Length and weight of very low birth weight infants in Germany at 2 years of age: does it matter at what age they start complementary food?

Introduction of Solid Foods in Preterm Infants and Its Impact on Growth in the First Year of Life-A Prospective Observational Study

The aim of this study was to investigate whether age at introduction of solid foods in preterm infants influences growth in the first year of life. This was a prospective observational study in very low birth weight infants stratified to an early (<17 weeks corrected age) or a late (≥17 weeks corrected age) feeding group according to the individual timing of weaning. In total, 115 infants were assigned to the early group, and 82 were assigned to the late group. Mean birth weight and gestational age were comparable between groups (early: 926 g, 26 + 6 weeks; late: 881 g, 26 + 5 weeks). Mean age at weaning was 13.2 weeks corrected age in the early group and 20.4 weeks corrected age in the late group. At 12 months corrected age, anthropometric parameters showed no significant differences between groups (early vs. late, mean length 75.0 vs. 74.1 cm, weight 9.2 vs. 8.9 kg, head circumference 45.5 vs. 45.0 cm). A machine learning model showed no effect of age at weaning on length and length z-scores at 12 months corrected age. Infants with comorbidities had significantly lower anthropometric z-scores compared to infants without comorbidities. Therefore, regardless of growth considerations, we recommend weaning preterm infants according to their neurological abilities.

Early Extra-Uterine Growth Restriction in Very-Low-Birth-Weight Neonates with Normal or Mildly Abnormal Brain MRI: Effects on a 2-3-Year Neurodevelopmental Outcome

Extra-uterine growth restriction (EUGR) is a common complication and a known risk factor for impaired development in very-low-birth-weight (VLBW) neonates. We report a population of 288 patients with no or with low-grade MRI lesions scanned at a term equivalent age (TEA) born between 2012 and 2018. Griffiths Mental Development Scale II (GMDS II) at 2 and 3 years, preterm complications and weight growth were retrospectively analyzed. EUGR was defined for weight z-score ˂ 10 percentile at TEA, 6 and 12 months of correct age or as z-score decreased by 1-point standard deviation (SDS) from birth to TEA and from TEA to 6 months. Multivariate analysis showed that a higher weight z-score at 6 months is protective for the global developmental quotient (DQ) at 2 years (OR 0.74; CI 95% 0.59-0.93; p = 0.01). EUGR at 6 months was associated with worse locomotor, personal/social, language and performance DQ at 2 years and worse language and practical reasoning DQ at 3 years. In conclusion, a worse weight z-score at 6 months of age seems to be an independent risk factor for significantly reduced GMDS in many areas. These results suggest that we should invest more into post-discharge nutrition, optimizing family nutritional education.

Development of a nutritional risk screening tool for preterm children in outpatient settings during a complementary feeding period: a pilot study

BACKGROUND

A complementary feeding (CF) period is necessary for nutritional and developmental reasons. Preterm children encounter more feeding problems than their term counterparts in the CF period. The goal of this study was to develop a nutritional risk screening tool specific to preterm children (the NRSP) in outpatient settings in the CF period, with the expectation of providing a standardised process to determine feeding problems and subsequently offering targeted nutritional advice.

