Early aggressive nutrition in preterm infants

Effects of early parenteral nutrition on the development of premature infants born at 22-23 weeks of gestation: a retrospective cohort study evaluated by brain magnetic resonance imaging

BACKGROUND

The effect of early parenteral nutrition (EPN) therapy on brain development in extremely premature infants at a gestational age (GA) of 22-25 weeks remains unknown.

OBJECTIVES

This study investigated the effect of EPN therapy on GA 22 to 25 weeks of gestation using magnetic resonance imaging (MRI) global brain abnormality score (GBAS).

SUBJECTS

Forty-six preterm infants born before 26 weeks of gestation were divided into the GA 22-23 weeks (GA 22-23; n = 18) and GA 24-25 weeks (GA 24-25; n = 28) group.

METHODS

Each infant received ≥3.0 g/kg/day of amino acids from day 1 of life and ≥1.0 g/kg/day of lipid emulsion the next day. Weight change during hospitalization, GBAS at discharge, and developmental quotient (DQ) until three years old were compared between the groups.

RESULTS

GA 22-23 showed long-term postnatal weight loss, but weight at 41 weeks of postmenstrual age did not differ between the groups. The GBAS score was not significantly different, but the head circumference was smaller in GA 22-23 than in GA 24-25 until 2 years old. The DQ at 1-1.5 years old was lower in GA 22-23 than that of GA 24-25; however, there was no significant difference in DQ after 2 years old between the groups.

CONCLUSIONS

The effect of nutritional support with EPN therapy in premature neonates born at <24 weeks of gestation may still be inadequate. GBAS is useful for assessing brain development in very preterm infants, and the importance of nutritional support during the first few weeks of life should continue to be explored.

Effects of Total Parenteral Nutrition on Serum Osmolality and Patent Ductus Arteriosus

BACKGROUND

The persistence of high serum osmolality in the early postnatal period is a risk for developing patent ductus arteriosus (PDA). Early aggressive nutrition (EAN), involving total parenteral nutrition (TPN), by which enough concentrations of glucose and amino acids are administered intravenously, is recommended postnatally to improve the neurological prognosis in preterm infants. However, the effects of EAN involving TPN on serum osmolality and the development of a PDA have not been adequately studied.

OBJECTIVES

Thus, in this study, we aimed to investigate the impact of TPN on serum osmolality and determine whether increased serum osmolality could be associated with a higher incidence of PDA in preterm infants.

METHODS

In this single-center retrospective observational study, preterm infants born at <28 weeks of gestation who had been admitted to our neonatal intensive care unit (NICU) before (pre-TPN period) and after the introduction of TPN (post-TPN) were included. We reviewed the medical records of these patients, compared the changes in serum osmolality from birth to five days after birth, the clinical background, and the incidence of PDA between these two periods, and analyzed the risk factors. Additionally, the factors affecting the serum osmolality in very preterm infants were examined. The patients who met the intervention criteria of our NICU and received a cyclooxygenase (COX) inhibitor, Indacin® (Nobelpharma, Tokyo, Japan), within seven days after birth were classified as PDA+; those who could not be identified to have PDA flow by echo and did not receive a COX inhibitor were classified as PDA-.

RESULTS

The postnatal day and serum sodium (Na+) were statistically significantly correlated with a higher serum osmolality. Serum osmolality remained statistically significantly higher in the PDA+ cohort compared with the PDA- cohort after the first day of life. However, no statistically significant differences were observed in serum osmolality after 24 hours of age, weeks of gestational age, birth weight, or incidence of PDA between the pre- and post-TPN periods. The results of the multiple logistic regression analyses revealed that the increased serum osmolality correlated with PDA development.

CONCLUSIONS

In this study, the serum Na+ statistically significantly correlated with a higher serum osmolality. Moreover, the increased serum osmolality correlated with PDA development. Thus, the prevention of hypernatremia might reduce the incidence of PDA. Nonetheless, the findings in this study revealed that no statistically significant differences in serum osmolality were observed between the pre-and post-TPN periods, indicating that TPN had little effect on serum osmolality.

Association between timing of re-introduction of enteral feeding and short-term outcomes following laparotomy for necrotising enterocolitis

PURPOSE

To investigate the relationship between timing of re-introduction of feeds following surgery for Necrotising Enterocolitis (NEC) and important early outcomes.

METHODS

Secondary analysis of prospectively collected data from paediatric surgical units in UK/Ireland of infants who underwent laparotomy for NEC between 01/03/2013 and 28/02/2014. Multivariable logistic regression analysis was used to compare the relationship of early (≤ 7 days) and later (8-27 days) re-introduction of feeding after surgery on death or need for PN at 28 days, correcting for known cofounders.

RESULTS

41/143 infants (29%) received early and 102/143 infants (71%) had delayed reintroduction of feeding. Infants in the early feeding group had a higher gestational age at birth, higher proportion of growth restriction, lower inotrope requirement, and weremore likely to have undergone primary anastomosis. Following adjustment there was no statistically significant difference detected in the rate of death or need for PN at 28 days, adjusted OR 0.4 (95% CI 0.2-1.1), noting the limited statistical power of this comparison.

CONCLUSIONS

There is no evidence from this study to support a minimum period of 7 days nil by mouth post laparotomy for infants with NEC. Early feed reintroduction following laparotomy for NEC is safe in appropriate cases.

LEVEL OF EVIDENCE

Level II - Treatment Study Group; Prospective comparative study.

Creating experiences from active treatment towards extremely preterm infants born at less than 25 weeks in Japan

Treatment for extremely preterm infants born at less than 25 weeks of gestation in Japan was initiated mainly due to the amendment of the Maternal Health Act lowering the upper limit of abortion from 24 weeks to 22 weeks in 1990. Five years after the amendment, the Japanese national government started a nationwide project to improve the perinatal care system. Once selected perinatal centers reported improvements in survival rates, more centers have adopted aggressive treatments. They have accumulated their knowledge by experiencing the treatment of infants with a limit of viability. As a result, more than 50% of infants born even at 22 weeks of gestation can survive to discharge currently. This progress has resulted from the accumulation of experience at each perinatal center rather than the results from clinical trials. Furthermore, these experiences have been standardized to some extent through sharing information.

The association between duration of postnatal weight loss and neurodevelopment outcomes in very low birth weight infants

BACKGROUND

Premature births account for around 11% of the world's live births. With the improvements in survival that have been achieved in recent years, the neurological outcomes of these infants have attracted greater attention. The aim of this study was to evaluate the association between postnatal weight loss and neurodevelopment outcomes of very low birth weight premature infants.

METHODS

This was a prospective cohort study that was conducted in a tertiary referral center. Premature infants of birth weight less than 1500 g born between October 2015 and January 2017 were enrolled. Perinatal-demographic characteristics, medical interventions, and nutrition records were collected. The Bayley III tests performed by licensed child psychiatrists at corrected ages 6, 12, and 24 months old were adopted as outcome measurements.

RESULTS

In total, 52 infants were enrolled. The mean birth weight was 1071 g and the mean gestational age was 29.0 weeks. According to the univariate analysis, the duration of postnatal weight loss had a significantly negative impact on motor outcomes at 12 and 24 months old. The negative impact remained robust after adjusting for confounding factors by multiple linear regression models. The effect of repeated measurement was further considered by generalized estimating equation (GEE) models. GEE models also demonstrated a negative association between the duration of body weight loss and motor scores.

