mind the risk of refeeding syndrome in case of high amino acid intake and inadequate electrolyte supply, closely monitoring them. Conversely, when preterm infants undergo surgery, nutritional strategies are still based on retrospective studies and opinions rather than on randomized controlled trials. Finally, this review also highlights how the use of adequately fortified human milk is strongly recommended, as it offers unique benefits for immune and gastrointestinal health and neurodevelopmental outcomes.

Gut development following insulin-like growth factor-1 supplementation to preterm pigs

BACKGROUND

Reduced insulin-like growth factor-1 (IGF-1) levels may contribute to impaired organ development in preterm infants. Using preterm pigs as a model, we hypothesized that IGF-1 supplementation improves health and gut development during the first three weeks of life.

METHODS

First, clinical and organ endpoints were compared between artificially-reared, cesarean-delivered preterm pigs and vaginally-delivered, sow-reared term pigs at 5, 9 and 19 days. Next, preterm pigs were treated with recombinant human IGF-1 for 19 days (2.25 mg/kg/day, systemically).

RESULTS

Relative to term pigs, preterm pigs had lower body weight, fat, bone contents, relative weights of liver and spleen and a longer and thinner intestine at 19 days. Preterm birth reduced intestinal villi heights and peptidase activities, but only at 5 and 9 days. In preterm pigs, IGF-1 reduced mortality primarily occurring from gastrointestinal complications and with a tendency towards salvaging smaller pigs. IGF-1 supplementation also increased spleen and kidney weights, small intestine length and maltase to lactase activity, reflecting gut maturation.

CONCLUSION

Preterm birth affects body composition and gut maturation in the first 1-2 weeks, but differences are marginal thereafter. Supplemental IGF-1 may improve gut health in pigs and infants in the first few weeks after preterm birth.

IMPACT

Insulin-like growth factor 1 (IGF-1) supplementation may improve gut health and development in prematurity, but whether the effects are sustained beyond the immediate postnatal period is unclear. In preterm pigs, the prematurity effects on IGF-1 and gut health deficiencies are most pronounced during the first week of life and diminishes thereafter. In preterm pigs, IGF-1 supplementation beyond the first week of life reduced mortality. The present study provides evidence of a sustained effect of IGF-1 supplementation on the gastrointestinal tract after the immediate postnatal period.

Feeding intolerance scoring system in very preterm and very low birth weight infants using clinical and ultrasound findings

Very preterm infants are at a high risk of developing feeding intolerance; however, there are no widely accepted definitions of feeding intolerance. This study aimed to develop a scoring system for feeding intolerance in very preterm infants by combining clinical symptoms and ultrasonography (US) findings. This prospective cohort study included very preterm and/or very low birth weight infants. We defined feeding intolerance as the inability to achieve full feeding (150 ml/kg/day) by 14 days of life. The clinical findings included vomiting, abdominal distention, and gastric fluid color. US findings included intestinal peristaltic frequency, gastric residual volume, peak systolic velocity, and the resistive index of the superior mesenteric artery. We conducted multivariate analyses to evaluate the potential predictors and developed a scoring system to predict feeding intolerance. A total of 156 infants fulfilled the eligibility criteria; however, 16 dropped out due to death. The proportion of patients with feeding intolerance was 60 (42.8%). Based on the predictive ability, predictors of feeding intolerance were determined using data from the US at 5-7 days of age. According to multivariate analysis, the final model consisted of 5 predictors: abdominal distention (score 1), hemorrhagic gastric fluid (score 2), intestinal peristaltic movement ≤18x/2 min (score 2), gastric fluid residue >25% (score 2), and resistive index >0.785 (score 2). A score equal to or above 5 indicated an increased risk of feeding intolerance with a positive predictive value of 84.4% (95% confidence interval:73.9-95.0) and a negative predictive value of 76.8% (95% confidence interval:68.4-85.3). The scoring system had good discrimination (area under the receiver operating characteristic curve:0.90) and calibration (p = 0.530) abilities. This study developed an objective, accurate, easy, and safe scoring system for predicting feeding intolerance based on clinical findings, 2D US, and color Doppler US.

Could early life DHA supplementation benefit neurodevelopment? A systematic review and meta-analysis

Background

Docosahexaenoic acid (DHA) plays a crucial role in the growth and functional development of the infant brain. However, the impact of additional DHA supplementation on neurodevelopment in infants remains controversial in randomized controlled trials. In this systematic review and meta-analysis, we aimed to investigate the effects of prenatal and postnatal DHA supplementation on neurodevelopment.

Methods

We systematically searched the MEDLINE, EMBASE, and Cochrane Library electronic databases using a predefined strategy until 8 February 2024. We extracted relevant study characteristics and outcomes related to the nervous system. Two independent reviewers critically evaluated the included studies to assess their validity and risk of bias.

Results

A total of 21 studies met our inclusion criteria, one study was removed after quality assessment, and the meta-analysis included 9 randomized controlled trials. The meta-analysis results indicated that there was no statistically significant difference between the DHA supplementation group and the placebo group, as assessed by the Mental Development Index [MDI; mean difference (MD), 0.41; 95% confidence interval (CI), -0.91 to 1.73; p = 0.55]. However, the DHA group had a significantly higher Psychomotor Development Index (PDI) than the placebo group (MD, 1.47; 95% CI, 0.23 to 2.72; p = 0.02). Subgroup analyses based on populations showed that DHA supplementation was superior to placebo for infants in both MDI (language score conversion; MD, 2.05; 95% CI, -0.16 to 4.26; p = 0.07) and PDI (MD, 1.94; 95% CI, 0.23 to 3.65; p = 0.03). Other subgroup analyses indicated no statistical differences between the two groups. The remaining assessments that could not be summarized quantitatively underwent a narrative evaluation.

Conclusion

Based on the BSID assessments, DHA supplementation in infants may have potential neurodevelopmental benefits. Because the meta-analysis included few high-quality articles and had some limitations, more relevant articles are needed to address the need for separate DHA supplementation in infants, pregnant women, and lactating mothers.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022348100, identifier: CRD42022348100.

Metagenomic estimation of dietary intake from human stool

Dietary intake is tightly coupled to gut microbiota composition, human metabolism, and to the incidence of virtually all major chronic diseases. Dietary and nutrient intake are usually quantified using dietary questionnaires, which tend to focus on broad food categories, suffer from self-reporting biases, and require strong compliance from study participants. Here, we present MEDI (Metagenomic Estimation of Dietary Intake): a method for quantifying dietary intake using food-derived DNA in stool metagenomes. We show that food items can be accurately detected in metagenomic shotgun sequencing data, even when present at low abundances (>10 reads). Furthermore, we show how dietary intake, in terms of DNA abundance from specific organisms, can be converted into a detailed metabolic representation of nutrient intake. MEDI could identify the onset of solid food consumption in infants and it accurately predicted food questionnaire responses in an adult population. Additionally, we were able to identify specific dietary features associated with metabolic syndrome in a large clinical cohort, providing a proof-of-concept for detailed quantification of individual-specific dietary patterns without the need for questionnaires.

Vanilla odor promotes oral feeding in premature infants-A randomized controlled trial

PROPOSE

Introducing early oral feeding in premature infants is important because it supports intestinal maturation and helps prevent infections. In addition, early oral feeding is likely to contribute to improved neurocognitive outcomes in preterm infants. Several holistic therapeutic strategies have been developed to improve feeding skills, food tolerance, and the ability to drink independently, including practices such as early breastfeeding, oral stimulation, and subsequent olfactory stimulation. Based on several studies using olfactory stimulation with food odors (vanilla, breast milk) to promote oral feeding in preterm infants this study was conducted to test the following hypothesis: Does olfactory stimulation with vanilla or milk odor (breast milk or formula) lead to a reduction in the time required for nasogastric tube weaning in premature infants older than 26 + 6 weeks of gestational age? In addition, does it influence secondary outcomes such as length of hospital stay, weight development, and attainment of greater amounts of independently consumed food?