METHODS

This study was a 2-phase study consisting of the development and evaluation phases. In the development phase, the items of the NRSP were initially developed based on references and the Delphi expert consultation method. Second, 329 preterm individuals with corrected ages from 5 to 36 months were enrolled. The participating preterm children were interviewed with the NRSP and anthropometric measurements, and underwent intellectual developmental tests and biochemistry detection (haemoglobin, red blood cell count, mean corpuscular volume, mean corpuscular haemoglobin, mean corpuscular haemoglobin concentration, serum iron, vitamin D). Third, preterm children's anthropometric parameters were remeasured 1 month (for infants whose corrected age was 5-11 months) or 3 months (for children whose corrected age was 12-36 months) after the interview. Data in the development phase were analysed via univariate and binary logistic regression analysis sequentially to assign scores for items of the NRSP and to generate the models to predict underweight, stunting, and microcephaly of the NRSP. In the evaluation phase, another 605 preterm individuals were recruited to undergo the interview, anthropometric measurements, intellectual developmental tests, and biochemistry detection as in the development phase. Interrater reliability, test-retest reliability, area under the curve (AUC), accuracy, sensitivity, specificity, the positive/negative predictive value (P/NPV), the positive/negative likelihood ratio (LR+/-), and the correlation coefficient by Spearman's correlation analysis (r_s) were used to assess the reliability and validity of the NRSP. Finally, anthropometric parameters, biochemistry levels, and intellectual development quotients (DQs) from the development and evaluation phases between the high- and low-risk groups classified by the NRSP were compared using a t-test.

RESULTS

The κ coefficients of the interrater and test-retest reliability of the NRSP were all above 0.600, which meant that the reliability of the NRSP was moderate to substantial. The NRSP exhibited relatively higher efficiency in predicting underweight and stunting, with AUCs, accuracies, specificities, and NPVs near to or greater than 0.900, sensitivities above 0.600, PPVs above 0.400, LR + s near to or greater than 10, and r_ss above 0.400. On the other hand, the NRSP manifested a weaker ability in predicting microcephaly, with most of the values of validity indicators lower than those of underweight and stunting prediction. Z scores of body weight, body length and head circumference, as well as DQs, were all higher in the low-risk groups than in the high-risk groups. There were no significant differences with respect to biochemistry levels between the high- and low-risk groups.

CONCLUSION

The NRSP shows moderate to substantial reliability and validity in predicting underweight, stunting, and microcephaly. Health care staff should shed light on improving the feeding practices of preterm children with high nutritional risk classified by the NRSP to facilitate their physical growth and intellectual development. More research is expected to promote the NRSP models.

Complementary feeding in preterm infants: a position paper by Italian neonatal, paediatric and paediatric gastroenterology joint societies

Nutrition in the first 1000 days of life is essential to ensure appropriate growth rates, prevent adverse short- and long-term outcomes, and allow physiologic neurocognitive development. Appropriate management of early nutritional needs is particularly crucial for preterm infants. Although the impact of early nutrition on health outcomes in preterm infants is well established, evidence-based recommendations on complementary feeding for preterm neonates and especially extremely low birth weight and extremely low gestational age neonates are still lacking. In the present position paper we performed a narrative review to summarize current evidence regarding complementary feeding in preterm neonates and draw recommendation shared by joint societies (SIP, SIN and SIGENP) for paediatricians, healthcare providers and families with the final aim to reduce the variability of attitude and timing among professionals.

Duration of Exclusive Breastfeeding for Preterm or Low Birth Weight Infants: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVES

Cessation of exclusive breastfeeding (EBF) with early introduction of complementary food provides additional calories for catch-up growth but may also increase the risk of adverse outcomes. The objective of this study was to assess effects of exclusive breastfeeding for less than 6 months compared with 6 months in preterm and low birth weight infants.

METHODS

Data sources include Medline, Scopus, Web of Science, CINAHL, and Index Medicus through June 30, 2021. Study selection includes randomized trials and observational studies. Primary outcomes were mortality, morbidity, growth, and neurodevelopment. Data were extracted and pooled using random-effects models. The Cochrane Risk of Bias 2 tool was used to assess the risk of bias of included studies.

RESULTS

A total of 2 studies of 307 preterm or low birth weight infants were included. None of the study results could be pooled. Both studies compared EBF for 4 months to 6 months. Growth was similar between the 4-month and 6-month EBF groups for the following outcomes: weight-for-age z-score at corrected age 12 months (mean [standard deviation], 4-month group: -1.7 [1.1], 6-month group: -1.8 [1.2], 1 study, 188 participants, low certainty evidence), absolute weight gain (gram) from 16 to 26 weeks of age (4-month group: 1004 [366], 6-month group: 1017 [350], 1 study, 119 participants, very low certainty evidence), and linear growth gain (cm) from 16 to 26 weeks of age (4-month group: 4.3 [0.9], 6-month group: 4.5 [1.2], 1 study, 119 participants, very low certainty evidence). There were no apparent differences in reported morbidity symptoms. No difference in the timing to achieve motor development milestones between the 2 groups was found (1 study; 119 participants, very low certainty evidence). A limited number of studies prevented data pooling.