CONCLUSION

The duration of postnatal weight loss might have a negative influence on long-term motor development in premature infants. Further studies of nutrition status and motor development are needed to elucidate the precise underlying mechanism.

The short-term mortality and morbidity of very low birth weight infants with trisomy 18 or trisomy 13 in Japan

Trisomy 18 (T18) and trisomy 13 (T13) are major concerns in prenatal genetic testing due to their poor prognosis; very low birth weight (VLBW) is also a concern in neonatology. The aim of this study was to investigate the mortality and morbidity of VLBW infants diagnosed with T18/T13 in Japan, compared with those with no birth defects (BD-). Maternal and neonatal data were collected prospectively from infants weighing <1501 g and were admitted to centers of the Neonatal Research Network of Japan during 2003 to 2016. Among 60,136 infants, 563 and 60 was diagnosed with T18 and T13, respectively. Although the age of mothers of infants with T18/T13 was higher, the frequency of maternal complications was lower than those with BD-. With maternal and neonatal characteristic adjustments, T18/T13 had a higher incidence of each morbidity when compared with BD-. Mortality rates in the NICU were 70, 77, and 5.8% for T18, T13, and BD-, respectively, while the survival discharge rates of T18 and T13 were 29.5 and 23.3%, respectively, which was significantly higher than previous reports. This was the first nationwide survey for VLBW infants with T18/T13 in Japan; this novel data will be relevant and useful for prenatal genetic counseling and perinatal management. Although T18/T13 were considered to be fatal in the past, with proper epidemiological information, discussions with affected families, and compassionate patient care, the mortality rate of T18/T13 can be improved.

Predicting intestinal recovery after necrotizing enterocolitis in preterm infants

BACKGROUND

Intestinal recovery after NEC is difficult to predict in individuals. We evaluated whether several biomarkers predict intestinal recovery after NEC in preterm infants.

METHODS

We measured intestinal tissue oxygen saturation (r_intSO₂) and collected urinary intestinal-fatty acid binding protein (I-FABP_u) levels 0-24 h and 24-48 h after NEC onset, and before and after the first re-feed. We assessed intestinal recovery in two ways: time to full enteral feeding (FEFt; below or equal/above group's median) and development of post-NEC complications (recurrent NEC/post-NEC stricture). We determined whether the r_intSO₂, its range, and I-FABP_u differed between groups.

RESULTS

We included 27 preterm infants who survived NEC (Bell's stage ≥ 2). Median FEFt was 14 [IQR: 12-23] days. Biomarkers only predicted intestinal recovery after the first re-feed. Mean r_intSO₂ ≥ 53% combined with mean r_intSO_2range ≥ 50% predicted FEFt < 14 days with OR 16.7 (CI: 2.3-122.2). The r_intSO_2range was smaller (33% vs. 51%, p < 0.01) and I-FABP_u was higher (92.4 vs. 25.5 ng/mL, p = 0.03) in case of post-NEC stricture, but not different in case of recurrent NEC, compared with infants without complications.

CONCLUSION

The r_intSO₂, its range, and I-FABP_u after the first re-feed after NEC predicted intestinal recovery. These biomarkers have potential value in individualizing feeding regimens after NEC.

The effect of enteral bolus feeding on regional intestinal oxygen saturation in preterm infants is age-dependent: a longitudinal observational study

Background

The factors that determine the effect of enteral feeding on intestinal perfusion after preterm birth remain largely unknown. We aimed to determine the effect of enteral feeding on intestinal oxygen saturation (r_intSO₂) in preterm infants and evaluated whether this effect depended on postnatal age (PNA), postmenstrual age (PMA), and/or feeding volumes. We also evaluated whether changes in postprandial r_intSO₂ affected cerebral oxygen saturation (r_cSO₂).

Methods

In a longitudinal observational pilot study using near-infrared spectroscopy we measured r_intSO₂ and r_cSO₂ continuously for two hours on postnatal Days 2 to 5, 8, 15, 22, 29, and 36. We compared preprandial with postprandial values over time using multi-level analyses. To assess the effect of PNA, PMA, and feeding volumes, we performed Wilcoxon signed-rank tests or logistic regression analyses. To evaluate the effect on r_cSO₂, we also used logistic regression analyses.

Results

We included 29 infants: median (range) gestational age 28.1 weeks (25.1–30.7) and birth weight 1025 g (580–1495). On Day 5, r_intSO₂ values decreased postprandially: mean (SE) 44% (10) versus 35% (7), P = .01. On Day 29, r_intSO₂ values increased: 44% (11) versus 54% (7), P = .01. Infants with a PMA ≥ 32 weeks showed a r_intSO₂ increase after feeding (37% versus 51%, P = .04) whereas infants with a PMA < 32 weeks did not. Feeding volumes were associated with an increased postprandial r_intSO₂ (per 10 mL/kg: OR 1.63, 95% CI, 1.02–2.59). We did not find an effect on r_cSO₂ when r_intSO₂ increased postprandially.

Conclusions

Our study suggests that postprandial r_intSO₂ increases in preterm infants only from the fifth week after birth, particularly at PMA ≥ 32 weeks when greater volumes of enteral feeding are tolerated. We speculate that at young gestational and postmenstrual ages preterm infants are still unable to increase intestinal oxygen saturation after feeding, which might be essential to meet metabolic demands.

Trial registration

For this prospective longitudinal pilot study we derived patients from a larger observational cohort study: CALIFORNIA-Trial, Dutch Trial Registry NTR4153.

Effects of oral zinc supplementation on zinc status and catch-up growth during the first 2 years of life in children with non-organic failure to thrive born preterm and at term

BACKGROUND

We aimed to analyze the effect of oral zinc supplementation on serum insulin-like growth factor-1 (IGF-1) levels and catch-up growth in infants with non-organic failure to thrive (NOFTT) who were born preterm as compared to those born at term.

METHODS

Totally, 105 NOFTT infants aged 2 years or less were enrolled and divided into two groups according to gestational age at birth. Oral zinc sulfate was administered for 6 months to 49/66 children born at term, and 21/39 children born preterm. Serum zinc, IGF-1, weight, and height were measured at baseline and at 6 months.

RESULTS

There were no differences in baseline serum zinc levels between the two groups. In preterm NOFTT infants, zinc supplementation significantly increased serum zinc levels compared to those in the non-supplementation group (Δ zinc _{0-6 month} 10.3 ± 26.4 μg/dL vs. -8.8 ± 23.7 μg/dL, p = 0.018), but it did not significantly change serum IGF-1 levels or weight- and height for age Z-scores. In NOFTT infants born at term who received zinc supplementation, serum zinc levels, IGF-1, weight for age Z-score, and height for age Z-score increased at 6 months (p = 0.001, p = 0.014, p = 0.049, and p = 0.029, respectively), but this increase was not significantly greater than in the non-supplementation group. Only the increase in serum zinc levels was significant after 6 months (Δ zinc _{0-6 month} 16.8 ± 32.0 μg/dL vs. -10.0 ± 22.6 μg/dL, p = 0.002).

