Growth, Body Composition, and Neurodevelopmental Outcomes at 2 Years Among Preterm Infants Fed an Exclusive Human Milk Diet in the Neonatal Intensive Care Unit: A Pilot Study

Music therapy and weight gain in preterm infants: Secondary analysis of the randomized controlled LongSTEP trial

OBJECTIVES

This study assessed the association between MT and weight gain among preterm infants hospitalized in Neonatal Intensive Care Units.

METHODS

Data collected during the international, randomized, Longitudinal Study of Music Therapy's Effectiveness for Premature Infants and their Caregivers (LongSTEP) study were compared between the MT group and the standard care (SC) group. Weights were recorded at birth, enrollment, and discharge. Weight percentiles, Z-scores, weight gain velocity, and extrauterine growth restriction (EUGR) were calculated.

RESULTS

Among 201 preterm infants included, no significant differences in weight parameters (weight, weight percentiles, weight Z-scores; all p ≥ 0.23) were found between the MT group (n = 104) and the SC (n = 97) group at birth, enrollment, or discharge. No statistical differences in EUGR represented by change in Z-scores from birth to discharge were recorded between MT and SC (0.8 vs. 0.7). Among perinatal parameters, younger gestational age (p = 0.005) and male sex (p = 0.012) were associated with increased risk of EUGR at discharge. Antenatal steroid treatment, systemic infection, bronchopulmonary dysplasia, neurological morbidities, retinopathy of prematurity, necrotizing enterocolitis, parental factors (amount of skin-to-skin care, bonding, anxiety, and depression questionnaire scores), and type of enteral nutrition did not significantly influence weight gain parameters (all p > 0.05).

CONCLUSIONS

In the LongSTEP study, MT for preterm infants and families was not associated with better weight parameters compared to the SC group. The degree of prematurity remains the main risk factor for unfavorable weight parameters.

Infant body composition: A comprehensive overview of assessment techniques, nutrition factors, and health outcomes

Body composition assessment is a valuable tool for clinical assessment and research that has implications for long-term health. Unlike traditional measurements such as anthropometrics or body mass index, body composition assessments provide more accurate measures of body fatness and lean mass. Moreover, depending on the technique, they can offer insight into regional body composition, bone mineral density, and brown adipose tissue. Various methods of body composition assessment exist, including air displacement plethysmography, dual-energy x-ray absorptiometry, bioelectrical impedance, magnetic resonance imaging, D3 creatine, ultrasound, and skinfold thickness, each with its own strengths and limitations. In infants, several feeding practices and nutrition factors are associated with body composition outcomes, such as breast milk vs formula feeding, protein intake, breast milk composition, and postdischarge formulas for preterm infants. Longitudinal studies suggest that body composition in infancy predicts later body composition, obesity, and other cardiometabolic outcomes in childhood, making it a useful early marker of cardiometabolic health in both term and preterm infants. Emerging evidence also suggests that body composition during infancy predicts neurodevelopmental outcomes, particularly in preterm infants at high risk of neurodevelopmental impairment. The purpose of this narrative review is to provide clinicians and researchers with a comprehensive overview of body composition assessment techniques, summarize the links between specific nutrition practices and body composition in infancy, and describe the neurodevelopmental and cardiometabolic outcomes associated with body composition patterns in term and preterm infants.

Trends in Preterm Body Composition and Neurodevelopmental Outcomes after Discharge

INTRODUCTION

Body composition, specifically fat-free mass (FFM), of preterm infants is associated with improved neurodevelopmental outcomes. Little is known about body composition of preterm infants after discharge. Preterm body composition was measured by air displacement plethysmography (ADP) at two time points, inpatient (35-40 weeks postmenstrual age [PMA]) and outpatient (48-58 weeks PMA), with neonatal factors and neurodevelopmental testing at 4-6 months corrected age. We hypothesized increased FFM is positively associated with neurodevelopment.

