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Mo I, Lapillonne A, van den Akker CHP, Khashu M, Johnson MJ, McElroy SJ, Zachariassen G. Nutritional management after necrotizing enterocolitis and focal intestinal perforation in preterm infants. Pediatr Res 2024:10.1038/s41390-024-03386-y. [PMID: 38992154 DOI: 10.1038/s41390-024-03386-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 06/04/2024] [Accepted: 06/16/2024] [Indexed: 07/13/2024]
Abstract
Nutritional management of preterm infants recovering from necrotizing enterocolitis (NEC) or focal intestinal perforation (FIP) is challenging, especially in infants managed surgically. The logistics of how, when, and what to feed are unclear and current nutritional practices are primarily based on physiological principles and consensus opinion in individual units, rather than high-quality evidence. The aim of this narrative review is to summarize the literature on nutritional management after NEC or FIP in preterm infants: when to restart enteral nutrition, type of enteral nutrition to use, and how to advance nutrition. We also discuss treatment of micronutrient deficiencies, cholestasis, replacement of stoma losses, and optimal time of stoma closure. In conclusion, there are in sufficient high-quality studies available to provide evidence-based recommendations on the best nutritional practice after NEC or FIP in preterm infants. A local or national consensus based early nutrition guideline agreed upon by a multidisciplinary team including pediatric surgeons, pediatricians/neonatologists, nurses, and nutritionists is recommended. Further studies are urgently needed. IMPACT: There is no good quality evidence or nutritional standard across neonatal units treating infants after medical or surgical NEC or FIP. With this review we hope to start providing some consistency across patients and between providers treating patients with NEC and FIP. Mother's own milk is recommended when restarting enteral nutrition after NEC or FIP. In the absence of high-quality evidence, a consensus based early nutrition guideline agreed upon by a multidisciplinary team is recommended. Nutritional research projects are urgently needed in NEC and FIP patients.
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Affiliation(s)
- Ingrid Mo
- Department of Clinical Research, University of Southern Denmark, 5000, Odense, Denmark
| | - Alexandre Lapillonne
- Department of Neonatology, Necker-Enfants Malades Hospital, EHU 7328 PACT, University of Paris Cite, Paris, France
- CNRC Baylor College of Medicine, Houston, Texas, USA
| | - C H P van den Akker
- Department of Pediatrics-Neonatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - Minesh Khashu
- Department of Neonatology, University Hospitals Dorset NHS Foundation Trust, Dorset, United Kingdom
| | - Mark J Johnson
- Department of Neonatal Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | - Steven J McElroy
- Department of Pediatrics, Division of Neonatology, University of California Davis, Sacramento, CA, USA
| | - Gitte Zachariassen
- Department of Clinical Research, University of Southern Denmark, 5000, Odense, Denmark.
- Hans Christian Andersen Children's Hospital, Department of Neonatology, Odense University Hospital, 5000, Odense, Denmark.
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Liang L, Zhuo R, Zhu H, Xie Q, Yang M, Liu Y, Lin J. Establishment of a nomogram model for predicting metabolic bone disease in preterm infants: A case‒control study. Eur J Pediatr 2023:10.1007/s00431-023-04985-3. [PMID: 37184649 DOI: 10.1007/s00431-023-04985-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/12/2023] [Accepted: 04/15/2023] [Indexed: 05/16/2023]
Abstract
OBJECTIVE To investigate risk factors for metabolic bone disease (MBD) in preterm infants and establish a nomogram model for predicting MBD risk. METHODS A total of 1104 preterm infants were enrolled, among whom 809 were included in the modelling set and 295 were included in the validation set. The modelling set was divided into MBD (n = 185) and non-MBD (n = 624) groups. A multivariate logistic regression analysis was used to investigate the independent risk factors for MBD. R software was used to plot the nomogram model, which was then validated by the data of the validation set. Receiver operating characteristic (ROC) and calibration curves were used to evaluate the nomogram model's performance, and the clinical decision curve was used to assess the clinical practicability of the model. RESULTS Gestational age, time of trophic feeding initiation, parenteral nutrition duration, necrotizing enterocolitis, bronchopulmonary dysplasia, cholestasis and sepsis were independent risk factors for MBD in preterm infants (P < 0.05). The ROC curve of the modelling set had an area under the curve (AUC) of 0.801; the risk prediction value of 0.196 corresponding to the maximum Youden index was the best value, and the prediction critical value was 125 points. The ROC curve of the validation set had an AUC of 0.854. The calibration curve analysis showed good accuracy and consistency between the model's predicted and actual values. CONCLUSIONS The nomogram model provides an efficient tool for the early assessment of MBD risk. Preterm infants with scores ≥ 125 should receive close attention and interventions in the early stage. WHAT IS KNOWN • The incidence and severity of MBD are inversely proportional to gestational age and birth weight. Bone loss can lead to prolonged hospital stay, ventilator dependence, pathological fractures and short stature. WHAT IS NEW • Gestational age, time of trophic feeding initiation, parenteral nutrition duration, necrotizing enterocolitis, bronchopulmonary dysplasia, cholestasis and sepsis were independent risk factors for MBD in preterm infants. The nomogram model provides an efficient tool for the early assessment of MBD risk.