METHODS

Premature with complete or partial feeding by gastric tube and without ventilation were included. For this study, 207 infants over 26 + 6 gestational weeks were randomized into three different study groups. Before each feeding, an olfactory presentation was made with milk odor, a vanilla Sniffin' Stick, or a control stick. In the final analysis, 165 infants were included (87 males, 78 females). At the time of randomization, infants were on average 12 ± 9.5 days old.

RESULTS

While the influence of vanilla and milk odor did not provide a significant difference from the control for the primary outcome, a secondary analysis showed a significant group difference in the cumulative amount of independently drunk food consumed in the first ten days was the highest amount in the vanilla group. This time period was chosen due to the high dropout rate after the first ten days. In addition, there was a promising significance for earlier hospital discharge for prematurely below 32 weeks of gestation receiving vanilla odor stimulation in comparison to milk odor stimulation.

CONCLUSION

Although the primary outcome of this study (gastric tube removal) did not provide significant results, a significant benefit of vanilla olfactory stimulation for preterm infants was demonstrated in subgroup analysis above milk odor stimulation. Younger preterm infants seem to benefit from the stimulation.

Nutrition guidelines for preterm infants: A systematic review

BACKGROUND

There is no consensus on optimal nutrition for preterm infants, leading to substantial practice variation. We aimed to assess the quality of nutrition guidelines for preterm infants, the consistency of recommendations, and the gaps in recommendations.

METHODS

We searched databases and websites for nutrition guidelines for preterm infants before first hospital discharge, which were endorsed, prepared, or authorized by a regional, national, or international body, written in English, and published between 2012 and 2023. Two reviewers independently screened articles and extracted the recommendations. Four reviewers appraised the included guidelines using Appraisal of Guidelines, Research, and Evaluation II.

RESULTS

A total of 7051 were identified, with 27 guidelines included, 26% of which were high in quality. Most guidelines lacked stakeholder involvement and rigor of development. We found considerable variation in recommendations, many of which lacked details on certainty of evidence and strength of recommendation. Recommendations for type of feed and breastmilk fortification were consistent among high-quality guidelines, but recommendations varied for intakes of almost all nutrients and monitoring of nutrition adequacy. Different guidelines gave different certainty of evidence for the same recommendations. Most gaps in recommendations were due to very low certainty of evidence.

CONCLUSION

Future development of nutrition guidelines for preterm infants should follow the standard guideline development method and ensure the rigorous process, including stakeholders' involvement, to improve the reporting of strength of recommendation, certainty of evidence, and gaps in recommendation. Evidence is needed to support recommendations about macro and micronutrient intakes, breastmilk fortification, and markers on adequacy of intake of different nutrients.

Central Lines and Their Complications in Neonates: A Case Report and Literature Review

Central lines are essential devices in NICUs, used primarily in preterm neonates and critically ill term neonates. They are typically divided into non-tunnelled, tunnelled and totally implanted. In light of the increasing use of central lines in the NICU setting, monitoring of the risk factors associated with complications has to be an important part of neonatal care quality management. Presented here is a case of a preterm neonate with cardiac tamponade caused by UVC tip migration. Among complications of central lines are CLABSI, with an incidence of 3 to 21 per 1000 catheter days, and portal vein thrombosis, which is common but probably under-recognised, whereas other mechanical complications such as pericardial and pleural effusions are rare, with an incidence of less than 1%. Complications can cause injury to the neonates, as well as increase the costs of health services because of increases in the length of stay in the NICU. It is recommended that the catheter tip location is confirmed either by X-ray or ultrasonography. In order to minimise the risk of CLABSI, the use of bundles is recommended. Certain recommendations need to be followed when using different types of catheters. Future research is aimed at novel ways of central line securement to minimise mechanical complications and the use of antimicrobial catheters to reduce the rate of CLABSI.

[Human milk oligosaccharides play major roles in child development and future health]

Human milk oligosaccharides (HMO) represent the third largest component of human breast milk (BM). The BM level is comprised between 5 to 20 g per liter and they have a great structural complexity with more than 150 HMO characterized to date. In this review, we present a summary of the main experimental and clinical data that have demonstrated their multiple biological roles in infants such as for gut development, microbiota, immune protection and neurodevelopment. Some HMO-enriched infant formulas are available yet, even if their benefits on the infant health remain to be confirmed. Further researches could allow therapeutic use in preterm newborns or in infants with intestinal diseases. Experimental data suggest that they could also be used in the prevention of some chronic diseases with immunometabolic or neurodevelopmental components.

High protein content in breast milk from South African mothers of preterm infants

AIM

Macronutrient and energy content of human milk are largely assumed for fortification practices. The aim was to explore macronutrient and energy content of transition and mature human milk from South African mothers of preterm infants with a birth weight <1800 g. Secondary objectives compared day to night milk; and explored associations with selected innate factors.

METHODS

In this single-centre, observational study macronutrient and energy content of day, night and mixed samples of transition (first 14 days of life) and mature (from Day 15 of life) human milk were analysed with mid-infrared spectroscopy.

RESULTS

In total, 116 samples (38 days; 37 night; 41 mixed) from 47 mothers were retained for statistical analysis. Mean true protein, carbohydrate, fat and energy content of mixed samples per 100 mL were 1.5 ± 0.4 g, 7.2 ± 0.7 g, 3.5 ± 0.9 g and 69.4 ± 9.9 kcal, respectively. Mixed transition milk (n = 9) had 1.9 ± 0.3 g protein and 67.4 ± 9.6 kcal and mixed mature milk (n = 32) 1.4 ± 0.4 g protein and 70.0 ± 10.1 kcal, per 100 mL.The protein content of transition (p = 0.004) and mature (p = 0.004) milk were significantly higher than published data. Transition milk: 1.5 g protein, 65 kcal; mature milk: 1.2 g protein, 72 kcal per 100 mL. Night samples had less fat (p = 0.014) and energy (p = 0.033) than day samples. With increasing day of life protein content declined (p = 0.003).

CONCLUSION

The protein content of human milk from South African mothers of preterm babies differs from published data and has implications for human milk fortification practises.

Does Growth Velocity Affect Associations between Birth Weight and Neurodevelopment for Infants Born Very Preterm?

OBJECTIVE

To determine how neonatal growth velocity affects the association between birth weight and neurodevelopmental outcomes in infants born preterm.

STUDY DESIGN

This study is a secondary analysis of the Maternal Omega-3 Supplementation to Reduce Bronchopulmonary Dysplasia in Very Preterm Infants (MOBYDIck) randomized multicenter trial conducted in breastfed infants born at <29 weeks of gestation, whose mothers were supplemented with docosahexaenoic acid or placebo during the neonatal period. Neurodevelopmental outcomes were assessed at 18-22 months of corrected age using the Bayley-III cognitive and language composite scores. The role of neonatal growth velocity was assessed with causal mediation and linear regression models. Subgroup analyses were stratified by birth weight z-score categories (<25th, ≥25th-≤75th, and >75th percentiles).

RESULTS

Neurodevelopmental outcomes were available for 379 children (mean gestational age, 26.7 ± 1.5 weeks). Growth velocity partially mediated the relationships between birth weight and cognitive (β = -1.1; 95% CI, -2.2 to -0.02; P = .05) and language scores (β = -2.1; 95% CI, -3.3 to -0.8; P = .002). An increase by 1 g/kg/day in growth velocity was associated with an increase by 1.1 point in the cognitive score (95% CI, -0.03 to 2.1; P = .06) and 1.9 point in the language score (95% CI, 0.7 to 3.1; P = .001), after adjustment for birth weight z-score. For children with birth weight <25th percentile, a 1 g/kg/day increase in growth velocity was associated with an increase by 3.3 points in the cognitive score (95% CI, 0.5 to 6.0; P = .02) and 4.1 points in the language score (95% CI, 1.3 to 7.0; P = .004).