METHODS

From 2007 to 2011, 510 infants admitted to the Medical University of South Carolina's neonatal intensive care unit underwent ADP. A total of 379 of 510 (74%) had anthropometrics at birth, an ADP scan with FFM, fat mass, fat percent z-scores, and an outpatient neurodevelopmental evaluation (CAT/CLAMS, Peabody Gross Motor). Variables were compared using multivariate analyses for body composition measurements.

RESULTS

The infants were 32 ± 4.8 weeks gestational age at birth with an average birth weight of 1,697 ± 932 g. Most (56%) infants received maternal milk at discharge. CAT, CLAMS, and gross motor scores had positive correlations with FFM z-scores at inpatient and outpatient ADP (p < 0.05). Receiving maternal milk at discharge was positively associated with cognitive (β = 0.22, p < 0.05) and language scores (β = 0.26, p < 0.05).

CONCLUSION

Increased FFM is associated with improved cognitive, language, and gross motor testing. Maternal milk was positively associated with language and cognitive scores.

Differential associations between body composition indices and neurodevelopment during early life in term-born infants: findings from the Pakistan cohort: Multi-Center Body Composition Reference Study

OBJECTIVE

We examined associations between fat free mass (FFM) and fat mass (FM) accretion during the first 1000 days of life and neurodevelopment in term-born, low-risk infants from Karachi, Pakistan.

DESIGN

Prospective, observational study nested within the larger Multi-Center Body Composition Reference Study. FFM, FM, and fat% were estimated using measured deuterium dilution method. Neurodevelopmental outcomes were assessed at 24 months on the INTER-NDA (INTERGROWTH-21st Project Neurodevelopment Assessment) (n = 132).

RESULTS

Children with gross motor delays had significantly lower FFM at 18 months (8.01 ± 0.97 kg vs. 7.55 ± 0.20 kg). Children with positive and negative behavior problems had significantly higher fat% at 24 months (20.62 ± 4.30% vs. 18.23 ± 5.46%) and 20.89 ± 4.24% vs. 18.54 ± 5.38%). No associations remained significant after adjusting for covariates. Trajectory modeling showed that between 12 and 18 months, negative behavior scores changed by 13.8 points for every standard deviation change in fat accretion.

CONCLUSIONS

Our findings highlight the importance of balancing neurodevelopment and metabolic risk when designing nutritional interventions for young children.

Impact of an Infant-Driven Feeding Initiative on Feeding Outcomes in the Preterm Neonate

BACKGROUND

Poor feeding techniques result in adverse outcomes for preterm infants. Infant-driven feeding (IDF) is a structured feeding method that standardizes neonatal cue-based feedings, and matches the neurodevelopmental stage of the preterm infant. The purpose of this quality improvement project is to assess whether initiation of an IDF initiative impacts time from first nipple feed (NF) to full NF and to discharge in infants born before 35 weeks' gestational age. Secondary aims include assessment of the impact of IDF on neonatal growth and feasibility of following an IDF protocol in a level III neonatal intensive care unit (NICU).

METHODS

This quality improvement project assesses differences in time to first NF, length of hospital stay, and neonatal growth before and after usage of an IDF protocol. Eighty infants were included, 40 prior to and 40 after IDF intervention. Nurses were trained on IDF philosophy and methods prior to initiation.

RESULTS

IDF was associated with discharge at a younger corrected gestational age (CGA), attainment of ad lib feeds at a younger CGA, and shorter amount of days between first NF and discharge. Infants utilizing IDF had slower weight gain, demonstrated by a larger drop in z score in the IDF group. The medical team and bedside nurses were able to follow the IDF protocol with few exceptions.

IMPLICATIONS FOR PRACTICE/RESEARCH

IDF allows for optimization of a preterm infant's NICU stay and prepares infants for a safe discharge sooner. This could lead to increased parental satisfaction and decreased hospital cost. Further studies are indicated to ensure these benefits remain and focus on impact direct breastfeeding plays in the IDF model.

