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Salas AA, Chetta K, Lach L, Katikaneni L, Itriago E, Hair AB, Moreira A, Bergner EM, Elabiad MT, Ramel SE. Race as social determinant of growth and body composition among infants born very preterm. Pediatr Res 2024:10.1038/s41390-024-03406-x. [PMID: 39034355 DOI: 10.1038/s41390-024-03406-x] [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: 03/29/2024] [Revised: 06/03/2024] [Accepted: 06/27/2024] [Indexed: 07/23/2024]
Abstract
OBJECTIVE Racism leads to disparities in health outcomes. Our objective was to determine if black race was independently associated with differences in fat accretion at discharge in a large cohort of very preterm infants (32 weeks of gestation or less). METHODS De-identified demographic, anthropometric and body composition data were collected from seven neonatal units around the United States. Weight, length, and head circumference z-scores at birth and at the time of body composition assessment or hospital discharge were calculated. RESULTS The median gestational age and birthweight for this cohort (n = 888) were 29 weeks [IQR, 27-30] and 1167 g [SD, 354], respectively. The study population included 53% black preterm infants. Birthweight was lower in black preterm infants compared with white infants (1112 ± 334 g vs. 1228 ± 366 g; p < 0.0001). After adjusting for birthweight, gestational age, and birthweight-for-age z-score, black preterm infants had more weight gain (adjusted mean difference: 0.5 g/kg/day; p = 0.03) but not higher BF% z-scores at hospital discharge (adjusted mean: 1.2 vs. 1.3; p = 0.14) than white infants. CONCLUSIONS After adjusting for covariates, black race was associated with higher weight gain velocity but not higher BF% z-scores. IMPACT This study presents findings from a large-scale multicenter cohort. Racial differences were observed in birth weight and the rate of weight gain; however, these differences were not associated with dissimilarities in body composition outcomes. Understanding nutrition and growth outcomes across racial groups is necessary to combat racial disparities in the neonatal intensive care unit (NICU).
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Affiliation(s)
- Ariel A Salas
- Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Katherine Chetta
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Laura Lach
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Lakshmi Katikaneni
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Elena Itriago
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Amy B Hair
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Alvaro Moreira
- Department of Pediatrics, UT Health San Antonio, San Antonio, TX, USA
| | - Erynn M Bergner
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Mohamad T Elabiad
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sara E Ramel
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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Razzaghy J, Shukla VV, Gunawan E, Reeves A, Nguyen K, Salas AA. Early and exclusive enteral nutrition in infants born very preterm. Arch Dis Child Fetal Neonatal Ed 2024; 109:378-383. [PMID: 38135494 PMCID: PMC11186726 DOI: 10.1136/archdischild-2023-325969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE To characterise the effects of early and exclusive enteral nutrition with either maternal or donor milk in infants born very preterm (280/7-326/7 weeks of gestation). DESIGN Parallel-group, unmasked randomised controlled trial. SETTING Regional, tertiary neonatal intensive care unit. PARTICIPANTS 102 infants born very preterm between 2021 and 2022 (51 in each group). INTERVENTION Infants randomised to the intervention group received 60-80 mL/kg/day within the first 36 hours after birth. Infants randomised to the control group received 20-30 mL/kg/day (standard trophic feeding volumes). MAIN OUTCOME MEASURES The primary outcome was the number of full enteral feeding days (>150 mL/kg/day) in the first 28 days after birth. Secondary outcomes included growth and body composition at the end of the first two postnatal weeks, and length of hospitalisation. RESULTS The mean birth weight was 1477 g (SD: 334). Half of the infants were male, and 44% were black. Early and exclusive enteral nutrition increased the number of full enteral feeding days (+2; 0-2 days; p=0.004), the fat-free mass-for-age z-scores at postnatal day 14 (+0.5; 0.1-1.0; p=0.02) and the length-for-age z-scores at the time of hospital discharge (+0.6; 0.2-1.0; p=0.002). Hospitalisation costs differed between groups (mean difference favouring the intervention group: -$28 754; -$647 to -$56 861; p=0.04). CONCLUSIONS In infants born very preterm, early and exclusive enteral nutrition increases the number of full enteral feeding days. This feeding practice may also improve fat-free mass accretion, increase length and reduce hospitalisation costs. TRIAL REGISTRATION NUMBER NCT04337710.