CONCLUSIONS

Postnatal growth velocity mediated the relationship between birth weight and neurodevelopmental performance, with larger effects for children with lower birth weight.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02371460.

Blood-Biomarkers for Glucose Metabolism in Preterm Infants

This was an exploratory, prospective, longitudinal, cohort study that aimed to establish "healthy" reference levels related to growth parameters and glucose metabolites in preterm infants. This was conducted to further investigate growth and metabolic disturbances potentially related to neonatal illness. The study sample consisted of 108 preterm infants born before 32 weeks in 2018-2019 in the Capital Region of Denmark. Repetitive blood samples were acquired at the neonatal wards, while clinical data were obtained from the regional hospital medical record system. Thirty-four "healthy" preterm infants (31%) were identified. The "ill" infants were divided into four subgroups dependent on gestational age and small for gestational age. Reference levels for the growth parameters and metabolic biomarkers glucose, albumin, and adiponectin, and two glucose control indicators, glycated albumin and fructosamine, were determined for the "healthy" and "ill" subgroups. The "ill" extremely preterm infants had increased glucose levels (mean difference 0.71 mmol/L, 95% CI 0.23; 1.18 mmol/L) and glycated albumin (corrected; %) (mean difference 0.92 mmol/L, 95% CI 0.38 mmol/L;1.47 mmol/L) compared to the "healthy" infants. In "ill" extremely preterm infants and "ill" very preterm infants born small for gestational age, levels of biomarkers containing proteins were decreased. In the "Ill" extremely preterm infants and infants born small for gestational age, postnatal growth was continuously decreased throughout the postconceptional period. The short-term glucose-control indicator, glycated albumin (corrected; %), reflected well the high glucose levels due to its correction for the depleted plasma-protein pool.

The Impact of Estimated Energy and Protein Balances on Extrauterine Growth in Preterm Infants

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.

Noninvasive Ventilation and Rapid Enteral Feeding Advances in Preterm Infants-2-Year Follow-Up of the STENA-Cohort

The importance of nutritional supply for somatic growth and neurodevelopmental outcome in very-low-birthweight infants is an established medical strategy for reducing long-term morbidities. Our cohort study on rapid enteral feeding advances using a standardized protocol (STENA) previously demonstrated a 4-day reduction of parenteral nutrition. STENA did not impede the success of noninvasive ventilations strategies but significantly less infants required mechanical ventilation. Most importantly, STENA resulted in improved somatic growth at 36 weeks of gestation. Here, we evaluated our cohort for psychomotor outcomes and somatic growth at 2 years of age. n = 218 infants of the original cohort were followed-up (74.4%). Z-scores for weight and length did not differ but the benefits of STENA for head circumference persisted until the age of 2 years (p = 0.034). Concerning the psychomotor outcome, we neither found any statistically significant differences in the mental developmental index (MDI) (p = 0.738), norin the psychomotor developmental index (PDI) (p = 0.122). In conclusion, our data adds important insights on the topic of rapid enteral feeding advances and confirms the safety of STENA with respect to somatic growth and psychomotor outcome measures.

A novel and controllable method for simultaneous preparation of human milk fat substitutes (OPL, OPO and LPL): two-step enzymatic ethanolysis-esterification strategy

A novel and effective approach based on the two-step ethanolysis-esterification strategy was proposed for the controllable and simultaneous preparation of 1-oleoyl-2-palmitoyl-3-linoleoylglycerol (OPL), 1,3-dioleoyl-2-palmitoyl-glycerol (OPO) and 1,3-dilinoleoyl-2-palmitoyl-glycerol (LPL) with adjustable proportions. Enzymatic ethanolysis of fractionated palm stearin was carried out to yield 2-monopalmitoylglycerol (79.4 ± 0.6 %) with over 91.0 % purity at the optimal conditions. The immobilized Candida sp. lipase (CSL) on octyl-functionalized ordered mesoporous silica (OMS-C₈) was applied to re-esterify 2-monopalmitoylglycerol with oleic acid and linoleic acid for the simultaneous production of OPL, OPO, and LPL. The total content in the final products was 81.5 %, with 91.3 % of palmitic acid (PA) content at the sn-2 position. Besides, OPL/OPO/LPL was conveniently prepared with suitable proportions for worldwide infants by adjusting the ratio of acyl donors. This paper provides a novel and effective two-step ethanolysis-esterification strategy for the development of human milk fat substitutes (HMFS).

LioNeo project: a randomised double-blind clinical trial for nutrition of very-low-birth-weight infants

We assessed the effectiveness of lyophilised banked human milk (HM) as a fortifier to feed very-low-birth-weight infants (VLBWI). This study aimed to evaluate the safety and tolerability of HM with HM lyophilisate as an additive compared with the standard additive (cows' milk protein). In this phase I double-blind randomised controlled clinical trial, set in the intensive and intermediate care units of a tertiary hospital, forty VLBWI were enrolled and allocated into two groups: HM plus HM lyophilisate (LioNeo) or HM plus commercial additive (HMCA). The inclusion criteria were preterm infants, birth weight 750-1500 g, small or adequate for gestational age, exclusively receiving donor HM, volume ≥ 100 ml/kg per d and haemodynamically stable. Participants were followed up for 21 consecutive days. The primary outcome measures were necrotising enterocolitis (NEC), late-onset sepsis (LOS), death, gastrointestinal (GI) bleeding or perforation, diarrhoea, regurgitation, vomiting and abdominal distension. The LioNeo and HMCA groups had similar weights at baseline. The regression models showed no differences between the groups in terms of the primary outcomes. Diarrhoea, GI perforation, NEC and LOS were absent in the LioNeo group (one LOS and one NEC in the HMCA group). Multiple regression analysis with the total volume of milk as a covariate did not show significant differences. The lyophilisation of donor HM was considered safe and tolerable for use in stable haemodynamically VLBWI.

Effect of supplementation with select human milk oligosaccharides on artificially reared newborn rats

Early life nutrition fundamentally influences neonatal development and health. Human milk oligosaccharides (HMO) are key components of breast milk but not standard infant formula that support the establishment of the newborn gut microbiota. Using an artificial rearing system, our objective was to test the effect of two HMO on the whole body and organ growth, adiposity, glucose tolerance and faecal microbiota in young rat pups. From postnatal days 4 to 21, Sprague-Dawley rats were randomised to receive one of: (1) CTR (rat milk substitute); (2) 2'FL (CTR + 1·2 g/l 2'-fucosyllactose); (3) 3'SL (CTR + 1·2 g/l 3'-sialyllactose) and (4) 2'FL + 3'SL (CTR + 0·6 g/l 2'-FL + 0·6 g/l 3'-SL). Body weight (BW), bowel movements and food intake were monitored daily, faecal samples collected each week and oral glucose tolerance, body composition and organ weight measured at weaning. No significant differences were observed between groups in growth performance, body composition, organ weight and abundance of dominant faecal microbes. A decreased relative abundance of genus Proteus in week 1 faecal samples and Terrisporobacter in week 3 faecal samples (P < 0·05) was suggestive of a potential pathogen inhibitory effect of 3'SL. Longitudinal changes in the faecal microbiota of artificially reared suckling rats were primarily governed by age (P = 0·001) and not affected by the presence of 2'-FL and/or 3'-SL in rat milk substitutes (P = 0·479). Considering the known protective effects of HMO, further investigation of supplementation with these and other HMO in models of premature birth, extremely low BW or malnutrition may show more pronounced outcomes.