CONCLUSION

Zinc supplementation in NOFTT infants improves serum zinc status, regardless of gestational age at birth. Zinc supplementation in NOFTT infants born at term may improve serum IGF-1 levels and growth, but it does not in NOFTT infants born preterm. Overall nutritional support rather than supplementation of a single nutrient may be more effective for catch-up growth in NOFTT infants born preterm.

Down-regulation of MEIS1 promotes the maturation of oxidative phosphorylation in perinatal cardiomyocytes

Fetal cardiomyocytes shift from glycolysis to oxidative phosphorylation around the time of birth. Myeloid ecotropic viral integration site 1 (MEIS1) is a transcription factor that promotes glycolysis in hematopoietic stem cells. We reasoned that MEIS1 could have a similar role in the developing heart. We hypothesized that suppression of MEIS1 expression in fetal sheep cardiomyocytes leads to a metabolic switch as found at birth. Expression of MEIS1 was assayed in left ventricular cardiac tissue and primary cultures of cardiomyocytes from fetal (100- and 135-d gestation, term = 145 d), neonatal, and adult sheep. Cultured cells were treated with short interfering RNA (siRNA) to suppress MEIS1. Oxygen consumption rate was assessed with the Seahorse metabolic flux analyzer, and mitochondrial activity was assessed by staining cells with MitoTracker Orange. Cardiomyocyte respiratory capacity increased with advancing age concurrently with decreased expression of MEIS1. MEIS1 suppression with siRNA increased maximal oxygen consumption in fetal cells but not in postnatal cells. Mitochondrial activity was increased and expression of glycolytic genes decreased when MEIS1 expression was suppressed. Thus, we conclude that MEIS1 is a key regulator of cardiomyocyte metabolism and that the normal down-regulation of MEIS1 with age underlies a gradual switch to oxidative metabolism.-Lindgren, I. M., Drake, R. R., Chattergoon, N. N., Thornburg, K. L. Down-regulation of MEIS1 promotes the maturation of oxidative phosphorylation in perinatal cardiomyocytes.

Postnatal Growth Restriction Is Reduced If Birth Weight Is Used for Nutritional Calculations in ELBW Infants

Since fluid and nutrition needs and delivery in ELBW infants are calculated based on their body weights, there could be a measurable difference in fluid, nutrition, and protein intake calculations based on birth weight (BW) or current weight of the infant, especially in the first two weeks of life. Theoretically, the use of current daily weight (CW) for calculations may result in decreased fluid, nutrition, and protein delivery as well as a cumulative protein deficit (cPD) over the first two weeks of life until the infant regains birth weight. However, there have been no clinical studies comparing the clinical and nutritional impact of these two strategies is unknown. Aims. The aims of this study were to quantify the amount of protein intake and to compare growth parameters at hospital discharge (as measured by discharge weight and head circumference percentiles) when using two different methodologies (BW vesrsus current daily weight until BW is regained) for calculating fluid and protein intake in the first two weeks after birth in ELBW infants. Methods. A retrospective review of infants weighing ≤ 1kg at birth was conducted from January 2005 to December 2009 (Phase 1; P1) and January 2012 to December 2014 (Phase 2; P2) in a tertiary care NICU. At this center, in P1 (2005-09) CW was exclusively used for calculating fluid, calorie, and protein administration till BW was regained. In P2 (2012-14), BW was exclusively used for all calculations. Both P1 and P2 periods were compared and analyzed for differences in demographics, nutritional intake, comorbid conditions, and growth outcomes. Results. We studied 146 infants with 84 and 62 infants in P1 and P2 periods, respectively. The mean gestational age was lower during Phase 1 (25.74 ±1.32 vs. 26.47 ±1.82 weeks. P value =0.01). However, the birth weights were not different between the two periods. When the multiple-regression analysis was done using a discharge weight of >10^th percentile as the dependent variable, protein intake before regaining of BW (OR of 4.126 with 95^th CI of 2.03-8.36, a P value of 0.00) and AGA status at birth (OR of 8.37 with 95^th CI of 2.67-26.24) remained significant factors. Compared to P1, babies in P2 received 1g/kg/day more protein till BW was regained. In P1, 27% of babies who were appropriate for gestational age (AGA) for head circumference at birth became microcephalic by discharge, compared to 15.6% in P2 (p=0.03). Similarly, 75.3% of the babies who were AGA for weight at birth in P1 became small for gestational age (SGA) by discharge, compared to 16.7% in P2 (p=<0.0001). The number of days it took to regain BW was 9.6 days in P1 vs. 7 days in P2 (p=<0.0001). Conclusions. Basing nutrition calculations in ELBW on birth weight rather than current daily weight until the birth weight is regained resulted in significantly greater protein delivery, a significant decrease in the incidence of failure to thrive and smaller head circumference percentiles at discharge in ELBW infants.

Preterm formula use in the preterm very low birth weight infant

Whereas human milk is the recommended diet for all infants, preterm formulas are indicated for enteral feeding of preterm very low birth weight infants when sufficient maternal breast milk and donor human milk are not available. Feeding with preterm formulas helps to ensure consistent delivery of nutrients. The balance of risks and benefits of feeding preterm formulas versus supplemented maternal and donor breast milk for preterm infants, however, is uncertain. Numerous studies and extensive practice have shown improved growth with preterm formulas, but there is concern for increased risks of necrotizing enterocolitis, possibly from cow milk antigen in the formulas or from different gut microbiomes, increased duration of total parenteral nutrition, and increased rates of sepsis in infants receiving preterm formulas. Furthermore, whereas preterm formulas improve neurodevelopmental outcomes compared to term formulas and unfortified donor milk, they do not produce neurodevelopmental outcomes better than fortified human milk, again indicating that maternal milk has unique properties that formulas need to mimic as closely as possible.

Optimizing nutrition of the preterm infant

The goal of nutrition of the preterm infant is to meet the growth rate of the healthy fetus of the same gestational age and to produce the same body composition of the healthy fetus in terms of organ growth, tissue components, and cell number and structure. Nutritional quantity and quality are fundamental for normal growth and development of preterm infants, including neurodevelopmental outcomes. Failure to provide the necessary amounts of all of the essential nutrients has produced not only growth failure, but also increased morbidity and less than optimal neurodevelopment. Growth velocities during the NICU hospitalization period for preterm infants exert a significant effect on neurodevelopmental and anthropometric outcomes. Despite the obvious need for optimal nutrition, growth failure is almost universal among preterm infants. There is every reason, therefore, to optimize nutrition of the preterm infant, in terms of total energy and protein, but also in terms of individual components such as amino acids, specific carbohydrates and lipids, and even oxygen. This review presents scientific rationale for nutrient requirements and practical guidelines and approaches to intravenous and enteral feeding for preterm infants. Intravenous feeding, including amino acids, should be started right after birth at rates that are appropriate for the gestational age of the infant. Enteral feeding should be started as soon as possible after birth, using mother's colostrum and milk as first choices. Enteral feeding should begin with trophic amounts and advanced as rapidly as tolerated, decreasing IV nutrition accordingly, while maintaining nutrient intakes at recommended rates. Feeding protocols are valuable for improving nutrition and related outcomes. Further research is needed to determine the optimal nutrition and rate of growth in preterm infants that will achieve optimal neurocognitive benefits while minimizing the longer-term risk of chronic diseases.

