Enteral nutrient supply for preterm infants: commentary from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition

Nutrient Intake and Plasma and Erythrocyte Content Among Lactating Mothers of Hospitalized Very Preterm Infants: Associations with Human Milk Composition

BACKGROUND/OBJECTIVES

Lactating mothers have increased nutritional requirements, but nutritional adequacy is difficult to achieve. Additionally, human milk (HM) composition depends on maternal diet. However, the nutritional intake and status of mothers with hospitalized very preterm infants (MHVPIs) (<32 weeks of gestational age) have rarely been assessed. Hence, the aim of the present study was to determine the intake of macronutrients, micronutrients, and lipids, as well as the nutritional status of MHVPIs. The results were compared with a group of HM donors (HMDs), and associations with HM composition were evaluated using multiple linear regression.

METHODS

For dietary assessment, a 5-day dietary record including supplement intake was completed by 15 MHVPIs and 110 HMDs. Vitamins and fatty acids (FA) were determined in plasma and erythrocytes; minerals and methylmalonic acid were determined in urine; and macronutrients, vitamins, minerals, and the lipid profile were determined in HM.

RESULTS

Considering dietary reference intakes, the dietary evaluation of MHVPIs revealed a high percentage of inadequate nutrient intake in relation to total energy, as well as for iodine and vitamins B8, B9, C, D, and E. A high protein intake was observed. The percentage of energy from carbohydrates was low, whereas the percentage of energy from fat was high. However, the diet of MHVPIs did not differ substantially from the diet of HMDs. Associations were observed between the study groups (MHVPI vs. HMD) and the HM concentration of protein, several micronutrients, and fatty acids independent from intake and status.

CONCLUSIONS

Deficient nutrient intakes did not appear to be exclusively related to MHVPI but rather seemed to be widespread in both study groups. However, for preterm infants, an insufficient supply of nutrients is critical and should be addressed in order to improve preterm infant's outcomes. Furthermore, we provided additional insights into the exploration of HM by relating its composition to prematurity.

Association of the addition of a multicomponent additive to the human milk provided to preterm newborns with outcomes: A prospective cohort

BACKGROUND

The nutritional needs of preterm newborns (PTNB) are increased and enhancing nutritional management is essential to meet them. The addition of multicomponent additive (MA) to human milk (HM) is used as a treatment strategy. The objective of the research is to analyze the association between the use of MA added to HM with nutritional and clinical outcomes in low-birth weight PTNB admitted to a neonatal intensive care unit (NICU).

METHODS

Prospective cohort study with PTNB weighing less than 2500 g during hospitalization in the NICU, who were divided into two distinct groups based on the presence or absence of MA supplementation. We investigated outcomes related to nutritional status at discharge, length of stay, presence of metabolic bone disease of prematurity (MBDP), extrauterine growth restriction (EUGR) and encouragement of breastfeeding at discharge.

RESULTS

A total of 65 PTNB were included. We found that the lower the BW, the more often the use of MA was observed (p = 0.006). At discharge, there was a decline in z- scores, in which 46 % of PTNB who used MA developed malnutrition. The length of stay was longer in the group of PTNB who used MA (p < 0.001). The percentage of PTNB with MBDP who used MA (52.5 %) was higher than the percentage of those who did not use it (p = 0.006). The probability of PTNB with MBDP using MA is 2.65 times higher than those without MDBP.

CONCLUSION

The use of MA to HM did not prevent or avoid the decline in nutritional status of the PTNBs, considering that those who used it had greater difficulty gaining weight, longer hospital stays, and more MBPD diagnoses compared to the group that did not use supplementation. However, the MA was crucial as it provided essential nutritional support for those PTNB who are more susceptible to MBDP.

Individualized Target Fortification of Breast Milk with Protein, Carbohydrates, and Fat for Preterm Infants: Effect on Neurodevelopment

Background/Objectives: Preterm infants are at high risk of extrauterine growth restriction and suboptimal neurological development due to cumulative nutrient deficits. Standard fortification (SF) of human milk does not account for individual macronutrient variability, potentially leading to inadequate intake. Target fortification (TFO) adjusts supplementation based on the measured macronutrient content, aimed at providing macronutrient intake aligned with ESPGHAN (European Society for Paediatric Gastroenterology, Hepatology and Nutrition) recommendations and optimize growth and development. This study aims to evaluate the effects of TFO compared to SF on growth, body composition, and neurological outcomes at 18 months corrected age. Methods: In this double-blind, randomized controlled trial, preterm infants (<30 weeks gestation) received either SF or TFO for at least three weeks. Macronutrient levels in breast milk were analyzed three times per week, with modular adjustments in the TFO group. Growth parameters, body composition at 36 weeks postmenstrual age, and Bayley Scales of Infant and Toddler Development III (BSID-III) scores at 18 months corrected age were assessed (n = 69). Results: TFO significantly increased protein, fat, and carbohydrate intake compared to SF, leading to higher weight gain (2514 ± 289 g vs. 2283 ± 332 g, p < 0.01) and growth velocity (21.7 ± 2.3 g/kg/d vs. 19.2 ± 2.2 g/kg/d, p < 0.001). In infants whose mother's milk had low protein levels, fat-free mass was significantly higher with TFO compared to SF. BSID-III scores were higher in the TFO group across cognitive, language, and motor domains, with significant improvements in expressive language scores in infants whose mother's milk had high protein levels (p < 0.05). The number of preterm infants with a motor BSID-III score of ≤70 was significantly lower in the TFO group compared to the SF group (0 vs. 3, p < 0.05). Conclusions: TFO enhanced growth and body composition and may support better neurological outcomes in preterm infants. While most BSID-III differences were not statistically significant, the data suggest that TFO may reduce the risk of developmental delays. Larger, multicenter trials are needed to confirm these findings.

Vitamin D metabolome in preterm infants: insights into postnatal metabolism

OBJECTIVES

To describe the structure of vitamin D metabolome and investigate the possible cause of high serum levels of C3 epimers of 25-(OH)D in preterm infants, we compared the vitamin D metabolites in umbilical cord blood with serum samples taken at 28 days of age.

METHODS

We analysed 40 preterm infants (29+0-32+6 weeks of gestation). Cholecalciferol, 25-(OH)D, and its C3-epimers were measured using liquid chromatography. A microsomal study with human liver and kidney microsomes was conducted to assess vitamin D metabolism. Identified metabolites were then examined in cord blood and serum samples.

RESULTS

Cholecalciferol, 25-(OH)D, and its C3-epimers were significantly lower in cord blood compared to serum at 28 days of age (p<0.001 for all metabolites). Conversely, metabolites from the microsomal study (monohydroxylated-, dihydroxylated-, and mono-oxylated dihydroxylated-cholecalciferol and their C3-epimers) were significantly higher in cord blood (p<0.001 for all).

CONCLUSIONS

Our findings indicate that cholecalciferol, 25-(OH)D, and its C3-epimers increase during the first month of life, suggesting functional biosynthesis and postnatal accumulation of these metabolites. Conversely, based on microsomal study results, it seems that biotransformation responsible for a degradation of vitamin D during the first month of life in preterm infants is functionally impaired.

Evaluating Prevalence of Preterm Postnatal Growth Faltering Using Fenton 2013 and INTERGROWTH-21st Growth Charts with Logistic and Machine Learning Models

Background/Objectives: Postnatal growth faltering (PGF) significantly affects premature neonates, leading to compromised neurodevelopment and an increased risk of long-term health complications. Methods: This retrospective study at a level III NICU of a tertiary hospital analyzed 650 preterm neonates born before 33 weeks. Postnatal growth was evaluated using the Fenton2013 and INTERGROWTH-21st growth charts, with changes in weight z-scores from birth to discharge classified as normal growth (ΔZ ≥ -1), non-severe PGF (-2 ≤ ΔZ < -1), and severe PGF (ΔZ < -2). Results: Mean gestational and postmenstrual age at discharge was 30 weeks (SD 1.9) and 37.1 weeks (SD 2.7), respectively. Fenton2013 growth curves revealed a higher prevalence of non-severe and severe PGF (43% and 14.6%) compared to INTERGROWTH-21st (24.5% and 10.3%). A more rapid establishment of full enteral feeds was strongly associated with reduced severe PGF prevalence in both growth charts (p < 0.001), as was shorter hospitalization. Late-onset sepsis was associated with an increased risk of severe PGF, while being small for gestational age (SGA) was protective against severe PGF across both growth charts (p < 0.001). A trend of decreasing PGF prevalence was noted over the study years, most probably attributed to the implementation of updated nutritional guidelines. Interestingly, when machine learning classification models were evaluated in our Greek cohort, a notable decline in predictive accuracy depending on the growth standard applied was observed. Conclusions: Our study highlights the need for standardizing PGF definition in an attempt to enhance nutritional management and further investigate the long-term impacts of nutritional interventions on growth, neurodevelopment, and overall health outcomes.

The effect of implementing parenteral nutrition guideline on growth and clinical outcomes in preterm infants: a comparative study

BACKGROUND

To improve the nutritional management of premature infants in neonatal intensive care units (NICUs), we developed and implemented a standardized parenteral nutrition (PN) protocol aimed at optimizing early macronutrient delivery. This study evaluated the impact of the new protocol on growth parameters and clinical outcomes in preterm neonates.

METHODS

This prospective, non-randomized interventional cohort study included two groups of preterm infants born before 32 weeks of gestation or with birth weights under 1250 g. The PRE group received individualized PN formulations based on clinician discretion, while the POST group received PN guided by a newly introduced, stepwise algorithmic protocol aiming to optimize early protein and energy intake. Anthropometric data, daily energy and macronutrient intakes during the first 14 days, and weight at day 28 were collected. Clinical outcomes-including the incidence of sepsis, necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH) retinopathy of prematurity (ROP) and hospitalization duration-were compared between groups.

RESULTS

A total of 139 infants were enrolled (69 PRE, 70 POST). While weight gain in the first 14 days was similar, the POST group showed significantly greater weight and weight velocity by day 28. These improvements paralleled higher mean daily energy and protein intakes during the early postnatal period. The incidence of bacterial sepsis was significantly reduced in the POST cohort, possibly reflecting better nutritional status and improved PN preparation practices. Although other complications did not differ significantly, fewer infants in the POST group required prolonged hospitalization (> 90 days).

