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Essex C, Hegedus C, Vincent K, Shiflett A, Rohrer A, Chetta KE. Maternal, neonatal, and nutritional risk factors for medical and surgical necrotizing enterocolitis. J Perinatol 2024:10.1038/s41372-024-02066-3. [PMID: 39030319 DOI: 10.1038/s41372-024-02066-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 07/09/2024] [Accepted: 07/15/2024] [Indexed: 07/21/2024]
Abstract
OBJECTIVE To identify maternal and neonatal risk factors associated with progression to surgery or death after diagnosis of NEC. STUDY DESIGN Forty-seven demographic and clinical factors were evaluated across 216 validated cases of NEC occurring between 2010-2020. Nutrition at NEC onset was evaluated in 149 cases. The binary outcome of surgical NEC (progressing to surgery or death) vs. medical NEC (resolved with antibiotic/bowel rest) was compared across variables. RESULTS Elevated CRP, rapidly decreasing platelet counts, inotropic medication, intubation, and positive blood cultures within 24 h of diagnosis were associated with progression to surgery/death. Infants with surgical NEC had higher abdominal circumferences at birth. Maternal milk intake and receipt of human milk fortifiers were associated with medical NEC, and infants receiving fortified, maternal milk showed the lowest progression to surgery/death. CONCLUSION The index of suspicion should be heightened for surgical NEC when these risk factors are present.
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Affiliation(s)
- Clare Essex
- Medical University of South Carolina, 96 Jonathan Lucas Street Suite 601, MSC 617, Charleston, SC, 29425, USA
| | - Clifford Hegedus
- C.P. Darby Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, 10 McClennan Banks Drive, MSC 915, Charleston, SC, 29425, USA
| | - Katherine Vincent
- C.P. Darby Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, 10 McClennan Banks Drive, MSC 915, Charleston, SC, 29425, USA
| | - Alanna Shiflett
- C.P. Darby Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, 10 McClennan Banks Drive, MSC 915, Charleston, SC, 29425, USA
| | - Allison Rohrer
- C.P. Darby Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, 10 McClennan Banks Drive, MSC 915, Charleston, SC, 29425, USA
| | - Katherine E Chetta
- C.P. Darby Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, 10 McClennan Banks Drive, MSC 915, Charleston, SC, 29425, USA.
- C.P. Darby Children's Research Institute, Medical University of South Carolina, Shawn Jenkins Children's Hospital, 171 Ashley Avenue, Charleston, SC, 29425, USA.
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Agostoni C, Giannì ML. Supplementing human milk for preterm infants: a nutritional challenge? Pediatr Res 2024; 95:1404-1405. [PMID: 38253878 DOI: 10.1038/s41390-024-03030-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024]
Affiliation(s)
- Carlo Agostoni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Pediatric Unit, Milan, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
| | - Maria L Giannì
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy
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Res G, Bishara RF, Church PT, Rosenthal R, Bishara RM, Dupuis A, Asztalos E, Banihani R. Growth and Neurodevelopmental Outcomes of Preterm Infants Born < 26 Weeks Gestation before and after Implementation of a Nutrition-Care Bundle. CHILDREN (BASEL, SWITZERLAND) 2024; 11:475. [PMID: 38671692 PMCID: PMC11049117 DOI: 10.3390/children11040475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND This study aimed to assess the impact of a nutrition-care bundle on growth and neurodevelopmental outcomes of micro-preterm infants born in a level III neonatal intensive care unit (NICU) by two years corrected age. METHODS A nutrition-care bundle emphasizing the prompt initiation of parenteral nutrition at birth, initiation of enteral feeds within 6 h after birth, and early addition of human milk fortifiers was implemented in 2015 for infants born < 26 weeks gestation. This before-and-after study evaluated growth and neurodevelopmental outcomes in infants born between 2012-2013 (before-nutrition-bundle, BNB) and 2016-2017 (after-nutrition-bundle, ANB). RESULTS A total of 145 infants were included in the study. Infants in the ANB group (n = 73) were smaller (birthweight and gestational age), and there were more male infants and multiples included compared to the BNB group (n = 72). Enteral feeds and fortifiers started earlier in the ANB group. Growth velocity and weight z-score changes were similar in both groups during NICU stay and post-discharge. Systemic steroid use, but not cohort, was linked to lower Bayley scores across all domains. CONCLUSIONS Implementing a nutrition-care bundle was not consistently associated with improved weight gain and neurodevelopmental outcomes in the micro-preterm infant population, possibly due to ongoing high-quality nutritional care by the clinical team.