Percutaneous central venous catheters versus peripheral cannulae for delivery of parenteral nutrition in neonates

BACKGROUND

Neonatal parenteral nutrition may be delivered via peripheral cannulas or central venous catheters (umbilical or percutaneous). As the result of complications associated with umbilical catheters, many neonatal units prefer to use percutaneous catheters after initial stabilisation. Although they can be difficult to place, these catheters may be more stable than peripheral cannulae and require less frequent replacement. These delivery methods may be associated with different risks of adverse events, including acquired invasive infection and extravasation injury.

OBJECTIVES

To determine the effects of infusion of parenteral nutrition via percutaneous central venous catheters versus peripheral cannulae on nutrient input, growth and development and complications among hospitalised neonates receiving parenteral nutrition in terms of adverse consequences such as bacteraemia or invasive fungal infection, cardiac tamponade or other extravasation injuries.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 5), MEDLINE (1966 to June 2015) and EMBASE (1980 to June 2015), as well as conference proceedings and previous reviews.

SELECTION CRITERIA

Randomised controlled trials that compared delivery of intravenous fluids (primarily parenteral nutrition) via percutaneous central venous catheters versus peripheral cannulae in hospitalised neonates.

DATA COLLECTION AND ANALYSIS

We extracted data using standard methods of the Cochrane Neonatal Group, with separate evaluation of trial quality and data extraction by two review authors.

MAIN RESULTS

We found six trials recruiting a total of 549 infants. One trial showed that use of a percutaneous central venous catheter was associated with a smaller deficit between prescribed and actual nutrient intake during the trial period (mean difference (MD) -7.1%, 95% confidence interval (CI) -11.02 to -3.2). Infants in the percutaneous central venous catheter group needed significantly fewer catheters/cannulae (MD -4.3, 95% CI -5.24, -3.43). Meta-analysis of data from all trials revealed no evidence of an effect on the incidence of invasive infection (typical risk ratio (RR) 0.95, 95% CI 0.72 to 1.25; typical risk difference (RD) -0.01, 95% CI -0.08 to 0.06).

AUTHORS' CONCLUSIONS

Data from one small trial suggest that use of percutaneous central venous catheters to deliver parenteral nutrition increases nutrient input. The significance of this in relation to long-term growth and developmental outcomes is unclear. Three trials suggest that use of percutaneous central venous catheters decreases the number of catheters/cannulae needed to deliver nutrition. No evidence suggests that percutaneous central venous catheter use increases risks of adverse events, particularly invasive infection, although none of the included trials was large enough to rule out an effect on uncommon severe adverse events such as pericardial effusion.

Prevention of postnatal growth restriction by the implementation of an evidence-based premature infant feeding bundle

OBJECTIVE

To develop an evidence-based feeding bundle to safely decrease the rate of PNGR in VLBW infants.

STUDY DESIGN

The bundle was developed and implemented in January 2010, followed by 3 years of monitoring bundle compliance and infant outcomes (days to first feed (FD), days to reach full feeds (FF), and birth-discharge growth trajectories (delta z-score)).

RESULTS

Data were collected on 482 infants (119 pre-bundle). PNGR decreased from 35% to 19% (P<0.01) and weight delta z-score improved from -0.82 to -0.45 (P<0.001). Percentage of infants with head circumference (HC) below 10th percentile at discharge decreased from 21% to 9% (P<0.01) and HC delta z-score improved from -0.65 to -0.17 (P<0.001). FD and FF also decreased significantly. Rates of necrotizing enterocolitis, peak alkaline phosphatase and peak direct bilirubin levels all trended downward.

CONCLUSIONS

An evidence-based, standardized feeding bundle was safe and effective in reducing the rate of PNGR and in improving head growth in VLBW infants.

Leucine is a major regulator of muscle protein synthesis in neonates

Approximately 10% of infants born in the United States are of low birth weight. Growth failure during the neonatal period is a common occurrence in low birth weight infants due to their inability to tolerate full feeds, concerns about advancing protein supply, and high nutrient requirements for growth. An improved understanding of the nutritional regulation of growth during this critical period of postnatal growth is vital for the development of strategies to improve lean gain. Past studies with animal models have demonstrated that muscle protein synthesis is increased substantially following a meal and that this increase is due to the postprandial rise in amino acids as well as insulin. Both amino acids and insulin act independently to stimulate protein synthesis in a mammalian target of rapamycin-dependent manner. Further studies have elucidated that leucine, in particular, and its metabolites, α-ketoisocaproic acid and β-hydroxy-β-methylbutyrate, have unique anabolic properties. Supplementation with leucine, provided either parenterally or enterally, has been shown to enhance muscle protein synthesis in neonatal pigs, making it an ideal candidate for stimulating growth of low birth weight infants.

Protein intake and neurodevelopmental outcomes

There is a compelling body of literature that suggests that the provision of an inadequate amount of protein to preterm infants in the neonatal period has detrimental effects on the developing brain with the potential to result in long-term, neurodevelopmental sequelae. Although a great deal of indirect evidence implies that the provision of adequate amounts of protein may be associated with better neurodevelopmental outcomes, there remains a paucity of direct evidence that would allow us to draw any final conclusions.

Review of macronutrients in parenteral nutrition for neonatal intensive care population

Parenteral nutrition (PN) has become essential in the management of sick and growing newborn populations in the NICU. In the past few decades, PN has become fundamental in the nutritional management of the very low birth weight infant (<1,500 g).1 Although the components in PN are commonly determined and ordered by the physician or neonatal nurse practitioner provider, the NICU nurse is responsible for confirming the components in the daily PN prior to infusion and is responsible for maintaining the infusion of PN. Nurses should understand the nutritional components of PN as well as the indications, side effects, and infusion limitations of each component. The purpose of this article is to review the macronutrients in PN, including carbohydrates, protein, and fat. A subsequent article will review the micronutrients in PN, including electrolytes, minerals, and vitamins.

Aggressive Nutrition of the Preterm Infant

Nutrition of preterm infants should result in growth similar to that of normally growing fetuses of the same gestational age. Unfortunately, most preterm infants are not fed enough to achieve this objective; as a result they are growth restricted by term gestation. Recent studies have demonstrated that early and enhanced "aggressive" nutrition of preterm infants can reduce postnatal growth failure and improve longer-term outcomes, particularly for the brain and its cognitive functions. When preterm infants are fed more aggressively (earlier onset of intravenous and enteral feeding, earlier achievement of full enteral feeding) cumulative energy and protein deficits are reduced and they consistently regain birth weight sooner, the incidence of necrotizing enterocolitis and late-onset sepsis is unchanged or reduced, and they achieve discharge criteria and go home sooner, with overall shorter hospital stays, and have improved anthropometrics by term gestation. More research is needed, however, to determine optimum feeding of preterm infants, particularly during periods of illness and physiological instability.

GLP-2 delays but does not prevent the onset of necrotizing enterocolitis in preterm pigs

OBJECTIVES

Necrotizing enterocolitis (NEC) is complex disease thought to occur as a result of an immaturity of the gastrointestinal tract of preterm infants. Intestinal dysfunction induced by total parental nutrition (TPN) may increase the risk for NEC upon introduction of enteral feeding. We hypothesized that the intestinal trophic and anti-inflammatory actions previously ascribed to the gut hormone, glucagon-like peptide-2 (GLP-2), would reduce the incidence of NEC when given in combination with TPN in preterm piglets.