CONCLUSION

Implementation of a standardized PN protocol improved early nutritional intake and was associated with better growth and reduced infection rates in premature infants. These findings support the use of structured PN strategies to enhance early neonatal outcomes in NICU settings.

TRIAL REGISTRATION

The Iranian Registry of Clinical Trials (http//www.irct.ir) with the identification No. IRCT20240519061838N2. Registered 24 November 2024.

Plasma amino acids after human milk fortification and associations with growth in preterm infants

BACKGROUND

It is unknown how plasma amino acid (AA) concentrations vary with fortification type, growth and insulin-like growth factor 1 (IGF-1) concentrations in the first weeks of life in very preterm infants (VPIs).

METHODS

Human milk for VPIs (n = 225) was fortified with bovine colostrum (BC, intact proteins, high bioactivity) or conventional fortifier (CF, hydrolysed bovine whey proteins). Plasma was sampled at fortification start (T0, ~1 week of age) and after one (T1) and two (T2) weeks. Changes in Z-scores for weight, length and head circumference (HC) were calculated from T0 to 35 weeks postmenstrual age.

RESULTS

Compared with CF, BC fortification increased 12 AAs (~10-40%, p < 0.05) and reduced Lys concentrations (10-16%, p < 0.05). Analysed across groups, T0-T2 AA increments associated positively with HC growth (12 AAs) and IGF-1 concentrations (5 AAs), and inversely with gestational age (13 AAs) and weight (8 AAs) at birth. The plasma protein profile (proteome) was unaffected by fortification.

CONCLUSIONS

BC fortification increased the plasma concentrations of many AAs. Fortification-induced AA increments associated positively with HC growth and IGF-1 concentrations, and were affected by immaturity and birth weight. Still, plasma AA variability within physiological levels appears to have limited implications for clinical outcomes during the early life of VPIs.

IMPACT

It is unknown how human milk fortification affects plasma amino acid concentrations, in turn influencing growth patterns in very preterm infants. We show that a fortifier based on bovine colostrum induces higher amino acid concentrations than a conventional fortifier. Fortification-induced increments in amino acid concentrations associated with gestational age, birth weight and head growth, but with small effect sizes and limited relation to body weight or length growth. Plasma amino acid concentrations are influenced by fortification of human milk in early life, but have limited practical application as predictors of body growth and health in individual very preterm infants.

Use of human milk and fortification in the neonatal intensive care unit

Human milk is the gold standard for the nutrition of very-low-birthweight (VLBW) infants. Pasteurized donor human milk (DM) should be provided for VLBW infants when own mother's milk (OMM) is not available. Prevention of Necrotizing enterocolitis (NEC) is an important short-term benefit associated with human milk feeding. Human milk alone does not meet the nutritional requirements for VLBW infants leading to nutritional inadequacy, postnatal growthfaltering,and risk of poor neurodevelopmental outcome. Human milk fortification with multicomponent fortifiers increases calories and provides additional protein and minerals and should minimize nutritional deficits. Human milk derived fortifiers (HMDF) provide an exclusive human milk diet but recent evidence to recommend their use over cow milk derived fortifiers is lacking. Individualized fortification using human milk analyzers in real time is an emerging practice that allows for a more personalized provision of nutrient needs.

Effect of Multi-Nutrient Milk Fortification on Preterm Neonate Outcomes: A Network Meta-Analysis

Background/Objectives: Optimal feeding regimens for preterm neonates, including the role of multi-nutrient fortification, are unknown, leading to large practice variation in comparing different feeding regimens that include fortification and their impact on outcomes for preterm infants. Methods: Using a network meta-analyses design, two reviewers independently extracted data. A Cochrane CENTRAL, Medline, Embase, and CINAHL search was conducted for all studies published up to 27 June 2023. Randomized clinical trials of feeding regimens for preterm infants that included multi-nutrient fortification were included. Outcomes were mortality, necrotizing enterocolitis (NEC), retinopathy of prematurity (ROP), sepsis, periventricular leukomalacia (PVL), bronchopulmonary dysplasia (BPD), time to full enteral feeds, and the Bayley II MDI developmental score. Results: Fifty-nine studies were included. For mortality, NEC, and time to reach full enteral feeds, the top-ranked treatment class was the mother's own milk with donor milk and a human-milk-based fortifier. For ROP and BPD, the top-ranked treatment class was mother's own milk with a phosphorus fortifier. For sepsis, the top-ranked treatment class was mother's own milk with formula. For PVL, the top-ranked treatment classes were mother's own milk and mother's own milk with donor milk and a bovine fortifier in the two disconnected networks. For the Bayley II MDI score, the top-ranked treatment class was mother's own milk with formula and bovine fortification. Conclusions: Treatment rankings are consistent with the underlying hypothesis that increased mother's own milk intake appears to be associated with better clinical outcomes. This review provides the first global view of interventions and highlights insufficient high-quality evidence to support or refute one fortification feeding regimen over another.

Choline in Pediatric Nutrition: Assessing Formula, Fortifiers and Supplements Across Age Groups and Clinical Indications

Background: Sufficient choline supply is essential for tissue functions via phosphatidylcholine and sphingomyelin within membranes and secretions like bile, lipoproteins and surfactant, and in one-carbon metabolism via betaine. Choline requirements are linked to age and genetics, folate and cobalamin via betaine, and arachidonic (ARA) and docosahexaenoic (DHA) acid transport via the phosphatidylcholine moiety of lipoproteins. Groups at risk of choline deficiency include preterm infants, children with cystic fibrosis (CF) and patients dependent on parenteral nutrition. Fortifiers, formula and supplements may differently impact their choline supply. Objective: To evaluate added amounts of choline, folate, cobalamin, ARA and DHA in fortifiers, supplements and formula used in pediatric care from product files. Methods: Nutrient contents from commonly used products, categorized by age and patient groups, were obtained from public sources. Data are shown as medians and interquartile ranges. Results: 105 nutritional products including fortifiers, formula and products for special indications were analyzed. Choline concentrations were comparable in preterm and term infant formulas (≤6 months) (31.9 [27.6-33.3] vs. 33.3 [30.8-35.2] mg/100 kcal). Products for toddlers, and patients with CF, kidney or Crohn's disease showed Choline levels from 0 to 39 mg/100 kcal. Several products contain milk components and lecithin-based emulsifiers potentially increasing choline content beyond indicated amounts. Conclusions: Choline addition is standardized in formula for term and preterm infants up to 6 months, but not in other products. Choline content may be higher in several products due to non-declared sources. The potential impact of insufficient choline supply in patients at risk for choline deficiency suggests the need for biochemical analysis of products.

Vitamin D status and the adequacy of its supplementation during the first year of life in preterm infants in northern Japan

BACKGROUND

Vitamin D (VD) deficiency (VDD) is a major concern in preterm infants. The prevalence of VDD in mothers and infants varies between countries and is affected by a range of factors, such as geography and lifestyle. Thus, strategies aimed at preventing VDD must consider the status of each region. However, few reports have explored VDD in preterm infants in Japan and the safety and efficacy of VD supplementation in addressing VDD remain unclear.

METHODS

This study was conducted between September 2019 and October 2022. The participants were 108 preterm infants who were divided into three groups based on their gestational age: <28 weeks (Group 1), 28-33 weeks (Group 2), and 34-36 weeks (Group 3). VD status at birth was assessed, and 25-hydroxyvitamin D (25OHD) levels and biochemical markers were monitored during supplementation with 400 IU/day of VD over the first year of life.

RESULTS

Levels of 25OHD at birth were 10.0 (10.0-16.1), 10.5 (10.0-18.0), and 13.0 (10.0-19.0) nmol/L in Groups 1, 2, and 3, respectively. Infants in all three groups exhibited marked VDD. Their 25OHD levels gradually increased with VD supplementation before plateauing at 6 months. Nevertheless, VDD persisted in the majority of infants at 1 month of age. Serum intact parathyroid hormone levels peaked at 1 month of age and declined thereafter, negatively correlating with 25OHD levels. None of the infants exhibited symptoms of VD toxicity.

CONCLUSION

Preterm infants in northern Japan exhibited substantial VDD, regardless of gestational age. In our cohort, VD supplementation at 400 IU/day safely increased 25OHD levels. However, VD levels improved gradually over the months, and several of these infants developed secondary hyperparathyroidism. Further studies are warranted to determine the optimal VD supplementation dose for preterm infants in this region.

Determination of macronutrient profile and energy composition in human milk via Mid-Infrared Spectrometer Analysis: An experimental study

BACKGROUND

To study the effect of specific maternal and neonatal variables on the macronutrients and energy composition of expressed human milk samples.

METHODS

A prospective study was conducted including 296 samples of human milk delivered from 201 participant mothers. Human milk was analyzed using Mid-Infrared Spectrometer Analysis.

RESULTS

Colostrum exhibited significantly higher crude protein and lower fat, carbohydrate, total solids, and energy content compared with transitional or mature milk. Milk from mothers who were obese showed significantly higher total solids levels and energy, compared with milk from mothers who were overweight, or of normal weight. Milk from mothers of preterm infants had higher crude protein, and lower carbohydrate content, compared with that of full-term infants. Finally, significant differences were observed in fat, carbohydrate, total solids, and energy between extremely and very low, low, or normal birth weight infants. Maternal body mass index and the phase of lactation were significantly associated with crude protein, whereas pregnancy duration and birth weight were positively correlated with carbohydrates and negatively correlated with fat, total solids, and energy content.

CONCLUSION

Neonatal and maternal factors are associated with the macronutrients and energy content of expressed human milk samples. Further research is warranted to explore the specific preterm infants' nutrition needs.