Evolution of Preterm Infant Nutrition from Breastfeeding to an Exclusive Human Milk Diet: A Review

The benefits of feeding human milk to human infants are well-established. Preterm infants, particularly those born with very low birthweight (VLBW; <1,500 g), are a uniquely vulnerable population at risk for serious, life-threatening complications as well as disruptions in normal growth and development that can affect their lives into adulthood. Feeding VLBW preterm infants an exclusive human milk diet (EHMD) from birth that consists of the mother's own milk or donor human milk plus a nutritional fortifier made exclusively from human milk has been associated with a reduction in morbidity and mortality and improved early growth and developmental metrics. Preliminary evidence suggests that the health benefits of adopting an EHMD (or avoiding cow milk products) early in life may last into adulthood. This review briefly summarizes the history of breastfeeding and describes the available evidence on the benefits of an EHMD among VLBW preterm infants as well as the importance of high-quality manufacturing standards for producing safe and effective human milk-based products.

The Impact of Homogenization on Donor Human Milk and Human Milk-Based Fortifiers and Implications for Preterm Infant Health

An exclusive human milk diet (EHMD) has been shown to reduce health complications of prematurity in infants born weighing ≤1250 g compared with cow milk-based diets. Accordingly, the number of available human milk (HM)-based nutritional products continues to increase. Newly available products, and those reportedly soon to enter the market, include homogenized donor HM and homogenized HM-based fortifiers. Existing literature demonstrating the benefits of an EHMD, however, is limited to non-homogenized HM-based products. Herein, we summarize existing evidence on the impact of homogenization on HM, with a particular focus on changes to the macromolecular structure of the milk fat globule and the subsequent impact on digestion kinetics. We use these published data to create a conceptual framework for the potential implications of homogenized HM-based nutritional products on preterm infant health. Importantly, we underscore that the safety and efficacy of homogenized HM-based products warrant investigation.

Neurodevelopmental outcomes of extremely preterm infants fed an exclusive human milk-based diet versus a mixed human milk + bovine milk-based diet: a multi-center study

OBJECTIVE

The objective of this multi-center study was to compare, in infants ≤1250 g birth weight (BW) with neurodevelopmental assessment at 18-22 months of corrected age (CA), whether their neurodevelopmental outcomes differed based on exposure to an exclusive human milk-based (HUM) or to a bovine milk-based fortifier and/or preterm formula (BOV).

STUDY DESIGN

Retrospective multi-center cohort study of infants undergoing neurodevelopmental assessment as to whether HUM or BOV exposure related to differences in outcomes of infants at 18-22 months CA, using the Bayley Scales of Infant Development III (BSID-III). BSID-III cognitive, language, and motor scores were adjusted for BW, sex, study site, and necrotizing enterocolitis.

RESULTS

252 infants from 6 centers were included. BSID-III cognitive scores were higher in the HUM group (96.5 ± 15.1 vs 89.6 ± 14.1, adjusted p = 0.0001). Mean BSID-III language scores were 85.5 ± 15.0 in HUM and 82.2 ± 14.1 in BOV (adjusted p = 0.09). Mean BSID-III motor scores were 92.9 ± 11.7 in HUM and 91.4 ± 14.6 in BOV (adjusted p = 0.32).

CONCLUSION

In this cohort of infants undergoing neurodevelopmental assessment, infants receiving HUM diet had significantly higher cognitive BSID-III scores at 18-22 months CA. Further investigation is needed of this potential for HUM to positively influence infant cognitive outcomes.

Preterm nutrition and neurodevelopmental outcomes

Survival of preterm infants has been steadily improving in recent years because of many recent advances in perinatal and neonatal medicine. Despite these advances, the growth of survivors does not reach the ideal target level of the normal fetus of the same gestational age. Postnatal weight gain is often not achieved because extrauterine growth has higher energy requirements than intrauterine growth, due to the intensive care environment, illness and inadequate nutrition. Although many other factors influence infant brain development, including family socioeconomic and educational background, the role of nutrition is considerable and fortunately, amenable to intervention. In the preterm neonate, the brain is the most metabolically demanding organ, consuming the largest proportions of energy and nutrient intake for its function and programmed growth and maturation. Weight gain, linear and head circumference growth are all markers of nutritional status and are independently associated with long-term neurodevelopment. Brain development is not only the result of nutrients intake, but in addition, of the interaction with growth factors which depend on adequate nutrient supply and overall health status. This explains why conditions such as sepsis, necrotizing enterocolitis and chronic lung disease alter the distribution and accretion of nutrients thereby suppressing growth factor synthesis. In this review, we will focus on the direct role of nutrition on neurodevelopment, emphasizing why it should be started without delay. The nutritional requirements of the preterm infant will be discussed, followed by the effects of general nutritional interventions and specific nutrients, as well as the role of nutritional supplements on neurodevelopment. The primordial role of human breast milk, breast milk fortifiers and human milk oligosaccharides will be discussed in detail. We will also examine the role of nutrition in preventing neonatal complications which can affect neurodevelopment in their own right.