METHODS

Preterm, newborn piglets were nourished by TPN and infused continuously with either human GLP-2 (100 μg · kg⁻¹ · day⁻¹) or control saline for 2 days (n = 12/group). On day 3, TPN was discontinued and pigs were given orogastric formula feeding every 3 hours, and continued GLP-2 or control treatment until the onset of clinical signs of NEC for an additional 96 hours and tissue was collected for molecular and histological endpoints.

RESULTS

GLP-2 treatment delayed the onset of NEC but was unable to prevent a high NEC incidence (~70%) and severity that occurred in both groups. GLP-2-treated pigs had less histological injury and increased proximal intestinal weight and mucosal villus height, but not crypt depth or Ki-67-positive cells. Inflammatory markers of intestinal myeloperoxidase were unchanged and serum amyloid A levels were higher in GLP-2-treated pigs.

CONCLUSIONS

GLP-2 did not prevent NEC and a proinflammatory response despite some reduction in mucosal injury and increased trophic effect.

From parenteral to enteral nutrition: a nutrition-based approach for evaluating postnatal growth failure in preterm infants

BACKGROUND

Nutrition practices for preterm infants include phases of parenteral nutrition (PN), full enteral nutrition (EN), and the transitional phase in between. Our aim was to identify the nutrition phases during which infants are most likely to exhibit poor growth that would affect risk for growth failure (GF) at discharge and to examine factors associated with GF.

METHODS

A retrospective chart review was conducted on infants born <32 weeks' gestation. The neonatal intensive care unit stay was divided into 3 nutrition phases: (1) full PN, (2) transitional PN + EN, and (3) full EN. Weekly growth rates were calculated, and for each growth velocity <10 g/kg/d, the coinciding phase was recorded. GF was defined as a discharge weight below the 10th percentile. The nutrition phases during which growth inadequacy predicted GF at discharge were determined, correcting for other clinical factors associated with GF.

RESULTS

In total, 156 eligible infants were identified. Seventy-six infants (49%) were discharged with weights <10%. Incidence of poor growth was highest during the transitional phase (46%) and was predictive of GF when adjusted for gestational age, birth weight, and severity of illness. Although energy intakes during the transitional phase were comparable to baseline parenteral provision, protein intakes progressively decreased ( P < .0001), consistently providing 3 g/kg/d as PN was weaned. Serum urea nitrogen also declined and was correlated with protein intake (r = -0.32, P < .001).

CONCLUSION

Growth was compromised during the transitional phase, likely related to decreased protein intake. Optimizing protein provision while PN is weaned is an important strategy to prevent postnatal growth failure.

Standardised parenteral nutrition

Parenteral nutrition (PN) has become an integral part of clinical management of very low birth weight premature neonates. Traditionally different components of PN are prescribed individually considering requirements of an individual neonate (IPN). More recently, standardised PN formulations (SPN) for preterm neonates have been assessed and may have advantages including better provision of nutrients, less prescription and administration errors, decreased risk of infection, and cost savings. The recent introduction of triple-chamber bag that provides total nutrient admixture for neonates may have additional advantage of decreased risk of contamination and ease of administration.

Reduction in postnatal cumulative nutritional deficit and improvement of growth in extremely preterm infants

AIM

To evaluate the influence of gestational age (GA) on cumulative nutritional deficit and postnatal growth in extremely preterm (EPT) infants after optimizing nutritional protocol as recently recommended.

METHODS

A prospective, nonrandomized, observational study in extremely preterm (EPT, <28 weeks) and very preterm (VPT, 28-30 weeks) infants.

RESULTS

Eighty-four infants were included (BW: 978 ± 156 g, GA: 27.8 ± 1.3 weeks). Cumulative nutritional deficit increased during first week of life to -290 ± 84 and -285 ± 117 kcal/kg and -4.2 ± 3.1 and -4.8 ± 3.9 g/kg of protein in EPT and VPT groups, respectively. After 6 weeks, only cumulative energy deficit in EPT group remained significant (p < 0.05) even when 96% of theoretical energy intakes were provided. Weight z score decreased during first 3 days in average with initial weight loss, and then, the z score increased during the first 6 weeks of life in the majority (75%) of infants. Cumulative protein deficit during the first week of life was the major determinant of the postnatal growth during the first 6 weeks of life.

CONCLUSION

Cumulative nutritional deficit may be drastically reduced in both EPT and VPT infants after optimizing nutritional policy during the first weeks of life, and the postnatal growth restriction could even be prevented.

Prevention of protein deprivation in the extremely low birth weight infant: a nutritional emergency

Insufficient nutrient supply in preterm infants and protein deprivation in particular can represent a nutritional emergency. It can cause many of the features of the starvation response, including insulin resistance and hyperglycemia, as well as growth failure and neurological injury. At Baylor University Medical Center, we began providing intravenous protein on the first day of life to extremely low birth weight infants in 2000. This has led to significant improvements in the time to regain birth weight and the rate of daily weight gain during the first month of life. While neonatologists traditionally focus first on newborns' warmth, respiratory support, and cardiovascular support, early aggressive nutrition support, in the form of intravenous amino acids at time of admission as well as glucose, is of great benefit and should be a standard element in the initial care of the extremely low birth weight infant.

Optimizing early nutritional support based on recent recommendations in VLBW infants and postnatal growth restriction

OBJECTIVE

The aim of this study was to evaluate postnatal growth up to discharge in very low birth weight infants after optimizing nutritional support based on recent nutritional recommendations.

PATIENTS AND METHODS

A prospective, nonrandomized, consecutive, and observational study in infants weighing <1250 g.

RESULTS

One hundred two infants were included during a 2-year period (birth weight 1005 ± 157 g, gestational age 28.5 ± 1.9 weeks). First-day nutritional intake was 38 ± 6 kcal/kg/day with 2.4 ± 0.3 g/kg/day of protein. Mean intake during the first week of life was 80 ± 14 kcal/kg/day with 3.2 ± 0.5 g/kg/day of protein. On average from birth to discharge, 122 ± 10 kcal/kg/day and 3.7 ± 0.2 g/kg/day of protein were administered. Postnatal weight loss was limited to the first 3 days of life, and birth weight was regained after 7 days in average. Catch-up occurred after the second week in all groups of very low birth weight infants. Small-for-gestational age infants demonstrated an earlier and higher weight gain, allowing a rapid catch-up growth. The same proportion of infants was small-for-gestational age at birth and at discharge (20%, P = 0.74).

CONCLUSIONS

This study confirmed that the first week of life is a critical period to promote growth and that early nutrition from the first day of life is essential. Postnatal weight loss may be limited and subsequent growth may be optimized with a dramatic reduction of postnatal growth restriction.

A nutritional program to improve outcome of very low birth weight infants

BACKGROUND & AIMS

The growth of very low birth weight infants does not match intrauterine trajectories, likely due to inappropriate caloric intake. We therefore investigated whether modification of the standard nutritional schedule can impact postnatal growth.

METHODS

We introduced a set of evidence-based strategies in a study group of infants (n = 123): 1) higher maximum intake of intravenous amino acids and lipids; 2) prioritisation of earlier enteral feeding; 3) faster attainment of full enteral feeds; 4) daily adjustment of enteral feeds according to growth trajectory; and 5) utilisation of an electronic pre-structured prescription ordering system that tracks individual growth and energy intake. These infants were compared with a control group (n = 115) in a pre/post retrospective cohort study.