Comparison of the effects of different doses of vitamin D supplementation on the development of necrotizing enterocolitis: A retrospective study

This study aimed to evaluate the effects of different doses of vitamin D supplementation (400 and 800 IU) on the development of necrotizing enterocolitis (NEC) and potential differences in the clinical course of the disease in preterm infants. In addition, the potential correlation between D levels and NEC stage severity was assessed. Medical records of 363 preterm infants (gestational age <32 weeks) were retrospectively reviewed. Infants who developed NEC were divided into two groups based on the dose of vitamin D supplementation (400 and 800 IU/day). A comparison was made between the two groups with respect to demographic data, the severity of NEC, maternal and infant vitamin D levels, length of hospital stay, incidence of sepsis, and mortality rates. The incidence of NEC was significantly lower during the period when 800 IU of vitamin D was administered (7.7%) compared with the period when 400 IU was administered (12.6%). No significant differences were observed between the two groups in terms of NEC stage, mortality rates, or length of hospital stay. An inverse correlation was found between maternal and infant vitamin D levels and NEC stage severity, suggesting that the role of vitamin D metabolism in NEC pathogenesis may be more complex.

The Critical Role of Vitamin D Supplementation for Skeletal and Neurodevelopmental Outcomes in Preterm Neonates

Background/Objectives: Metabolic bone disease of prematurity (MBDP) is a multifactorial disorder resulting from disrupted transplacental mineral transfer and postnatal nutritional deficits, particularly affecting preterm neonates born before 32 weeks of gestation or weighing under 1500 g. Although substantial research has focused on skeletal outcomes, few studies have explored the association between MBDP and neonatal neurological impairment. This narrative review is the first to integrate the pathophysiological mechanisms, diagnostic methods, and preventive strategies for MBDP, while simultaneously investigating its potential impact on neurodevelopment. Methods: A narrative review of recent peer-reviewed studies, systematic reviews, and clinical trials was performed focusing on biochemical markers (alkaline phosphatase, FGF23, calcium, and phosphorus), emerging tools such as bioelectrical impedance analysis (BIA), and the effects of early nutritional interventions on both skeletal and neurodevelopmental outcomes in preterm infants (n = seven included articles). Results: Early elevations in ALP, particularly when combined with low serum phosphorus and FGF23 levels, provide sensitive markers for identifying MBDP. Furthermore, insufficient vitamin D levels during gestation and in the neonatal period have been associated with increased risks of seizures, hypotonia, and developmental delays. Studies suggest that enhanced vitamin D supplementation in preterm infants (up to 800 IU/day) may improve mineral absorption and bone formation and confer neuroprotective benefits through anti-inflammatory and antioxidant mechanisms. Conclusions: This is the first review on the neurological implications of biochemical actors of MBDP. As a result, diagnostic and therapeutic strategies, including vitamin D supplementation, can improve bone and neurodevelopmental outcomes. Future prospective studies are required to standardize diagnostic criteria and optimize therapeutic regimens for enhanced long-term benefits.

Human milk for preterm infants

The term "human milk" conceals important differences between that from an infant's own mother and that obtained from a person or persons who have donated or sold their breast milk. These include differences in nutritional content, and a wide range of non-nutritional components that promote immune, metabolic, and brain development and have evolved over the course of time to transmit biological information from mother to infant. Human milk feeding to preterm babies also encompasses elements such as processing and storage, differences between feeding expressed breast milk versus suckling at the breast, and societal and economic considerations. Current evidence of clinical effectiveness of donated or commercial human milk, and whether macro and micronutrient supplementation are required indicates considerable uncertainty and the possibility of harm. Preterm nutrition is an emotive subject, but important evidence gaps need to be recognised, acknowledged, and addressed if the care of very preterm babies is to improve through a strong evidence-base.

Recent advances in understanding pathophysiology of non-nutritional stunting in very preterm infants

Very preterm infants (VPIs) often experience extrauterine growth failure. Therefore, aggressive nutritional management of VPIs is recommended with the goal of achieving the postnatal growth of an equivalent fetus. However, VPIs frequently present postnatal length growth restriction at term-corrected age that remains lower than the standard weight and have greater fat mass and lower lean and bone mass than term-born infants. This condition differs from the classic pattern of infant undernutrition defined as a significantly lower weight for a given length. Moreover, it suggests that nonnutritional factors play a key role in length growth restriction. While weight faltering has been extensively studied, the significance of length growth failure in VPIs has only recently emerged. The nonnutritional factors underlying poor length growth in VPIs are currently not fully understood. In this review, we address recent advances in our understanding of the pathophysiology of length growth restriction, which has been identified as a major predictor of adverse neurodevelopmental and cognitive outcomes in VPIs. First, we review the shortand long-term consequences of poor length growth in VPIs; next, we highlight the effects of nonnutritional factors on postnatal length growth with focus on sustained neonatal inflammation; and finally, we discuss hypothesis and future lines of research attempting to understand the complex inflammatory-endocrine interactions and pathophysiological changes during early postnatal life, appropriately guide and apply clinical strategies aimed at optimizing length growth of VPIs, and identify evidence of the associations between sustained neonatal inflammation, stunting, and long-term health risks and the potential implications thereof.

A review on lipid inclusion in preterm formula: Characteristics, nutritional support, challenges, and future perspectives

The lack of nutrient accumulation during the last trimester and the physiological immaturity at birth make nutrition for preterm infants a significant challenge. Lipids are essential for preterm infant growth, neurodevelopment, immune function, and intestinal health. However, the inclusion of novel lipids in preterm formulas has rarely been discussed. This study discusses specific lipid recommendations for preterm infants according to authoritative legislation based on their physiological characteristics. The gaps in lipid composition, such as fatty acids, triacylglycerols, and complex lipids, between preterm formulas and human milk have been summarized. The focus of this study is mainly on the vital roles of lipids in nutritional support, including long-chain polyunsaturated fatty acids, structural lipids, milk fat global membrane ingredients, and other minor components. These lipids have potential applications in preterm formulas for improving lipid absorption, regulating lipid metabolism, and protecting against intestinal inflammation. The lipidome and microbiome can be used to provide adequately powered evidence of the effects of lipids. This study proposes nutritional strategies for preterm infants and suggests approaches to enhance their lipid quality in preterm formula.

Sodium Glycerophosphate vs. Inorganic Phosphate Use in Parenteral Nutrition for Preterm Infants: A Retrospective Study

BACKGROUND/OBJECTIVES

Sodium glycerophosphate improves the adverse side effects of parenteral nutrition. Therefore, this study aimed to evaluate different outcomes, including metabolic bone disease and electrolyte imbalance, associated with the use of sodium glycerophosphate or inorganic phosphate in parenteral nutrition for preterm neonates.

METHODS

This retrospective cohort study enrolled 402 newborns admitted to the neonatal intensive care unit of one medical center between January 2019 and September 2021. Of them, 205 received sodium glycerophosphate as parenteral nutrition, while the other 197 received inorganic phosphate. Baseline characteristics and growth parameters, including body weight, body length, and head circumference in the first year of life; calcium and phosphate content of parenteral nutrition in the first 4 weeks; calcium, phosphorus, alkaline phosphatase (ALP), and creatinine levels; and morbidities were compared.

RESULTS

During the first 4 weeks, the calcium and phosphate contents of parenteral nutrition were significantly higher in the sodium glycerophosphate vs. inorganic phosphate group. Growth parameters did not differ significantly between groups. The sodium glycerophosphate group showed a higher mean serum phosphate level (4.0 ± 1.2 mg/dL vs. 3.5 ± 1.3 mg/dL, p = 0.001), lower serum ALP level (402.8 ± 202.8 U/L vs. 466.4 ± 228.6 U/L, p = 0.004), lower seizure incidence (4.9% vs. 13.2%, p = 0.003), and higher hypocalcemia incidence (41.5% vs. 31.5%, p = 0.038). However, there were no significant intergroup differences in other common morbidities such as metabolic bone diseases of prematurity, bronchopulmonary dysplasia, electrolyte imbalance, hypoglycemia, retinopathy of prematurity, or intraventricular hemorrhage.

CONCLUSIONS

Compared to inorganic phosphate, sodium glycerophosphate is associated with higher serum phosphate levels, lower ALP levels, and reduced seizure incidence in premature infants. However, as the study was retrospective and single-center, further randomized controlled trials are needed to confirm these findings.

Survey of vitamin D supplementation practices in extremely preterm infants

BACKGROUND

Most extremely preterm (EP) infants are vitamin D deficient (serum 25-hydroxyvitamin D levels below 20 ng/mL), and optimal supplementation practices for EP infants remain unknown. Our objective is to assess current vitamin D supplementation practices in U.S. neonatal intensive care units (NICU) for EP infants to provide baseline information for the design of future clinical trials.

METHODS

We conducted an online survey to study vitamin D intake and supplementation practices in U.S. NICUs caring for EP infants. Descriptive statistics compared responses by affiliation and level of care.

RESULTS

We analyzed responses from 253 NICUs, representing the majority of academic and level IV centers. Nearly all centers (97%) provided enteral vitamin D supplementation during the NICU stay, with 400 IU/day as the most common dosage (77%). Over half (56%) used feeding volume to initiate supplementation, with 71% of centers starting after achieving at least 120 ml/kg/day. Additionally, 94% of NICUs reported prescribing a vitamin D supplementation at discharge.

CONCLUSIONS

Most NICUs in the U.S. supplement EP infants with 400 IU/day of enteral vitamin D. Clinical trials of vitamin D supplementation comparing the most common regimen to earlier and higher doses are needed to identify adequate regimens for EP infants.

IMPACT

Despite the prevalence of vitamin D deficiency in extremely preterm (EP) infants at birth, optimal levels and supplementation strategies remain debated. Recent studies have suggested benefits of early high-dose vitamin D supplementation (800 IU/day) for reducing complications like bronchopulmonary dysplasia, infections, and disability. There is US center variation in timing and dose of vitamin D supplementation, being the most common regimen 400 IU/d started after established feedings (≥120 ml/kg/day). These findings inform and highlight the need for clinical trials of usual vs. early, higher-dose vitamin D supplementation to advance clinical outcomes and define desirable blood levels of EP infants.