E-nose, E-tongue Combined with GC-IMS to Analyze the Influence of Key Additives during Processing on the Flavor of Infant Formula

In order to analyze the influence of key additives during processing on the flavor of infant formula, the headspace-gas chromatography-ion mobility spectrometry, electronic tongue, and electronic nose techniques were used to evaluate flavor during the processing of stage 1 infant formula milk powder (0-6 months), including the analysis of seven critical additives. A total of 41 volatile compounds were identified, involving 12 aldehydes, 11 ketones, 9 esters, 4 olefins, 2 alcohols, 2 furans, and 1 acid. The electronic nose metal oxide sensor W5S had the highest response, followed by W1S and W2S, illustrating that these three sensors had great effects on distinguishing samples. The response results of the electronic tongue showed that the three sensory attributes of bitter, salty, and umami, as well as the richness of aftertaste, were more prominent, which contributed significantly to evaluating the taste profile and distinguishing among samples. Raw milk is an essential control point in the flavor formation process of stage 1 infant formula milk powder. Demineralized whey powder is the primary source of potential off-flavor components in hydrolyzed milk protein infant formula. This study revealed the quality characteristics and flavor differences of key additives in the production process of stage 1 infant formula milk powder, which could provide theoretical guidance for the quality control and sensory improvement of the industrialized production of infant formula.

Association of Zn and Cu Levels in Cord Blood and Maternal Milk with Pregnancy Outcomes among the Slovenian Population

Trace elements, including zinc (Zn) and copper (Cu), are known to play important roles in human health. The present study aimed to assess the levels of Zn and Cu in cord blood and maternal milk and to analyze their association with maternal and infant characteristics and pregnancy outcomes in a Slovenian study population of mothers and their neonates recruited within the PHIME prospective cohort study. The study included 324 mothers, but the data on Zn and Cu levels in both cord blood and maternal milk was available for 243 mothers. Questionnaires were used to assess the socio-demographic and health status of the mothers, their lifestyle habits (including detailed nutritional habits), and their residential and occupational histories. Inductively Coupled Plasma Mass Spectrometry (ICP-MS) was used to measure Zn and Cu levels in cord blood and maternal milk. Low Zn levels in cord blood were associated with lower gestational age and birth weight and were correlated with an increased probability of the birth of small for gestational age (SGA) infants. Maternal smoking influenced the Cu levels in both cord blood and maternal milk. Cord blood Cu levels were higher and Cu levels in maternal milk were lower in smoking compared to non-smoking mothers. Most importantly, a decreased Zn/Cu ratio in cord blood was associated with lower gestational age and lower birth weight. This indicates the overall positive effects of Zn and negative effects of Cu on pregnancy outcomes.

Use of human milk and fortification in the NICU

Human milk is the gold standard to provide nutritional support for all healthy and sick newborn infants including the very low birth weight (VLBW) infant (<1500 g). It has both nutritional and anti-infective properties which are especially important for these infants at risk for sepsis and necrotizing enterocolitis. Human milk alone is insufficient to meet the nutritional needs for VLBW infants, especially protein and minerals. There is a conundrum between achieving the nutritional, immunologic, developmental, psychological, social, and economic benefit with human milk vs. the inadequate growth with unfortified human milk for VLBW leading to nutritional inadequacy, growth failure and poor neurodevelopmental outcome. The use of multicomponent fortifiers to increase calories and provide additional protein, vitamins, and minerals has been associated with short-term benefits in growth. Most current fortifiers are derived from cow's milk, however there are concerns regarding a possible association between the use of cow's milk-based fortifier and NEC. There is also an exclusive human milk diet with a fortifier derived solely from human milk. There are three approaches for fortifying human milk and include fixed dosage or "blind fortification", adjustable fortification using the blood urea nitrogen as a surrogate for protein nutriture to modify dosage of fortification, and targeted, individualized fortification that is based on periodic human milk analysis.

Infant age at egg introduction and malnutrition‐related child growth in the United States

To evaluate the relationship between infant age of egg introduction and malnutrition‐related growth outcomes in the United States, we analysed secondary data of 1716 mother–child dyads in the Infant Feeding Practices Study II and its Year 6 Follow‐Up Study. Malnutrition‐related growth outcomes included body mass index z‐score (BMIZ), obesity (weight‐for‐height z‐score [WHZ] ≥3 or BMIZ ≥ 2), WHZ, wasting (WHZ < −2), height‐for‐age z‐score (HAZ), and stunting (HAZ < –2). Infant age at egg introduction was analysed as a continuous variable. We used generalised estimating equations to estimate the mean difference in continuous outcomes and relative risk [RR]) for binary outcomes, adjusting for related maternal and child confounders. We also explored interactions with child sex, maternal race/ethnicity, maternal educational level, ever breastfeeding, and formula feeding. In the total sample, a later infant age at egg introduction was associated with a lower mean difference in HAZ (confounder‐adjusted mean difference = −0.08, 95% confidence interval [CI]: −0.12 to −0.03 per month) and a higher risk of stunting (confounder‐adjusted RR = 1.17, 95% CI: 1.03–1.33 per month) at 6 years. The associations between infant age at egg introduction and 12‐month growth outcomes differed by child sex. Among females but not among males, later introduction of eggs was associated with a lower mean WHZ (−0.06 [−0.12 to 0.00] per month) at 12 months. Later egg introduction during infancy was associated with a lower mean HAZ and a higher risk of stunting in 6‐year‐old children. Besides this, it was associated with a lower WHZ among females at 12 months.

This secondary data analysis evaluated the relationship between infant age at egg introduction and malnutrition‐related growth outcomes among young US children within the Infant Feeding Practices Study II and its Year 6 Follow‐up Study.

In the total sample, a later infant age at egg introduction was associated with a lower mean 6‐year height‐for‐age z‐score and a higher risk of stunting at 6 years.

The associations between infant age at egg introduction and 12‐month growth outcomes differed by child sex. Later introduction of eggs was associated with a lower mean weight‐for‐height z‐score among females. However, this association was not observed among males.

Identifying the essential knowledge and skills for Neonatal-Perinatal Medicine: a systematic analysis of practice

The knowledge and skills expected for board certification in Neonatal-Perinatal Medicine (NPM) should reflect the clinical practice of neonatology. First, a 14-member panel of practicing neonatologists, convened by the American Board of Pediatrics (ABP), drafted a practice analysis document which identified the practice domains, tasks, knowledge, and skills deemed essential for clinical practice. NPM fellowship program directors provided feedback via online survey resulting in revisions to the document. During the second phase of the project, the panel organized testable knowledge areas into content domains and subdomains to update the existing ABP NPM content outline. All ABP board-certified neonatologists were asked to review via online survey, and results were used to guide final revisions to the content outline. The NPM practice analysis document and the updated NPM content outline should serve as helpful resources for educators, trainees, and practicing neonatologists.