RESULTS

The study group achieved a higher caloric intake, attained full enteral feeds 5 days earlier, and returned to their birth weight more rapidly than the control group. At 36 weeks postmenstrual age, infants who had been born at <30 weeks were heavier (Δ260 g) but had a similar percentage fat mass. Those born at <28 weeks had a larger head circumference (Δ1.4 cm) and lower sepsis rate (7.8%).

CONCLUSIONS

Optimization of early postnatal nutrition and daily adjustment of milk intake according to weight gain improved growth, without any unfavourable outcomes for body composition and neurodevelopmental follow-up.

Outcomes of early parenteral nutrition for premature infants

OBJECTIVE

The objective of this study was to evaluate the safety and efficacy of early amino acid (early AA) administration in very low birth weight (VLBW) infants.

STUDY DESIGN

A pre- and post-intervention study was conducted after initiating an early AA administration protocol. Clinical outcomes were collected for all VLBW infants admitted on the first day of life for 9 months before protocol initiation (standard parenteral nutrition (PN)), and 10 months after initiation of early AA.

RESULT

In all, 88 infants met study criteria for standard PN, and 85 infants for early AA administration. The patient characteristics were similar between the groups. There were no differences in mortality, the day birth weight was regained, the day enteral feeds started, the duration of PN, the day full feeds achieved and weight at 32 weeks post-menstrual age. No differences were found for late sepsis, direct hyperbilirubinemia and chronic lung disease. Necrotizing enterocolitis (NEC) occurred more frequently in the early AA administration group (12 vs 1%, P=0.012).

CONCLUSION

Early AA administration for VLBW infants was as efficacious as standard therapy, although increased NEC in the early AA period may have negatively affected growth and nutrition in that period.

Initial nutritional management of the preterm infant

Postnatal nutrition has a large impact on long-term outcome of preterm infants. Evidence is accumulating showing even a relationship between nutrient supply in the first week of life and later cognitive development in extremely low birth weight infants. Since enteral nutrition is often not tolerated following birth, parenteral nutrition is necessary. Yet, optimal parenteral intakes of both energy and amino acids are not well established. Subsequently, many preterm infants fail to grow well, with long-term consequences. Early and high dose amino acid administration has been shown to be effective and safe in very low birth weight infants, but the effect of additional lipid administration needs to be defined.

Extrauterine growth retardation in premature infants in Shanghai: a multicenter retrospective review

Intrauterine growth retardation (IUGR) represents the degree of body growth and development decided by genes and by placental function. Extrauterine growth retardation/restriction (EUGR) refers to severe nutritional deficits during the first weeks of life that result in growth that is less than expected based on intrauterine growth rates (growth values < or =10th percentile of intrauterine growth expected in accordance with the estimated gestational age). The deficits affect not only weight but also head circumference and height. As is well known, a nutrition support team (NST) is a multidisciplinary team comprised of physicians, nurses, dietitians, pharmacists, social workers, and medical technologists who provide nutritional management. In this study, we review 2,015 premature infants (1,209 boys and 806 girls) from four hospitals in the Shanghai area from January 1, 2003 to December 31, 2006, two of which had NSTs. The overall incidence of EUGR was 56.8% assessed by weight, while the incidence of IUGR was 26.1%. Higher incidence of EUGR was associated with lower birth weight, but higher gestational age. There was a significant relationship between EUGR incidence and NST availability (chi(2) = 60.630, p < 0.001), though there was no similar finding for IUGR incidence. The incidence of EUGR was 44% in NST hospitals and 62.6% in non-NST hospitals. According to logistic regression, the following five factors were related to EUGR: male gender, gestational age at birth, birth weight, length of hospital stay, and NST availability. NSTs reduced the risk of EUGR by a magnitude of 0.47. EUGR remains a serious problem in premature infants in Shanghai, but NSTs can reduce EUGR incidence.

Altered body composition in preterm infants at hospital discharge

AIM

To test the hypotheses that body size is reduced and body composition altered in preterm infants at hospital discharge.

METHODS

Preterm infants (< or = 34 weeks gestation, < or = 1750 g at birth) were enrolled. Body weight, length and head circumference were converted to standard deviation or z-scores. Body composition was measured using dual emission X-ray absorptiometry. The results were analysed using standard statistics.

RESULTS

One hundred and forty-nine infants (birth weight = 1406 +/- 248 g, gestation = 31 +/- 1.7 weeks) were studied. Postmenstrual age at discharge was 37 +/- 1.2 weeks. Z-scores for head circumference, weight and length differed (-0.1 +/- 0.6 > -1.4 +/- 0.6 > -1.9 +/- 0.6; p < 0.0001). Global fat-free mass was less in study infants than the reference infant at the same weight (2062 < 2252 g; p < 0.0001) or gestation (2062 < 2667 g; p < 0.0001). Global fat mass was greater in study infants than the reference infant at the same weight (307 > 198 g, 13 > 8%) or gestation (307 > 273 g; 13 > 9%; p < 0.0001). Changes in central fat mass closely paralleled those in global fat mass (r(2) = 0.76, p < 0.0001).

CONCLUSION

Reduced linear growth and a reduced fat-free mass suggest that dietary protein needs were not met before discharge. A reduced fat-free mass coupled with an increased global and central fat mass echoes concerns about the development of insulin resistance and metabolic syndrome X in these high-risk infants.

Effects of light exposure on total parenteral nutrition and its implications in the neonatal population

Total parenteral nutrition (TPN) is a necessary form of nutrition in neonates with functional or anatomical disruption of the digestive tract. However, laboratory and human investigation have shown that exposure of the TPN solution to light causes the formation of peroxides and other degradation products that are quantifiable in experimental TPN solutions, laboratory animals, and neonates. Premature neonates are at a higher risk for the development and progression of peroxide damage due to their relative lack of antioxidant and free radical scavenger reserves. Furthermore, cell damage seen in a number of neonatal disease states is exacerbated by the presence of peroxides that are generated via intrinsic pathologic processes and from exogenous sources such as TPN. Numerous studies show that the formation of TPN photodegradation products can be slowed or prevented by the application of various light protection mechanisms. While it is not yet known if minimizing TPN associated photodegradation byproducts has a significant direct effect on preventing or mitigating the overall clinical course of some neonatal disease states, it is becoming increasingly clear that light protecting TPN can avoid specific metabolic complications in neonatal patients. It is prudent to implement mechanisms that prevent photodegradation of TPN components from the manufacturer source to the point of patient administration.

Early amino-acid administration improves preterm infant weight

OBJECTIVE

Premature infants, especially those born less than 1500 g, often exhibit slow overall growth after birth and lack of early nutritional support may be an important element. We tested the hypothesis that early administration of amino acids (within the first few hours of life) to infants born at less than 1500 g would be associated with fewer infants that were less than the 10th percentile at 36 weeks post-conceptual age than infants that received amino acids after the first 24 h of life.

STUDY DESIGN

A prospective intervention of early amino-acid (EAA) supplementation, began before 24 h of life, in preterm infants, <1500 g, was compared to a retrospective cohort of preterm infants receiving late amino-acid (LAA) supplementation, began after 24 h of life. The primary outcome variable was the proportion of infants at less than the 10th percentile at 36 weeks post-conceptual age.