Association of Neonatal Morbidities and Postnatal Growth Faltering in Preterm Neonates

BACKGROUND/OBJECTIVES

Postnatal growth faltering (PGF) is a risk factor for adverse neurodevelopment in very preterm neonates. The aim of this retrospective study was to determine which infants' baseline characteristics, prenatal risk factors and neonatal morbidities are associated with two definitions of PGF: defined as loss of >2 weight z-scores (severe PGF) or as loss of >1 weight, length, and head circumference z-scores between birth and discharge (complex PGF); Methods: 146 premature newborns (<32 weeks of gestational age, <1500 g) were included in the study. Anonymized data including anthropometric measurements (weight, length, and head circumference), perinatal and neonatal data (demographics, maternal morbidities and previous pregnancies, and neonatal and perinatal morbidities) were extracted from the clinical electronic database. Changes in anthropometric age- and sex-specific z-scores using the Fenton 2013 preterm growth charts were calculated to diagnose severe PGF and complex PGF; Results: The incidence of severe PGF was 11% and complex PGF was 24%. Both PGF definitions were associated with bronchopulmonary dysplasia (BPD), severe retinopathy of prematurity (ROP), longer respiratory support, and longer hospital stay. Severe PGF was associated with surgical necrotizing enterocolitis at 25% vs. 1.5%, p = 0.001. Complex PGF was associated with severe brain injury at 51% versus 27%, p = 0.007. Complex PGF was more common in newborns born most prematurely, while severe PGF was more common in newborns born small for gestational age (SGA); Conclusions: Both severe and complex PGF are associated with several important neonatal morbidities, which might explain why growth faltering is associated with suboptimal neurodevelopment. Appropriate early identification of faltered growth may influence medical and nutrition interventions which in turn could improve the outcome of very preterm newborns.

Neonatal Nutrition and Brain Structure at 7 Years in Children Born Very Preterm

Importance

Neonatal protein intake following very preterm birth has long lasting effects on brain development. However, it is uncertain whether these effects are associated with improved or impaired brain maturation.

Objective

To assess the association of neonatal protein intake following very preterm birth with brain structure at 7 years of age.

Design, Setting, and Participants

This cohort study involved children born very preterm before or after a change in neonatal intensive care unit nutritional protocol that increased protein intake at the National Women's Hospital in Auckland, New Zealand. The children completed magnetic resonance imaging (MRI) scanning at 7 years. There were 128 children who were initially eligible. MRI data were ineligible for analysis if excessive head motion or clinical brain abnormalities were present. Data were collected from July 2012 to January 2016, and data analysis took place from January 2017 to March 2024.

Exposure

Neonatal intensive care unit nutritional protocol. Those who were born before the protocol change took place (July 2005 to December 2006) were in the old protocol group, while those who were born after the protocol change (January 2007 to October 2008) were in the new protocol group. Observers were blind to participant grouping.

Main Outcomes and Measures

All actual enteral and parenteral intakes of protein, fat, energy, and breast milk for days 1 to 7 and days 1 to 14, and growth velocity to postnatal day 28 were calculated for each infant. Preplanned outcomes were group comparisons between regional brain volumes and diffusion parameters of major white matter tracts along with analyses with both groups combined exploring associations of nutrition with brain metrics.

Results

Data from 99 children were analyzed, including 42 in the old protocol group (26 female [55%]; mean [SD] gestational age at birth, 27 [2] weeks) and 57 in the new protocol group (27 female [47%]; mean [SD] gestational age at birth, 26 [2] weeks). Protein intake differed between the groups at both 7 days (old protocol: mean [SD] intake, 17 [2] g/kg-1; new protocol: mean [SD] intake, 21 [2] g/kg-1) and 14 days after birth (old protocol: mean [SD] intake, 41 [6] g/kg-1; new protocol: mean [SD] intake, 45 [7] g/kg-1). The new protocol group had smaller brain volume as a percentage of intercranial volume than the old protocol group (mean [SD], 80% [4%] vs 86% [7%]) but absolute brain volumes were similar. The new protocol group had significantly thinner lateral occipital and lateral parietal cortices than the old protocol group. With both groups combined, those with greater protein, fat, energy, and breast milk intake had more mature diffusion tensor metrics (higher fractional anisotropy and less diffusion) across multiple tracts, although this finding did not reach statistical significance for every tract.

Conclusions and Relevance

In this cohort of children born very preterm, children with greater neonatal protein intake had a more mature profile of brain metrics assessed with MRI at 7 years of age. These results contribute to the ongoing evaluation of optimal nutrition for infants born very preterm and suggest that the protein intake experienced by the new protocol group may promote brain maturation in a way that is still observable at 7 years of age.

High protein intake on later outcomes in preterm children: a systematic review and meta-analysis

BACKGROUND

Appropriate protein intake is crucial for growth and development in children born preterm. We assessed the effects of high (HP) versus low protein (LP) intake on neurodevelopment, growth, and biochemical anomalies in these children.

METHODS

Randomised and quasi-randomised trials providing protein to children born preterm (<37 completed weeks of gestation) were searched following PRISMA guideline in three databases and four registers (PROSPERO registration CRD42022325659). Random-effects model was used for assessing the effects of HP (≥3.5 g/kg/d) vs. LP (<3.5 g/kg/d).

RESULTS

Data from forty-four studies (n = 5338) showed HP might slightly reduce the chance of survival without neurodisability at ≥12 months (four studies, 1109 children, relative risk [RR] 0.95 [95% CI 0.90, 1.01]; P = 0.13; low certainty evidence) and might increase risk of cognitive impairment at toddler age (two studies; 436 children; RR 1.36 [0.89, 2.09]; P = 0.16; low certainty evidence). At discharge or 36 weeks, HP intake might result in higher weight and greater head circumference z-scores. HP intake probably increased the risk of hypophosphatemia, hypercalcemia, refeeding syndrome and high blood urea, but reduced risk of hyperglycaemia.

CONCLUSIONS

HP intake for children born preterm may be harmful for neonatal metabolism and later neurodisability and has few short-term benefits for growth.

IMPACT STATEMENT

Planned high protein intake after birth for infants born preterm might be harmful for survival, neurodisability and metabolism during infancy and did not improve growth after the neonatal period. Protein intake ≥3.5 g/kg/d should not be recommended for children born preterm.

Risk factors and outcomes of vitamin D deficiency in very preterm infants

BACKGROUND

Vitamin D is essential for bone health and immune system. Vitamin D deficiency (VDD) poses a high-risk to very preterm (VP) infants. This study aimed to evaluate the risk factors associated with VDD in VP infants and its potential clinical outcomes.

METHODS

A retrospective cohort study was conducted on VP infants admitted to the neonatal intensive care unit of a specialized tertiary hospital in Seoul, Republic of Korea, between January 2018 and June 2022. Serum 25-hydroxyvitamin D (25(OH)D) levels and other biochemical parameters were measured between 4 and 6 weeks of age. VDD was defined as a serum 25(OH)D level <20 ng/mL. Prenatal and postnatal risk factors and clinical outcomes were compared between the VDD and non-VDD groups.

RESULTS

Of the 82 VP infants analyzed, 27 (32.9%) were diagnosed with VDD. The VDD group exhibited a significantly longer duration of parenteral nutrition (PN) compared to the non-VDD group (adjusted odds ratio [OR] = 1.12; 95% confidence interval [CI]: 1.008-1.245). Breast milk intake was lower in the VDD group than in the non-VDD group (adjusted OR = 0.976, 95% CI, 0.955-0.999). Notably, calcium levels were significantly lower in the VDD group, while parathyroid hormone levels were significantly higher, compared with the non-VDD group. Additionally, the rickets severity score was higher in the VDD group than in the non-VDD, although the difference was not statistically significant.

CONCLUSIONS

Prolonged PN duration and low breast milk intake significantly increased the risk of VDD in VP infants.

Supplemental Iron and Recombinant Erythropoietin for Anemia in Infants Born Very Preterm: A Survey of Clinical Practice in Europe

OBJECTIVES

To survey practices of iron and recombinant human erythropoietin (rhEpo) administration to infants born preterm across Europe.

STUDY DESIGN

Over a 3-month period, we conducted an online survey in 597 neonatal intensive care units (NICUs) of 18 European countries treating infants born with a gestational age of <32 weeks.

RESULTS

We included 343 NICUs (response rate 56.3%) in the survey. Almost all NICUs (97.7%) routinely supplement enteral iron, and 74.3% of respondents to all infants born <32 weeks of gestation. We found that 65.3% of NICUs routinely evaluate erythropoiesis and iron parameters beyond day 28 after birth. Most NICUs initiate iron supplementation at postnatal age of 2 weeks and stop after 6 months (34.3%) or 12 months (34.3%). Routine use of rhEpo was reported in 22.2% of NICUs, and in individual cases in 6.9%. RhEpo was mostly administered subcutaneously (70.1%) and most frequently at a dose of 250 U/kg 3 times a week (44.3%), but the dose varied greatly between centers.

CONCLUSIONS

This survey highlights wide heterogeneity in evaluating erythropoietic activity and iron deficiency in infants born preterm. Variation in iron supplementation during infancy likely reflects an inadequate evidence base. Current evidence on the efficacy and safety profile of rhEpo is only poorly translated into clinical practice. This survey demonstrates a need for standards to optimize patient blood management in anemia of prematurity.

Tracing Zinc's Role in Preterm Infants' Health: A Narrative Review

Zinc (Zn) is a trace element involved in numerous physiological processes, including enzyme function, gene transcription, and cell signaling. Its importance is especially pronounced in preterm infants, who are at high risk of Zn deficiency due to disrupted transplacental transfer, high nutrient demands, and medical complications. The inherent risk of Zn deficiency in this population is further increased by poor Zn dietary intake. Human milk from preterm mothers contains low concentrations of Zn, although it is highly bioavailable. Additionally, the Zn content steadily declines from colostrum (first few days postpartum) to mature milk (>10-14 d postpartum). Formula milk contains higher Zn concentrations to compensate for nutrient losses during production and storage, and lower bioavailability compared with human milk, which is further decreased in case of high phytate content, such as in soy milk-based formulas. Zn supplements may prove useful in meeting the preterm infant's needs, although caution is warranted regarding potential interactions with other nutrients within multinutrient supplements. Early detection of Zn deficiency is challenging due to the lack of reliable Zn status biomarkers, necessitating a high index of suspicion. Clinical signs of Zn deficiency can range from mild, nonspecific symptoms to severe, multisystem involvement. Chronic deficiency may lead to failure to thrive. Zn supplementation can support growth and mitigate comorbidities in preterm infants, although variability across studies complicates efforts to establish optimal dosing, and define safety and long-term effects. Although rare, Zn toxicity in preterm infants should not be overlooked, especially in infants on long-term parenteral nutrition. This narrative review aimed to consolidate existing knowledge and identify research gaps, highlighting the critical role of Zn in supporting preterm infants' health. Further research is needed to establish evidence-based practices to improve health outcomes in this vulnerable population.