CONCLUSIONS

The evidence is very uncertain about the effect of exclusive breastfeeding for less than 6 months for preterm and low birth weight infants. Further studies are warranted to better answer this question.

Factors Affecting Complementary Feeding of Infants. A Pilot Study Conducted after the Introduction of New Infant Feeding Guidelines in Poland

Adequate nutrition in the first year of life is the key prerequisite for a child’s healthy growth and development. The success of complementary feeding is influenced by various factors, including the family’s socioeconomic status, maternal age, place of residence and educational level, older children and duration of breastfeeding. Modified infant feeding guidelines were introduced in Poland in 2016. The aim of this study was to identify the factors that exert the greatest influence on infant feeding practices in the Polish population. A thorough understanding of maternal factors that are responsible for undesirable feeding practices is required to improve the mothers’ knowledge and to promote healthy feeding practices. This study was carried out in March–June 2018 and between November 2018 and March 2019 in the Region of Lublin in southeastern Poland. The mothers of children aged 9–14 months, who had introduced complementary foods, were invited to the study. A total of 441 mothers agreed to participate, and 289 of them fully and correctly completed the questionnaires. Logistic regression models were developed to assess the association between maternal factors, such as age, educational level and the nutrition knowledge score, and introduction of solid foods. The infant’s sex and birth weight and the mother’s place of residence had no significant influence on the duration of breastfeeding. The mother’s age and educational level, the number of children in the family and maternal nutrition knowledge scores contributed to significant differences in breastfeeding duration. Older mothers (30–34 years vs. 25–29 years, p = 0.001), better educated mothers (university vs. secondary school education p = 0.002) and mothers with one or two children exclusively breastfed their children for longer (17 weeks vs. 11 weeks, p = 0.002) than younger mothers with secondary school education and more than three children. Exclusive formula feeding was significantly correlated with untimely introduction of solid foods compared to exclusive breastfeeding (13 weeks vs. 19.7 weeks, p = 0.001). Mothers with nutrition knowledge scores in the upper tertile were more likely to adapt food consistency to the skills manifested by the child (88%) (OR = 1.88; Cl: 1.53–2.26, p < 0.05) and were less likely to delay the introduction of new foods that required chewing and biting (84%) (OR = 0.22; Cl: 0.09–0.34, p < 0.05) than mothers with nutrition knowledge scores in the bottom tertile. Maternal age, educational level and nutrition knowledge significantly increased the age at which infants were introduced to solid foods and the correct identification of the signs indicative of the child’s readiness to explore new tastes and foods with a new consistency. The above factors contributed to delayed, but not untimely, introduction of complementary foods (6 months of age or later), including gluten.

Preterm's Nutrition from Hospital to Solid Foods: Are We Still Navigating by Sight?

As preterm birth rates are globally increasing, together with research on preterms’ peculiar needs, neonatologists are still facing the challenge of how to properly feed them. The need to strike a balance between excessive catch-up growth and extrauterine growth retardation, both leading to adverse outcomes, is made even more difficult by the broad range of preterms’ needs. Although mother’s fresh milk is undoubtedly the best nourishment, its availability during hospital stay is often lower than recommended, and its fortification at discharge is still an open issue. Formula milks are available as an alternative to breast milk. However, choosing the right formula requires a thorough evaluation of the infant’s perinatal history and targets. Last but not least, adequate timing and initiation of weaning in premature babies are still a poorly explored matter. This narrative review aims at evaluating the multitude of issues to consider when feeding preterms in the three stages of their first life: in-hospital care, discharge, and, eventually, weaning. Given the current absence of internationally shared guidelines, understanding the potential pitfalls of preterms’ nutrition could help us trace the right path for the right preterm.