Neuroprotective Role of Lactoferrin during Early Brain Development and Injury through Lifespan

Early adverse fetal environments can significantly disturb central nervous system (CNS) development and subsequently alter brain maturation. Nutritional status is a major variable to be considered during development and increasing evidence links neonate and preterm infant impaired brain growth with neurological and psychiatric diseases in adulthood. Breastfeeding is one of the main components required for healthy newborn development due to the many "constitutive" elements breastmilk contains. Maternal intake of specific nutrients during lactation may alter milk composition, thus affecting newborn nutrition and, potentially, brain development. Lactoferrin (Lf) is a major protein present in colostrum and the main protein in human milk, which plays an important role in the benefits of breastfeeding during postnatal development. It has been demonstrated that Lf has antimicrobial, as well as anti-inflammatory properties, and is potentially able to reduce the incidence of sepsis and necrotizing enterocolitis (NEC), which are particularly frequent in premature births. The anti-inflammatory effects of Lf can reduce birth-related pathologies by decreasing the release of pro-inflammatory factors and inhibiting premature cervix maturation (also related to commensal microbiome abnormalities) that could contribute to disrupting brain development. Pre-clinical evidence shows that Lf protects the developing brain from neuronal injury, enhances brain connectivity and neurotrophin production, and decreases inflammation in models of perinatal inflammatory challenge, intrauterine growth restriction (IUGR) and neonatal hypoxia-ischemia (HI). In this context, Lf can provide nutritional support for brain development and cognition and prevent the origin of neuropsychiatric diseases later in life. In this narrative review, we consider the role of certain nutrients during neurodevelopment linking to the latest research on lactoferrin with respect to neonatology. We also discuss new evidence indicating that early neuroprotective pathways modulated by Lf could prevent neurodegeneration through anti-inflammatory and immunomodulatory processes.

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

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.

Impact of Kangaroo Mother Care Intervention on Immunological and Pulmonary Functions of Preterm Infants during Breastfeeding

Objective

Preterm infants (PTIs) are prone to respiratory failure or other diseases due to immature organ development and poor immunological function. Herein, the effects of Kangaroo Mother Care (KMC) on the immunological and pulmonary functions of PTIs during breastfeeding were investigated in this study.

Methods

The study recruited 86 delivery women and their PTIs with preterm pregnancy outcomes, consisting of 46 cases receiving breastfeeding plus KMC intervention (KMC group) and 40 cases receiving breastfeeding plus routine care (control group). The time of first lactation, time of first breastfeeding, and duration of first breastfeeding were observed in both cohorts. The breastfeeding status was assessed using the LATCH system. Maternal psychological status was evaluated by the breastfeeding self-efficacy scale (BSES) and self-rating anxiety/depression scale (SAS/SDS). The growth and development of PTIs were recorded, and the levels of postalbumin (PA), transferrin (TRF), plasma albumin (ALB), immunoglobulin (Ig) A, IgG, IgM, and complement C3 and C4 were measured. The tidal volume (VT), tidal volume per kilogram (VT/kg), minute volume (MV), and minute volume per kilogram (MV/kg) were detected using a pulmonary function tester.

Results

The KMC group presented shorter time of first lactation and first breastfeeding than the control group, with longer duration of first breastfeeding (P < 0.05). After intervention, the BSES scores of delivery women were increased, while the SAS and SDS scores were decreased, with more notable improvements in the KMC group (P < 0.05). The levels of PA, TRF, ALB, IgA, IgG, VT, and MV were elevated in PTIs in both groups, with more evident increase in the KMC group than in the control group (P < 0.05). A better growth of PTIs was found in the KMC group than the control group (P < 0.05).

Conclusions

The study demonstrated that KMC intervention during breastfeeding could benefit PTIs specifically regarding their immunological and pulmonary functions.

Effects of a Formula with scGOS/lcFOS (9:1) and Glycomacropeptide (GMP) Supplementation on the Gut Microbiota of Very Preterm Infants

Microbial colonization of very preterm (VPT) infants is detrimentally affected by the complex interplay of physiological, dietary, medical, and environmental factors. The aim of this study was to evaluate the effects of an infant formula containing the specific prebiotic mixture of scGOS/lcFOS (9:1) and glycomacropeptide (GMP) on the composition and function of VPT infants’ gut microbiota. Metagenomic analysis was performed on the gut microbiota of VPT infants sampled at four time points: 24 h before the trial and 7, 14, and 28 days after the trial. Functional profiling was aggregated into gut and brain modules (GBMs) and gut metabolic modules (GMMs) based on the Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways. Enterococcus faecium, Escherichia coli, Klebsiella aerogenes, and Klebsiella pneumoniae were dominant species in both the test group and the control group. After the 4-week intervention, the abundance of Bifidobacterium in the test group was significantly increased. We found two GBMs (quinolinic acid synthesis and kynurenine degradation) and four GMMs (glutamine degradation, glyoxylate bypass, dissimilatory nitrate reduction, and preparatory phase of glycolysis) were significantly enriched in the test group, respectively. The results of this study suggested that formula enriched with scGOS/lcFOS (9:1) and GPM is beneficial to the intestinal microecology of VPT infants.

Development of the Gastrointestinal Tract in Newborns as a Challenge for an Appropriate Nutrition: A Narrative Review

The second and third trimesters of pregnancy are crucial for the anatomical and functional development of the gastrointestinal (GI) tract. If premature birth occurs, the immaturity of the digestive and absorptive processes and of GI motility represent a critical challenge to meet adequate nutritional needs, leading to poor extrauterine growth and to other critical complications. Knowledge of the main developmental stages of the processes involved in the digestion and absorption of proteins, carbohydrates, and lipids, as well as of the maturational phases underlying the development of GI motility, may aid clinicians to optimize the nutritional management of preterm infants. The immaturity of these GI systems and functions may negatively influence the patterns of gut colonization, predisposing to an abnormal microbiome. This, in turn, further contributes to alter the functional, immune, and neural development of the GI tract and, especially in preterm infants, has been associated with an increased risk of severe GI complications, such as necrotizing enterocolitis. Deeper understanding of the physiological colonization patterns in term and preterm infants may support the promotion of these patterns and the avoidance of microbial perturbations associated with the development of several diseases throughout life. This review aims to provide a global overview on the maturational features of the main GI functions and on their implications following preterm birth. We will particularly focus on the developmental differences in intestinal digestion and absorption functionality, motility, gut–brain axis interaction, and microbiomes.

Malnutrition and Pressure Injury Risk in Vulnerable Populations: Application of the 2019 International Clinical Practice Guideline

ABSTRACT

Nutrition plays a vital role in promoting skin integrity and supporting tissue repair in the presence of chronic wounds such as pressure injuries (PIs). Individuals who are malnourished are at greater risk of polymorbid conditions, adverse clinical outcomes, longer hospital lengths of stay, PI development, and mortality, and incur increased healthcare costs compared with patients who are adequately nourished. In addition, some patient populations tend to be more vulnerable to PI formation, such as neonates, patients with obesity, older adults, and individuals who are critically ill. Accordingly, this article aims to review the latest nutrition care recommendations for the prevention and treatment of PIs, including those recommendations tailored to special populations. A secondary objective is to translate nutrition recommendations into actionable steps for the healthcare professional to implement as part of a patient plan of care.Implementing an evidence-based plan of care built around individualized nutrition interventions is an essential step supporting skin integrity for these populations. The 2019 Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline (CPG) affirms that meeting nutrient requirements is essential for growth, development, maintenance, and repair of body tissues. Many macronutrients and micronutrients work synergistically to heal PIs. Registered dietitian nutritionists play an important role in helping patients identify the most nutrient dense foods, protein supplements, and oral nutrition supplements to meet their unique requirements.