Increased enteral lipid supplementation is not associated with weight gain in extremely preterm infants with sufficient energy intakes

OBJECTIVES

Practices for fortifying human milk vary among neonatal intensive care units (NICUs). It is unclear whether enteral energy intake above 140 kcal/kg/day with increased fat supplementation leads to greater weight gain in breastmilk-fed extremely preterm (EPT) infants.

METHODS

Anthropometric and nutritional data were collected from clinical records for Swedish EPT infants born between gestational weeks 26 + 0 and 27 + 6. Included infants were treated at NICU A (n = 17) or NICU B (n = 39). The primary outcome was change in standard deviation (SD) scores (ΔSDS) for weight between postmenstrual weeks 29 + 0 and 34 + 0.

RESULTS

At birth, the mean gestational age was 26.9 (±0.45 SD) weeks and the mean birthweight was 969 (±107 SD) g. Between postmenstrual weeks 29 + 0 and 33 + 6, the energy intake was significantly higher at NICU B: mean (SD) 149 (±14.9) versus 132 (±11.2) kcal/kg/day, p ≤ 0.001. This was driven by a higher fat intake at NICU B: mean (SD) 7.97 (±1.05) versus 6.20 (±0.92) g/kg/day, p ≤ 0.001, which in turn was explained by more liberal use of lipid supplements at NICU B. No significant differences were found in ΔSDS for weight, length or head circumference between the two NICUs.

CONCLUSIONS

Despite considerable differences in energy intake due to the use of enteral lipid supplements, our study showed no differences in ΔSDS for weight, length or head circumference. This may be due to limited fat absorption in infants already receiving adequate energy and fat, and poor absorption of fat from human donor milk.

Effects of Early Enteral to Parenteral Protein Ratios on Brain Volume and Somatic Growth in Very Low Birth Weight Infants

OBJECTIVE

To evaluate whether a higher proportion of enteral vs parenteral protein ratio (E:P ratio) in the first 28 days after birth is associated with increased brain volume and somatic growth in very low birth weight (VLBW; birth weight <1500 g) infants.

STUDY DESIGN

This was a retrospective analysis of a subcohort of VLBW infants (n = 256, gestational age mean 28.07 [SD 2.17] weeks, birth weight 1038.80 [SD 262.95] grams) from the Cincinnati Infant Neurodevelopment Early Prediction Study, a regional prospective study of infants born at ≤32 weeks' gestation. Brain magnetic resonance imaging was obtained at term-equivalent age. Macronutrient intake and growth metrics for the first 28 days were collected retrospectively. The primary outcome was total brain tissue volume. The relationships between E:P ratio, total and regional brain tissue volumes, and somatic growth were analyzed by multivariable linear regression models; composite variables were used to adjust for potential confounders including pregnancy risk factors and initial severity of illness.

RESULTS

Higher E:P ratio was associated with increased total brain tissue volume but was not associated with change in head circumference z score. In secondary analyses, higher E:P ratio was associated with increased weight velocity. There were no significant associations between E:P ratio and change in weight or length z scores or regional brain volumes.

CONCLUSIONS

Higher E:P ratio in the first 28 days was positively associated with total brain volume and weight gain. Promoting the provision of enteral over parenteral protein may improve brain and somatic growth in VLBW infants.

Risk Assessment of Cognitive Impairment at 2 Years of Age in Infants Born Extremely Preterm Using the INTERGROWTH-21st Growth Standards

OBJECTIVE

To assess the risk of cognitive impairment among infants born extremely preterm using the INTERGROWTH-21st standards.

STUDY DESIGN

We analyzed anthropometric data at birth and 36 weeks postmenstrual age (PMA) from infants born extremely preterm (24-26 weeks of gestation) admitted to US neonatal units between 2008 and 2018. To determine INTERGROWTH-21st z-score values that indicate an increased risk of cognitive impairment at 2 years of age (Bayley cognitive score <85), we employed classification and regression trees and redefined growth failure (weight, length, and head circumference z-scores at 36 weeks PMA) and growth faltering (weight, length, and head circumference z-score declines from birth to 36 weeks PMA).

RESULTS

Among 5393 infants with a mean gestational age of 25 weeks, growth failure defined as a weight z-score of -1.8 or below at 36 weeks PMA and growth faltering defined as a weight z-score decline of 1.1 or greater from birth to 36 weeks PMA indicated a higher likelihood of cognitive impairment. A length z-score less than -1 at 36 weeks PMA had the highest sensitivity to detect cognitive impairment at 2 years (80%). A head circumference z-score decline of 2.43 or greater from birth to 36 weeks PMA had the highest specificity (86%). Standard definitions had fair to low sensitivity and specificity for risk detection of cognitive impairment.

CONCLUSIONS

Length and head circumference z-scores had the highest sensitivity and specificity for risk detection of cognitive impairment. Monitoring these growth parameters could guide earlier individualized interventions with potential to reduce cognitive impairment.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov ID Generic Database: NCT00063063.

Systemic immune markers and infection risk in preterm infants fed human milk fortified with bovine colostrum or conventional fortifier, a secondary analysis of the FortiColos trial

BACKGROUND

For very preterm infants, human milk is often fortified with formula products based on processed bovine milk. Intact bovine colostrum (BC), rich in anti-inflammatory milk factors, is considered an alternative. We investigated if BC affects anti-inflammatory/TH2 immunity and infection risk in very preterm infants.

METHODS

For a secondary analysis of a multicenter, randomized controlled trial (NCT03537365), very preterm infants (26-31 weeks gestation, 23% small for gestational age, SGA) were randomized to receive BC (ColoDan, Biofiber, Denmark, n = 113) or conventional fortifier (PreNAN, Nestlé, Switzerland, n = 116). Infection was defined as antibiotic treatment for five or more consecutive days and 29 cytokines/chemokines were measured in plasma before and after start of fortification.

RESULTS

In general, infection risk after start of fortification was associated with low gestational age, SGA status and antibiotics use prior to fortification. Adjusted for confounders, infants fortified with BC showed more infection episodes (20 vs 12%, P < 0.05) and higher cumulative infection risk (hazard ratio, HR 1.9, P = 0.06), particularly for SGA infants (HR 3.6, P < 0.05). Additionally, BC-fortified infants had higher levels of TH2-related cytokines/chemokines (IL-10, MDC, MCP4) and reduced levels of cytokines related to TH1/TH17-responses (IL-15, IL-17, GM-CSF). The differences were most pronounced in SGA infants, displaying higher levels of TH2-related IL-4, IL-6, and IL-13, and lower interferon-γ and IL-1α levels in the BC group.

CONCLUSION

Infants fortified with BC displayed a delayed shift from TH2- to TH1-biased systemic immunity, notably in SGA infants, possibly influenced by multiple confounding factors, alongside elevated antibiotic use, suggesting increased susceptibility to infection.

Metabolomics reveals changes in levels of fecal branched chain amino acids and organic acids in very preterm infants fed human milk fortified with bovine colostrum

BACKGROUND & AIMS

Human milk is the optimal diet for very preterm infants (VPIs), but it requires nutrient fortification to support growth. Bovine colostrum (BC), rich in intact proteins and bioactive components, could serve as a novel fortifier with potential benefits to VPIs gut health. To evaluate a possible effect of feeding BC on intestinal metabolism, the gut microbiota, and their interaction, we studied the fecal metabolome of VPIs in the first month of life, as compared with a conventional fortifier (CF, based on infant formula ingredients).

METHODS

Fecal samples were collected from VPIs recruited to the FortiColos trial (NCT03537365, BC, n = 107; CF, n = 112) before (FT0) and one (FT1) or two (FT2) weeks after start of fortification and analyzed using 1H NMR spectroscopy. Abundances of metabolites were compared between BC versus CF groups. Further, temporal changes in metabolite levels after start of fortification, as well as correlations with specific gut bacterial genera were explored.

RESULTS

Infants in the BC group had higher levels of fecal acetoacetate, choline, methanol, uracil, creatine, creatinine, lysine and a lower leucine at both FT1 and FT2, relative to the CF group. Asparagine, tryptophan and phenylalanine levels were higher, and butyrate was lower in the BC group at FT1. At FT2, higher fecal succinate and lower isoleucine were found in the BC group. In addition, eight metabolites (asparagine, phenylalanine, tryptophan, lysine, creatinine, acetoacetate, methanol and uracil) had fortification-specific changes over time. Positive correlations were found between succinate and unclassified Enterobacteriaceae, butyrate and Clostridium, uracil and Staphylococcus, while negative correlation were found between uracil and unclassified Enterobacteriaceae members.

CONCLUSION

Our study shows distinct fecal metabolome profiles in VPIs in the first weeks after fortification with BC versus CF. The fortification- and time-specific gut metabolite changes suggest that fortifiers influence luminal nutrient metabolism and microbiota activity in VPIs. Fortifier type for human milk affected gut health of VPIs via altered gut metabolite levels, interacting with microbiota in VPIs.

Impact of vitamin D on hyperoxic acute lung injury in neonatal mice

BACKGROUND

Prolonged exposure to hyperoxia can lead to hyperoxic acute lung injury (HALI) in preterm neonates. Vitamin D (VitD) stimulates lung maturation and acts as an anti-inflammatory agent. Our objective was to determine if VitD provides a dose-dependent protective effect against HALI by reducing inflammatory cytokine expression and improving alveolarization and lung function in neonatal mice.