RESULT

Fewer infants fell below the 10th percentile (P<0.001) in the EAA group. Furthermore, infants in the EAA groups had significantly greater weight gains than did the LAA group (P<0.003) after adjusting for gestational age and time from birth to discharge. In addition, shorter duration of parenteral nutrition was associated with EAA supplementation (P<0.001).

CONCLUSION

A prospective strategy of EAA in preterm infants <1500 g was associated with an improved weight gain, suggesting that nutrition that included amino acids may be critical during the first 24 h of life.

Gently caring: supporting the first few critical hours of life for the extremely low birth weight infant

Caring for the extremely low birth weight infant in the first days of life is complex and challenging, yet rewarding. It is the experienced health care provider who will be best prepared to meet the needs of these fragile infants and their concerned/frightened parents. Understanding how to minimize stress and support body functions will enable us to better care for these infants in the first few days of life. We should strive to partner with parents, even in the resuscitative and stabilization phases of care, particularly when an infant may not survive. Nursing plays an essential role in providing this minute-to-minute support. It is not always what we do, but how we do it, that may matter most.

First-week protein and energy intakes are associated with 18-month developmental outcomes in extremely low birth weight infants

OBJECTIVE

We sought to evaluate the association between early protein and energy intake and neurodevelopment and growth of extremely low birth weight (<1000 g) infants.

STUDY DESIGN

Daily protein and energy intakes were collected by chart review for the first 4 weeks of life on 148 extremely low birth weight survivors. A total of 124 infants (84%) returned for evaluation at 18 months' corrected age. Bivariate analysis tested correlations between weekly protein or energy intakes and Bayley Mental Development Index, Psychomotor Development Index, or growth at 18 months. Separate regression models evaluated contributions of protein (grams per kilogram per day) and energy intake (kilojoules per kilogram per day) to the Mental Development Index, Psychomotor Development Index, and growth, while controlling for known confounders.

RESULTS

After adjusting for confounding variables, week 1 energy and protein intakes were each independently associated with the Mental Development Index. During week 1, every 42 kJ (10 kcal)/kg per day were associated with a 4.6-point increase in the Mental Development Index and each gram per kilogram per day in protein intake with an 8.2-point increase in the Mental Development Index; higher protein intake was also associated with lower likelihood of length <10th percentile.

CONCLUSIONS

Increased first-week protein and energy intakes are associated with higher Mental Development Index scores and lower likelihood of length growth restrictions at 18 months in extremely low birth weight infants. Emphasis should be placed on providing more optimal protein and energy during this first week.

Intrauterine, early neonatal, and postdischarge growth and neurodevelopmental outcome at 5.4 years in extremely preterm infants after intensive neonatal nutritional support

OBJECTIVE

Extremely preterm infants are at risk for poor growth and impaired neurodevelopment. The objective of this study was to determine whether intrauterine, early neonatal, or postdischarge growth is associated with neurocognitive and motor-developmental outcome in extremely preterm infants.

METHODS

Surviving children who were born between July 1996 and June 1999 at <30 weeks' gestation and with a birth weight <1500 g were evaluated at the age of school entry by application of (1) a standardized neurologic evaluation, (2) the Kaufmann Assessment Battery for Children, and (3) the Gross Motor Function Classification Scale. Growth was assessed on the basis of SD scores of weight and head circumference measured at birth, at discharge, and at the time of the follow-up examination. All infants had received intensive early nutritional support.

RESULTS

A total of 219 (83%) of 263 long-term survivors were evaluated at a median corrected age of 5.4 years. Increasing SD scores for weight and head circumference from birth to discharge were associated with a reduced risk for an abnormal neurologic examination. Catch-up growth of head circumference from birth to discharge was also associated with a reduced risk for impaired mobility. Weight SD score at birth, an increase of weight SD score from birth to discharge, and an increase of head circumference SD score from discharge to follow-up had an effect on the mental processing composite score. The effects of growth on neurodevelopment were by far exceeded by the consequences of intraventricular and periventricular hemorrhage.

CONCLUSIONS

Growth from birth to discharge seemed to be associated with long-term motor development. Cognitive development was associated with intrauterine growth measured as weight at birth, early neonatal weight gain, and postdischarge head circumference growth. Improving particularly early neonatal growth may improve long-term outcome in extremely preterm infants, but the effects of improved growth may only be small.

Nutrição parenteral no recém-nascido pré-termo: proposta de protocolo prático

OBJETIVO: Revisar a literatura e os conceitos relacionados à terapia nutricional parenteral de recém-nascidos pré-termo e propor fluxograma prático de indicação, progressão dos parâmetros e monitoramento para utilização em unidades neonatais. FONTES DE DADOS: Artigos publicados em inglês e português nas bases de dados Medline, Embase, Lilacs e SciELO nos últimos dez anos, além de referências clássicas e consensos internacionais. As palavras-chave utilizadas como fonte de busca foram recém-nascido pré-termo, nutrição parenteral, terapia nutricional e emulsões lipídicas. SÍNTESE DOS DADOS: A nutrição parenteral é procedimento essencial no tratamento intra-hospitalar do recém-nascido pré-termo. Além dos avanços no conhecimento e progressos na legislação, vários fatores contribuíram para reduzir a morbimortalidade desses recém-nascidos e elevar a segurança na utilização da nutrição parenteral, tais como qualidade dos cateteres empregados, treinamento e capacitação adequada dos profissionais envolvidos, existência de equipes multiprofissionais e o desenvolvimento de novos insumos. CONCLUSÕES: Esse protocolo prático sobre nutrição parenteral para recém-nascidos prematuros foi desenvolvido com base em recomendações internacionais de sociedades científicas e na análise crítica de estudos científicos.

[Reduced postnatal growth in very low birth weight newborns with GE < or = 32 weeks in Spain]

AIM

To analyze postnatal growth restriction in a cohort of very low birth weight (VLBW) infants with gestational age < or = 32 weeks in 55 Spanish neonatal units (SEN 1500 Network) during 2002 and 2003.

METHODS

Weight, length and head circumference were recorded at birth, and at discharge. Weight was also recorded at 28 days postnatal, and 36 weeks of postmenstrual age. Growth restriction was measured as the shift in weight z score from birth to 28th day.

RESULTS

The study included 2317 VLBW infants. Weight z score at birth, 28 days, 36 weeks of postmenstrual age and discharge were: -0.66 +/- 1.3, -2.54 +/- 1.35, -3.12 +/- 1.7, -1.56 +/- 1.1, respectively. Length z score at birth and at discharge were: -0.88 +/- 1.8, and -1.97 +/- 1.56. Head circumference z score at birth and at discharge: -0.83 +/- 1.87, and -0.60 +/- 1.96. Prenatal steroids, gestational age, place of birth, type of hospital, CRIB score, symptomatic patent ductus arteriosus and late-onset bacterial sepsis were related with the shift in weight z score at 28 days (multiple linear regression), but explained very little (14 %) of his change. Weight and length at discharge were under the 10th percentile in 77 % and 80 % of the infants, respectively.