Comparison of intergrowth-21st and Fenton curves for evaluation of premature newborns

Abstract Objectives: to compare the intrauterine and postnatal growth of preterm infants according to the Intergrowth-21st and Fenton curves. Methods: study carried out in a maternity hospital, reference in high-risk pregnancy, with preterm infants born in 2018 who were hospitalized in the neonatal units of the institution. Preterm newborns weighed at least twice after birth were included in the sample and those that were syndromic, malformed or presented fluid retention were excluded. Proportions and means were compared using Pearson’s chi-square and Student’s t tests for paired samples, respectively. The McNemar test was used to compare categorical variables and the Kappa test to verify the degree of agreement between birth weight classifications obtained by the curves. Results: one hundred and fifty three infants with a median gestational age of 34.4 weeks were included. The incidences of the categories of nutritional status at birth did not differ between the curves. There was perfect agreement between the curves, except when newborns born under 33 weeks of gestational age were evaluated, in which case the agreement was substantial. About 21% of the babies classified as small for gestational age (SGA) by Intergrowth-21st were adequate for gestational age (AGA) according to Fenton and, on average, 20% of cases that had postnatal growth restriction (PNGR) according to Fenton standards were categorized as adequate weight by Intergrowth-21st. Postnatal weight classifications obtained by the evaluated curves had perfect agreement. Conclusions: the differences in theclassifications found between the charts reveal the importance of choosing the growth curve for monitoring preterm infants since behaviors based on their diagnoses can impact the life of this population.

Gestational Age-Related Associations between Early-Life Feeding Trajectories and Growth Outcomes at Term Equivalent Age in Very Preterm Infants

Establishing the different feeding trajectories based on daily enteral feeding data in preterm infants at different gestational ages (GAs), may help to identify the risks and extrauterine growth restriction (EUGR) outcomes associated with the adverse feeding pattern. In a single center, we retrospectively included 625 infants born at 23-30 weeks of gestation who survived to term-equivalent age (TEA) from 2009 to 2020. The infants were designated into three GA groups: 23-26, 27-28, and 29-30 weeks. The daily enteral feeding amounts in the first 56 postnatal days were analyzed to determine the feeding trajectories. The primary outcomes were EUGR in body weight and head circumference calculated, respectively, by the changes between birth and TEA. Clustering analysis identified two feeding trajectories, namely the improving and adverse patterns in each GA group. The adverse feeding pattern that occurred in 49%, 20%, and 17% of GA 23-26, 27-28, and 29-30 weeks, respectively, was differentiated from the improving feeding pattern as early as day 7 in infants at GA 23-26 and 27-28 weeks, in contrast to day 21 in infants at GA 29-30 weeks. The adverse feeding patterns were associated with sepsis, respiratory, and gastrointestinal morbidities at GA 23-26 weeks; sepsis, hemodynamic and gastrointestinal morbidities at GA 27-28 weeks; and preeclampsia, respiratory, and gastrointestinal morbidities at GA 29-30 weeks. Using the improving feeding group as a reference, the adverse feeding group showed significantly higher adjusted odds ratios of EUGR in body weight and head circumference in infants at GA 23-26 and 27-28 weeks. Identifying the early-life adverse feeding trajectories may help recognize the related EUGR outcomes of preterm infants in a GA-related manner.

Evaluation of total, sn-2 fatty acid, and triacylglycerol composition in commercial infant formulas on the Chinese market: A comparative study of preterm and term formulas

Preterm infants with physiological immaturity require higher lipid provision than term infants. This study compared the lipid composition, including total, sn-2 fatty acid, and triacylglycerol (TAG) compositions in 14 preterm formulas and 25 term formulas in the Chinese market, in 2020-2021. Preterm formula had higher medium-chain fatty acid (MCFA) and comparable C22:6n-3 (DHA) contents than term formula. Notably, significantly lower C16:0 and C18:0 (p < 0.001) were distributed on the sn-2 position in preterm formula. Two hundred and thirteen kinds of TAG molecular species were identified using UPLC-Q-TOF-MS. In preterm formula, significantly higher Ca-Ca-Cy and Ca-Ca-Ca (p < 0.001) existed. These clear distinctions showed the challenge of the progress in preterm formula, such as DHA status, MCFA pattern, and TAG esterified with palmitic acid on the sn-2 position.

Effect of prophylactic use of hydrolyzed protein formula on gastrointestinal diseases and physical growth in preterm infants: a Meta analysis

OBJECTIVES

To systematically evaluate the effect of prophylactic use of hydrolyzed protein formula on gastrointestinal diseases and physical development in preterm infants.

METHODS

A computerized search was performed in the databases including China National Knowledge Infrastructure, Wanfang Data, Weipu, PubMed, Embase, and the Cochrane Library to identify randomized controlled trials of the effect of prophylactic use of hydrolyzed protein formula on gastrointestinal diseases and physical growth in preterm infants. RevMan 5.3 software was used to perform a Meta analysis for the included studies.

RESULTS

A total of 7 randomized controlled studies were included. The results of Meta analysis showed that compared with the whole protein formula, the prophylactic use of hydrolyzed protein formula could reduce the risk of neonatal necrotizing enterocolitis (RR=0.40, P=0.04) and feeding intolerance (RR=0.40, P=0.005), and had no significant effect on the growth of weight, length and head circumference (P>0.05).

CONCLUSIONS

Compared with the whole protein formula, the prophylactic use of hydrolyzed protein formula in preterm infants may reduce the occurrence of necrotizing enterocolitis and feeding intolerance, and can meet the nutrient requirement of physical development. However, the evidence is limited, and the results of this study cannot support the routine prophylactic use of hydrolyzed protein formula in preterm infants.

Cardiac hypertrophy and insulin therapy in a pre-term newborn: is there a relationship?

Background

Hypertrophic cardiomyopathy (HCM) in newborns is a rare condition with heterogeneous etiologies. While the relationship between hyperinsulinism and cardiac hypertrophy (CH) is known, hyperinsulinism has not been reported as cause of HCM.

Case presentation

We report the case of cardiac hypertrophy (CH) in an Extremely Low Birth Weight (ELBW) infant; this patient underwent insulin therapy after the onset of persistent hyperglycemia due to parenteral nutrition (PN), supporting the hypothesis of a role of iatrogenic hyperinsulinemia in the development of HCM.

Conclusions

The present case underlines the importance of a close cardiological follow-up in infants undergoing insulin infusion for an alteration in the glucose metabolism.

An Infant Formula with Large, Milk Phospholipid-Coated Lipid Droplets Supports Adequate Growth and Is Well-Tolerated in Healthy, Term Asian Infants: A Randomized, Controlled Double-Blind Clinical Trial

Lipids are essential for healthy infant growth and development. The structural complexity of lipids in human milk is not present in infant milk formula (IF). A concept IF was developed mimicking more closely the structure and composition of human milk fat globules. The current study evaluates whether a concept IF with large, milk phospholipid-coated lipid droplets (mode diameter 3 to 5 μm) is equivalent to standard IF with regard to growth adequacy and safety in healthy, term Asian infants. In this randomized, double-blind, controlled trial, infants were randomized after parents decided to introduce formula. Infants received a standard IF with (Control) or without the specific prebiotic mixture scGOS/lcFOS (9:1 ratio; Control w/o prebiotics), or a Concept IF with large, milk phospholipid-coated lipid droplets and the prebiotic mixture. A group of 67 breastfed infants served as a reference. As a priori defined, only those infants who were fully intervention formula-fed ≤28 days of age were included in the equivalence analysis (Control n = 29; Control w/o prebiotics n = 28; Concept n = 35, per-protocol population). Primary outcome was daily weight gain during the first four months of life, with the difference between the Concept and Control as the key comparison of interest. Additionally, adverse events, growth and tolerance parameters were evaluated. Equivalence of daily weight gain was demonstrated between the Concept and Control group after additional correction for ethnicity and birthweight (difference in estimated means of 0.1 g/d, 90%CI [-2.30, 2.47]; equivalence margin +/- 3 g/d). No clinically relevant group differences were observed in secondary growth outcomes, tolerance outcomes or number, severity or relatedness of adverse events. This study corroborates that an infant formula with large, milk phospholipid-coated lipid droplets supports adequate growth and is well tolerated and safe for use in healthy infants.