Complementary Feeding in Preterm Infants: A Systematic Review

Background: This systematic review summarizes available literature regarding complementary feeding (CF) in preterm infants, with or without comorbidities that may interfere with oral functions. Methods: A literature search was conducted in PubMed and the Cochrane Library. Studies relating to preterm infants (gestational age <37 weeks) were included in the analysis. Retrieved papers were categorized according to their main topic: CF timing and quality; clinical outcome; recommendations; strategies in infants with oral dysfunction. Results: The literature search in PubMed retrieved 6295 papers. Forty met inclusion criteria. The Cochrane search identified four additional study protocols, two related to studies included among PubMed search results, and two ongoing trials. Moreover, among 112 papers dealing with oral feeding, four aiming at managing CF in preterm infants with oral dysfunctions were identified. Conclusions: The available literature does not provide specific guidelines on the management of CF in preterm infants, who are generally weaned earlier than term infants. There is a paucity of data regarding the relationship between CF and growth/quality of growth and health outcomes in preterm infants. It could be suggested to start CF between five and eight months of chronological age if infants have reached three months corrected age and if they have acquired the necessary developmental skills. An individualized multidisciplinary intervention is advisable for preterm infants with oral dysfunctions.

Quality of complementary feeding and its effect on nutritional status in preterm infants: a cross-sectional study

BACKGROUND

The first 2 years of life represent a critical phase for growth and development, with the quality of the diet at this stage having repercussions throughout adulthood. The present study aimed to develop an Index for Measuring the Quality of Complementary Feeding (IMQCF) for infants, as well as to evaluate diet quality and its effects on the nutritional status of preterm infants.

METHODS

This cross-sectional study was conducted at a Brazilian University Hospital. The data were extracted by care protocol of outpatient preterm infants at 2 years of corrected age (CA). Dietary data were collected from 24-h recalls. The diet quality was assessed by the IMQCF composed of nine items based on a Brazilian Food Guide for children aged <2 years. Response options were scored 0-100, with scores closer to 100 representing a better quality diet. Association with growth indicators (Z-scores for weight- and length-for-age (WAZ and LAZ) were evaluated via tests of mean difference and multiple linear regression.

RESULTS

The median complementary feeding (CF) score was 72.2 (61.1-77.8) A shorter breastfeeding duration or infant formula use and the early introduction of wheat-based foods, ultra-processed foods and cow's milk in the preterm's diet were the main factors interfering in the adequacy of diet. There was an association between the quality of the diet score and WAZ (0.44; 95% confidence interval = 0.03-0.85; P = 0.03).

CONCLUSIONS

The introduction of poor quality food in the first 2 years of life interfered with the CF quality of preterm infants and can affect nutritional status at 2 years of CA, possibly in the long term.

Current practice in the introduction of solid foods for preterm infants

OBJECTIVE

The present study compared the age of first solid foods in a cohort of preterm infants with term infants and identified factors influencing timing of solid food introduction.

DESIGN

Structured interviews on infant feeding practices, growth and medical status at term equivalence and at 3, 6, 9 and 12 months corrected postnatal age. The age of solid food introduction was compared between term and preterm infants, and the influence of maternal, infant and milk feeding factors was assessed.

SETTING

This prospective longitudinal study recruited primary carers of preterm and term infants from a regional metropolitan referral hospital in eastern Australia.

PARTICIPANTS

One hundred and fifty infants (preterm, n 85; term, n 65).

RESULTS

When corrected for prematurity, preterm infants received solid foods before the recommended age for the introduction of solid foods for term infants. Median introduction of solid foods for preterm infants was 14 weeks corrected age (range 12-17 weeks). This was significantly less than 19 weeks (range 17-21 weeks) for term infants (P < 0·001). Lower maternal education and male gender were associated with earlier introduction of solid foods among preterm infants.