METHODS

C57BL/6 mouse neonates were randomized and placed in room air or hyperoxic (85% O2) conditions for 6 days. Control, low (5 ng/neonate) and high (25 ng/neonate) doses of VitD were administered daily beginning at day 2 via oral gavage. Lung tissue was analyzed for edema, changes in pulmonary structure and function, and inflammatory cytokine expression.

RESULTS

Neonatal mice treated with VitD in hyperoxic conditions had improved weight gain, reduced pulmonary edema and increased alveolar surface area compared to untreated pups in hyperoxia. No significant changes in cytokine expression were observed between untreated and VitD neonates. While changes in surfactant protein mRNA expression were impacted by hyperoxia and VitD administration, no significant changes in alveolar type II cell percentages were observed. At 3 weeks, mice in hyperoxia treated with VitD had greater lung compliance, diminished airway reactivity and improved weight gain.

CONCLUSIONS

High dose VitD significantly limited harmful effects of HALI. These results suggest that supplementation of VitD to neonatal mice during hyperoxia exposure provides both short-term and long-term protective benefits against HALI.

Effects of two-stage preterm formulas on growth, nutritional biomarkers, and neurodevelopment in preterm infants

Background

Formula-fed preterm infants require nutrient-enriched formulas with optimized protein levels to support growth and neurodevelopment. The purpose of this study was to evaluate the safety, tolerability, and effectiveness of a new liquid two-staged formula system designed to provide tailored nutrition during hospital stay and after discharge.

Methods

Male and female very-low-birth-weight preterm infants (birth weight ≤1,500 g; gestational age ≤32 weeks) were recruited from three neonatal units in Poland and Slovakia in a prospective, open-label, interventional study. Stage 1 formula providing 3.6 g intact protein/100 kcal was consumed from enrollment until reaching 1,800 g, followed by a post-discharge (PD) Stage 2 formula with 2.8 g/100 kcal protein, which was consumed for 30 days. Weight gain velocity (WGV in g/kg/day) between the first day of achieving full enteral feeding (FEF D1 rate of 150 ml/kg/day and cessation of parenteral feeding) and day reaching 1,800 g was compared to the minimally required WGV (15 g/kg/day) for non-inferiority (primary endpoint), and to the Fenton median growth rate for superiority (17.3 g/kg/day), adjusting for sex, gestational age, site, visit, and WGV. Changes in z-scores, feeding tolerance, nutritional biomarker status, and safety were also assessed from FEF D1 to 30 days PD. In an observational follow-up at 2 years of age, neurodevelopment was evaluated using the Bayley Scales of Infant and Toddler Development (BSID-III).

Results

Adjusted weight gain velocity (95% CI) between the first day of full enteral feeding and day reaching 1,800 g in per protocol (PP, N = 18) was 23.0 (20.1-25.9) g/kg/day; lower limit of the 95% CIs exceeded the non-inferiority margin (15 g/kg/day, p < 0.001) and the superiority margin (17.3 g/kg/day, p < 0.001). Mean stool frequency ranged from 2.5 to 3.3 stools per day. The two-stage formula supported adequate growth patterns throughout the study and nutritional biomarkers of protein and mineral status were within normal ranges. At 24 months corrected age, the mean ± SD of the BSID cognitive scale was 97.3 ± 13.9 in PP, with all infants achieving a score >70. None of the adverse events reported were related to the study formulas.

Conclusion

The two-stage preterm formulas supported postnatal weight gain, adequate growth, cognitive development within normal ranges, and a safe profile of protein and bone biomarkers.

Clinical Trial Registration

Clinicaltrials.gov registration, NCT03728764, NCT04962035.

Identification of risk factors for necrotizing enterocolitis in twins: a case-control matching analysis of over ten-years' experience

OBJECTIVE

The identification of risk factors is crucial for the clinical prevention and diagnosis of necrotizing enterocolitis (NEC). Monochorionic twins (MCT), due to the high genetic homogeneity, provided a valuable model for investigating the risk factors of various diseases. This study aimed to explore the risk factors for NEC using MCT.

METHODS

A retrospective review was conducted on the medical records of monochorionic twins (MCT) treated at Guangzhou Women and Children's Medical Center from January 2012 to March 2023. We compared perinatal condition, feeding and preceding condition between MCT pairs with NEC (NEC MCT) and without NEC(No NEC MCT).Logistic regression analysis was utilized to identify independent risk factors.

RESULT

In 85 pairs of monochorionic twins (MCT), NEC occurred in one twin in 78.8% of cases, whereas both twins were affected in 21.2% of cases. In the final cohort of 60 pairs of MCT, several parameters were found to differ significantly between NEC MCT group and No NEC MCT group. Compared to No NEC MCT group, the incidence of umbilical cord abnormalities was significantly higher in the NEC MCT group (25% vs. 8.3%, P = 0.014). Meanwhile, NEC MCT group showed higher prevalence of SGA infants (48.3% vs. 21.7%, P = 0.002) and sFGR (38.3% vs. 6.7%, P = 0.000). Furthermore, TTTs (13.3% vs. 3.3%, P = 0.027) and septicemia (25% vs. 5%, P = 0.002) were more common in NEC MCT group. In a multivariable logistic regression model, sFGR (OR 6.81,95%CI 2.1-21.9, p = 0.001) was eventually output as an independent risk factor.

CONCLUSION

Non-genetic factors play a predominant role in the pathogenesis of NEC. Umbilical cord abnormalities, SGA, sFGR, TTTs and septicemia significantly increase the risk of NEC. sFGR is an independent risk factor of NEC.

A low-fat amino acid diet reverses intestinal failure and shows good growth trends in five infants with diacylglycerol transferase 1 (DGAT1) deficiency: a prospective cohort study

BACKGROUND

Congenital diarrheas and enteropathies (CODEs) caused by diacylglycerol transferase 1 (DGAT1) mutations often cause disease within 2 weeks after birth. If not treated properly, the disease can be life-threatening; therefore, early diagnosis and rational treatment strategies are essential. This study was conducted to improve the understanding of congenital diarrhea caused by DGAT1 deficiency.

METHODS

Clinical data from five congenital diarrhea infant cases caused by DGAT1 deficiency were analyzed. Infants were prospectively provided with a nutritional intervention with a low-fat amino acid formula for special medical purposes (FSMP). Their gastrointestinal symptoms and nutritional complications before and after interventions were compared.

RESULTS

Due to poor weight gain and gastrointestinal symptoms after birth, infants were treated by our clinical nutritionist. Genetic testing confirmed a compound heterozygous mutation in DGAT1. Neither hydrolyzed nor high-medium chain triglyceride (MCT) formula significantly alleviated diarrheal symptoms; however, a low-fat amino acid diet rapidly relieved symptoms and significantly improved nutritional status, with infants showing better tolerance to dietary fat content with age.

CONCLUSIONS

Infants with DGAT1 deficiency can be diagnosed by genetic testing. A low-fat amino acid FSMP formula and diet can quickly relieve diarrhea, vomiting, and other symptoms, and also improve infant growth and development.

TRIAL REGISTRATION

Ethical approval was obtained from the Medical Ethics Committee of the Children's Hospital of Fudan University (reference code: No.(2022)405).

Thermal equilibrium as a predictor of growth efficiency in preterm infants

Introduction

Providing adequate nutrition to preterm infants to achieve postnatal growth similar to intrauterine growth remains challenging due to the unpredictability of individual determinants.

Material and methods

We used a calculation program for infant incubators to compare the estimated heat balance with the caloric intake and growth rate in Very Low Birth Weight Infants (VLBWI).

Results and discussion

A group of 32 VLBWI was studied over a period of 14-28 days. An interrelationship between thermal equilibrium and growth rate was observed, with standardized incubator settings being unable to avoid periods of negative thermal balance and concomitantly poor growth rate.

Conclusion

Determining personalized incubator settings by means of a calculation program could help improve nutrition and growth in preterm infants.

Are We Enhancing Recovery After Neonatal Surgery? Assessment of Enhanced Recovery After Surgery Principles for Ostomy Takedown

INTRODUCTION

Enhanced Recovery After Surgery (ERAS) guidelines in adults have demonstrated reduced complications, length of stay, and cost. However, neonatal ERAS studies are limited and translation of adult ERAS guidelines to neonates is challenging. Furthermore, the knowledge, perception, and practice of neonatal ERAS guidelines is largely unknown. Our aim is to address this practice gap by determining current practice of the 2020 neonatal intestinal surgery ERAS guidelines at our institution and evaluating postoperative outcomes.

METHODS

A retrospective study was conducted of patients <1 y who underwent elective ostomy takedown at a single-center tertiary children's hospital between 2013 and 2023. A 13-point ERAS score was developed. Demographics, clinical course, pain management, nutrition, ERAS scores, and outcomes were analyzed using descriptive statistics, logistic and negative binomial regression.

RESULTS

One hundred eighty-six patients met the inclusion criteria. At surgery, the median age was 124 d (interquartile range [IQR] 81-220) and median weight was 4360 g (IQR 2920-7200). The median ERAS score was 6 (IQR 5-7). The highest scores were for appropriate (97.9%) and timely (91.9%) prophylactic antibiotics, and the lowest for preventing intraoperative hypothermia (14.5%), limiting opioids (9.1%), and early enteral feeding postoperatively (24.7%). Surgical site infection occurred in 14.5% and median length of stay was 28 (IQR 5-127) d.

CONCLUSIONS

Our institution's current practice of the 2020 neonatal intestinal surgery ERAS guidelines was poor. We identified opportunities for improvement including postoperative antibiotic administration, prevention of intraoperative hypothermia, nutrition, and pain management. Future studies will focus on implementation of neonatal ERAS guidelines at our institution and evaluation of adherence and outcomes.

