The effects of the introduction of a high-nutrient transitional formula on growth and development of very-low-birth-weight infants

Feeding Interventions for Infants with Growth Failure in the First Six Months of Life: A Systematic Review

(1) Introduction: Current evidence on managing infants under six months with growth failure or other nutrition-related risk is sparse and low quality. This review aims to inform research priorities to fill this evidence gap, focusing on breastfeeding practices. (2) Methods: We searched PubMed, CINAHL Plus, and Cochrane Library for studies on feeding interventions that aim to restore or improve the volume or quality of breastmilk and breastfeeding when breastfeeding practices are sub-optimal or prematurely stopped. We included studies from both low- and middle-income countries and high-income countries. (3) Results: Forty-seven studies met the inclusion criteria. Most were from high-income countries (n = 35, 74.5%) and included infants who were at risk of growth failure at birth (preterm infants/small for gestational age) and newborns with early growth faltering. Interventions included formula fortification or supplementation (n = 31, 66%), enteral feeds (n = 8, 17%), cup feeding (n = 2, 4.2%), and other (n = 6, 12.8%). Outcomes included anthropometric change (n = 40, 85.1%), reported feeding practices (n = 16, 34%), morbidity (n = 11, 23.4%), and mortality (n = 5, 10.6%). Of 31 studies that assessed formula fortification or supplementation, 30 reported anthropometric changes (n = 17 no effect, n = 9 positive, n = 4 mixed), seven morbidity (n = 3 no effect, n = 2 positive, n = 2 negative), five feeding (n = 2 positive, n = 2 no effect, n = 1 negative), and four mortality (n = 3 no effect, n = 1 negative). Of eight studies that assessed enteral feed interventions, seven reported anthropometric changes (n = 4 positive, n = 3 no effect), five feeding practices (n = 2 positive, n = 2 no effect, n = 1 negative), four morbidity (n = 4 no effect), and one reported mortality (n = 1 no effect). Overall, interventions with positive effects on feeding practices were cup feeding compared to bottle-feeding among preterm; nasogastric tube feed compared to bottle-feeding among low birth weight preterm; and early progressive feeding compared to delayed feeding among extremely low birth weight preterm. Bovine/cow milk feeding and high volume feeding interventions had an unfavourable effect, while electric breast pump and Galactagogue had a mixed effect. Regarding anthropometric outcomes, overall, macronutrient fortified formula, cream supplementation, and fortified human milk formula had a positive effect (weight gain) on preterm infants. Interventions comparing human breastmilk/donor milk with formula had mixed effects. Overall, only human milk compared to formula intervention had a positive effect on morbidity among preterm infants, while none of the interventions had any positive effect on mortality. Bovine/cow milk supplementation had unfavourable effects on both morbidity and mortality. (4) Conclusion: Future research should prioritise low- and middle-income countries, include infants presenting with growth failure in the post-neonatal period and record effects on morbidity and mortality outcomes.

Very preterm infants who receive transitional formulas as a complement to human milk can achieve catch-up growth

OBJECTIVE

To evaluate the growth of premature infants fed a postdischarge diet of human milk (HM) complemented with transitional formula (TF) as compared with those fed TF only.

STUDY DESIGN

In this prospective cohort study, 51 infants' diets and anthropometrics were collected at discharge and at 12-15 months corrected gestational age.

RESULTS

Post discharge, infants in both groups exhibited similar growth velocities and changes in z-scores. The duration of infants' HM consumption was not correlated with weight gain (r = -0.25, p = 0.26). The duration of complementary TF feeds also did not correlate with increased growth (r = -0.11, p = 0.44). Both groups achieved catch-up growth and displayed growth velocities that significantly exceeded the upper limit of the World Health Organization (WHO) weight growth standard (p < 0.001).

CONCLUSIONS

Preterm infants receiving HM and complementary TF post discharge had growth velocities at or exceeding weight gain projected by the WHO growth standard for term infants.