Nutritional Management of Moderate- and Late-Preterm Infants Commenced on Intravenous Fluids Pending Mother's Own Milk: Cohort Analysis From the DIAMOND Trial

BACKGROUND

Exclusive breastmilk is the desired enteral nutrition for babies born moderate- and late-preterm between 32⁺⁰ and 36⁺⁶ weeks' gestation; however, this goal is often difficult to achieve.

METHODS

A prospective cohort of babies 32⁺⁰ -35⁺⁶ weeks' gestation enrolled in the DIAMOND trial were randomized to a condition specifying that babies should receive mother's own milk (MOM) as the only enteral feed. Factors associated with the successful transition to MOM, defined as MOM being the sole enteral feeding at the time of the first cessation of intravenous (IV) fluids, were investigated by logistic regression. Time to commencement of a milk other than MOM was analyzed by Kaplan-Meier survival curves.

RESULTS

A total of 151 eligible babies (60% boys) were included, 93 (63%) of whom successfully transitioned from IV fluids onto MOM only. Alternative sources of milk, mostly formula, were used to transition from IV fluids onto enteral feeds more often in multiples and Māori, and was commenced earlier in Māori than other ethnicities (p = 0.007) and in late-preterm compared with moderate-preterm babies (p=0.01). Receiving exclusively breastmilk at discharge was more likely for babies who successfully transitioned from IV fluids onto MOM only [OR (95% confidence intervals) 4.9 (2.3-10.6)] and who received only MOM in the first week after birth [4.8 (2.2-10.4)], both p < 0.0001. Receiving breastmilk exclusively at discharge was less likely for Māori than Caucasian babies [0.2 (0.1-0.6), p < 0.0006]. There was no difference in the use of alternative sources of milk in babies who received parenteral nutrition or dextrose or between small-for-gestational-age and appropriate-for-gestational-age babies.

CONCLUSIONS

Despite an intention to provide only MOM, significant numbers of moderate- and late-preterm babies received formula to transition from IV fluids, and this differed by ethnicity. The drivers underlying these decisions require further investigation. These data highlight an urgent need for quality initiatives to support and encourage mothers of moderate- and late-preterm babies in their lactation.

A Role for Data Science in Precision Nutrition and Early Brain Development

Multimodal brain magnetic resonance imaging (MRI) can provide biomarkers of early influences on neurodevelopment such as nutrition, environmental and genetic factors. As the exposure to early influences can be separated from neurodevelopmental outcomes by many months or years, MRI markers can serve as an important intermediate outcome in multivariate analyses of neurodevelopmental determinants. Key to the success of such work are recent advances in data science as well as the growth of relevant data resources. Multimodal MRI assessment of neurodevelopment can be supplemented with other biomarkers of neurodevelopment such as electroencephalograms, magnetoencephalogram, and non-imaging biomarkers. This review focuses on how maternal nutrition impacts infant brain development, with three purposes: (1) to summarize the current knowledge about how nutrition in stages of pregnancy and breastfeeding impact infant brain development; (2) to discuss multimodal MRI and other measures of early neurodevelopment; and (3) to discuss potential opportunities for data science and artificial intelligence to advance precision nutrition. We hope this review can facilitate the collaborative march toward precision nutrition during pregnancy and the first year of life.

In vivo magnetic resonance imaging evidence of olfactory bulbs changes in a newborn with congenital Citomegalovirus: a case report

BACKGROUND

Citomegalovirus (CMV) infects approximately 1% of live newborns. About 10% of the infants affected by congenital CMV infection are symptomatic at birth and up to 60% of these infants will develop permanent neurological disabilities. Depending on gestational age (GA) at the time of infection, the involvement of central nervous system (CNS) can lead to malformations of cortical development, calcifications, periventricular white matter lesions and cysts, ventriculomegaly and cerebellar hypoplasia.

CASE PRESENTATION

We report the MRI findings in a Caucasian female born at 32 weeks of post-menstrual age with post-birth diagnosis of congenital CMV infection showing an unusual and peculiar marked T2 hyperintensity of the inner part of olfactory bulbs in addition to the CMV related diffuse brain involvement. Despite the known extensively described fetal and neonatal Magnetic Resonance Imaging (MRI) findings in CMV infected fetuses and newborns, any in vivo MRI depiction of olfactory system damage have never been reported so far. Nevertheless, in murine studies CMV is known to infect the placenta during pregnancy showing particular tropism for neural stem cells of the olfactory system and previous neuropathologic study on CMV infected human fetal brains from 23 to 28 weeks of GA reported damage in the olfactory bulbs (OB) consisting in disseminated cytomegalic cells, inflammation, necrosis and neuronal and radial glial cell loss. Therefore, we assume an OB involvement and damage in congenital CMV infection.

CONCLUSION

To our knowledge this is the first in vivo MRI evidence of OB damage in a newborn with congenital CMV infection that may give new insights on CMV infection.

Growth Rates of Infants Randomized to Continuous Positive Airway Pressure or Intubation After Extremely Preterm Birth

OBJECTIVE

To evaluate the effects of early treatment with continuous positive airway pressure (CPAP) on nutritional intake and in-hospital growth rates of extremely preterm (EPT) infants.

STUDY DESIGN

EPT infants (24^0/7-27^6/7 weeks of gestation) enrolled in the Surfactant Positive Airway Pressure and Pulse Oximetry Trial (SUPPORT) were included. EPT infants who died before 36 weeks of postmenstrual age (PMA) were excluded. The growth rates from birth to 36 weeks of PMA and follow-up outcomes at 18-22 months corrected age of EPT infants randomized at birth to either early CPAP (intervention group) or early intubation for surfactant administration (control group) were analyzed.

RESULTS

Growth data were analyzed for 810 of 1316 infants enrolled in SUPPORT (414 in the intervention group, 396 in the control group). The median gestational age was 26 weeks, and the mean birth weight was 839 g. Baseline characteristics, total nutritional intake, and in-hospital comorbidities were not significantly different between the 2 groups. In a regression model, growth rates between birth and 36 weeks of PMA, as well as growth rates during multiple intervals from birth to day 7, days 7-14, days 14-21, days 21-28, day 28 to 32 weeks PMA, and 32-36 weeks PMA did not differ between treatment groups. Independent of treatment group, higher growth rates from day 21 to day 28 were associated with a lower risk of having a Bayley-III cognitive score <85 at 18-22 months corrected age (P = .002).

CONCLUSIONS

EPT infants randomized to early CPAP did not have higher in-hospital growth rates than infants randomized to early intubation.

Human milk microbes: Strategies to improve delivery to the infant

Mother's own milk provides personalized nutrition and immune protection to the developing infant. The presence of healthy microbes plays an important role in the infant's gut by programming the microbiota and excluding potential pathogens. This review describes the important components in mother's own milk that contribute to its superiority for infant nutrition and suggest potential strategies to replicate these factors in alternative feedings when sufficient milk is unavailable. Current strategies to supplement, substitute and replicate mother's own milk including microbial restoration, use of unpasteurized donor human milk, probiotics and fortification are discussed. Critical work remains to be done in understanding the human milk microbiome and metabolome and in improving lactation support for mothers of preterm infants. Increasing delivery of mother's own milk and milk components to infants would likely positively impact infant mortality and health worldwide.

An innovative postnatal risk assessment and corresponding care pathways in Preventive Child Healthcare

Aims

This study aims to evaluate the effectiveness of an innovative postnatal risk assessment (the postnatal Rotterdam Reproductive Risk Reduction checklist: R4U) and corresponding care pathways in Preventive Child Healthcare (PCHC), along with PCHC professional satisfaction.

Design

Four PCHC organizations located in three municipalities with a higher adverse perinatal outcome than the national average were selected for participation. The study concerns a historically controlled study design.