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Affiliation(s)
- Liyu Liang
- Neonatal Intensive Care Unit of Fujian Provincial Hospital, Fuzhou, 350001, Fujian, China
| | - Ruiyan Zhuo
- Neonatal Intensive Care Unit of Fujian Provincial Hospital, Fuzhou, 350001, Fujian, China
| | - Hui Zhu
- Neonatal Intensive Care Unit of Fujian Provincial Hospital, Fuzhou, 350001, Fujian, China.
| | - Qinmei Xie
- Neonatal Intensive Care Unit of Fujian Provincial Hospital, Fuzhou, 350001, Fujian, China
| | - Meijun Yang
- Neonatal Intensive Care Unit of Fujian Provincial Hospital, Fuzhou, 350001, Fujian, China
| | - Yongle Liu
- Neonatal Intensive Care Unit of Fujian Provincial Hospital, Fuzhou, 350001, Fujian, China
| | - Jinwen Lin
- Neonatal Intensive Care Unit of Fujian Provincial Hospital, Fuzhou, 350001, Fujian, China
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Magnusson A, Swolin-Eide D, Elfvin A. Body composition and bone mass among 5-year-old survivors of necrotizing enterocolitis. Pediatr Res 2023; 93:924-931. [PMID: 35974161 PMCID: PMC10033411 DOI: 10.1038/s41390-022-02236-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 07/09/2022] [Accepted: 07/19/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) affects the intestine of preterm infants. Preterm infants risk inadequate bone mineralization. This risk may increase if the intestinal uptake of minerals is affected after NEC. METHODS This is a study of growth, bone mineral density (BMD), bone mineral content (BMC), and body composition at 5 years of age among Swedish children born before gestational week 37 + 0 with a history of NEC, minimum stage IIA, compared to matched controls. Fifty children, 25 NEC cases and 25 controls, were examined with dual energy X-ray absorptiometry (DXA) and DXA with laser. RESULTS The NEC cases had lower weight, -1.3 SDS vs -0.7 SDS, a lower fat mass and fat percent, 23.4 vs 29.1%, compared to the controls. NEC cases had lower BMC total body head excluded, 355.6 g vs 416.7 g. BMD Z-scores were lower among NEC cases in total body head excluded, -0.7 vs -0.1, and in lumbar spine. CONCLUSIONS Preterm NEC survivors at 5 years of age had reduced growth, an altered body composition, and indications of a lower bone mass compared to matched controls. The study suggests that preterm infants diagnosed with NEC need special attention during childhood regarding growth and bone health. IMPACT A follow-up longitudinal study of growth, bone health, and body composition at 5 years of age among children born preterm with a history of NEC compared to matched controls. The NEC cases had lower weight than controls. NEC cases had an altered body composition with lower fat mass compared to controls. The DXA results showed that the NEC cases had lower bone mineral content and a tendency to lower bone mineral density. The study suggests that preterm infants diagnosed with NEC need special attention at follow-up regarding growth and bone health compared to preterm infants without NEC.
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Affiliation(s)
- Amanda Magnusson
- Department of Pediatrics, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Pediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Diana Swolin-Eide
- Department of Pediatrics, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Pediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Elfvin
- Department of Pediatrics, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Region Västra Götaland, Department of Pediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Guiducci S, Duci M, Moschino L, Meneghelli M, Fascetti Leon F, Bonadies L, Cavicchiolo ME, Verlato G. Providing the Best Parenteral Nutrition before and after Surgery for NEC: Macro and Micronutrients Intakes. Nutrients 2022; 14:919. [PMID: 35267894 PMCID: PMC8912377 DOI: 10.3390/nu14050919] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 11/18/2022] Open
Abstract
Necrotizing enterocolitis (NEC) is the main gastrointestinal emergency of preterm infants for whom bowel rest and parenteral nutrition (PN) is essential. Despite the improvements in neonatal care, the incidence of NEC remains high (11% in preterm newborns with a birth weight <1500 g) and up to 20−50% of cases still require surgery. In this narrative review, we report how to optimize PN in severe NEC requiring surgery. PN should begin as soon as possible in the acute phase: close fluid monitoring is advocated to maintain volemia, however fluid overload and electrolytes abnormalities should be prevented. Macronutrients intake (protein, glucose, and lipids) should be adequately guaranteed and is essential in each phase of the disease. Composite lipid emulsion should be the first choice to reduce the risk of parenteral nutrition associated liver disease (PNALD). Vitamin and trace elements deficiency or overload are frequent in long-term PN, therefore careful monitoring should be planned starting from the recovery phase to adjust their parenteral intake. Neonatologists must be aware of the role of nutrition especially in patients requiring long-term PN to sustain growth, limiting possible adverse effects and long-term deficiencies.
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Affiliation(s)
- Silvia Guiducci
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (S.G.); (L.M.); (M.M.); (L.B.); (M.E.C.)
| | - Miriam Duci
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (M.D.); (F.F.L.)
| | - Laura Moschino
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (S.G.); (L.M.); (M.M.); (L.B.); (M.E.C.)
| | - Marta Meneghelli
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (S.G.); (L.M.); (M.M.); (L.B.); (M.E.C.)
| | - Francesco Fascetti Leon
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (M.D.); (F.F.L.)
| | - Luca Bonadies
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (S.G.); (L.M.); (M.M.); (L.B.); (M.E.C.)
| | - Maria Elena Cavicchiolo
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (S.G.); (L.M.); (M.M.); (L.B.); (M.E.C.)
| | - Giovanna Verlato
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (S.G.); (L.M.); (M.M.); (L.B.); (M.E.C.)
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