Postdischarge growth assessment in very low birth weight infants

Purpose

The goal of nutritional support for very-low-birth-weight (VLBW) infants from birth to term is to match the in utero growth rates; however, this is rarely achieved.

Methods

We evaluated postdischarge growth patterns and growth failure in 81 Korean VLBW infants through a retrospective study. Weight and height were measured and calculated based on age percentile distribution every 3 months until age 24 months. Growth failure was defined as weight and height below the 10th percentile at 24 months. For the subgroup analysis, small-for-gestational age (SGA) and extremely low birth weight (ELBW) infants were evaluated. The growth patterns based on the Korean, World Health Organization (WHO), or Centers for Disease Control and Prevention (CDC) standard were serially compared over time.

Results

At postconception age (PCA) 40 weeks, 47 (58%) and 45 infants (55%) showed growth failure in terms of weight and height, respectively. At PCA 24 months, 20 infants (24%) showed growth failure for weight and 14 (18%) for height. Growth failure rates were higher for the SGA infants than for the appropriate-weight-for-gestational age infants at PCA 24 months (P=0.045 for weight and P=0.038 for height). Growth failure rates were higher for the ELBW infants than for the non-ELBW infants at PCA 24 months (P<0.001 for weight and P=0.003 for height). Significant differences were found among the WHO, CDC, and Korean standards (P<0.001).

Conclusion

Advancements in neonatal care have improved the catch-up growth of VLBW infants, but this is insufficient. Careful observation and aggressive interventions, especially in SGA and ELBW infants, are needed.

Growth and body composition of human milk-fed premature infants provided with extra energy and nutrients early after hospital discharge: 1-year follow-up

OBJECTIVES

Human milk (HM) is the optimal source of nutrition for premature infants; however, it is unclear whether HM alone is sufficient to meet their elevated nutritional requirements early after hospital discharge. We previously reported that premature infants (750-1800 g birth weight) fed HM containing extra nutrients for 12 weeks after discharge had dietary intakes closer to recommended levels and grew more rapidly than those fed HM alone. The objectives of the present article are to examine the impact of this intervention on bone mineralization, body composition, and HM use up to 1 year. Data are also presented on general developmental level at 18-month corrected age (CA).

PATIENTS AND METHODS

At discharge, predominantly HM-fed infants were randomized to receive for 12 weeks either approximately half of their feedings containing a multinutrient fortifier (intervention, n=19) or all of their feedings as HM alone (control, n=20).

RESULTS

Intervention infants remained longer (P<0.001) and had greater whole-body bone mineral content (P=0.02) until 12-month CA compared with controls. Intervention infants born less than or equal to 1250 g continued to have a larger mean head circumference throughout the first year of life (P<0.0001). Human milk feeding (mL.kg(-1).day(-1)) differed between groups at 6- (P=0.035), but not 12-month CA. No statistically significant differences were found between groups in the mental, motor, or behavior rating scale scores of the Bayley II at 18-month CA.

CONCLUSIONS

Adding a multinutrient fortifier to HM provided to predominantly HM-fed premature infants early after discharge results in sustained differences in weight, length, and whole-body bone mineral content, and in smaller babies, head circumference for the first year of life.

Growth and nutrient intakes of human milk-fed preterm infants provided with extra energy and nutrients after hospital discharge

OBJECTIVES

The purpose of this pilot study was to determine whether mixing a multinutrient fortifier to approximately one half of the human milk fed each day for a finite period after discharge improves the nutrient intake and growth of predominantly human milk-fed low birth weight infants. We also assessed the impact of this intervention on the exclusivity of human milk feeding.