A Narrative Review of Strategies to Optimize Nutrition, Feeding, and Growth among Preterm-Born Infants: Implications for Practice

Preterm birth is the leading cause of neonatal and under-5 mortality globally, and healthcare-related burden and nutrition-related morbidities are unsustainable, particularly in resource-limited regions. Additionally, preterm infants are susceptible to multiple adverse outcomes including growth faltering, suboptimal neurodevelopment, and multisystemic morbidities. Maturation, healing, repair, and restoration to normalcy in preterm-born infants require optimizing nutrition; only then, prognosis, growth, neurodevelopment, and overall quality of life can improve. In this article, we discuss the various evidence-based feeding and nutritional strategies that can be applicable even in resource-limited settings, where resources and infrastructure for advanced neonatal care are limited. This article addresses nutrition, feeding strategies, and growth monitoring in the neonatal intensive care unit and at discharge to optimize nutrition, growth, and development.

Immediate fortification of human milk with a bovine milk-derived human milk fortifier in very low birth weight infants: a randomized clinical trial

OBJECTIVE

Double-blind randomized control trial of early addition of a bovine milk-derived human milk fortifier (HMF) in very low birth weight (VLBW) infants (NCT05228535).

METHODS

VLBW infants were randomized to receive bovine milk-derived HMF with first feedings or delayed fortification at 80 ml/kg/day. Anthropometrics were assessed weekly through 36 weeks postmenstrual age (PMA). Unadjusted and adjusted (race, gender, gestational age, and birth weight) differences between study arms were examined using two-sample t-test and ANCOVA, respectively.

RESULTS

Fifty-two VLBW infants (57% female, 60% Black) were enrolled. Baseline demographics did not differ between groups. Weight velocity at DOL 28 did not differ between study arms. Secondary outcomes including NPO occurrence, incidence of metabolic acidosis, NEC, retinopathy, or late-onset sepsis did not differ between groups.

CONCLUSION

Immediate fortification of enteral feedings with a bovine milk-derived HMF appears safe and well-tolerated although no clear growth benefit could be established.

Breastmilk use in preterm infants <29 weeks' gestational age in Australia, New Zealand and Singapore

AIMS

To describe the prevalence of use of breastmilk and explore demographic characteristics and clinical outcomes associated with breastmilk provision in infants born <29 weeks' gestational age in Australia, New Zealand and Singapore.

METHODS

This is a secondary analysis of data from a randomised controlled trial, which enrolled 1273 infants in 13 neonatal units across Australia, New Zealand and Singapore from 2012 to 2015. Infants were classified as formula-fed, donor milk-fed or mother's milk-fed at their first enteral feed and separately, at hospital discharge.

RESULTS

The percentage of infants receiving mother's own milk differed between centres both at first feed (79% to 100%), and at hospital discharge (47.1% to 71.6%). Aboriginal, Torres Strait Islander and Southeast Asian heritage, drug use and smoking were associated with lower rates of fully breastmilk feeding at hospital discharge. There was no significant difference in growth outcomes, length of stay and feeding tolerance between feeding groups.

CONCLUSIONS

Achieving high breastmilk feeding rates at hospital discharge for all preterm infants born <29 weeks' gestational age at hospital discharge is possible; however, targeted support for mothers who are Indigenous, Southeast Asian and/or using recreational drugs and/or smoking and/or experiencing social disadvantage may be needed. A better understanding and shared knowledge of practice variations within neonatal units with high breastfeeding rates could improve breastmilk access and equity for preterm infants.

AUSTRALIAN NEW ZEALAND CLINICAL TRIALS REGISTRY

ACTRN12612000503820.

Do preterm infants' retinas like bovine colostrum? A randomized controlled trial

BACKGROUND

Bovine colostrum (BC) with liposomal delivery system (LDS) is a promising supplement to premature infant formula in absence of mother own milk. We propose that BC with LDS can target multiple etiological factors that threaten the developing retina, making premature infant less liable for retinopathy of prematurity (ROP). The aim of this study was to evaluate the effect of BC with LDS in the prevention of ROP.

METHODS

This was a single center, randomized, controlled trial. Two hundred and eleven preterm infants of gestational age ≤ 32weeks were admitted to the NICU of Alexandria University Children Hospital, Egypt, and randomly allocated into either non-BC group (n = 105) or BC group (n = 106). Patients in BC group received 3.5 ml /kg/day of BC for 14 days. All patients were monitored for development of ROP, anemia, late onset sepsis (LOS), bronchopulmonary dysplasia (BPD), periventricular leukomalacia (PVL) and necrotizing enterocolitis (NEC), in addition to growth assessment. Multivariate binary logistic regression analysis was performed to determine factors predicting ROP development.

RESULTS

Compared with the non-BC group, BC group was associated with a significantly lower incidence of ROP (5/100 vs. 16/100, respectively) with a p-value of 0.033. The administration of BC significantly decreased serum C- reactive protein (CRP) level and increased weight on day-14 of the study in comparison with the CRP level and birthweight at the beginning of study, with Cohen's D= -0.184, D = -2.246, respectively. Patients with suspected sepsis were significantly less in BC than non-BC group, p = 0.004. Patients with BC had significantly higher hemoglobin level on day-14 than non-BC-group, with median (IQR) 12.2 (11.0-13.9) and 11.7 (10.5-12.9), respectively. BC intake is one of factors that decreased development of ROP in univariate analysis. Nevertheless, weight gain and birth weight were the most significant factors affecting ROP development in multivariate-regression model.

CONCLUSION

BC may reduce the incidence of ROP in preterm neonates aged ≤ 32 weeks. This might be due to keeping better Hb level and growth rate, as well as anti-inflammatory properties through its ability to decrease CRP level.

TRIAL REGISTRATION

This work was registered on 06/13/2022 in clinicaltrial.gov with ID no.: NCT05438680 and URL: https://classic.

CLINICALTRIALS

gov/ct2/show/NCT05438680?term=NCT05438680&draw=2&rank=1 .

Effects of vitamin D supplementation on serum 25(OH)D3 levels and neurobehavioral development in premature infants after birth

This study explored the factors influencing serum 25(OH)D3 levels and the effects of Vitamin D deficiency (VDD) and VD supplementation on 25(OH)D3 levels and neuropsychobehavioral development in premature infants, to provide a theoretical basis for improving their prognosis. Physical examination, neuropsychobehavioral development and serum 25(OH)D3 levels were assessed regularly in 158 preterm infants supplemented with VD formulation. 25(OH)D3 levels were analyzed at 3, 6, 9, 12, and 18 months after birth. The Gesell neuropsychological development test was conducted at 6, 9, 12, and 18 months after birth to obtain the developmental quotient (DQ). Based on the serum 25(OH)D3 levels at 42 days of age, the infants were divided into VDD and non-VDD groups. Preterm infants in the VDD group were supplemented with more VD until their 25(OH)D3 levels were normal, and were divided into sustained VDD (SVDD) and corrected VDD (CVDD) groups according to serum 25(OH)D3 levels at 3 months of age. Appropriate statistical methods were chosen to compare differences in 25(OH)D3 and DQ between or among different groups, screen for the factors influencing 25(OH)D3 levels in preterm infants at 42 days of age, and analyze the relationship between 25(OH)D3 and DQ. The 25(OH)D3 levels of preterm infants at 42 days of age were positively correlated with VD supplementation during pregnancy, and before 42 days after birth (P < 0.05). The 25(OH)D3 levels in preterm infants at 42 days and 3 months of age were positively correlated with the DQ levels at 6, 9, 12, and 18 months of age (P < 0.05). The DQ level in the VDD group, especially SVDD group, was lower than that in CVDD and non-VDD groups at the same time point (P < 0.05). This research thus demonstrates that VD supplementations during pregnancy and after birth is a major factor affecting 25(OH)D3 levels in premature infants. Early VDD and SVDD can affect their neuropsychobehavioral development, and effective VD supplementation can gradually correct VDD and mitigate this influence.

Evaluation of efficacy of oral calcium phosphate as an adjunct to standard-of-care regular phototherapy in cases of neonatal jaundice: a hospital-based double-blind, randomised, placebo-controlled trial

OBJECTIVE

Neonatal jaundice is the most common cause of neonatal morbidity and rehospitalisation in the first week of life, affecting approximately 60% of term and 80% of preterm neonates, with 10% requiring phototherapy to prevent bilirubin-induced neurological dysfunction. Enterohepatic circulation contributes 10%-20% of the body's bilirubin load, and oral calcium-phosphate can inhibit this process by binding to unconjugated bilirubin and acting as a bilirubin-trapping agent in the gut. This study aimed to evaluate the efficacy of oral calcium phosphate as an adjunct to phototherapy in reducing phototherapy duration, improving bilirubin decline rate and lowering rebound hyperbilirubinaemia incidence.

METHODS

This double-blind, placebo-controlled randomised controlled trial with a 1:1 allocation ratio was conducted in the neonatal intensive care unit of a tertiary care hospital in Eastern India. The investigator and the analyst were blinded to the treatment assignments. Eligible neonates with neonatal jaundice requiring phototherapy as per the 'American Academy of Pediatrics or 'National Institute for Health and Care Excellence' guidelines were enrolled and randomly assigned to receive either oral calcium phosphate or placebo.

RESULTS

The total duration of phototherapy was significantly lower in the intervention group compared with placebo (18.8±5.63 hours vs 24.3±4.50 hours; mean difference=-5.55 (95% CI -7.82 to -3.28), p<0.001). The rate of fall of bilirubin (mg/dL/hour) was also significantly higher in the intervention group (0.186±0.0137 vs 0.116±0.0088; mean difference=0.0693 (95% CI 0.0642 to 0.0745), p<0.001). The intervention group showed a trend towards a decrease in the incidence of rebound hyperbilirubinaemia, with a relative risk of 0.30 ((95% CI 0.0891 to 1.01), p=0.066).

CONCLUSION

The use of oral calcium phosphate results in a statistically significant reduction in phototherapy hours, an improvement in the rate of bilirubin decline and a decrease in rebound hyperbilirubinaemia incidence. This allows for shorter hospital stays and reduces the need for rehospitalisation, resulting in less mother-baby dyad separation, lower hospital resource consumption and reduced financial burden on parents.