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Affiliation(s)
- Jacqueline Razzaghy
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Vivek V Shukla
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Emily Gunawan
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Audrey Reeves
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kelly Nguyen
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ariel A Salas
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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Lücke L, Fusch C, Knab K, Schäfer S, Zimmermann JL, Felderhoff-Müser U, Meis A, Lohmüller-Weiß S, Szakacs-Fusch A, Rochow N. Reproducibility of Air Displacement Plethysmography in Term and Preterm Infants-A Study to Enhance Body Composition Analysis in Clinical Routine. Nutrients 2024; 16:1810. [PMID: 38931164 PMCID: PMC11206819 DOI: 10.3390/nu16121810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/02/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024] Open
Abstract
The quality-initiative analysis of weekly duplicate PEAPOD® body composition measurements was conducted from clinical practice (January to September 2021) on preterm and term infants without respiratory support. Statistical analysis, including regression analysis, Bland-Altman plots and cv-root-mean-square tests, was performed. A total of 188 duplicate (376 individual) measurements were collected from 119 infants (88 preterm, 31 term). The median absolute difference between duplicates was 31.5 g for fat-free mass (FFM). Linear correlation analysis showed R2 = 0.97 for FFM. The absolute differences in FFM and fat mass did not significantly correlate with increasing age. The %FFM differed (p = 0.02) across body weight groups of 1 kg < BW ≤ 2 kg (1.8%; IQR: 0.8, 3.6) and BW > 3 kg (0.9%; IQR: 0.3, 2.1). The median absolute differences were 1 g (IQR: 0.4, 3.1) for body weight and 5.6 mL (IQR: 2.1, 11.8) for body volume. Body volume estimation is charged with a constant absolute error, which is the main factor for differences between repeated body composition assessments. This error becomes more prominent in infants with lower body weights. Nevertheless, reproducibility of weekly PEAPOD testing is sufficient to monitor body compartment changes, offering a foundation for nutritional decisions in both preterm and term infants.
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Affiliation(s)
- Lennart Lücke
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany; (L.L.)
- Research Department of Child Nutrition, University Hospital of Pediatrics and Adolescent Medicine, St. Josef-Hospital, Ruhr University Bochum, 44791 Bochum, Germany
| | - Christoph Fusch
- Department of Pediatrics, University Hospital Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471 Nürnberg, Germany; (C.F.); (K.K.); (S.S.)
- Department of Pediatrics, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Katja Knab
- Department of Pediatrics, University Hospital Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471 Nürnberg, Germany; (C.F.); (K.K.); (S.S.)
| | - Stefan Schäfer
- Department of Pediatrics, University Hospital Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471 Nürnberg, Germany; (C.F.); (K.K.); (S.S.)
| | - Jasper L. Zimmermann
- Department of Pediatrics, University Hospital Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471 Nürnberg, Germany; (C.F.); (K.K.); (S.S.)
| | - Ursula Felderhoff-Müser
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany; (L.L.)
| | - Anastasia Meis
- Department of Pediatrics, University Hospital Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471 Nürnberg, Germany; (C.F.); (K.K.); (S.S.)
| | - Stephanie Lohmüller-Weiß
- Department of Pediatrics, University Hospital Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471 Nürnberg, Germany; (C.F.); (K.K.); (S.S.)
| | - Adel Szakacs-Fusch
- Department of Pediatrics, University Hospital Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471 Nürnberg, Germany; (C.F.); (K.K.); (S.S.)
| | - Niels Rochow
- Department of Pediatrics, University Hospital Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471 Nürnberg, Germany; (C.F.); (K.K.); (S.S.)
- DeuZWEG German Center for Growth, Development and Health Encouragement during Childhood and Youth, 10249 Berlin, Germany
- Department of Pediatrics, University Medicine Rostock, 18057 Rostock, Germany
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Salas AA. Revolutionizing Neonatal Nutrition: Rethinking Definitions and Standards for Optimal Care. Adv Nutr 2024; 15:100235. [PMID: 38679235 PMCID: PMC11251398 DOI: 10.1016/j.advnut.2024.100235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 04/23/2024] [Indexed: 05/01/2024] Open
Affiliation(s)
- Ariel A Salas
- University of Alabama at Birmingham, Birmingham, AL, United States.