Methods

The study enrolled participants from September 2016 until December 2017. The historical cohort existed of children born in previous years from 2008 until 2016. The outcome measure was defined as catch‐up growth: more than 0.67 standard deviation score weight for height increase in the first 6 months of life. PCHC professional opinion was assessed with a digital survey.

Results

After the inclusion period, 1,953 children were included in the intervention cohort and 7,436 children in the historical cohort. Catch‐up growth was significantly less common in the intervention cohort; 14.9% versus 19.5% in the historical cohort (p < 0.001). A regression sensitivity analysis, using matching, showed an odds ratio of 0.957 (95% CI 0.938–0.976) for the intervention cohort. In the survey, 74 PCHC physicians and nurses participated; most of them were neutral concerning the benefits of the postnatal R4U.

Conclusion

This study shows that the implementation of a novel postnatal risk assessment including in PCHC is feasible and effective. Final efforts to ensure a widespread implementation should be taken.

Impact

PCHC offers a unique opportunity to recognize and address risk factors for growth and development in children and to implement care pathways. Effective and widely implemented risk assessments in antenatal and PCHC are scarce. To our knowledge, this kind of evidence‐based postnatal risk assessment has not been implemented in PCHC before and seizes the opportunity to prevent catch‐up growth and its long‐term effects.

Nutrition Considerations in Neonatal Extracorporeal Life Support

Extracorporeal life support (ECLS) is a life-saving therapy, but neonates who require ECLS have unique nutritional needs and require aggressive, early nutritional support. These critically ill neonates are at increased risk for long-term feeding difficulties, malnutrition, and growth failure with associated increased morbidity and mortality. Unfortunately, few studies specific to this population exist. Clinical guidelines published by the American Society for Parenteral and Enteral Nutrition are specific to this population and available to aid clinicians in appropriate nutrition regimens, but studies to date suggest that nutrition provision varies greatly from center to center and often is inadequate. Though enteral feedings are becoming more common, aggressive parenteral nutrition is still needed to ensure nutrition goals are met, including the goal of increased protein provision. Long-term complications, including the need for tube feedings and growth failure, are common in neonatal ECLS survivors, particularly those with congenital diaphragmatic hernia. Oral aversion with poor feeding and growth failure must be anticipated and recognized early if present. The nutritional implications associated with the development of acute kidney injury, fluid overload, or the use of continuous renal replacement therapy must be recognized. In this state-of-the-art review, we examine aspects of nutrition for neonates receiving ECLS including nutritional requirements, nutrition provision, current practices, long-term outcomes, and special population considerations.

Human Milk Concentrations of Minerals, Essential and Toxic Trace Elements and Association with Selective Medical, Social, Demographic and Environmental Factors

This study aims to quantify concentrations of minerals and trace elements in human milk (HM) and infant formula (IF) and evaluate associations with medical, social, environmental, and demographic variables. A prospective, case series study of 170 nursing mothers was made. HM samples were obtained from full-term (colostrum, intermediate and mature HM) and preterm (mature HM) mothers. Variables of interest were assessed by a questionnaire. For comparison, IF samples (n = 30) were analyzed in a cross-sectional study. Concentrations of 35 minerals, essential and toxic trace elements were quantified, 5 for the first time: thallium in HM and IF; strontium in preterm HM; and gallium, lithium and uranium in IF. In preterm and full-term HM, levels of selenium (p < 0.001) were significantly lower than recommended and were associated with low birth weight (p < 0.002). Cesium and strontium concentrations were significantly higher than recommended (p < 0.001). Associations were observed between arsenic and residence in an urban area (p = 0.013), and between lead and smoking (p = 0.024) and well-water consumption (p = 0.046). In IF, aluminum, vanadium, and uranium levels were higher than in HM (p < 0.001); uranium, quantified for the first time, was 100 times higher in all types of IF than in HM. Our results indicate that concentrations of most trace elements were within internationally accepted ranges for HM and IF. However, preterm infants are at increased risk of nutritional deficiencies and toxicity. IF manufacturers should reduce the content of toxic trace elements.

Chinese Breast Milk Fat Composition and Its Associated Dietary Factors: A Pilot Study on Lactating Mothers in Beijing

Regional differences were found in breast milk composition. This study intended to profile the composition of fatty acid (FA) and triacylglycerol (TAG) in Chinese breast milk and to explore its association with maternal diet. Breast milk samples and data of 52 lactating women at 60–90 days postpartum were collected. The FA composition was measured using gas chromatography–flame ionization detection (GC-FID), and the TAG profile was detected by an ultra-performance liquid chromatography system, coupled with accurate-mass quadrupole time-of-flight mass spectrometer. A semi-quantitative food intake frequency questionnaire and a one-time 24-h dietary recall were used to evaluate the previous month's and the short-term dietary intake, including dietary patterns, food groups, and nutrients. Oleic–palmitic–linoleic (OPL) is the most predominant TAG within the Chinese human milk, followed by oleic–palmitic–oleic (OPO), with an average OPL-to-OPO ratio of 1.35. Linoleic acid (LA) and oleic acid (OA) accounted for 23.9 and 32.0% of the total FAs, respectively. Among the food groups consumed during the preceding month, LA content was positively associated with the consumption of soybeans and soybean products (r = 0.311, p = 0.030), whereas a negative correlation was identified with seafood consumption (r = −0.302, p = 0.030). Negative correlations were found between the OA content and the consumption of soybeans and soybean products (r = −0.363, p = 0.009), livestock and poultry meat (r = −0.375, p = 0.006), nuts (r = −0.305, p = 0.028), as well as cooking oil (r = −0.445, p = 0.001). No significant associations were identified between the LA and OA contents and the dietary patterns. This study confirmed a high OPL level in Chinese breast milk and revealed associations of FAs with maternal dietary intake.

In-hospital Growth of Very Low Birth Weight Preterm Infants: Comparative Effectiveness of 2 Human Milk Fortifiers

OBJECTIVE

Amidst a high prevalence of prematurity, limited research on the growth of very low birth weight (VLBW) preterm infants and the availability of a reformulated fortifier c(RF), the study aimed to compare in-hospital growth of such infants receiving exclusively human milk fortified with either of 2 different formulations in a tertiary South African hospital.

METHODS

In a prospective comparative effectiveness design, intakes and growth of VLBW infants on the Original Fortifier (OF; 2016-2017) were compared with those receiving RF (2017-2018). Daily intake was calculated using published composition of preterm and mature milk with fortifier (OF: 0.2 g protein, 3.5kcal/g powder; RF: 0.4 g protein, 4.4 kcal/g powder). Change in z scores from start to end of fortification for weight (WFAZ), length (LFAZ), and head circumference (HCFAZ) for age was the primary outcome. Additionally, weight gain velocity (g · kg-1 · day-1) and gain in length and head circumference (HC) (cm/week) were calculated.

RESULTS

Fifty-eight infants (52% girls; gestational age: 30 ± 2 weeks; birth weight: 1215 ± 187 g) received OF for 16 days and 59 infants (56% girls; gestational age: 29 ± 2 weeks; birth weight 1202 ± 167 g) received RF for 15 days. Protein intake of RF (3.7 ± 0.4 g · kg-1 · day-1) was significantly higher (P < 0.001) than of OF (3.4 ± 0.2 g · kg-1 · day-1). Protein-to-energy ratio of RF (2.6 ± 0.2 g/100 kcal) was significantly higher (P < 0.001) than of OF (2.3 ± 0.1 g/100 kcal). In both groups, WFAZ and LFAZ decreased; HCFAZ improved slightly. No significant differences (P > 0.05) were noted between the 2 groups for change in z scores, weight gain velocity, length or HC gain.

CONCLUSIONS

Despite a modest increase in protein intake and protein-to-energy ratio, the growth of VLBW infants on RF was not better than on OF during their hospital stay.