Individualized Target Fortification of Breast Milk: Optimizing Macronutrient Content Using Different Fortifiers and Approaches

Background: Native breast milk composition displays significant inter- and intra-individual variation which persists after standard fortification with fixed doses and challenges target fortification. This study aims to analyze the macronutrient composition of different commercially available fortifiers and the effect of different fortification strategies on nutritional intake of preterm infants.

Methods: In 103 preterm infants, native breast milk samples were collected from 24-h feeding batches (n = 3,338) and fat, protein and carbohydrate contents were analyzed. Nutrient content was compared for breast milk that had undergone either (i) standard fortification, (ii) targeted fortification, (iii) selective batching according to breast milk composition, or (iv) partial lyophilization. For (i) eight commercially available standard fortifiers were tested. Targeted fortification (ii) involved the addition of single component modulars of either protein, fat or carbohydrates to standard fortified breast milk. Using a mathematical growth model, the combined effect of protein, fat and carbohydrate intake on growth was assessed. The best composition of standard fortifiers as the initial step for target fortification was explored assuming three clinical scenarios for milk analysis.

Results: Macronutrient content was highly variable between native breast milk samples, and this variation was still present after standard fortification, however at elevated macronutrient levels. Standard fortification, breast milk batching, as well as partial lyophilization of human milk resulted in deficient and imbalanced enteral intakes in a significant proportion of infants. Target fortification reduced this variation in a, respectively, higher percentage of samples. The effect size was dependent on the number of measurements per week. The optimum composition of standard fortifiers was dependent on the clinical scenario (measurement frequency) for target fortification.

Conclusions: To provide precise and accurate intakes of macronutrients, breast milk should be target fortified. Standard fortified breast milk can result in excess above recommended intakes of some macronutrients which limits the efficiency of target fortification. Standard fortifiers with improved composition are needed for target fortification.

Expressed Breast Milk Contamination in Neonatal Intensive Care Unit

Background

The health benefits of breastfeeding are well known. However, some ill babies including those admitted to the neonatal intensive care unit (NICU) cannot be directly breastfed. In this situation, expressed breast milk (EBM) can be used. However, breast milk is not always sterile and may be contaminated by many microorganisms. EBM contamination is probably attributed to improper technical and hygienic factors and may pose significant threats to the newborn baby. The present study aimed to document the prevalence of EBM contamination in NICU and to uncover the relevant risk factors.

Subjects and Methods

The study included 118 mothers who could express breast milk for their own neonates admitted to the NICU. A checklist was used to document the steps the mothers followed during expression of milk and all steps of handling until the EBM reached the NICU. A 1 mL sample of EBM was obtained and sent to the microbiology laboratory within 20 minutes. Data obtained from the present study are expressed as number and percentage or mean ± standard deviation (SD). Statistical calculations were computed using SPSS 25.

Results

In the present study, 106 (89.8%) out of the assessed 118 EBM samples were contaminated. Hygienic factors related to EBM contamination included hand only wash, possible recontamination of hands during turning taps off, lack of using cotton pads or cloth piece on nipple and breast cleaning by water only. Other factors related to EBM contamination included container cleaning by water only, fresh milk refrigeration after > 4 hours, adding freshly expressed warm breast milk to refrigerated milk expressed earlier in the same day, milk transport in plastic bags with ice packs and longer transportation time. In the contaminated samples, the most commonly isolated organisms included Staphylococcus aureus (55.7%),Staphylococcus epidermidis (21.7%) and Enterobacter (11.6%).