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Lyle ANJ, Shaikh H, Oslin E, Gray MM, Weiss EM. Race and Ethnicity of Infants Enrolled in Neonatal Clinical Trials: A Systematic Review. JAMA Netw Open 2023; 6:e2348882. [PMID: 38127349 PMCID: PMC10739112 DOI: 10.1001/jamanetworkopen.2023.48882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/08/2023] [Indexed: 12/23/2023] Open
Abstract
Importance Representativeness of populations within neonatal clinical trials is crucial to moving the field forward. Although racial and ethnic disparities in research inclusion are well documented in other fields, they are poorly described within neonatology. Objective To describe the race and ethnicity of infants included in a sample of recent US neonatal clinical trials and the variability in this reporting. Evidence Review A systematic search of US neonatal clinical trials entered into Cochrane CENTRAL 2017 to 2021 was conducted. Two individuals performed inclusion determination, data extraction, and quality assessment independently with discrepancies adjudicated by consensus. Findings Of 120 studies with 14 479 participants that met the inclusion criteria, 75 (62.5%) included any participant race or ethnicity data. In the studies that reported race and ethnicity, the median (IQR) percentage of participants of each background were 0% (0%-1%) Asian, 26% (9%-42%) Black, 3% (0%-12%) Hispanic, 0% (0%-0%) Indigenous (eg, Alaska Native, American Indian, and Native Hawaiian), 0% (0%-0%) multiple races, 57% (30%-68%) White, and 7% (1%-21%) other race or ethnicity. Asian, Black, Hispanic, and Indigenous participants were underrepresented, while White participants were overrepresented compared with a reference sample of the US clinical neonatal intensive care unit (NICU) population from the Vermont Oxford Network. Many participants were labeled as other race or ethnicity without adequate description. There was substantial variability in terms and methods of reporting race and ethnicity data. Geographic representation was heavily skewed toward the Northeast, with nearly one-quarter of states unrepresented. Conclusions and Relevance These findings suggest that neonatal research may perpetuate inequities by underrepresenting Asian, Black, Hispanic, and Indigenous neonates in clinical trials. Studies varied in documentation of race and ethnicity, and there was regional variation in the sites included. Based on these findings, funders and clinical trialists are advised to consider a 3-point targeted approach to address these issues: prioritize identifying ways to increase diversity in neonatal clinical trial participation, agree on a standardized method to report race and ethnicity among neonatal clinical trial participants, and prioritize the inclusion of participants from all regions of the US in neonatal clinical trials.
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Affiliation(s)
- Allison N J Lyle
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Henna Shaikh
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Ellie Oslin
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, Seattle, Washington
| | - Megan M Gray
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Elliott Mark Weiss
- Department of Pediatrics, University of Washington School of Medicine, Seattle
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, Seattle, Washington
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Razzaghy J, Zhang L, Yi N, Salas AA. Predicting body fat percentage at 36 weeks of postmenstrual age in infants born preterm: A diagnostic accuracy study. JPEN J Parenter Enteral Nutr 2023; 47:1056-1061. [PMID: 37709722 PMCID: PMC10843079 DOI: 10.1002/jpen.2561] [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: 11/23/2022] [Revised: 07/30/2023] [Accepted: 09/12/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Current standards for assessing body composition can be costly and technically challenging. There is a need for a predictive equation that combines multiple clinical and anthropometric factors to predictbody composition outcomes at 36 weeks of postmenstrual age (PMA) or discharge. METHODS To develop a widely applicable equation that predicts body fat percentage in preterm infants, we analyzed anthropometric data collected prospectively from a cohort of infants born very preterm between 2017 and 2018. We integrated clinical variables significantly associated with adiposity into a predictive equation using Bayesian linear regression models and leave-one-out cross-validation. RESULTS We analyzed data from 86 infants born at 32 weeks of gestation or less (median gestational age, 30 weeks; mean birthweight, 1471 ± 270 g). Weight gain and increase in length per week from birth to 36 weeks of PMA, midarm circumference at 36 weeks of PMA, male sex, and higher enteral fluid intake (>180 ml/kg/day) were the strongest predictors of body fat percentage in the model with the highest predictive value (R2 = 0.65). The correlation between actual and predicted body fat percentage using this Bayesian model was high (r = 0.82). CONCLUSIONS Weight gain and increase in length per week from birth to 36 weeks of PMA, midarm circumference at 36 weeks of PMA, male sex, and enteral fluid intake are significant predictors of body fat percentage at 36 weeks of PMA in very preterm infants.