CONCLUSIONS

VLBW infants < or = 32 GA suffer postnatal growth restriction with respect to intrauterine growth pattern, which is more relevant in the first 28 days of life, in patients with more severe illnesses, and differs among neonatal units. Perinatal and neonatal items evaluated are poorly related with restriction.

Is the early and aggressive administration of protein to very low birth weight infants safe and efficacious?

PURPOSE OF REVIEW

Most conventionally managed very low birth weight infants experience postnatal growth restriction. There is some evidence that this postnatal growth restriction may have long-lasting effects, and contribute to short stature and poor neurodevelopmental outcomes. There is also evidence suggesting that early protein intake may improve growth in these very low birth weight infants. Therefore, to optimize protein intake early in the infant's neonatal course seems a logical goal.

RECENT FINDINGS

Randomized controlled trials provide evidence of short-term safety and efficacy for starting amino acid infusion as soon as possible after birth at 2.5-3.0 g/kg/day in very low birth weight infants; however, there are no long-term data to support the safety or efficacy of this practice. There is some evidence from recent studies of improved growth by providing 4.0 g/kg/day of amino acid early in the neonatal period while keeping the nitrogen to energy ratio above 1:100 and continuing with this protein intake during the infants stay in the hospital. At the present time long-term safety of this strategy is also not known.

SUMMARY

Appropriately designed large-scale randomized controlled trials are needed to determine the long-term safety and efficacy of early and aggressive administration of protein to very low birth weight infants.

Demographic and nutritional factors associated with prolonged cholestatic jaundice in the premature infant

OBJECTIVE

The primary aim of this study was to determine if an association exists between amino-acid levels and development of cholestasis. The secondary aim of our amino-acid dose comparison trial was to identify factors associated with the development of prolonged cholestatic jaundice.

STUDY DESIGN

We compared demographic characteristics and amino-acid levels in neonates who developed cholestasis with those who did not. Parenteral-associated cholestatic liver disease was defined as a direct serum bilirubin above 5 mg per 100 ml any time during the first 28 days after birth in neonates with no history of biliary atresia or viral hepatitis. We obtained filter paper blood spots for amino acid and acylcarnitine measurements on the day of randomization and days 7 and 28 of age to identify a profile of values that could be used to identify neonates with evidence of abnormal liver function.

RESULT

We enrolled 122 neonates in our study; 13 (10.7%) developed cholestasis. Neonates who developed cholestasis were more immature, had lower birth weight, were exposed to parenteral nutrition for a longer period, had a higher cumulative dose of amino acids, were less often on enteral nutrition by day 7 of age, more often had a patent ductus arteriosus and severe intraventricular hemorrhage and were more commonly treated with steroids by 28 days of age. Amino acid and acylcarnitine values were not different for the two groups on the day of randomization. On day 7 (parenteral phase of nutrition), blood urea nitrogen, citrulline, histidine, methionine and succinyl carnitine were higher, and serine, glutamate and thyroxine levels were lower in the neonates who developed cholestasis than in who did not.

CONCLUSION

Cholestasis remains an important complication of parenteral nutrition, and several clinical and biochemical factors may be helpful in identifying high-risk patients.

Extrauterine growth restriction in preterm infants of gestational age < or =32 weeks

BACKGROUND

Extrauterine growth restriction (EUGR) in low-birthweight (LBW) infants affects their growth and developmental prognoses as well as their incidence of adult diseases. The aim of the present paper was to determine the frequency and contributing factors of EUGR in infants > or =32 weeks of gestational age.

METHODS

The subjects consisted of 416 infants from 22 facilities born between February and October 2002, whose gestational age was > or =32 weeks. For EUGR assessment, subjects whose body measurements in the 37-42 week postmenstrual age (PMA) period were below the 10th percentile of the standard normal distribution, were selected.

RESULTS

EUGR incidence rates for weight, length, and head circumference were 57%, 49%, and 6%. In appropriate-for-gestational-age infants, a negative correlation was found between number of gestational weeks and EUGR incidence rates for weight, length, and head circumference, but in small-for-gestational-age infants this was true only for head circumference. Lower gestational age and age in days to achieve complete feeding were among the shared factors contributing to EUGR incidence for weight, length, and head circumference. The significant factors for EUGR incidence for weight and length included whether the infant was small for gestational age, whether oxygen was administered at 36 weeks PMA, age in days at which breast-feeding was initiated, and age in days when the infant regained birthweight.

CONCLUSIONS

The growth retardation of preterm LBW infants in the neonatal intensive care unit continues to pose challenges. Relevant factors other than gestational age include intrauterine growth restriction, severe chronic lung disease, and poor nutrition.

Could lipid infusion be a risk for parenteral nutrition-associated cholestasis in low birth weight neonates?

To assess whether lipid infusion could be a risk factor for parenteral nutrition-associated cholestasis (PNAC) in low birth weight neonates, 22 newborns with cholestasis (29.8 +/- 1.6 weeks, 1298 +/- 217 g) were compared with 22 without cholestasis (29.5 +/- 1.7 weeks, 1286 +/- 363 g). The mean level of peak direct bilirubin for the cholestasis group was 4.6 mg/dl compared to 1.2 mg/dl for the noncholestasis group. A univariate analysis revealed that PNAC was significantly related to duration of fasting (p = 0.008) and parenteral nutrition (p < 0.0001), days of antibiotics use (p = 0.025), positive C-reactive protein (p = 0.018) or gastric culture (p = 0.018), and feeding intolerance (p < 0.0001). Total amino acid amount (p < 0.0001), total lipid amount (p < 0.0001), and average daily lipid amount (p = 0.002) were significantly higher in the cholestasis group than in the noncholestasis group. Conversely, prenatal administration of dexamethasone was a significant protective factor of PNAC (p = 0.008). Logistic regression analysis revealed that the cumulative amount of lipid infusion was an independent risk factor for PNAC (p = 0.041; OR 1.174; CI 1.007-1.369). We suggest that decreasing the cumulative load of amino acids and intralipids with early trophic feeding, control of infection, and prenatal administration of dexamethasone could possibly attenuate the severity of PNAC.

Variations in metabolic response to TPN are influenced more by sex than by light exposure

BACKGROUND

Failure to protect total parenteral nutrition (TPN) solutions from ambient light induces the generation of peroxides, which contributes to the oxidation of several amino acids. We hypothesized that photo-protection improves the metabolic response to TPN.

AIM

To study the effects of photo-protecting TPN on urinary nitrogen and vitamin C excretion and to evaluate in premature infants the influence of sex.

PATIENTS AND METHODS

Premature infants were randomized to receive from birth light-exposed (LE) or light-protected (LP) TPN. Upon reaching full TPN, parenteral nutrient intakes were correlated with normalized urinary nitrogen and vitamin C concentrations.

RESULTS

No differences were observed between LE and LP. However, sex-related differences were observed in nitrogen and vitamin C handling. In boys, 50% of the nitrogen loss was explained by parenteral amino acid intake, whereas in girls, no correlation was found. The inverse correlation observed between intake and urinary excretion only in girls suggests a state of greater vitamin C utilization in girls.

CONCLUSIONS

These results demonstrate that sex-related differences in nitrogen/protein metabolism reported during enteral nutrition are seen during TPN as well. Sex is an important variable that will need to be taken into account in future studies evaluating the potential clinical effects of photo-protecting TPN.