METHODS

Human milk-fed (> or = 80% feeding per day) low birth weight (750-1800 g) infants (n = 39) were randomly assigned at hospital discharge to either a control or an intervention group. Infants in the control group were discharged from the hospital on unfortified human milk. Nutrient enrichment of human milk in the intervention group was achieved by mixing approximately one half of the human milk provided each day with a powdered multinutrient human milk fortifier for 12 weeks after discharge. Milk with added nutrients was estimated to contain approximately 80 kcal (336 kJ) and 2.2 g protein/100 mL plus other nutrients. Intensive lactation support was provided to both groups.

RESULTS

Infants in the intervention group were longer during the study period, and those born < or = 1250 g had larger head circumferences than infants in the control group. There was a trend toward infants in the intervention group to be heavier at the end of the intervention compared with those in the control group. Mean protein, zinc, calcium, phosphorus, and vitamins A and D intakes were higher in the intervention group.

CONCLUSIONS

Results from this study suggest that adding a multinutrient fortifier to approximately one half of the milk provided to predominantly human milk-fed infants for 12 weeks after hospital discharge may be an effective strategy in addressing early discharge nutrient deficits and poor growth without unduly influencing human milk feeding when intensive lactation support is provided.

Post-discharge nutrition: what does the evidence support?

Although there are no official recommendations for specific nutrient intakes in premature infants after hospital discharge, it is agreed that the goal should be to achieve the body composition and rate of growth of that of a normal fetus of the same postmenstrual age during the entire first year of life. A general recommendation to use the special formulas designed for preterm infants after hospital discharge in place of the formulas for term infants cannot be made from the available evidence at this time. Infants fed human milk after discharge are of the greatest concern as human milk does not in theory meet the requirements for growth in these infants. Such infants should remain on supplemental vitamins and Fe while breastfeeding, and growth as well as serum levels of phosphorus and alkaline phosphatase should be carefully monitored. The increased risk of preterm infants for obesity and the metabolic syndrome secondary to the metabolic/nutritional events early in life (programming) is likely to be small compared with the contribution of other risk factors, such as parental size, weight as an adolescent, and various lifestyle factors such as physical activity.

Nutrition for preterm infants after hospital discharge

Preterm infants accrue significant nutrient deficits during hospitalization, and at the time of discharge most VLBW preterm infants have moderate to severe growth failure. Infants with significant morbidities and infants with ELBW have more severe growth failure since they regain birth weight at a later age, and they gain weight more slowly. Catch-up growth accelerates after hospital discharge. The rates of catch-up growth vary according to many factors including birth weight, gestational age, parental size, adequacy of intrauterine growth, neurologic impairment, clinical course, and nutrition. Most catch-up growth occurs within the first 2 to 3 years of life; however, compensatory catch-up growth may continue into adolescence and adulthood. Despite evidence of ongoing catch-up growth, the mean growth measurements of children and adults who were born preterm and with VLBW are lower than their term-born peers. Accelerated rates of catch-up growth are associated with better neurodevelopmental outcomes. Inadequate head circumference growth, in particular, may have long-term prognostic significance for later neurodevelopment in preterm infants. Nutrient-enriched formulas that provide 22 kcal/oz are often prescribed for VLBW preterm infants after hospital discharge. Several studies have reported that preterm infants fed the enriched versus standard term infant formulas have greater rates of catch-up growth during the first year of life, including greater increases in head circumference. The nutrient-enriched formulas appear to be of particular benefit for male infants. There is less information regarding the nutrient needs of breast-fed infants after hospital discharge. However, several studies have demonstrated that preterm infants fed unfortified human milk after discharge have growth rates and bone mass that are lower than formula-fed infants during infancy. The use of fortified human milk, or alternate feedings with a nutrient-enriched formula may be useful for breast-fed infants who have delays in catch-up growth. Additional studies are needed to determine whether enriched feedings might be of particular benefit for preterm infants who are at greater risk for postnatal growth failure, including infants born SGA, or with extremely low birth weights, intrauterine growth restriction, or chronic conditions such as bronchopulmonary dysplasia. The potential effect of nutritional programming on long-term outcomes of preterm infants also requires further investigation.