Conclusion

The present study identified bacterial contamination in about 90% of EBM samples delivered to NICU infants. Factors related to EBM contamination include hygienic, storage and transport factors.

The effect of continuous clustered care on the physical growth of preterm infants and the satisfaction with the nursing care

PURPOSE

This study aimed to evaluate the effect of continuous clustered care on the physical growth of preterm infants and on the satisfaction with the nursing care.

METHODS

120 preterm infants who were admitted to our hospital from Jan 2018 to Dec 2018 were recruited as the study cohort. These infants were randomly divided into a control group (n=60, routine care) and an experimental group (n=60, continuous clustered nursing care). The study compared the parenting skills in the two groups, the infant development at 6 and 12 months, the prevalence of diseases within one year after discharge, and the parents' satisfaction with the nursing care.

RESULTS

There was no significant difference in the parenting skill levels between the two groups. The body masses, heights, and head circumferences of the infants at 6-months and 12-months in the experimental group were better than they were in the control group. The experimental group's physical and intellectual development were significantly better than the physical and intellectual development in the control group (P<0.05). In the experimental group, the number of cases with infantile respiratory, umbilical, and intestinal infections was lower than it was in the control group. The parental satisfaction level with the nursing care in the experimental group was significantly higher than it was in the control group (96.67% vs 78.33%) (P<0.05).

CONCLUSION

Continuous clustered nursing care can improve the physical growth of preterm infants, reduce the adverse events and improve the nursing satisfaction level.

Update on Calcium and Phosphorus Requirements of Preterm Infants and Recommendations for Enteral Mineral Intake

Background: With current Ca and P recommendations for enteral nutrition, preterm infants, especially VLBW, fail to achieve a bone mineral content (BMC) equivalent to term infants. During the first 3 years, most notably in light at term equivalent age (<−2 Z score) VLBW infants’ BMC does not catch up. In adults born preterm with VLBW or SGA, lower adult bone mass, lower peak bone mass, and higher frequency of osteopenia/osteoporosis have been found, implying an increased risk for future bone fractures. The aim of the present narrative review was to provide recommendation for enteral mineral intake for improving bone mineral accretion. Methods: Current preterm infant mineral recommendations together with fetal and preterm infant physiology of mineral accretion were reviewed to provide recommendations for improving bone mineral accretion. Results: Current Ca and P recommendations systematically underestimate the needs, especially for Ca. Conclusion: Higher enteral fortifier/formula mineral content or individual supplementation is required. Higher general mineral intake (especially Ca) will most likely improve bone mineralization in preterm infants and possibly the long-term bone health. However, the nephrocalcinosis risk may increase in infants with high Ca absorption. Therefore, individual additional enteral Ca and/or P supplementations are recommended to improve current fortifier/formula mineral intake.

Relationship between Fatty Acids Composition/Antioxidant Potential of Breast Milk and Maternal Diet: Comparison with Infant Formulas

The fatty acid composition of human breast milk is relevant for the energy, immunity and eicosanoid production in infants. Additionally, the antioxidant properties of foods are essential for human health. Therefore, in the present study we aimed to investigate the relationship between maternal diet and fatty acids composition as well as the antioxidant potential of breast milk from donors to human milk bank of Perugia's hospital, Italy. Results were compared with infant formulas. We observed increased levels of total fatty acids and, in particular, saturated and monounsaturated fatty acids in milk from mothers fed on a vegetable and fruit-rich diet compared with a Mediterranean diet. In the same milk, a reduced antioxidant potential was found. All infant formulas resulted in richer total fatty acid content than human breast milk. Only some formulas were qualitatively similar to breast milk. Of note, the antioxidant potential of the formulas was higher or lower than the human milk with the exception of one sample. The antioxidant potential of four formulas was very high. Dietary supplementation with antioxidants has been shown to have a teratogenic effect and to increase the formation of metastases in adult. There are no data on the effects of excess antioxidants in the infants, but the possibility that they can be harmful cannot be excluded.