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Affiliation(s)
- Giulia Res
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada; (G.R.); (R.F.B.); (R.R.); (R.M.B.); (E.A.)
- Department of Paediatrics, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Rosine F. Bishara
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada; (G.R.); (R.F.B.); (R.R.); (R.M.B.); (E.A.)
| | - Paige Terrien Church
- Department of Pediatrics, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA;
- Department of Neonatology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Rena Rosenthal
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada; (G.R.); (R.F.B.); (R.R.); (R.M.B.); (E.A.)
| | - Rita Maria Bishara
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada; (G.R.); (R.F.B.); (R.R.); (R.M.B.); (E.A.)
| | - Annie Dupuis
- Biostatistics Division, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON M5T 3M7, Canada;
| | - Elizabeth Asztalos
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada; (G.R.); (R.F.B.); (R.R.); (R.M.B.); (E.A.)
- Department of Paediatrics, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Rudaina Banihani
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada; (G.R.); (R.F.B.); (R.R.); (R.M.B.); (E.A.)
- Department of Paediatrics, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada
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Pineda D, Bingham R, Gates A, Thompson AB, Stansfield BK. Osmolality of fortified donor human milk: An experimental study. JPEN J Parenter Enteral Nutr 2024; 48:57-63. [PMID: 37608726 DOI: 10.1002/jpen.2558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND We quantify the osmolality of human milk fortified with human milk fortifiers (HMFs), powder infant formulas and protein additives. METHODS Commercial liquid HMFs and powder infant formulas were added to pasteurized pooled donor human milk in triplicate and stirred. The osmolality of unfortified and fortified human milk at 22, 24, 26, 27, 28, and 30 kcal/oz (0.73, 0.8, 0.87, 0.9, 0.93, and 1 kcal/ml, respectively) was determined using freezing-point depression. RESULTS The osmolality of fortified human milk associated with energy density in a linear relationship regardless of the fortification strategies. Multiple liquid HMFs and every powder infant formula exceeded the osmolality threshold of 450 mOsm/kg H2 O within the energy densities tested. CONCLUSION The osmolality of fortified human milk is highly variable and should be considered when selecting a fortifying agent for human milk.
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Affiliation(s)
- Daphne Pineda
- Department of Pediatrics, Children's Hospital of Georgia, Division of Neonatology, Augusta, Georgia, USA
| | - Rhyan Bingham
- Department of Pediatrics, Children's Hospital of Georgia, Division of Neonatology, Augusta, Georgia, USA
| | - Amy Gates
- Department of Pediatrics, Children's Hospital of Georgia, Division of Neonatology, Augusta, Georgia, USA
| | - Amy B Thompson
- Department of Pediatrics, Children's Hospital of Georgia, Division of Neonatology, Augusta, Georgia, USA
| | - Brian K Stansfield
- Department of Pediatrics, Children's Hospital of Georgia, Division of Neonatology, Augusta, Georgia, USA
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Bingham R, Pineda D, Gates A, Thompson AB, Stansfield BK. Displacement of human milk during fortification: An experimental study. JPEN J Parenter Enteral Nutr 2023; 47:1062-1066. [PMID: 37488685 DOI: 10.1002/jpen.2553] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 07/18/2023] [Accepted: 07/24/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND This study quantified the displacement of human milk by commercial human milk fortifiers (HMFs) and infant formulas. METHODS Commercial liquid HMFs and powder infant formulas were added to pasteurized pooled donor human milk in triplicate, stirred, and weighed. The difference in weight between unfortified and fortified human milk at 22, 24, 26, 27, 28, and 30 kcal/ounce was calculated. RESULTS The displacement of human milk by liquid HMFs and powder infant formulas and powder HMF was highly associated with energy density. A human milk-derived HMF displaced significantly more human milk when compared with bovine milk-derived HMFs at equivalent energy densities. Similarly, powder infant formulas displaced less human milk when compared with a powder HMF, and the addition of hydrolyzed powder infant formulas resulted in less human milk displacement when compared with nonhydrolyzed powder infant formulas. CONCLUSIONS The displacement of human milk by commercial liquid HMFs and infant formulas must be considered when selecting a fortifying strategy.