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Affiliation(s)
- Jacqueline Razzaghy
- Department of Pediatrics, Division of Neonatology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Li Zhang
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Nengjun Yi
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Ariel A. Salas
- Department of Pediatrics, Division of Neonatology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
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Salas AA, Jerome M, Finck A, Razzaghy J, Chandler-Laney P, Carlo WA. Body composition of extremely preterm infants fed protein-enriched, fortified milk: a randomized trial. Pediatr Res 2022; 91:1231-1237. [PMID: 34183770 PMCID: PMC8237544 DOI: 10.1038/s41390-021-01628-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/19/2021] [Accepted: 06/11/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Critically ill extremely preterm infants fed human milk are often underrepresented in neonatal nutrition trials aimed to determine the effects of enteral protein supplementation on body composition outcomes. METHODS Masked randomized trial in which 56 extremely preterm infants 25-28 weeks of gestation were randomized to receive either fortified milk enriched with a fixed amount of extensively hydrolyzed protein (high protein group) or fortified milk without additional protein (standard protein group). RESULTS Baseline characteristics were similar between groups. In a longitudinal analysis, the mean percent body fat (%BF) at 30-32 weeks of postmenstrual age (PMA), 36 weeks PMA, and 3 months of corrected age (CA) did not differ between groups (17 ± 3 vs. 15 ± 4; p = 0.09). The high protein group had higher weight (-0.1 ± 1.2 vs. -0.8 ± 1.3; p = 0.03) and length (-0.8 ± 1.3 vs. -1.5 ± 1.3; p = 0.02) z scores from birth to 3 months CA. The high protein group also had higher fat-free mass (FFM) z scores at 36 weeks PMA (-0.9 ± 1.1 vs. -1.5 ± 1.1; p = 0.04). CONCLUSIONS Increased enteral intake of protein increased FFM accretion, weight, and length in extremely preterm infants receiving protein-enriched, fortified human milk. IMPACT Extremely preterm infants are at high risk of developing postnatal growth failure, particularly when they have low fat-free mass gains. Protein supplementation increases fat-free mass accretion in infants, but several neonatal nutrition trials aimed to determine the effects of enteral protein supplementation on body composition outcomes have systematically excluded critically ill extremely preterm infants fed human milk exclusively. In extremely preterm infants fed fortified human milk, higher enteral protein intake increases fat-free mass accretion and promotes growth without causing excessive body fat accretion.
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Affiliation(s)
- Ariel A Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Maggie Jerome
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Amber Finck
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jacqueline Razzaghy
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Paula Chandler-Laney
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
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Jerome M, Chandler-Laney P, Affuso O, Li P, Salas AA. Racial differences in growth rates and body composition of infants born preterm. J Perinatol 2022; 42:385-388. [PMID: 35067675 PMCID: PMC8917983 DOI: 10.1038/s41372-021-01305-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 12/01/2021] [Accepted: 12/21/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate racial disparities in weight gain velocity and body composition among preterm infants. STUDY DESIGN This observational study analyzed race differences in fat-free mass (FFM), fat mass (FM), percent body fat (%BF), and weight gain at discharge of infants born at 25-32 weeks of gestation. RESULTS No racial differences in FFM, FM and %BF measurements were found between black and white preterm infants after adjusting for birth weight, gestational age, and the presence/absence of breastfeeding (n = 143). Black infants born preterm had lower birthweights and higher weight gain from birth to discharge in unadjusted and adjusted models (13 ± 3 vs. 11 ± 3 g/kg/day; <0.001). CONCLUSION Black infants had higher weight gain from birth to discharge, but comparable body composition measurements at discharge. More research is needed to understand contributing factors and long-term implications of this finding.
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Affiliation(s)
- Maggie Jerome
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Paula Chandler-Laney
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Olivia Affuso
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Peng Li
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ariel A Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA.
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