TRIAL REGISTRATION NUMBER

Clinical-trials-registry-India, Ref No.CTRI/2022/03/041203, dated 21 March 2022https://ctri.nic.in/Clinicaltrials/showallp.php?mid1=57944&EncHid=&userName=Phototherapy.

Impact of Refeeding Syndrome on the Short-Term Clinical Outcomes of Very-Premature Infants

BACKGROUND

Refeeding syndrome (RFS) is a potentially life-threatening condition that can occur in preterm infants if nutritional support is initiated or increased after a period of starvation or malnutrition.

OBJECTIVES

The current study aimed to examine the short-term clinical outcomes of RFS in preterm infants born at ≤32 weeks of gestation.

METHODS

Infants with a gestational age of ≤32 weeks and a birth weight of <1500 g who were born and admitted to the level III neonatal intensive care unit and received parenteral nutrition upon admission were retrospectively evaluated. The modified log Poisson regression with generalized linear models and a robust variance estimator was applied to adjust the outcomes of infants.

RESULTS

In total, 760 infants met this study's inclusion criteria. Of them, 289 (38%) developed RFS. RFS was significantly associated with a composite outcome of mortality and intraventricular hemorrhage. Based on the multivariate Cox regression analysis adjusted for significant potential confounders, RFS was significantly associated with increased mortality risk, with a hazard ratio for death in infants with RFS being 1.74-fold higher compared to those without RFS.

CONCLUSIONS

Preterm infants born at ≤32 weeks of gestation who develop RFS within the first week of life are at increased risk for both intraventricular hemorrhage and mortality. This study underscores the need for standardized clinical approaches for managing RFS in the neonatal intensive care unit to improve outcomes. Future research should establish a unified RFS definition and conduct clinical trials to optimize parenteral nutrition strategies for this vulnerable population.

Preterm Infant Enteral Feeding Practices in Saudi Arabia: A Scoping Review

Background

Preterm infants are at risk of developing nutritional deficiencies, which is further compounded by the fact that providing them with adequate nutrition is often challenging. Enteral feeding (EF) practices vary across neonatal units and can be impacted by the setting and geographical region. There is also a lack of evidence on best practices.

Objective

To investigate EF practices and related nutrition factors, patterns, and outcomes in preterm infants in Saudi Arabia by examining studies published in this area.

Methods

A search was conducted for articles on EF practices among preterm infants in Saudi Arabia that were published between January 2010 and May 2024. Searches were carried out across five electronic databases and through searching inward and backward citation and reference lists of relevant papers. Studies that described or assessed EF practices used in preterm infants from any region of Saudi Arabia and were published in English or Arabic were included.

Results

The database and manual search resulted in 1905 articles. After removing duplicates and applying the inclusion/exclusion criteria, 14 publications were included: 12 were observational studies, 1 was a conference abstract (with retrospective analysis), and 1 was a commentary. Of these, 7 studies were conducted in the Central Province, 6 in the Western Province, and 1 in the Eastern Province. More than half of the publications (8 of 14) were published between 2021 and 2023. The studies included were categorized to three themes based on their aim: studies describing practices on mother-infant bond to encourage breastfeeding, assessing nutritional status and EF, and assessing EF as a risk factor for developing prematurity complications.

Conclusion

While research activity on EF practices in Saudi Arabia has increased very recently, yet there is a paucity of studies, particularly experimental studies that focus on both short- and long-term health outcomes.

Micronutrient Intake during Complementary Feeding in Very Low Birth Weight Infants Comparing Early and Late Introduction of Solid Foods: A Secondary Outcome Analysis

Background/Objectives: The complementary feeding period is crucial for addressing micronutrient imbalances, particularly in very low birth weight (VLBW) infants. However, the impact of the timing of solid food introduction on micronutrient intake in a representative VLBW population remains unclear. Methods: This prospective, observational study investigated micronutrient intake during complementary feeding in VLBW infants categorized based on whether solids were introduced early (<17 weeks corrected age (CA)) or late (≥17 weeks CA). Nutritional intake was assessed using a 24 h recall at 6 weeks CA and with 3-day dietary records at 12 weeks and at 6, 9, and 12 months CA. Results: Among 218 infants, 115 were assigned to the early group and 82 to the late group. In total, 114-170 dietary records were valid for the final analysis at each timepoint. The timepoint of solid introduction did not affect micronutrient intake, except for a higher iron and phosphorus intake at 6 months CA in the early group (early vs. late: iron 0.71 vs. 0.58 mg/kg/d, adjusted p-value (p-adj.) = 0.04; phosphorus 341 vs. 286 mg/d, p-adj. = 0.04). Total vitamin D, calcium, zinc, and phosphorus greatly met intake recommendations; however, dietary iron intake was insufficient to equalize the iron quantity from supplements during the second half year CA. While nutrient intakes were similar between infants with and without comorbidities, breastfed infants had lower micronutrient intakes compared with formula-fed infants. Conclusions: This study suggests that micronutrient intakes were sufficient during complementary feeding in VLBW infants. However, prolonged iron supplementation may be necessary beyond the introduction of iron-rich solids. Further research is essential to determine micronutrient requirements for infants with comorbidities.

Key Influences on Oral Feeding Achievement in Preterm Infants: Insights From a Tertiary Hospital in Indonesia

Objective: Effective oral feeding is one of the critical milestones that must be achieved by preterm infants. While gestational age and birth weight have been recognized as influential factors, recent studies have found additional variables impacting the achievement of full oral feeding (FOF). This study is aimed at describing factors associated with the attainment of FOF in preterm infants. Methods: This retrospective cohort study examines preterm infants born between 28 and 34 weeks' gestation admitted to Dr. Cipto Mangunkusumo General Hospital in Jakarta between July and December 2016. Comparative analysis utilized the Kruskal-Wallis test, while Cox's regression was employed for multivariate analysis to assess factors influencing the achievement of FOF. Results: This study included 87 preterm infants meeting the inclusion criteria. The median gestational age was 33 weeks (IQR: 3). The most common birth weight range was 1500-1999 g (51.7%). Median durations from birth to the first feed, full enteral feed, and FOF were observed to be 1 day (IQR: 1), 6 days (IQR: 10), and 14 days (IQR: 24), respectively. Notably, the duration of oxygen therapy, episodes of sepsis, and frequency of blood transfusions showed significant associations with the time taken to achieve FOF. Conclusion: This study found significant associations between the time to achieve FOF and factors such as oxygen therapy duration, sepsis episodes, and frequency of blood transfusion. These findings highlight the importance of considering these factors in managing preterm infants. However, a further prospective study is warranted to identify additional factors that influence feeding milestones in preterm infants.

Improving growth in preterm infants through nutrition: a practical overview

The primary purpose of this practical overview is to provide a practical update on appropriate nutritional strategies to improve growth in preterm infants. Current recommendations for improving preterm growth concern both macronutrients and micronutrients, with tailored nutrition since the first days of life, particularly when fetal growth restriction has been reported. Human milk is undoubtedly the best nutrition for all newborns, but, in some populations, if not adequately fortified, it does not adequately support their growth. In all preterms, growth should be correctly monitored weekly to intercept a negative trend of growth and implement nutritional strategies to avoid growth restriction. Similarly, growth should be accurately supported and monitored after discharge to improve long-term health consequences.

Is choline deficiency an unrecognized factor in necrotizing enterocolitis of preterm infants?

We undertook this review to determine if it is plausible that choline or phosphatidylcholine (PC) deficiency is a factor in necrotizing enterocolitis (NEC) after two clinical trials found a dramatic and unexpected reduction in NEC in an experimental group provided higher PC compared to a control group. Sources and amounts of choline/PC for preterm infants are compared to the choline status of preterm infants at birth and following conventional nutritional management. The roles of choline/PC in intestinal structure, mucus, mesenteric blood flow, and the cholinergic anti-inflammatory system are summarized. Low choline/PC status is linked to prematurity/immaturity, parenteral and enteral feeding, microbial dysbiosis and hypoxia/ischemia, factors long associated with the risk of developing NEC. We conclude that low choline status exists in preterm infants provided conventional parenteral and enteral nutritional management, and that it is plausible low choline/PC status adversely affects intestinal function to set up the vicious cycle of inflammation, loss of intestinal barrier function and worsening tissue hypoxia that occurs with NEC. In conclusion, this review supports the need for randomized clinical trials to test the hypothesis that additional choline or PC provided parenterally or enterally can reduce the incidence of NEC in preterm infants. IMPACT STATEMENT: Low choline status in preterm infants who are managed by conventional nutrition is plausibly linked to the risk of developing necrotizing enterocolitis.

Reference values of parathyroid hormone in very low birth weight infants

PURPOSE

The primary goal was to estimate reference values of parathyroid hormone (PTH) in very low birth weight infants without severe neonatal morbidity. A secondary objective was to assess the relationship between PTH serum levels and selected laboratory markers of bone metabolism.

METHODS

Ninety two infants with birth weight less than 1500 g met the inclusion criteria of the study. Serum levels of PTH, 25-hydroxyvitamin-D [25(OH)D], C3-epi-25(OH)D, total calcium, phosphorus, and alkaline phosphatase, and urinary levels of calcium, phosphorus, and creatinine were examined on day 14 and subsequently every 2 weeks until discharge.

RESULTS

Of the total 167 serum samples examined for PTH levels in infants without 25(OH)D deficiency the estimated range was 0.9-11.9 pmol/l (8.5-112.3 pg/mL). During the first month, no statistically significant correlation was observed between PTH level and that of 25(OH)D, C3-epimers of 25(OH)D, S-Ca, S-P, or ALP, nor with urinary excretion of calcium and phosphorus. From the second month of life, there was a moderately significant correlation between PTH and 25(OH)D (Rho = -0.40, P =< .001), between PTH and calcium/creatinine ratio (Rho = -0.56, P = < .001), and between PTH and phosphorus/creatinine ratio (Rho = 0.51, P = < .001).

CONCLUSIONS

The physiological range for PTH levels for preterm neonates without 25(OH)D deficiency was estimated as 0.9-11.9 pmol/l (8.5-112.3 pg/mL). It seems that elevation of serum PTH above this range can be considered as hyperparathyroidism in very low birth weight infants.