CONCLUSIONS

Preterm infants are introduced to solid foods earlier than recommended for term infants, taking account of their corrected age. Further research is needed to assess any risk or benefit associated with this pattern and thus to develop clear evidence-based feeding guidelines for preterm infants.

Appropriate age range for introduction of complementary feeding into an infant's diet

Following a request from the European Commission, the Panel on Nutrition, Novel Foods and Food Allergens (NDA) revised its 2009 Opinion on the appropriate age for introduction of complementary feeding of infants. This age has been evaluated considering the effects on health outcomes, nutritional aspects and infant development, and depends on the individual's characteristics and development. As long as foods have an age-appropriate texture, are nutritionally appropriate and prepared following good hygiene practices, there is no convincing evidence that at any age investigated in the included studies (< 1 to < 6 months), the introduction of complementary foods (CFs) is associated with adverse health effects or benefits (except for infants at risk of iron depletion). For nutritional reasons, the majority of infants need CFs from around 6 months of age. Infants at risk of iron depletion (exclusively breastfed infants born to mothers with low iron status, or with early umbilical cord clamping (< 1 min after birth), or born preterm, or born small-for-gestational age or with high growth velocity) may benefit from earlier introduction of CFs that are a source of iron. The earliest developmental skills relevant for consuming pureed CFs can be observed between 3 and 4 months of age. Skills for consuming finger foods can be observed in some infants at 4 months, but more commonly at 5-7 months. The fact that an infant may be ready from a neurodevelopmental perspective to progress to a more diversified diet before 6 months of age does not imply that there is a need to introduce CFs. There is no reason to postpone the introduction of potentially allergenic foods (egg, cereals, fish and peanut) to a later age than that of other CFs as far as the risk of developing atopic diseases is concerned. Regarding the risk of coeliac disease, gluten can be introduced with other CFs.

Feeding Patterns and Parental Perceptions of Feeding Issues of Preterm Infants in the First 2 Years of Life

We explored parental feeding practices, feeding issues during the first 2 yr of life, and the relationship between feeding issues and levels of maternal distress in preterm infants. Four hundred twenty mothers (239 with preterm infants, 181 with full-term infants) participated in the study. The Behavior-Based Feeding Questionnaire for Infants With Premature History and the Parenting Stress Index-Chinese Version were used as the two outcome measures. The results indicated that preterm infants had different feeding experiences compared with their full-term counterparts. They tended to start solid food later in life and had limited experiences in food variation. Parenting stress was prevalent in parents with preterm infants and was associated with the frequency of feeding issues, especially at later ages when supplementary foods were being introduced.

Complementary Feeding Practices in a Cohort of Italian Late Preterm Infants

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

The Timing of Initiating Complementary Feeding in Preterm Infants and Its Effect on Overweight: A Systematic Review

BACKGROUND

What is the appropriate time to start complementary feeding for preterm infants? The answer to this question is yet under debate. The timing of initiating complementary feeding may be associated with overweight in term infants. This systematic review aimed to study the effect of the timing of initiating complementary feeding on overweight in preterm infants. Predefined search items included preterm infants, complementary feeding, overweight, and their synonyms.

SUMMARY

The search identified 15,749 articles, of which 5 articles were included. Three studies presented data of randomized controlled trials and 2 studies were cohort studies. Two randomized controlled trials found no significant difference in body mass index (BMI) Z-score between the intervention groups at 12 months of age. One randomized controlled trial presented a significant greater mean rate of growth in length per week until 12 months in the preterm weaning strategy-group compared with the current best practices. One observational study concluded that each month the infants received complementary food later, the Z-score for length and weight was reduced by 0.1. Key Messages: No clear conclusion could be drawn from the included studies. This review illustrates the need for further research to access the effect of the timing of initiating complementary feeding on overweight in preterm infants.