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Affiliation(s)
- Rhyan Bingham
- Department of Pediatrics, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Daphne Pineda
- Department of Pediatrics, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Amy Gates
- Department of Pediatrics, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Amy B Thompson
- Department of Pediatrics, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Brian K Stansfield
- Department of Pediatrics, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
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Rodríguez-Suárez J, Solís-Sánchez G, Riaño-Galán I. Neonatal Growth, Nutrition, and Neurodevelopment: A Complex Relationship. Nutrients 2023; 15:4634. [PMID: 37960285 PMCID: PMC10649361 DOI: 10.3390/nu15214634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023] Open
Abstract
Growth in the neonatal period is critical for the neurodevelopment of the individual, both in low- and middle-income countries [...].
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Affiliation(s)
| | - Gonzalo Solís-Sánchez
- AGC Pediatría, Hospital Universitario Central de Asturias, Instituto Investigación Sanitaria Principado de Asturias (ISPA), Universidad de Oviedo, 33011 Oviedo, Spain; (J.R.-S.); (I.R.-G.)
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Assad M, Jerome M, Olyaei A, Nizich S, Hedges M, Gosselin K, Scottoline B. Dilemmas in establishing preterm enteral feeding: where do we start and how fast do we go? J Perinatol 2023; 43:1194-1199. [PMID: 37169912 DOI: 10.1038/s41372-023-01665-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 03/06/2023] [Accepted: 03/23/2023] [Indexed: 05/13/2023]
Abstract
Beginning and achieving full enteral nutrition is a key step in the care of preterm infants, particularly very low birth weight (VLBW) infants. As is true for many organ system-specific complications of prematurity, the gastrointestinal tract must complete in utero development ex utero while concurrently serving a physiologic role reserved for after completion of full term development. The preterm gut must assume the placental function of the interface between a source of energy, precursors for anabolism, and micronutrients, and the developing infant-through digestion and absorption of milk, instead of directly from the mother via the uteroplacental interface. The benefits of enteral nourishment in preterm infants are counterbalanced by gastrointestinal complications of prematurity: dysmotility leading to difficulty establishing and advancing feeds, and the risk of necrotizing enterocolitis (NEC). Concern for these complications can prolong the need for parenteral nutrition with an associated increase in risk for central line-associated bloodstream infection (CLABSI) and parenteral nutrition (PN)-associated cholestasis or liver disease (PNALD). Thus, a daily issue facing neonatologists caring for preterm infants is how to optimally begin, advance, and reach full enteral nutrition sufficient to satisfy the nutrient, energy, and fluid requirements of VLBW infants while minimizing risk. In this perspective, we provide an overview of the approaches and supporting data for starting and advancing enteral feeds in preterm infants, particularly very low birth weight infants, and we discuss the significant gaps in knowledge that accompany current approaches. This framework recognizes the dilemmas of preterm feeding initiation and advancement and identifies areas of opportunity for further investigation.
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Affiliation(s)
- Maushumi Assad
- Division of Neonatology, Department of Pediatrics, University of Massachusetts T.H.Chan School of Medicine, Worcester, MA, 01655, USA
| | - Maggie Jerome
- Graduate Programs in Human Nutrition, Oregon Health & Sciences University, Portland, OR, 97239, USA
| | - Amy Olyaei
- Division of Neonatology, Department of Pediatrics, Oregon Health & Sciences University, Portland, OR, 97239, USA
| | - Samantha Nizich
- Division of Neonatology, Department of Pediatrics, Oregon Health & Sciences University, Portland, OR, 97239, USA
| | - Madeline Hedges
- Division of Neonatology, Department of Pediatrics, Oregon Health & Sciences University, Portland, OR, 97239, USA
| | - Kerri Gosselin
- Division of Neonatology, Department of Pediatrics, University of Massachusetts T.H.Chan School of Medicine, Worcester, MA, 01655, USA
| | - Brian Scottoline
- Division of Neonatology, Department of Pediatrics, Oregon Health & Sciences University, Portland, OR, 97239, USA.
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